Tranexamic Acid for Rotator Cuff Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Several randomized controlled trials (RCTs) have been conducted to assess the use of tranexamic acid (TXA) in the setting of arthroscopic rotator cuff repair (ARCR). However, these studies have shown mixed results, with some showing improved intraoperative visualization, subsequent operative times, and pain levels, and others finding no difference. PURPOSE: To perform a systematic review of the RCTs in the literature to evaluate the use of TXA on ARCR. STUDY DESIGN: Meta-analysis; Level of evidence, 1. METHODS: Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with a third author resolving any discrepancies. RCTs comparing TXA with a control in ARCR were included. Visualization, postoperative pain, operative time, pump pressures, and shoulder swelling were evaluated. A P value < .05 was deemed statistically significant. RESULTS: Six RCTs with 450 patients were included in this review. Overall, 5 studies evaluated intraoperative visualization, with 3 studies finding a significant difference in favor of TXA. With TXA, patients had a lower mean postoperative visual analog scale (VAS) score of 3.3, and with the control, patients had a mean VAS score of 4.1, which was statistically significant (P = .001). With TXA, the mean weighted operation time was 79.3 minutes, and with the control, the mean operation time was 88.8 minutes, which was statistically significant (P = .001). No study found any difference in intraoperative pump pressures or swelling. CONCLUSION: TXA improved visualization, operative time, and subsequent postoperative pain levels in patients undergoing ARCR.

Association between radiographic soft-tissue thickness and increased length of stay, operative time, and infection rate after reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a widely performed surgical procedure to address various shoulder pathologies. Several studies have suggested that radiographic soft-tissue thickness may play a role in predicting complications after orthopedic surgery, but there have been limited studies determining the use of radiographic soft-tissue thickness in RSA. The purpose of this study was to evaluate whether radiographic soft-tissue thickness could predict clinical outcomes after RSA and compare the predictive capabilities against body mass index (BMI). We hypothesized that increased radiographic shoulder soft-tissue thickness would be a strong predictor of operative time, length of stay (LOS), and infection in elective RSA. MATERIAL AND METHODS: A retrospective review of patients undergoing RSA at an academic institution was conducted. Preoperative radiographic images were evaluated including measurements of the radius from the humeral head center to the skin (HS), deltoid radius-to-humeral head radius ratio (DHR), deltoid size, and subcutaneous tissue size. Different correlation coefficients were used to analyze various types of relationships, and the strength of these associations was classified based on predefined boundaries. Subsequently, multivariable linear and logistic regressions were performed to determine whether HS, DHR, deltoid size, and subcutaneous tissue size could predict LOS, operative time, or infection while controlling for patient factors. RESULTS: HS was the most influential factor in predicting both operative time and LOS after RSA, with strong associations indicated by standardized ß coefficients of 0.234 for operative time and 0.432 for LOS. Subcutaneous tissue size, deltoid size, and DHR also showed stronger predictive values than BMI for both outcomes. In terms of prosthetic joint infection, HS, deltoid size, and DHR were significant predictors, with HS demonstrating the highest predictive power (Nagelkerke R2 = 0.44), whereas BMI did not show a statistically significant association with infection. Low event counts resulted in wide confidence intervals for odds ratios in the infection analysis. CONCLUSION: Greater shoulder soft-tissue thickness as measured with concentric circles on radiographs is a strong predictor of operative time, LOS, and postoperative infection in elective primary RSA patients.

Bilateral Sacroiliac Joint Dislocation, Discussion and Surgical Strategies: A Case Report.

CASE: A 16-year-old male patient presented with isolated bilateral sacroiliac (SI) joint dislocation. In this report, we discuss the presentation and focus on strategies for operative reduction and fixation for this rare injury. CONCLUSION: In conclusion, we present a case of a bilateral ligamentous SI joint dislocation in an adolescent. The patient was reduced in the supine position with a sacral bump and bilateral traction with direct and indirect reduction aids inserted through a lateral window. Bilateral SI screws stabilized the pelvis, facilitating uncomplicated healing.

Interfragmentary strain measurement post-fixation to guide intraoperative decision making: a narrative review.

PURPOSE: Interfragmentary strain influences whether a fracture will undergo direct and indirect fracture healing. Orthopedic trauma surgeons modulate strain and create optimal biomechanical environments for specific fracture patterns using fixation constructs. However, objective intraoperative interfragmentary strain measurement does not currently inform fixation strategy in common practice. This review identifies potential methods and technologies to enable intraoperative strain measurement for guiding optimal fracture fixation strategies. METHODS: PubMed, Scopus, and Web of Science were methodologically queried for manuscripts containing terms related to "bone fracture," "strain," "measurement," and "intraoperative." Manuscripts were systematically screened for relevance and adjudicated by three reviewers. Relevant articles describing methods to measure interfragmentary strain intraoperatively were summarized. RESULTS: After removing duplicates, 1404 records were screened initially. There were 49 manuscripts meeting criteria for in-depth review. Of these, four reports were included in this study that described methods applicable to measuring interfragmentary strain intraoperatively. Two of these reports described a method using instrumented staples, one described optical tracking of Kirschner wires, and one described using a digital linear variable displacement transducer with a custom external fixator. CONCLUSION: The four reports identified by this review describe potential methods to quantify interfragmentary strain after fixation. However, further studies are needed to confirm the precision and accuracy of these measurements across a range of fractures and fixation methods. Additionally, described methods require the insertion and likely removal of additional implants into the bone. Ideally, innovations that measure interfragmentary strain intraoperatively would provide dynamic biomechanical feedback for the surgeon to proactively modulate construct stability.

The characteristics of opioid use in patients with proximal humerus fractures.

BACKGROUND: Orthopaedic surgeons prescribe more opioid narcotics than any other surgical specialty. Proximal humerus fractures (PHF) often occur in the high-risk elderly population. The opioid epidemic has led to public policy aimed at reductions in opioid prescription. This study aimed to evaluate the impact that new legislation has had on opioid prescription patterns in patients who sustained proximal humerus fractures. METHODS: A retrospective review of all patients who sustained PHF at a single academic institution from 1/1/2015-12/31/2019 was performed. A total of 762 proximal humerus fractures were identified and final analysis included 383 patients. Collected data included basic demographics and opioid prescriptions obtained through review of the electronic medical record. The North Carolina Strengthen Opioid Misuse Prevention act legislation that went into effect on July 1, 2017. RESULTS: There was no difference in the number of pre- or postoperative opioid prescriptions provided with the new legislation. Our data showed a significant reduction in MeQs prescribed preoperatively pre-STOP act (188.1 MeQs) and post-STOP act (99.4 MeQs). There was also a significant difference in the amount of postoperative narcotics prescribed in the pre-STOP (972.6 MeQs) and post-STOP act (508.6 MeQs) groups (p < 0.01). CONCLUSIONS: With the enactment of the STOP act in North Carolina, we have seen a significant reduction in the amount of narcotic prescribed after sustaining a proximal humerus fracture preoperatively and postoperatively. This data demonstrates the impact that implementation of state-wide regulatory changes in opioid prescribing policy has had for a common orthopedic condition.

A Validated Pre-operative Risk Prediction Tool for Extended Inpatient Length of Stay Following Primary Total Hip or Knee Arthroplasty.

BACKGROUND: As value-based reimbursement models mature, understanding the potential trade-off between inpatient lengths of stay and complications or need for costly postacute care becomes more pressing. Understanding and predicting a patient's expected baseline length of stay may help providers understand how best to decide optimal discharge timing for high-risk total joint arthroplasty (TJA) patients. METHODS: A retrospective review was conducted of 37,406 primary total hip (17,134, 46%) and knee (20,272, 54%) arthroplasties performed at two high-volume, geographically diverse, tertiary health systems during the study period. Patients were stratified by 3 binary outcomes for extended inpatient length of stay: 72 + hours (29%), 4 + days (11%), or 5 + days (5%). The predictive ability of over 50 sociodemographic/comorbidity variables was tested. Multivariable logistic regression models were created using institution #1 (derivation), with accuracy tested using the cohort from institution #2 (validation). RESULTS: During the study period, patients underwent an extended length of stay with a decreasing frequency over time, with privately insured patients having a significantly shorter length of stay relative to those with Medicare (1.9 versus 2.3 days, P < .0001). Extended stay patients also had significantly higher 90-day readmission rates (P < .0001), even when excluding those discharged to postacute care (P < .01). Multivariable logistic regression models created from the training cohort demonstrated excellent accuracy (area under the curve (AUC): 0.755, 0.783, 0.810) and performed well under external validation (AUC: 0.719, 0.743, 0.763). Many important variables were common to all 3 models, including age, sex, American Society of Anesthesiologists (ASA) score, body mass index, marital status, bilateral case, insurance type, and 13 comorbidities. DISCUSSION: An online, freely available, preoperative clinical decision tool accurately predicts risk of extended inpatient length of stay after TJA. Many risk factors are potentially modifiable, and these validated tools may help guide clinicians in preoperative patient counseling, medical optimization, and understanding optimal discharge timing.

A validated preoperative risk prediction tool for extended inpatient length of stay following anatomic or reverse total shoulder arthroplasty.

BACKGROUND: Recent work has shown inpatient length of stay (LOS) following shoulder arthroplasty to hold the second strongest association with overall cost (after implant cost itself). In particular, a preoperative understanding for the patients at risk of extended inpatient stays (≥3 days) can allow for counseling, optimization, and anticipating postoperative adverse events. METHODS: A multicenter retrospective review was performed of 5410 anatomic (52%) and reverse (48%) total shoulder arthroplasties done at 2 large, tertiary referral health systems. The primary outcome was extended inpatient LOS of at least 3 days, and over 40 preoperative sociodemographic and comorbidity factors were tested for their predictive ability in a multivariable logistic regression model based on the patient cohort from institution 1 (derivation, N = 1773). External validation was performed using the patient cohort from institution 2 (validation, N = 3637), including area under the receiver operator characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values. RESULTS: A total of 814 patients, including 318 patients (18%) in the derivation cohort and 496 patients (14%) in the validation cohort, experienced an extended inpatient LOS of at least 3 days. Four hundred forty-five (55%) were discharged to a skilled nursing or rehabilitation facility. Following parameter selection, a multivariable logistic regression model based on the derivation cohort (institution 1) demonstrated excellent preliminary accuracy (AUC: 0.826), with minimal decrease in accuracy under external validation when tested against the patients from institution 2 (AUC: 0.816). The predictive model was composed of only preoperative factors, in descending predictive importance as follows: age, marital status, fracture case, ASA (American Society of Anesthesiologists) score, paralysis, electrolyte disorder, body mass index, gender, neurologic disease, coagulation deficiency, diabetes, chronic pulmonary disease, peripheral vascular disease, alcohol dependence, psychoses, smoking status, and revision case. CONCLUSION: A freely-available, preoperative online clinical decision tool for extended inpatient LOS (≥ 3 days) after shoulder arthroplasty reaches excellent predictive accuracy under external validation. As a result, this tool merits consideration for clinical implementation, as many risk factors are potentially modifiable as part of a preoperative optimization strategy.

Simple preoperative radiographic and computed tomography measurements predict adequate bone quality for stemless total shoulder arthroplasty.

INTRODUCTION: Although there is increased utilization of stemless humeral implants in anatomic total shoulder arthroplasty (TSA), there are inadequate objective metrics to evaluate bone quality sufficient for fixation. Our goals are to: (1) compare patient characteristics in patients who had plans for stemless TSA but received stemmed TSA due to intraoperative assessments and (2) propose threshold values of bone density, using the deltoid tuberosity index (DTI) and proximal humerus Hounsfield units (HU), on preoperative X-ray and computed tomography (CT) to allow for preoperative determination of adequate bone stock for stemless TSA. METHODS: This is an observational study conducted at an academic institution from 2019 to 2021, including consecutive primary TSAs templated to undergo stemless TSA based on 3-dimensional CT preoperative plans. Final implant selection was determined by intraoperative assessment of bone quality. Preoperative X-ray and CT images were assessed to obtain DTI and proximal humeral bone density in HU, respectively. A receiver operating characteristic curve was used to analyze the potential of preoperative X-ray and CT to classify patients as candidates for stemless TSA. RESULTS: A total of 61 planned stemless TSAs were included, with 56 (91.8%) undergoing stemless TSA and 5 (8.2%) undergoing stemmed TSA after intraoperative assessment determined that the bone quality was inadequate for stemless fixation. There were no significant differences between the 2 groups in terms of gender (P = .640), body mass index (P = .296), and race (P = .580). The stem cohort was significantly older (mean age 69 ± 12 years vs. 59 ± 10 years, P = .029), had significantly lower DTI (1.45 ± 0.13 vs. 1.68 ± 0.18, P = .007), and had significantly less proximal humeral HU (-1.4 ± 17.7 vs. 78.8 ± 52.4, P = .001). The receiver operating characteristic curve for DTI had an area under the curve (AUC) of 0.86, and bone density in HU had an AUC of 0.98 in its ability to distinguish patients who underwent stemless TSA vs. short-stem TSA. A threshold cutoff of 1.41 for DTI resulted in a sensitivity of 98% and a specificity of 60%, and a cutoff value of 14.4 HU resulted in a sensitivity of 95% and a specificity of 100%. CONCLUSIONS: Older age, lower DTI, and less proximal humeral bone density in HU were associated with the requirement to switch from stemless to short-stem humeral fixation in primary TSA. Preoperative DTI had good ability (AUC of 0.86) and preoperative HU had excellent ability (AUC of 0.98) to categorize patients as appropriate for stemless TSA. This can help surgeons adequately plan humeral fixation using standard preoperative imaging data.

Measuring intraoperative surgical instrument use with radio-frequency identification.

OBJECTIVE: Surgical instrument oversupply drives cost, confusion, and workload in the operating room. With an estimated 78%-87% of instruments being unused, many health systems have recognized the need for supply refinement. By manually recording instrument use and tasking surgeons to review instrument trays, previous quality improvement initiatives have achieved an average 52% reduction in supply. While demonstrating the degree of instrument oversupply, previous methods for identifying required instruments are qualitative, expensive, lack scalability and sustainability, and are prone to human error. In this work, we aim to develop and evaluate an automated system for measuring surgical instrument use. MATERIALS AND METHODS: We present the first system to our knowledge that automates the collection of real-time instrument use data with radio-frequency identification (RFID). Over 15 breast surgeries, 10 carpometacarpal (CMC) arthroplasties, and 4 craniotomies, instrument use was tracked by both a trained observer manually recording instrument use and the RFID system. RESULTS: The average Cohen's Kappa agreement between the system and the observer was 0.81 (near perfect agreement), and the system enabled a supply reduction of 50.8% in breast and orthopedic surgery. Over 10 monitored breast surgeries and 1 CMC arthroplasty with reduced trays, no eliminated instruments were requested, and both trays continue to be used as the supplied standard. Setup time in breast surgery decreased from 23 min to 17 min with the reduced supply. CONCLUSION: The RFID system presented herein achieves a novel data stream that enables accurate instrument supply optimization.

Addressing Surgical Instrument Oversupply: A Focused Literature Review and Case-Study in Orthopedic Hand Surgery.

BACKGROUND: Instrument oversupply drives cost in the operating room (OR). We review previously reported methodologies for surgical instrument reduction and report a pilot methodology for optimizing instrument supply via ethnographic instrument tracking of thumb carpometacarpal (CMC) arthroplasties. Additionally, we report a cost analysis of instrument oversupply and potential savings of tray optimization methods. METHODS: Instrument utilization was tracked over 8 CMC arthroplasties conducted by 2 surgeons at an ambulatory surgery center of a large academic hospital. An optimized supply methodology was designed. A cost analysis was conducted using health-system-specific data and previously published research. RESULTS: After tracking instrument use in 8 CMC arthroplasties, a cumulative total of 59 out of the 120 instruments in the Hand & Foot (H&F) tray were used in at least 1 case. Two instruments were used in all cases, and another 20 instruments were used in at least 50% of the cases. Using a reduced tray with 59 instruments, potential cost savings for tray reduction in 60 cases were estimated to be $2086 without peel-packing and $2356 with peel-packing. The estimated cost savings were lower than those reported in literature due to a reduced scope and exclusion of OR time cost in the analysis. CONCLUSIONS: Instrument oversupply drives cost at our institution's ambulatory surgery center. Ethnography is a cost-effective method to track instrument utilization and determine optimal tray composition for small services but is not scalable to large health systems. The time and cost required to observe sufficient surgeries to enable supply reduction to motivate the need for more efficient methods to determine instrument utility.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II.

BACKGROUND: Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous. METHODS: Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests. RESULTS: The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%. CONCLUSIONS: Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part I.

BACKGROUND: Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this 2-part study was to systematically review each of the most common complications of RSA, limiting each search to publications in 2010 or later. In this part (part I), we examined (1) scapular notching (SN), (2) periprosthetic infection (PJI), (3) mechanical failure (glenoid or humeral component), and (4) neurologic injury (NI). METHODS: Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Overall, 113 studies on SN, 62 on PJI, 34 on mechanical failure, and 48 on NI were included in our reviews. Univariate analysis was performed with the χ2 or Fisher exact test. RESULTS: The Grammont design had a higher SN rate vs. all other designs combined (42.5% vs. 12.3%, P < .001). The onlay humeral design had a lower rate than the lateralized glenoid design (10.5% vs. 14.8%, P < .001). The PJI rate was 2.4% for primary RSA and 2.6% for revision RSA. The incidence of glenoid and humeral component loosening was 2.3% and 1.4%, respectively. The Grammont design had an increased NI rate vs. all other designs combined (0.9% vs. 0.1%, P = .04). CONCLUSIONS: Focused systematic reviews of the recent literature with a large volume of RSAs demonstrate that with the use of non-Grammont modern prosthesis designs, complications including SN, PJI, glenoid component loosening, and NI are significantly reduced compared with previous studies. As the indications for RSA continue to expand, it is imperative to accurately track the rates and types of complications to justify its cost and increased indications.

The clinical impact of arthroscopic vs. open osteocapsular débridement for primary osteoarthritis of the elbow: a systematic review.

BACKGROUND: Primary elbow osteoarthritis (PEOA) is a debilitating disease that can be difficult to treat. Osteocapsular débridement (OD) has been described through various approaches, including arthroscopic and open approaches, with successful outcomes in treating PEOA. There is insufficient evidence in the literature to date to demonstrate the superiority of any approach. The purpose of this review was to compare the clinical results of arthroscopic vs. open OD for PEOA. METHODS: The online databases PubMed, Embase (Elsevier), and Scopus (Elsevier) were searched from inception through April 1, 2018, for clinical studies reporting on OD. Studies were stratified based on an arthroscopic vs. open approach. Weighted means were calculated for surgical and patient-reported outcomes. RESULTS: We included 30 studies, reporting on 871 patients and 887 elbows, with a mean follow-up period of 44.3 ± 25.5 months. Of these studies, 15 (420 elbows) reported on open OD, 14 (456 elbows) reported arthroscopic OD, and 1 reported on a cohort of each approach (open in 5 elbows and arthroscopic in 6). The Mayo Elbow Performance Score improved by 28.6 ± 4.57 in the open group vs. 26.6 ± 7.24 in the arthroscopic group. Flexion improved by 19° ± 6° in the open group and 10° ± 6° in the arthroscopic group. Extension improved by 11° ± 5° in the open group and 11° ± 6° in the arthroscopic group. CONCLUSIONS: Open OD and arthroscopic OD are effective surgical treatment options for patients with symptomatic PEOA, reliably improving flexion, extension, and functional outcome scores with low complication rates.

The Relationship Between Humeral Torsion and Arm Injury in Baseball Players: A Systematic Review and Meta-analysis.

CONTEXT: Humeral torsion (HT) has been linked to various injuries and benefits. However, the exact interplay between HT, shoulder range of motion (ROM), competition level differences, and injury risk is unclear. OBJECTIVE: To determine the relationship between HT, ROM, and injury risk in baseball players. Secondarily, to determine HT based on competition level. DATA SOURCES: PubMed, Embase, Web of Science, CINAHL, and Cochrane databases were searched from inception until November 4, 2018. STUDY SELECTION: Inclusion criteria consisted of (1) HT measurements and (2) arm injury or shoulder ROM. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 3. DATA EXTRACTION: Two reviewers recorded patient demographics, competition level, HT, shoulder ROM, and injury data. RESULTS: A total of 32 studies were included. There was no difference between baseball players with shoulder and elbow injuries and noninjured players (side-to-side HT difference: mean difference [MD], 1.75 [95% CI, -1.83 to 2.18]; dominant arm: MD, 0.17 [95% CI, -1.83 to 2.18]). Meta-regression determined that for every 1° increase in shoulder internal rotation (IR), there was a subsequent increase of 0.65° in HT (95% CI, 0.28 to 1.02). HT did not explain external rotation (ER ROM: 0.19 [95% CI, -0.24 to 0.61]) or horizontal adduction (HA ROM: 0.18 [95% CI, -0.46 to 0.82]). There were no differences between HT at the high school, college, or professional levels. CONCLUSION: No relationship was found between HT and injury risk. However, HT explained 65% of IR ROM but did not explain ER ROM or HA ROM. There were no differences in HT pertaining to competition level. The majority of IR may be nonmodifiable. Treatment to restore and maintain clinical IR may be important, especially in players with naturally greater torsion. HT adaptation may occur prior to high school, which can assist in decisions regarding adolescent baseball participation.

Assessing Quality of Surgical Real-World Data from an Automated Electronic Health Record Pipeline.

BACKGROUND: Significant analysis errors can be caused by nonvalidated data quality of electronic health records data. To determine surgical data fitness, a framework of foundational and study-specific data analyses was adapted and assessed using conformance, completeness, and plausibility analyses. STUDY DESIGN: Electronic health records-derived data from a cohort of 241,695 patients undergoing 412,182 procedures from October 1, 2014 to August 31, 2018 at 3 hospital sites was evaluated. Data quality analyses tested CPT codes, medication administrations, vital signs, provider notes, labs, orders, diagnosis codes, medication lists, and encounters. RESULTS: Foundational checks showed that all encounters had procedures within the inclusion period, all admission dates occurred before discharge dates, and race was missing for 1% of patients. All procedures had associated CPT codes, 69% had recorded blood pressure, pulse, temperature, respiration rate, and oxygen saturation. After curation, all medication matched RxNorm medication naming standards, 84% of procedures had current outpatient medication lists, and 15% of procedures had missing procedure notes. Study-specific checks temporally validated CPT codes, intraoperative medication doses were in conventional units, and of the 13,500 patients who received blood pressure medication intraoperatively, 93% had a systolic blood pressure >140 mmHg. All procedure notes were completed within less than 30 days of the procedure and 93% of patients after total knee arthroplasty had postoperative physical therapy notes. All patients with postoperative troponin-T lab values ≥0.10 ng/mL had more than 1 ECG with relevant diagnoses. Postoperative opioid prescription decreased by 8.8% and nonopioid use increased by 8.8%. CONCLUSIONS: High levels of conformance, completeness, and clinical plausability demonstrate higher quality of real-world data fitness and low levels demonstrate less-fit-for-use data.

The clinical and radiographic impact of center of rotation lateralization in reverse shoulder arthroplasty: a systematic review.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has been widely adopted in the United States since its approval by the United States Food and Drug Administration in 2003. Advancements in metallurgy and design (including locking screws) have yielded clinically successful prostheses with a lateralized center of rotation (COR). This systematic review compared postsurgical outcomes and failure rates for lateral vs. medial COR RSA. We hypothesized that progressive lateralization of the COR results in greater ROM, improved clinical outcome scores, fewer acromial stress fractures, and less notching but a higher rate of glenoid implant baseplate failure and dislocation. METHODS: PubMed, Embase, Web of Science, CINAHL, and Cochrane databases were searched from inception through June 7, 2017, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eighteen articles were included after final review. Studies were stratified on whether a prosthesis with a lateral or medial COR was used. Comparisons included shoulder range of motion (ROM), functional outcome scores, and reported complications. RESULTS: RSA demonstrated significant improvements in outcome scores postsurgery regardless of prosthesis type. Overall, this study found no clear difference in outcome scores between the lateralized and medialized COR groups. The lateralized COR group displayed increased postoperative ROM. There was a higher reported incidence of scapular notching with medial COR prostheses. Otherwise, there were no clear differences in complications between the 2 groups. DISCUSSION: The data suggest no significant differences exist between groups in outcome scores. The lateralized COR prosthesis showed increased postoperative external rotation and decreased scapular notching. Additional well-constructed randomized controlled trials would allow more effective comparison of these prosthesis designs.

The Value of MRI in Distinguishing Subtypes of Lipomatous Extremity Tumors Needs Reassessment in the Era of MDM2 and CDK4 Testing.

INTRODUCTION: Extremity lipomas and well-differentiated liposarcomas (WDLs) are difficult to distinguish on MR imaging. We sought to evaluate the accuracy of MRI interpretation using MDM2 amplification, via fluorescence in-situ hybridization (FISH), as the gold standard for pathologic diagnosis. Furthermore, we aimed to investigate the utility of a diagnostic formula proposed in the literature. METHODS: We retrospectively collected 49 patients with lipomas or WDLs utilizing MDM2 for pathologic diagnosis. Four expert readers interpreted each patient's MRI independently and provided a diagnosis. Additionally, a formula based on imaging characteristics (i.e. tumor depth, diameter, presence of septa, and internal cystic change) was used to predict the pathologic diagnosis. The accuracy and reliability of imaging-based diagnoses were then analyzed in comparison to the MDM2 pathologic diagnoses. RESULTS: The accuracy of MRI readers was 73.5% (95% CI 61-86%) with substantial interobserver agreement (κ=0.7022). The formula had an accuracy of 71%, which was not significantly different from the readers (p=0.71). The formula and expert observers had similar sensitivity (83% versus 83%) and specificity (64.5% versus 67.7%; p=0.659) for detecting WDLs. CONCLUSION: The accuracy of both our readers and the formula suggests that MRI remains unreliable for distinguishing between lipoma and WDLs.

Long-term Benefit of PD-L1 Blockade in Lung Cancer Associated with JAK3 Activation.

PD-1 immune checkpoint blockade occasionally results in durable clinical responses in advanced metastatic cancers. However, mechanism-based predictors of response to this immunotherapy remain incompletely characterized. We performed comprehensive genomic profiling on a tumor and germline sample from a patient with refractory lung adenocarcinoma who achieved marked long-term clinical benefit from anti-PD-L1 therapy. We discovered activating somatic and germline amino acid variants in JAK3 that promoted PD-L1 induction in lung cancer cells and in the tumor immune microenvironment. These findings suggest that genomic alterations that deregulate cytokine receptor signal transduction could contribute to PD-L1 activation and engagement of the PD-1 immune checkpoint in lung cancer.