Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum two-year follow-up.

BACKGROUND: Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up. METHODS: A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, range of motion (ROM), strength, complications, re-admissions, and re-operations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up. RESULTS: A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < 0.0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different. CONCLUSION: This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with mid-term follow-up.

Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update.

BACKGROUND: Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. METHODS: A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. RESULTS: A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. CONCLUSIONS: There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.

Superior humeral head osteophytes are associated with rotator cuff insufficiency in glenohumeral osteoarthritis: a retrospective analysis.

PURPOSE: The primary goal of this study was to investigate whether superior humeral head osteophyte (SHO) size is associated with rotator cuff insufficiency, including rotator cuff tear (RCT), supraspinatus tendon thickness, and fatty infiltration of the rotator cuff muscles. METHODS: Patients ≥ 18 years who were diagnosed with glenohumeral osteoarthritis were retrospectively reviewed. SHO size was determined by radiograph. MRI measured SHO and RCT presence, type, and size; supraspinatus tendon thickness; and fatty infiltration of rotator cuff musculature. RESULTS: A total of 461 patients were included. Mean SHO size was 1.93 mm on radiographs and 2.13 mm on MRI. Risk ratio for a RCT was 1.14. For each 1-mm increase in SHO size on radiograph, supraspinatus tendon thickness decreased by 0.20 mm. SHO presence was associated with moderate-to-severe fatty infiltration of the supraspinatus with a risk ratio of 3.16. CONCLUSION: SHOs were not associated with RCT but were associated with higher risk of supraspinatus FI and decreased tendon thickness, which could indicate rotator cuff insufficiency. LEVEL OF EVIDENCE: IV.

Body Habitus Impact on Success of Cryoneurolysis for Postoperative Total Knee Arthroplasty Pain Control: A Retrospective Cohort Study.

Background: Cryoneurolysis utilizes temperatures below -20°C for nonpermanent analgesia to control pain in total knee arthroplasty (TKA). There is concern that body habitus could limit pain control because of accuracy of cryoneurolysis to subcutaneous nerves. This study aimed to determine the relationship between body habitus and effectiveness of cryoneurolysis on postoperative pain control. Methods: A retrospective chart review was performed on patients undergoing cryoneurolysis before primary TKA from 2017 to 2019. Included were 114 patients (58 control group and 56 treatment group). Cryoneurolysis patients were divided into 3 groups (small, medium, and large) based on the soft tissue to femoral diaphysis ratio of 7 cm proximal to superior pole of the patella. Postoperative outcome measures were morphine equivalents, numerical rating score for pain, range of motion, and Knee Injury and Osteoarthritis Outcome Score Joint Replacement. Results: The small cryoneurolysis group showed decreased opioid consumption at the 2, 6, and 12 weeks compared with control group, with morphine equivalents significantly decreased at 2 weeks for small compared with medium groups (54.3 vs 142.9, P = .0097). Numerical rating score for pain decreased significantly between small and medium groups (3.4 vs 4.0, P = .012) and between medium and large groups (4.0 vs 2.4, P = .012). Range of motion increased at 12 weeks for small group compared with medium group (118 vs 112, P = .042). There were no differences in any outcome measure between small and large groups. Conclusions: Body habitus does not appear to affect efficacy of cryoneurolysis in controlling postoperative pain following TKA. Cryoneurolysis remains a useful tool for multimodal pain management.

Emerging Technologies in Shoulder Arthroplasty: Navigation, Mixed Reality, and Preoperative Planning.

Shoulder arthroplasty is a rapidly improving and utilized management for end-stage arthritis that is associated with improved functional outcomes, pain relief, and long-term implant survival. Accurate placement of the glenoid and humeral components is critical for improved outcomes. Traditionally, preoperative planning was limited to radiographs and 2-dimensional computed tomography (CT); however, 3-dimensional CT is becoming more commonly utilized and necessary to understand complex glenoid and humeral deformities. To further increase accurate component placement, intraoperative assistive devices-patient-specific instrumentation, navigation, and mixed reality-minimize malpositioning, increase surgeon accuracy, and maximize fixation. These intraoperative technologies likely represent the future of shoulder arthroplasty.

Clinical and radiographic outcomes of hybrid glenoid fixation with a central porous titanium post: analysis of 713 consecutive shoulders.

BACKGROUND: Hybrid glenoid component fixation represents an emerging technology in total shoulder arthroplasty (TSA) design. However, there is a paucity of larger-scale studies reporting the outcomes following implantation of these components. This study aimed to determine the outcomes following primary TSA using hybrid glenoid component fixation with a central porous titanium post. METHODS: A retrospective review of 2 institutional databases identified patients aged ≥ 18 years who underwent primary elective hybrid TSA between 2009 and 2018 with a minimum of 2 years of follow-up. Outcomes evaluated included the visual analog scale pain score, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and implant survivorship free from reoperation or revision. Postoperative imaging was assessed for glenoid radiolucent lines and evidence of aseptic glenoid component loosening (AGL). RESULTS: A total of 713 shoulders in 666 patients with a mean age of 61 ± 6 years were included in the study at a mean follow-up period of 4.3 years (range, 2.0-9.1 years); male shoulders comprised 50.9% of shoulders. Notable clinical improvements were observed with respect to the visual analog scale pain score (7.0 to 1.4, P < .001), active forward elevation (91° to 155°, P < .001), active external rotation (21° to 50°, P < .001), and the ASES score (38.6 to 82.7, P < .001), with all exceeding the substantial clinical benefit threshold for TSA. The active internal rotation score also showed significant improvement (3.1 to 5.7, P < .001). Glenoid radiolucent lines were identified in 57 TSAs (8.2%), with 1 radiographically loose glenoid component (0.1%). There were 54 complications (7.6%), with postoperative rotator cuff tear as the most common complication (n = 15, 2.1%); only 4 cases (0.6%) of glenoid-related complications (AGL) were observed. The Kaplan-Meier rate of survival free from revision surgery was 98.7% at 1 year, 98.5% at 2 years, and 96.7% at 5 years. CONCLUSIONS: Hybrid glenoid component fixation of anatomic TSA with a central porous titanium post demonstrated statistically significant and clinically meaningful improvements in pain, range of motion, and ASES scores. Although AGL remains a concern, only 0.6% of TSAs sustained glenoid-related complications at a mean follow-up period of 4.3 years and the rate of survivorship free from revision was 96.7% at 5 years. These favorable clinical findings support the theoretical advantages of hybrid glenoid fixation; however, large comparative investigations with long-term follow-up are needed to validate these results.

Harris Heel View is Inadequate to Visualize Screw Prominence of the Medial Calcaneus: A Case Report and Cadaveric Evaluation.

CASE: A 58-year-old man sustained multiple right foot injuries during a motor vehicle accident that included a calcaneus fracture requiring open reduction and internal fixation (ORIF). The procedure was complicated by a prominent implant inferior to the sustentaculum, which necessitated a return to the operating room. Commonly used fluoroscopic views do not adequately image this area. A cadaveric study was undertaken to identify the optimal 2-dimensional fluoroscopic view that evaluates prominent implants at the medial calcaneus. CONCLUSION: The sustentaculum tunnel view gives a reliable image of prominent medial implants, and use of this technique may limit complications after calcaneus ORIF.

Amplifying Riboswitch Signal Output Using Cellular Wiring.

If fieldable riboswitch-based biological sensors are to fulfill their potential, it is necessary to increase their signal output. Here we report a novel modular amplification system using a riboswitch to initiate signaling between a sensing strain and a reporter strain of E. coli. A quorum sensing signaling molecule biologically wires the sensing and reporter strains together. The amplification circuit increased the amount of fluorescence generated on ligand binding compared to when the riboswitch controlled fluorescence expression directly. This had the corollary effect of increasing the sensitivity of the system, and allowed riboswitch-based reporting in E. coli strains that did not produce a detectable output when the riboswitch directly controlled reporter expression. The amplification circuit also reduced the time required to detect a signal output. The modularity of this amplification system coupled with the achievable increases in output can advance the development of riboswitches and biological sensors.

Cathepsin K-targeted sub-micron particles for regenerative repair of vascular elastic matrix.

Abdominal Aortic Aneurysms (AAA) involve slow dilation and weakening of the aortic wall due to breakdown of structural matrix components, such as elastic fibers by chronically overexpressed matrix metalloproteinases (MMPs), primarily, MMPs-2 and -9. Auto-regenerative repair of disrupted elastic fibers by smooth muscle cells (SMCs) at the AAA site is intrinsically poor and together with chronic proteolysis prevents restoration of elastin homeostasis, necessary to enable AAA growth arrest or regression to a healthy state. Oral doxycycline (DOX) therapy can inhibit MMPs to slow AAA growth, but has systemwide side-effects and inhibits new elastin deposition within AAA tissue, diminishing prospects for restoring elastin homeostasis preventing the arrest/regression of AAA growth. We have thus developed cationic amphiphile (DMAB)-modified submicron particles (SMPs) that uniquely exhibit pro-elastogenic and anti-proteolytic properties, separate from similar effects of the encapsulated drug. These SMPs can enable sustained, low dose DOX delivery within AAA tissue to augment elastin regenerative repair. To provide greater specificity of SMP targeting, we have conjugated the DOX-SMP surface with an antibody against cathepsin K, a lysosomal protease that is highly overexpressed within AAA tissue. We have determined conditions for efficient cathepsin K Ab conjugation onto the SMPs, improved SMP binding to aneurysmal SMCs in culture and to injured vessel walls ex vivo, conjugation did not affect DOX release from the SMPs, and improved pro-elastogenic and anti-proteolytic effects due to the SMPs likely due to their increased proximity to cells via binding. Our study results suggest that cathepsin K Ab conjugation is a useful targeting modality for our pro-regenerative SMPs. Future studies will investigate SMP retention and biodistribution following targeting to induced AAAs in rat models through intravenous or catheter-based aortal infusion and thereafter their efficacy for regenerative elastic matrix repair in the AAA wall. STATEMENT OF SIGNIFICANCE: Proactive screening of high risk elderly patients now enables early detection of Abdominal Aortic Aneurysms (AAAs). Current management of small, growing AAAs is limited to passive, imaging based growth monitoring. There are also no established drug-based therapeutic alternatives to surgery for AAAs, which is unsuitable for many elderly patients, and none which can achieve restore disrupted and lost elastic matrix in the AAA wall, which is essential to achieve growth arrest or regression. We seek to test the feasibility of a regenerative therapy based on localized, one time delivery of drug-releasing Sub-Micron-sized drug delivery polymer Particles (SMPs) that are also uniquely chemically functionalized on their surface to also provide them pro-elastin-regenerative & anti-matrix degradative properties, and also conjugated with antibodies targeting cathepsin K, an elastolytic enzyme that is highly overexpressed in AAA tissues; the latter serves as a modality to enable targeted binding of the SMPs to the AAA wall following intravenous infusion, or intraoartal, catheter-based delivery. Such SMPs can potentially stimulate structural repair in the AAA wall following one time infusion to delay or prevent AAA growth to rupture. The therapy can provide a non-surgical treatment option for high risk AAA patients.