Reaching Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient-Acceptable Symptomatic State for Patient-Reported Outcome Measures following Arthroscopic Rotator Cuff Repair Does Not Correlate with Patient Satisfaction.

Purpose: Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) serve as metrics to gauge orthopedic treatment efficacy based on anchoring questions that do not account for a patient's satisfaction with their surgical outcome. This study evaluates if reaching MCID, SCB, or PASS values for American Shoulder and Elbow Surgeons score (ASES), Single Alpha Numeric Evaluation (SANE), Simple Shoulder Test (SST), and Visual Analog Score (VAS) for pain following arthroscopic rotator cuff repair (RCR) correlates with overall patient satisfaction. Methods: This was a single-institution, retrospective study of patients who underwent RCR from 2015 to 2019. Pre-operative and 2 year postoperative ASES, SANE, SST, and VAS scores were recorded. Patients underwent a survey to assess: (1) what is your overall satisfaction with your surgical outcome? (scale 1 to 10); (2) if you could go back in time, would you undergo this operation again? (yes/no); (3) for the same condition, would you recommend this operation to a friend or family member? (yes/no). Spearman correlation coefficients were run to assess relationship between reaching MCID, SCB, or PASS and satisfaction. Results: Ninety-two patients were included. Mean preoperative ASES was 51.1 ± 16.9, SANE was 43.3 ± 20.9, SST was 5.4 ± 2.9, and VAS was 4.6 ± 2.1. Mean 2 year ASES was 83.9 ± 18.5, SANE was 81.7 ± 27.0, SST was 9.8 ± 3.2, and VAS was 1.4 ± 1.9. Mean patient satisfaction was 9.0 ± 1.9; 89 (96.7%) patients would undergo surgery again and recommend surgery. Correlation for reaching PASS for SANE and satisfaction was moderate. Correlation coefficients were very weak for all other outcome metrics. Conclusions: Reaching MCID, SCB, and PASS in ASES, SANE, SST, or VAS following RCR did not correlate with a patient's overall satisfaction or willingness to undergo surgery again or recommend surgery. Further investigation into the statistical credibility and overall clinical value of MCID, SCB, and PASS is necessary.

Type I interferon blockade with anifrolumab in patients with systemic lupus erythematosus modulates key immunopathological pathways in a gene expression and proteomic analysis of two phase 3 trials.

INTRODUCTION: Anifrolumab is a type I interferon (IFN) receptor 1 (IFNAR1) blocking antibody approved for treating patients with systemic lupus erythematosus (SLE). Here, we investigated the immunomodulatory mechanisms of anifrolumab using longitudinal transcriptomic and proteomic analyses of the 52-week, randomised, phase 3 TULIP-1 and TULIP-2 trials. METHODS: Patients with moderate to severe SLE were enrolled in TULIP-1 and TULIP-2 and received intravenous anifrolumab or placebo alongside standard therapy. Whole-blood expression of 18 017 genes using genome-wide RNA sequencing (RNA-seq) (pooled TULIP; anifrolumab, n=244; placebo, n=258) and 184 plasma proteins using Olink and Simoa panels (TULIP-1; anifrolumab, n=124; placebo, n=132) were analysed. We compared treatment groups via gene set enrichment analysis using MetaBase pathway analysis, blood transcriptome modules, in silico deconvolution of RNA-seq and longitudinal linear mixed effect models for gene counts and protein levels. RESULTS: Compared with placebo, anifrolumab modulated >2000 genes by week 24, with overlapping results at week 52, and 41 proteins by week 52. IFNAR1 blockade with anifrolumab downregulated multiple type I and II IFN-induced gene modules/pathways and type III IFN-λ protein levels, and impacted apoptosis-associated and neutrophil extracellular traps-(NET)osis-associated transcriptional pathways, innate cell activating chemokines and receptors, proinflammatory cytokines and B-cell activating cytokines. In silico deconvolution of RNA-seq data indicated an increase from baseline of mucosal-associated invariant and γδT cells and a decrease of monocytes following anifrolumab treatment. DISCUSSION: Type I IFN blockade with anifrolumab modulated multiple inflammatory pathways downstream of type I IFN signalling, including apoptotic, innate and adaptive mechanisms that play key roles in SLE immunopathogenesis.

Clinical and radiographic outcomes of shoulder hemiarthroplasty for patients with glenoid medialization.

BACKGROUND: Glenoid bone loss in shoulder arthroplasty is a difficult problem that is prone to complications because of challenges with achieving glenoid component fixation and stability. The purpose of this study was to evaluate the outcomes of primary shoulder hemiarthroplasty for patients with severe glenoid medialization precluding placement of a glenoid component. METHODS: This was a retrospective case series evaluating patients who underwent shoulder hemiarthroplasty for severe glenoid erosion and medialization between 2010 and 2020. Patients were evaluated via chart review and phone survey to determine if there were any reoperations at final follow-up and to obtain Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Simple Shoulder Test (SST) scores. Preoperative and postoperative radiographs were evaluated and compared to determine glenoid morphology, version, medialization, acromiohumeral distance, and humeral offset. Final postoperative films were also evaluated for anterosuperior migration and signs of mechanical failure, including loosening or periprosthetic fracture. RESULTS: Overall, there were 28 patients during this period who underwent shoulder hemiarthroplasty for severe glenoid medialization. Eight patients were deceased at the time of the study, 2 were unable to complete surveys because of dementia, and 7 were lost to follow-up. The final cohort included 11 shoulders and 11 patients with a mean age of 71 ± 7.1 years and mean follow-up of 6.7 years (range 1.6-13.0 years). Mean postoperative SANE, ASES, and SST scores were 80.6 ± 17.6, 71.5 ± 29.3, and 7.6 ± 2.0, respectively. There were no reoperations or revision surgeries at final follow-up. Radiographic evaluation demonstrated severe glenoid medialization and decreased lateral humeral offset, which was unchanged postoperatively. There were 2 patients with signs of anterosuperior migration at final radiographic follow-up but no signs of implant failure. CONCLUSION: Shoulder hemiarthroplasty for severe medial glenoid bone loss provides modest clinical outcomes and low rates of reoperation at mid- to long-term follow-up and is an option worth considering in cases where placement of a glenoid component is challenging because of deficient bone stock and high risk for complications.

Humeral stem loosening is not always prosthetic joint infection.

BACKGROUND: Aseptic humeral stem loosening is an uncommon complication of shoulder arthroplasty, and its presence has been considered a highly specific predictor of prosthetic joint infection (PJI). Literature on aseptic humeral stem loosening is sparse. The primary purpose of this study was to determine the rate of aseptic humeral loosening in revision shoulder arthroplasty. Secondarily, we sought to identify predictors of septic and aseptic humeral loosening. METHODS: Our institutional revision shoulder arthroplasty database was reviewed. Inclusion criteria were patients with humeral stem loosening as indicated in the operative report. Patient demographics, index surgery and indication, revision surgery and indication, and operative data were recorded. Charts were manually reviewed, and PJI scores were calculated using the International Consensus Meeting scoring criteria. International Consensus Meeting classifications of PJI "unlikely" and "possible" were considered aseptic, and PJI "probable" and "definite" were considered septic. Statistical analysis was performed to determine associations between the abovementioned variables and aseptic humeral loosening. RESULTS: Forty-six patients with 48 shoulders were included in our analysis. Ten cases (21%) were classified as definite PJI, 13 cases (27%) were classified as probable PJI, 4 cases (8%) were classified as possible PJI, and 21 cases (44%) were classified as PJI unlikely. On analysis of stem design, there were no statistically significant associations with aseptic loosening; although, a lack of proximal porous ingrowth surface trended toward higher rates of aseptic loosening in all patients and in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) subgroup analyses. In the index RTSA subgroup, aseptic loosening was associated with female sex (P = .005). Seventeen of 39 shoulders (44%) that underwent either index ATSA or RTSA demonstrated concomitant glenoid loosening. The absence of glenoid loosening was associated with aseptic humeral loosening in index ATSA and RTSA (P < .001). CONCLUSION: Fifty-two % of revision shoulder arthroplasty cases with humeral loosening performed at our institution were aseptic. There appear to be distinct demographic and radiographic factors that are more commonly associated with aseptic as opposed to septic humeral loosening. Our data demonstrate that demographic predictors of aseptic loosening of RTSA include female sex. The absence of glenoid component loosening is associated with aseptic humeral loosening and concomitant glenoid loosening is associated with septic humeral loosening. Understanding of these factors can guide the preoperative index of suspicion for PJI in the setting of humeral stem loosening.

Management of proximal humerus bone loss with allograft prosthetic composite technique in shoulder arthroplasty.

BACKGROUND: Proximal humerus bone loss in shoulder arthroplasty is a difficult problem with limited treatment options. It most commonly occurs in the setting of a previously failed shoulder arthroplasty; however, it is occasionally encountered in cases of primary shoulder arthroplasty. Reconstruction of the proximal humerus is essential for soft tissue tension for implant stability and maximizing function. The purpose of this study was to analyze the clinical and functional outcomes of the allograft prosthetic composite (APC) technique for the management of proximal humeral bone loss in shoulder arthroplasty. METHODS: A retrospective review was performed of all patients who underwent primary or revision shoulder arthroplasty using an APC technique with a reverse shoulder arthroplasty prosthesis for the management of proximal humerus bone loss. Data collected included demographic variables, previous shoulder surgeries, indication for APC, type of allograft utilized, fixation technique, and reoperation and revision rates. Patients were contacted by phone and/or email survey to obtain the latest patient-reported functional outcome scores. RESULTS: We identified 14 patients who underwent shoulder arthroplasty using the APC technique with a reverse shoulder arthroplasty prosthesis. One (7.1%) was performed as a primary arthroplasty, and 13 (92.9%) were performed as revision arthroplasties. The indications for APC were instability (21.4%), periprosthetic fracture (21.4%), periprosthetic joint infection (14.3%), humeral component loosening (14.3%), rotator cuff failure (14.3%), fracture sequelae (7.1%), and failed hemiarthroplasty (7.1%). In terms of allograft type, 10 (71.4%) were performed with proximal femur allograft and 4 (28.6%) with proximal humerus allograft. There were 6 patients (42.9%) who sustained postoperative complications, 5 patients (35.7%) had instability, and 1 (7.1%) patient had postoperative wound drainage. All patients with a complication required a revision arthroplasty. CONCLUSION: The APC technique used to address proximal humerus bone loss in shoulder arthroplasty has a high complication rate with fair patient-reported functional outcome scores. Most of the postoperative complications and reoperations are related to implant instability.

Arthroscopic Transosseous Rotator Cuff Repair.

Open transosseous rotator cuff repair (RCR) was the original benchmark surgical technique for RCR. The advent of arthroscopic and suture anchor technology shifted the paradigm from open to arthroscopic surgery. Although technological advances have progressed, they come at a cost. Suture anchor technology is expensive, optimal constructs have yet to be determined, and the technology may lead to challenging complications and revision scenarios. In more recent years, a return to transosseous bone tunnels has been described with new arthroscopic techniques, eliminating the need for suture anchors. The purpose of this article is to review the historical, biomechanical, clinical, and economic literature surrounding arthroscopic transosseous RCR.

Work-related outcomes of revision rotator cuff repair for patients receiving workers' compensation.

BACKGROUND: Workers' compensation (WC) patients are susceptible to poorer outcomes following primary rotator cuff repair (RCR). Failure of structural healing can explain some poor results, and outcomes of revision RCR in this population are unknown. METHODS: A retrospective review was performed of individuals receiving WC who underwent arthroscopic revision RCR with or without dermal allograft augmentation at a single institution between January 2010 and April 2021. Preoperative magnetic resonance imaging (MRI) scans were assessed for rotator cuff tear characteristics, Sugaya classification, and Goutallier grade. Postoperative imaging was not routinely obtained unless for continued symptoms or reinjury. Primary outcome measures included return-to-work status, reoperation, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) scores. RESULTS: Twenty-seven shoulders (25 patients) were included. The population was 84% male, with a mean age of 54 years; 67% were manual laborers, 11% sedentary workers, and 22% with a mixed profession. Average follow-up was 35.4 months. Fifteen patients (56%) returned to work at full-duty status. Six (22%) returned to work with permanent restrictions. Six (22%) were unable to return to work in any capacity. Thirty percent of all patients and 35% of manual laborers changed occupation following revision RCR. Mean time to return to work was 6.7 months. Overall, symptomatic rotator cuff retear was found in 13 patients (48%). Reoperation rate after revision RCR was 37% (10 cases). Among patients who did not undergo reoperation, mean ASES scores improved from 37.8 to 69.4 at final follow-up (P < .001). Mean SANE scores only improved marginally from 51.6 to 57.0 (P = .61). No statistically significant correlation was found between preoperative MRI findings and outcome measures. CONCLUSION: Workers' compensation patients demonstrated fair improvements in outcome scores after revision RCR. Although some patients are able to return to full duty, nearly half were either unable to return or returned with permanent restrictions. These data are helpful for surgeons when counseling patients about expectations and return to work after revision RCR in this challenging population.

The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: an anonymized, randomized controlled trial.

BACKGROUND: Tranexamic acid (TXA) has been used surgically to decrease blood loss. The ability of TXA to improve arthroscopic visualization and allow for reduction in pump pressure is unknown. The purpose of this study was to determine the effect of intravenous (IV) TXA on change in pump pressure and visualization during arthroscopic rotator cuff repair. METHODS: This was a single-center, prospective, randomized, double-anonymized controlled trial. Patients with full-thickness rotator cuff tears undergoing operative repair were enrolled. Patients were randomized to receive 1 g of IV TXA preoperatively or no TXA (control group). All patients underwent arthroscopy using saline irrigation fluid with 3 mL epinephrine injected into the first 1000-mL saline bag. Total operative time, final pump pressure, number of increases in pump pressure, total amount of irrigation fluid used, blood pressure and anesthesia medical interventions for blood pressure were recorded. Visualization was measured by a visual analog scale (VAS) completed by the surgeon at the end of the case. Postoperative VAS pain scores were obtained 24 hours after surgery. The primary aim of this study was to investigate the effect that IV TXA has on change in pump pressure (ΔP) during shoulder arthroscopy, with a ΔP of 15 mm Hg set as a threshold for clinical significance. RESULTS: There were 50 patients randomized to the TXA group and 50 patients in the no TXA group. No significant differences were found between the TXA group and the control group regarding any measure of pump pressure, including the final arthroscopic fluid pump pressure (44.5 ± 8.1 mm Hg vs. 42.0 ± 8.08 mm Hg, P = .127), the mean ΔP (20.9 ± 10.5 mm Hg vs. 21.8 ± 8.5 mm Hg, P = .845), or the number of times a change in pump pressure was required (1.7 ± 0.9 vs. 1.7 ± 0.8, P = .915). Overall arthroscopic visualization was not significantly different between the TXA group and the control group (7.2 ± 1.8 vs. 7.4 ± 1.6, P = .464). No significant difference existed between the TXA and control groups regarding postoperative pain scores assessed by VAS pain scale (4.1 ± 2.0 vs. 4.3 ± 1.9, P = .519) at 24 hours after surgery. CONCLUSION: The use of IV TXA demonstrated no measurable improvement in surgeon ability to maintain a lower pump pressure during arthroscopic rotator cuff repair. Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores.

Outcomes Following Different Fixation Strategies of Neer Type IIB Distal Clavicle Fractures.

Background: Multiple surgical techniques for fixation of Neer type IIB distal clavicle fractures have been described without consensus on optimal treatment. The purpose of this study is to compare functional and radiographic results with surgical management of Neer type IIB distal clavicle fractures at a single institution. Methods: Sixty-three patients with acute Neer type IIB fractures treated operatively were evaluated. Patients with a minimum of two year follow up were included. Functional scores included American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), and Likert patient satisfaction (1 to 5). Radiographs were assessed for osseous union and coracoclavicular (CC) distance. Results: Thirty-eight patients met inclusion with a mean follow-up of 5.3 years. Patients were divided into five groups based on fixation technique: suture-only CC fixation (n=6), CC screw fixation only (n=3), open reduction internal fixation (ORIF) without CC fixation (n=8), hook plate fixation (n=4), and ORIF with suture CC reconstruction (n=17). Outcome scores for the entire cohort were 91.8 for ASES, 90.2 for SANE, and 10.8 for STT. Patients with hook plates had significantly lower SANE score (p=0.016), but no other significant differences in functional, satisfaction, or radiographic outcomes were found between groups. Sixteen patients (42.1%) required reoperation. Conclusion: Treatment of Neer type IIB fractures via suture- only fixation, plate-only fixation, or a combination of both demonstrated satisfactory mid to long term outcomes. While implant removal was more common in the CC screw and ORIF groups, no fixation technique proved functionally superior.

Fixed- vs. variable-angle humeral neck cut in anatomic total shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Variable neck-shaft angle (NSA) stemmed humeral components have been incorporated into certain implant designs to better re-create normal anatomy in total shoulder arthroplasty (TSA). The purpose of this study was to determine if premorbid glenohumeral joint anatomy is better restored with a fixed- vs. variable-NSA prosthesis. METHODS: A randomized controlled trial was performed including 50 patients with osteoarthritis indicated for primary anatomic TSA. Patients were randomized preoperatively to receive either a variable- (n = 26) or fixed-NSA (n = 24) prosthesis. Humeral neck cut in the variable-NSA group matched the patient's anatomic neck, with prosthetic NSA of 127.5°, 132.5°, and 137.5° available. Fixed-NSA cuts were made with an intramedullary guide of 132.5°. Preoperative and postoperative radiographs were evaluated for specific radiographic anatomic variables: NSA, head thickness, tuberosity-to-head height, head offset, articular arc, greater tuberosity offset, and center of rotation (COR). Postoperative radiographic criteria were compared between groups. RESULTS: No differences were found between groups in demographics or preoperative radiographic measures. When comparing average difference in preoperative and postoperative measurements in the fixed-NSA group, the humeral head offset from the humeral shaft axis significantly decreased by 1.4 mm (P = .046), and the COR moved superiorly (3.0 mm, P = .002) without significant medialization or lateralization. In the variable angle group, humeral head offset decreased but did not reach significance (1.2 mm, P = .091), and the COR also moved superiorly (2.9 mm, P < .001) without significant medialization or lateralization. All remaining radiographic parameters did not significantly change from pre- to postoperative imaging. In comparing the fixed- and variable-NSA groups' net change from the premorbid measurements, no significant differences were found in tuberosity-to-head height, head offset, or COR position in both the horizontal and vertical planes. CONCLUSIONS: Both fixed- and variable-NSA anatomic TSA humeral components demonstrate adequate restoration of premorbid anatomy radiographically.

Preoperative Single Assessment Numeric Evaluation Score Predicts Poor Outcomes After Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears Without Arthritis.

Limited clinical evidence is available to help to predict poor outcomes after reverse shoulder arthroplasty (RSA) among patients with massive rotator cuff tears without glenohumeral arthritis. A retrospective case-control study was performed for patients who underwent RSA for massive rotator cuff tear without glenohumeral arthritis (Hamada score ≤3) and had a minimum of 2 years of follow-up. Preoperative risk factors for poor outcomes were subsequently analyzed. Sixty patients (mean age, 71.4±7.4 years) met the inclusion criteria. Of these, 18 (30%) patients had poor outcomes (case group). The case group had significantly worse postoperative Single Assessment Numeric Evaluation (SANE) (61.6±29.5 vs 84.9±14.1, respectively; P=.002), American Shoulder and Elbow Surgeons (58.9±22.5 vs 82.2±14.2, respectively; P<.001), and Simple Shoulder Test (5.4±3.6 vs 8.5±2.4, respectively; P=.002) scores compared with the control group. Patients with poor outcomes had significantly higher preoperative SANE scores compared with control subjects (40.4±28.4 vs 18.8±15.7, respectively; P=.021). The results of this study suggest that patients with better overall preoperative function, as represented by higher SANE scores, have a greater likelihood of poor functional outcomes after RSA for massive rotator cuff tears without glenohumeral arthritis. For these patients, alternative treatment options should be considered. [Orthopedics. 2022;45(4):215-220.].

Outcomes of instability after reverse shoulder arthroplasty: reoperation and persistent instability are common.

HYPOTHESIS: Although risk factors for instability after reverse shoulder arthroplasty (RSA) have been extensively studied, the outcomes of patients who experience instability are unknown. The purpose of this study was to evaluate functional outcomes in patients with instability after RSA. METHODS: We retrospectively identified patients with instability after RSA with a minimum of 2 years' follow-up from an institutional database. Baseline data were recorded, and all patients we contacted to obtain clinical outcome scores. Patients who required revision surgery and those treated successfully with closed reduction were compared. RESULTS: Fifty patients were included. Of these patients, 40 (80%) required revision surgery whereas 10 (20%) were treated successfully with closed reduction. At an average follow-up of 63.7 months (range, 24-123 months), outcome scores did not differ between groups. Patients who required revision surgery were more likely to have undergone previous shoulder surgery, prior to their index arthroplasty (P = .031). Seventeen patients (42.5%) reported recurrent instability following revision surgery, and 14 (35.0%) required additional revision surgery. Ultimately, stability was never achieved in 7 of 50 patients (14%) after their index instability event. CONCLUSION: Although instability after RSA can commonly be corrected with reasonable functional results, multiple procedures may be needed and some patients may experience persistent instability.

Ambulatory shoulder arthroplasty provides a mild reduction in overall cost compared with inpatient shoulder arthroplasty cost of ambulatory shoulder arthroplasty.

HYPOTHESIS: The purpose of this study was to determine the relative cost difference of inpatient vs. ambulatory total shoulder arthroplasty (TSA) procedures. METHODS: A retrospective case series was performed to identify a consecutive series of patients who underwent primary anatomic or reverse TSA at 2 orthopedic specialty hospitals between September 2015 and August 2020. Those undergoing surgery for fracture or revision were excluded. Itemized facility costs were analyzed with a time-driven activity-based costing model and compared between ambulatory and non-ambulatory procedures. Ambulatory patients were defined as those admitted and discharged on the same calendar day. All other patients were considered non-ambulatory. RESULTS: A total of 1027 patients were analyzed, comprising 38 ambulatory patients (3.7%) and 989 non-ambulatory patients (96.3%). There was a higher proportion of anatomic TSA than reverse shoulder arthroplasty in the ambulatory group (81.6% vs. 51.7%, P < .0001). Overall, there was no difference in cost between the 2 groups ($8832 vs. $8841, P = .97). However, personnel costs were greater in the non-same-day group ($1895 vs. $2743, P < .0001) whereas supply costs were less ($6937 vs. $6097, P < .0003). When implant costs were excluded, outpatient shoulder arthroplasty provided a cost savings of $745. CONCLUSION: Ambulatory shoulder arthroplasty provides a mild cost savings of $745 after controlling for fixed costs. This is much less dramatic than previously reported and should raise concern as shoulder arthroplasty continues to be targeted by payers as a potential for cost savings through decreased reimbursement.

Shoulder Hemiarthroplasty with Nonprosthetic Glenoid Arthroplasty: The Ream-and-Run Procedure.

¼: Glenoid component wear and loosening are the principal failure modes of anatomic total shoulder arthroplasty (aTSA). ¼: The ream-and-run (RnR) procedure is an alternative glenohumeral arthroplasty for patients who wish to avoid the risks and limitations of a prosthetic glenoid component. ¼: During the RnR procedure, the arthritic glenoid is conservatively reamed to a single concavity, while the prosthetic humeral component and soft tissues are balanced to provide both mobility and stability of the joint. ¼: The success of the RnR procedure depends on careful patient selection, preoperative education and engagement, optimal surgical technique, targeted rehabilitation, and close postoperative communication between the surgeon and the patient. ¼: While the RnR procedure allows high levels of shoulder function in most patients, the recovery can be longer and more arduous than with aTSA. ¼: Patients who have undergone an RnR procedure occasionally require a second closed or open procedure to address refractory shoulder stiffness, infection, or persistent glenoid-sided pain. These second procedures are more common after the RnR than with aTSA.

Understanding Outcomes and the Ability to Return to Work After Rotator Cuff Repair in the Workers' Compensation Population.

Introduction Patients with a worker compensation claim are associated with a greater probability of continued symptoms and activity intolerance. This study aims to determine predictors of improved patient-reported outcomes in the workers' compensation population. Methods Patients with workers' compensation claims undergoing arthroscopic rotator cuff repair between 2010 and 2015 were included. Age, gender, dominant hand, occupation, and number of tendons involved were analyzed. At a minimum of two years, patients were contacted to complete American Shoulder and Elbow Surgeons (ASES) Survey, Simple Shoulder Test (SST), and return-to-work status (RTW). Preoperative characteristics and scores were then compared. Results Seventy patients were available for follow-up at an average of 5.4 years (range: 2.1-8.8 years). Average age was 55 years (range: 37-72); 55 (78.6%) were males, 23 (32.9%) were laborers; and 59 (84.2%) patients returned to work. The sole predictor for RTW was surgery on the non-dominant arm (96.5% versus 75.6%; p = 0.021). Laborers showed decreased RTW (p = 0.03). Patients who completed RTW had excellent outcomes with higher ASES (87 versus 50; p value < 0.001) and SST scores (10.4 versus 4.6; p < 0.001). Patients with three tendon tears had inferior ASES (p = 0.026) and SST (p = 0.023) scores than those with less. Conclusion Most workers' compensation patients have excellent outcomes from rotator cuff repair. Patients with three tendon tear repairs demonstrated the worst functional outcomes. Laborers showed decreased ability to RTW with nearly one-third unable.

Healing and Functional Results of Dermal Allograft Augmentation of Complex and Revision Rotator Cuff Repairs.

BACKGROUND: Primary rotator cuff repairs in complex cases (older patient age, larger tear sizes, chronic tears) and revision repairs are at high risk for failure of healing. PURPOSE: To examine clinical outcomes and healing rates in complex and revision rotator cuff repairs with dermal allograft augmentation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective study was made of cases performed by 3 fellowship-trained surgeons via a uniform technique involving rotator cuff repairs with allograft augmentation. In all cases, a 1.5-mm, human, decellularized dermal graft was tied on top of the tendon at the medial row and compressed to the rotator cuff footprint using a double-row technique. Postoperative magnetic resonance imaging (MRI) was performed at a minimum of 6 months and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and 12-Item Short Form Health Survey scores were collected at a minimum of 2 years postoperatively. RESULTS: A total of 35 patients (23 revision repairs, 12 primary complex repairs) were included. The mean patient age was 57.9 years (range, 41.0-70.5 years). All shoulders had 2-tendon tears (supraspinatus and infraspinatus), and 8 included the upper 50% of the subscapularis. At a minimum of 2 years after surgery (mean, 3.2 years), mean ASES and SANE scores improved from 42.4 and 35.3 to 77.6 and 73.5, respectively (P < .001). In the 23 patients (66%) with postoperative MRI evaluation, 11 (48%) had images showing the tendons were retorn. ASES (89.7 vs 66.4; P = .04) and SANE (84.1 vs 50.5; P = .02) scores were higher in healed patients than those with retears. The retear group had a higher degree of preoperative fatty atrophy of the infraspinatus (P = .024). CONCLUSION: Double-row arthroscopic repair with dermal allograft augmentation of complex and revision rotator cuff tears led to improved functional outcomes. Approximately half of patients experienced a failure of healing, which was associated with poorer functional results.

Is D-dimer a Reliable Serum Marker for Shoulder Periprosthetic Joint Infection?

BACKGROUND: The diagnosis of periprosthetic shoulder infection continues to be difficult to make with confidence. Serum D-dimer has proven to be effective as a screening tool for periprosthetic joint infection in other major joints; however, it has yet to be evaluated for use in periprosthetic shoulder infection. QUESTIONS/PURPOSES: (1) Is D-dimer elevated in patients with probable or definite periprosthetic shoulder infections? (2) What is the diagnostic accuracy of D-dimer for periprosthetic shoulder infections? (3) What are the diagnostic accuracies of serum tests (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and D-dimer), singly and in combination? METHODS: Between March 2016 and March 2020, 94 patients undergoing revision total shoulder arthroplasty (anatomic or reverse) at a single institution had preoperative serum testing with CRP, ESR, and D-dimer. These 94 patients were a subset of 189 revision shoulder arthroplasties performed at this institution during the study period who met inclusion criteria and consented to participate. Included patients had a mean ± SD age of 69 ± 8 years, and 56% (53 of 94) were men. Patient records were reviewed to classify patients as definitely having infection, probably having infection, possibly having infection, or unlikely to have an infection, according to the International Consensus Meeting (ICM) definition of periprosthetic shoulder infection. Statistical analyses, including a receiver operating characteristic curve analysis, were performed to quantify the diagnostic value of D-dimer for periprosthetic shoulder infection. Based on the ICM definition, 4% (4 of 94), 15% (14 of 94), 14% (13 of 94), and 67% (63 of 94) of patients had definite, probable, possible, or unlikely periprosthetic shoulder infections. RESULTS: D-dimer was elevated in patients with definite or probable infections (median [range] 661 ng/mL [150 to 8205]) compared with those with possible infections or those who were unlikely to have an infection (263 ng/mL [150 to 3060]; median difference 143 ng/mL [95% CI 40 to 503]; p = 0.01). In the receiver operating characteristic curve analysis, D-dimer had an area under the curve of 0.71 (0.50-0.92), demonstrating weak diagnostic value. A D-dimer level of 598 ng/mL provided a sensitivity and specificity of 61% (95% CI 36% to 82%) and 74% (95% CI 62% to 83%), respectively, for diagnosing a definite or probable infection according to the ICM definitions. The specificity of detecting periprosthetic joint infection (88% [95% CI 79% to 94%]) was high when three positive serum markers (ESR, CRP, and D-dimer) were required, at the expense of sensitivity (28% [95% CI 10% to 53%]). CONCLUSION: In periprosthetic shoulder infection, D-dimer is elevated. However, similar to other serum tests, it has limited diagnostic utility in identifying patients with periprosthetic shoulder infection. Further work is needed to understand the process by which D-dimer is associated with active infection. LEVEL OF EVIDENCE: Level III, diagnostic study.

Trends Related to the Treatment of Superior Labral Tears at a Single Institution.

BACKGROUND: As preferred treatment options for superior labral tears continue to evolve, this study aims to describe the recent longitudinal trends in the treatment of SLAP tears in a sub-specialized practice at a single institution. We hypothesized that there was a trend toward biceps tenodesis over repair for Type II SLAP lesions. METHODS: A retrospective review was performed using an institutional billing database to identify all patients with a SLAP tear who underwent surgical intervention between January 2002 and January 2016. Procedural codes associated with the surgery were analyzed to determine type of treatment each patient received. RESULTS: Of the 6,055 patients who underwent surgery for a SLAP tear during the study period, 39.1% (2,370) underwent labral repair, 15.4% (930) underwent tenodesis without repair, and 45.5% (2,755) underwent arthroscopy without tenodesis or repair. Labral repair made up a significantly higher proportion of surgical interventions in 2002 (82.2%) compared to in 2015 (21.8%; p <0.001). Surgeon experience did not impact trends. Over the study period, the mean age of patients receiving labral repair decreased from 40.4 years (range: 16.2 - 63.9) to 32.6 years (range: 14.0 - 64.7; p <0.001). CONCLUSION: This study demonstrates that over the 14-year study period the rate of labral repairs for SLAP tears has decreased significantly and that these repairs have been directed towards a younger patient population.

What was the Prevalence of COVID-19 in Asymptomatic Patients Undergoing Orthopaedic Surgery in One Large United States City Mid-pandemic?

BACKGROUND: Many patients with coronavirus disease 2019 (COVID-19) are asymptomatic. The prevalence of COVID-19 in orthopaedic populations will vary depending on the time and place where the sampling is performed. The idea that asymptomatic carriers play a role is generalizable but has not been studied in large populations of patients undergoing elective orthopaedic surgery. We therefore evaluated this topic in one large, metropolitan city in a state that had the ninth-most infections in the United States at the time this study was completed (June 2020). This work was based on a screening and testing protocol that required all patients to be tested for COVID-19 preoperatively. QUESTIONS/PURPOSES: (1) What is the prevalence of asymptomatic COVID-19 infection in patients planning to undergo orthopaedic surgery in one major city, in order to provide other surgeons with a framework for assessing COVID-19 rates in their healthcare system? (2) How did patients with positive test results for COVID-19 differ in terms of age, sex, and orthopaedic conditions? (3) What proportion of patients had complications treated, and how many patients had a symptomatic COVID-19 infection within 30 days of surgery (recognizing that some may have been missed and so our estimates of event rates will necessarily underestimate the frequency of this event)? METHODS: All adult patients scheduled for surgery at four facilities (two tertiary care hospitals, one orthopaedic specialty hospital, and one ambulatory surgery center) at a single institution in the Philadelphia metropolitan area from April 27, 2020 to June 12, 2020 were included in this study. A total of 1295 patients were screened for symptoms, exposure, temperature, and oxygen saturation via a standardized protocol before surgical scheduling; 1.5% (19 of 1295) were excluded because they had COVID-19 symptoms, exposure, or recent travel based on the initial screening questionnaire, leaving 98.5% (1276 of 1295) who underwent testing for COVID-19 preoperatively. All 1276 patients who passed the initial screening test underwent nasopharyngeal swabbing for COVID-19 via reverse transcription polymerase chain reaction before surgery. The mean age at the time of testing was 56 ± 16 years, and 53% (672 of 1276) were men. Eighty-seven percent (1106), 8% (103), and 5% (67) were tested via the Roche, Abbott, and Cepheid assays, respectively. All patients undergoing elective surgery were tested via the Roche assay, while those undergoing nonelective surgery received either the Abbott or Cepheid assay, based on availability. Patients with positive test results undergoing elective surgery had their procedures rescheduled, while patients scheduled for nonelective surgery underwent surgery regardless of their test results. Additionally, we reviewed the records of all patients at 30 days postoperatively for emergency room visits, readmissions, and COVID-19-related complications via electronic medical records and surgeon-reported complications. However, we had no method for definitively determining how many patients had complications, emergency department visits, or readmissions outside our system, so our event rate estimates for these endpoints are necessarily best-case estimates. RESULTS: A total of 0.5% (7 of 1276) of the patients tested positive for COVID-19: five via the Roche assay and two via the Abbott assay. Patients with positive test results were younger than those with negative results (39 ± 12 years versus 56 ± 16 years; p = 0.01). With the numbers available, we found no difference in the proportion of patients with positive test results for COVID-19 based on subspecialty area (examining the lowest and highest point estimates, respectively, we observed: trauma surgery [3%; 2 of 68 patients] versus hip and knee [0.3%; 1 of 401 patients], OR 12 [95% CI 1-135]; p = 0.06). No patients with negative preoperative test results for COVID-19 developed a symptomatic COVID-19 infection within 30 days postoperatively. Within 30 days of surgery, 0.9% (11 of 1276) of the patients presented to the emergency room, and 1.3% (16 of 1276) were readmitted for non-COVID-19-related complications. None of the patients with positive test results for COVID-19 preoperatively experienced complications. However, because some were likely treated outside our healthcare system, the actual percentages may be higher. CONCLUSION: Because younger patients are more likely to be asymptomatic carriers of disease, surgeons should emphasize the importance of taking proper precautions to prevent virus exposure preoperatively. Because the rates of COVID-19 infection differ based on city and time, surgeons should monitor the local prevalence of disease to properly advise patients on the risk of COVID-19 exposure. Further investigation is required to assess the prevalence in the orthopaedic population in cities with larger COVID-19 burdens. LEVEL OF EVIDENCE: Level III, therapeutic study.

Effect of perioperative acetaminophen on pain management in patients undergoing rotator cuff repair: a prospective randomized study.

BACKGROUND: Limiting opioid use in perioperative pain management is currently an important focus in orthopedic surgery. The ability of acetaminophen to reduce postoperative opioid consumption while providing acceptable pain management has not been thoroughly investigated in patients undergoing rotator cuff repair (RCR). METHODS: Patients undergoing primary arthroscopic RCR were prospectively randomized to 1 of 3 treatment groups: Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery and had the option to take either medication or both. Group 2 (control) received only 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery. Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery, which was subsequently decreased to administration every 8 hours during postoperative days 2-5. Group 3 patients were also allowed to take 5 mg of oxycodone every 6 hours as needed after surgery. All patients received interscalene blocks with liposomal bupivacaine (Exparel). Opioid use, pain scores, side effects, and overall satisfaction were assessed daily for the first week after surgery. RESULTS: A total of 57 patients (mean age, 57.8 ± 9.55 years) were included in this study. Baseline demographic characteristics including age, sex, and body mass index were similar between the groups (P > .05). Patients in group 3 took significantly fewer narcotics overall (P = .017) and took significantly fewer pills each day compared with group 2. Group 3 also reported significantly better overall pain control compared with the other groups (P = .040). There were no significant differences in overall patient satisfaction between the groups (P > .05). Additionally, there were no significant differences between groups regarding postoperative medication-associated side effects (P > .05). CONCLUSION: Perioperative acetaminophen represents an important component of multimodal analgesia in appropriately selected patients undergoing shoulder surgery. In this study, the use of perioperative acetaminophen significantly decreased opioid consumption and improved overall pain control after primary arthroscopic RCR.