Random forest identifies predictors of discharge destination following total shoulder arthroplasty.

Background: Machine learning algorithms are finding increasing use in prediction of surgical outcomes in orthopedics. Random forest is one of such algorithms popular for its relative ease of application and high predictability. In the process of sample classification, algorithms also generate a list of variables most crucial in the sorting process. Total shoulder arthroplasty (TSA) is a common orthopedic procedure after which most patients are discharged home. The authors hypothesized that random forest algorithm would be able to determine most important variables in prediction of nonhome discharge. Methods: Authors filtered the National Surgical Quality iImprovement Program database for patients undergoing elective TSA (Current Procedural Terminology 23472) between 2008 and 2018. Applied exclusion criteria included avascular necrosis, trauma, rheumatoid arthritis, and other inflammatory arthropathies to only include surgeries performed for primary osteoarthritis. Using Python and the scikit-learn package, various machine learning algorithms including random forest were trained based on the sample patients to predict patients who had nonhome discharge (to facility, nursing home, etc.). List of applied variables were then organized in order of feature importance. The algorithms were evaluated based on area under the curve of the receiver operating characteristic, accuracy, recall, and the F-1 score. Results: Application of inclusion and exclusion criteria yielded 18,883 patients undergoing elective TSA, of whom 1813 patients had nonhome discharge. Random forest outperformed other machine learning algorithms and logistic regression based on American Society of Anesthesiologists (ASA) classification. Random forest ranked age, sex, ASA classification, and functional status as the most important variables with feature importance of 0.340, 0.130, 0.126, and 0.120, respectively. Average age of patients going to facility was 76 years, while average age of patients going home was 68 years. 78.1% of patients going to facility were women, while 52.7% of patients going home were. Among patients with nonhome discharge, 80.3% had ASA scores of 3 or 4, while patients going home had 54% of patients with ASA scores 3 or 4. 10.5% of patients going to facility were considered of partially/totally dependent functional status, whereas 1.3% of patients going home were considered partially or totally dependent (P value < .05 for all). Conclusion: Of various algorithms, random forest best predicted discharge destination following TSA. When using random forest to predict nonhome discharge after TSA, age, gender, ASA scores, and functional status were the most important variables. Two patient groups (home discharge, nonhome discharge) were significantly different when it came to age, gender distribution, ASA scores, and functional status.

Patients With Intact Shoulder Superior Capsular Reconstruction Grafts on Ultrasound Show Significant Improvement in Functional Outcomes at Minimum 2-Year Follow-up.

Purpose: To assess the utility of using dynamic ultrasound for postoperative evaluation after superior capsular reconstruction (SCR) by evaluating graft integrity and its correlation with clinical outcomes at a minimum 2-year follow-up. Methods: A retrospective chart review was conducted to identify patients who underwent SCR between July 2015 and July 2020 with a minimum 2-year clinical and ultrasound follow-up. Clinical outcome measures included Simple Shoulder (SS) and American Shoulder and Elbow Surgeon (ASES) scores. Integrity of the SCR graft was evaluated by dynamic ultrasound. Results: We evaluated 22 shoulders in 21 patients with a mean follow-up of 44.8 months (range, 24-71 months). The graft was found to be intact by ultrasound evaluation in 82% (18/22). Patients with intact grafts had higher mean SS (11.6 vs 7.8, P = .00079) and ASES (91.2 vs 64.1, P = .0296) scores at latest follow-up compared to those with failed grafts. Those with intact grafts also had significant improvement in SS (3.7 vs 11.6, P < .00001) and ASES (23.2 vs 91.2, P < .00001) scores at latest follow-up compared to their preoperative scores. In contrast, patients with graft failure had no significant improvement in SS (6.3 vs 9.0, P = .123) and ASES (40.4 vs 58.3, P = .05469) scores at latest follow-up compared to their preoperative scores. There was no difference between clinical outcomes at 6 to 12 months vs latest follow-up for both SS (P = .11, P = .5) and ASES (P = .27, P = .21) scores. Conclusions: SCR grafts were found by ultrasound to be intact in 82% of cases. Patients with intact grafts on ultrasound had significant improvement in functional outcome scores while those with graft failure did not. Functional outcome scores suggest that maximal recovery from this procedure occurs by 6 to 12 months. Level of Evidence: Level IV, therapeutic case series.

Health literacy in rotator cuff repair: a quantitative assessment of the understandability of online patient education material.

Background: The American Medical Association and National Institutes of Health recommend online health information be written at a 6th grade or lower reading level for clear understanding. While syntax reading grade level has previously been utilized, those analyses do not determine whether readers are processing key information (understandability) or identifying available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT-P) is a method to measure the understandability and actionability of online patient education materials. The purpose of this study was to evaluate online resources regarding rotator cuff repair utilizing measures of readability, understandability, and actionability. Methods: The search term "rotator cuff surgery" was used in two independent online searches to obtain the top 50 search results. The readability of included resources was quantified using valid objective algorithms: Flesch-Kincaid Grade-Level, Simple Measure of Gobbledygook grade, Coleman-Liau Index, and Gunning Fog Index. The PEMAT-P form was used to assess actionability and understandability. Results: A total of 49 unique websites were identified to meet our inclusion criteria and were included in our analysis. The mean Flesch-Kincaid Grade Level graded materials at a 10.6 (approximately a 10th grade reading level), with only two websites offering materials at a 6th grade reading level or below. The remaining readability studies graded the mean reading level at high school or greater, with the Gunning Fog Index scoring at a collegiate reading level. Mean understandability and actionability scores were 64.6% and 29.5%, respectively, falling below the 70% PEMAT score threshold for both scales. Fourteen (28.6%) websites were above the threshold for understandability, while no website (0%) scored above the 70% threshold for actionability. When comparing source categories, commercial health publishers provided websites that scored higher in understandability (P < .05), while private practice materials scored higher in actionability (P < .05). Resources published by academic institutions or organizations scored lower in both understandability and actionability than private practice and commercial health publishers (P < .05). No readability, understandability, or actionability score was significantly associated with search result rank. Conclusion: Overall, online patient education materials related to rotator cuff surgery scored poorly with respect to readability, understandability, and actionability. Only two (4.1%) of the patient education websites scored at the American Medical Association and National Institutes of Health recommended reading level. Fourteen (28.6%) scored above the 70% PEMAT score for understandability; however, no website met the threshold for actionability.

Spin in the Abstracts of Meta-analyses and Systematic Reviews: Midshaft Clavicle Fracture.

OBJECTIVES: Spin is a reporting bias that presents the beneficial effect of an experimental treatment as greater than what is found in the results of the study. This bias can result in patient care recommendations that are more subjective than objective. The purpose of this study is to identify the prevalence of spin in meta-analysis and systematic review abstracts regarding treatment of midshaft clavicle fractures. METHODS: Electronic libraries (MEDLINE, Embase, Web of Science, Google Scholar) were systematically searched. Meta-analyses and systematic reviews regarding treatment of midshaft clavicular fractures were analyzed. The nine most severe types of spin commonly found in abstracts were used as an evaluation tool to assess the articles. Other variables analyzed include year of publication, journal impact factor, number of citations, and methodologic quality according to A Measurement Tool to Assess Systematic Reviews (AMSTAR-2). RESULTS: The database search resulted in 401 articles, of which 53 met inclusion criteria. After review, it was found that 52.8% (28/53) of the included articles contained spin within the abstract. Of the nine most severe types of spin found in abstracts, type 3 spin ("selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention") was found to be the most prevalent 28.3% (15/53). CONCLUSION: This study demonstrated the presence of spin in the majority of meta-analyses and systematic review abstracts pertaining to midshaft clavicular fractures. Orthopedic surgeons should be aware and recognize spin as they review articles when deciding the treatment course for such injuries. LEVEL OF EVIDENCE: Level 3. See Instructions for Authors for a complete description of levels of evidence.

Fragility of statistically significant findings from randomized clinical trials of surgical treatment of humeral shaft fractures: A systematic review.

BACKGROUND: Despite recent meta-analyses of randomized controlled trials (RCTs), there remains no consensus regarding the preferred surgical treatment for humeral shaft fractures. The fragility index (FI) is an emerging tool used to evaluate the robustness of RCTs by quantifying the number of participants in a study group that would need to switch outcomes in order to reverse the study conclusions. AIM: To investigate the fragility index of randomized control trials assessing outcomes of operative fixation in proximal humerus fractures. METHODS: We completed a systematic review of RCTs evaluating the surgical treatment of humeral shaft fractures. Inclusion criteria included: articles published in English; patients randomized and allotted in 1:1 ratio to 2 parallel arms; and dichotomous outcome variables. The FI was calculated for total complications, each complication individually, and secondary surgeries using the Fisher exact test, as previously published. RESULTS: Fifteen RCTs were included in the analysis comparing open reduction plate osteosynthesis with dynamic compression plate or locking compression plate, intramedullary nail, and minimally invasive plate osteosynthesis. The median FI was 0 for all parameters analyzed. Regarding individual outcomes, the FI was 0 for 81/91 (89%) of outcomes. The FI exceeded the number lost to follow up in only 2/91 (2%) outcomes. CONCLUSION: The FI shows that data from RCTs regarding operative treatment of humeral shaft fractures are fragile and does not demonstrate superiority of any particular surgical technique.

Percutaneous Intramedullary Nailing of Complex Humeral Shaft Fractures: A Retrospective Case Series.

BACKGROUND: Humeral diaphyseal fractures have been traditionally stabilized with plates and screws. However, surgical morbidity can be quite extensive, particularly in more complex segmental and comminuted fracture patterns. An intramedullary nail (IMN) has the biomechanical advantage of being a load-sharing device and can be placed with a more minimally invasive technique. The purpose of this study was to evaluate the clinical and radiographic outcomes of complex humeral shaft fractures treated with an IMN utilizing a percutaneous surgical technique. METHODS: A retrospective review was performed on a consecutive series of patients who underwent treatment of a complex humeral shaft fracture with an IMN placed with a percutaneous technique. Clinical outcome scores and radiographic analysis were performed at a minimum one-year follow-up. RESULTS: Of the 14 patients included, 12 had clinical and radiographic follow-ups at one year. The majority (64%) were obese and involved polytrauma (50%), and 79% were AO Foundation/Orthopaedic Trauma Association (AO/OTA) type C fractures. Union after the index procedure was 93%, with one nonunion requiring a secondary operation. The average operative time was 103 minutes. There were no other complications or additional procedures. The mean clinical outcome scores included American Shoulder and Elbow Society (ASES): 78.2, Constant Score: 72.1, Single Assessment Numerical Evaluation (SANE): 81.9, and Penn Shoulder Score: 82.7. CONCLUSION: This study demonstrates complex comminuted and segmental humeral shaft fractures in a higher-risk patient population can be effectively managed with IMN. Percutaneous placement of an IMN should be considered as a treatment option in complex humeral shaft fractures, particularly in patients with secondary comorbidities such as obesity and polytrauma.

Attitudes and awareness of suture anchor cost: a survey of shoulder surgeons performing rotator cuff repairs.

BACKGROUND: The cost of health care in the United States accounts for 18% of the nation's gross domestic product and is expected to reach 20% by 2020. Physicians are responsible for 60%-80% of decisions resulting in health care expenditures. Rotator cuff repairs account for $1.2-$1.6 billion in US health care expenditures annually. The purpose of this study is to assess surgeons' cost awareness in the setting of rotator cuff repairs. The hypothesis is that practice environment and training affect cost consciousness and incentivization will lead to more cost-effective choices. METHODS: In this cross-sectional study, a 21-item survey was distributed via the email list services of the American Shoulder and Elbow Surgeons and Arthroscopy Association of North America. Data collected included demographics, variables regarding rotator cuff repair (technique, number of companies used, procedures per month), and knowledge of costs. RESULTS: Responses from 345 surgeons in 23 countries were obtained with the majority (89%) being from the United States. Most surgeons were "cost-conscious" (275, 70.7%). Of these surgeons, 62.9% are willing to switch suture anchors brands to reduce overall costs if incentivized. Cost-conscious surgeons were more likely to be fellowship trained in shoulder and elbow (51.81% vs. 38.57%, P = .048), be paid based on productivity (73.53% vs. 61.43%, P = .047), and receive shared profits (85.4% vs. 75%, P = .02). CONCLUSION: The majority of orthopedic surgeons are both cost-conscious and willing to change their practice to reduce costs if incentivized to do so. A better understanding of implant costs combined with incentives may help reduce health care expenditure.

Adoption of Intramedullary Nail Fixation for Proximal Humerus Fractures: Assessment of Surgical Efficiency and Complications.

Fixation of proximal humerus fractures (PHFs) with intramedullary (IM) nails potentially is a newer, less invasive technique. The purpose of this study was to report on the early adoption results of IM nail use for PHF. Retrospective chart reviews were performed on the first 60 patients treated with IM nails for acute PHFs by two shoulder surgeons. The first 15 patients treated by each surgeon were compared with the subsequent 15 patients. Surgical and fluoroscopic times, fracture type, union, and varus collapse were compared. The average operating time decreased (p = .002). Fluoroscopy time, radiographic alignment, union rate, complications, and reoperations were not influenced. Three- and four-part fractures had a higher complication rate than two-part fractures (53% vs. 20%). When considering implementing use of IM nails for treatment of PHFs, initial cases can have outcomes and complications similar to those performed with greater experience. IM nailing appears a good treatment option for two-part PHFs. (Journal of Surgical Orthopaedic Advances 28(2):121-126, 2019).

Insurance-Mandated Stay Prolongs Hospitalization Following Total Shoulder Arthroplasty.

Medicare currently requires a 3-night hospitalization for a patient to be considered for skilled nursing facility (SNF) placement. The purpose of this study was to analyze the relationship between length of stay and (a) insurance status and (b) readmission rates in Medicare-age patients undergoing primary total shoulder arthroplasty. A retrospective review of 251 primary consecutive total shoulder arthroplasty cases was performed. In patients discharged to SNF, Medicare insurance was associated with a significantly longer hospital stay (p < .001) compared with patients with private insurance. Readmission rates for Medicare and private insurance patients were similar at 30 and 90 days after surgery (p = 1.000). Ninety-five percent of Medicare patients discharged to SNF had a prolonged hospital stay primarily to fulfill the 3-night requirement. These findings call into question the necessity of the current 3-night inpatient hospitalization requirement for facility placement following total shoulder arthroplasty.

Cyanoacrylate microbial sealant may reduce the prevalence of positive cultures in revision shoulder arthroplasty.

BACKGROUND: Cyanoacrylate-based, microbial sealant is an adhesive skin barrier designed to prevent bacterial contamination in surgical wounds. This type of adhesive barrier could have use in decreasing the incidence of positive cultures and subsequent infection in shoulder arthroplasty. QUESTIONS/PURPOSES: We therefore evaluated whether cyanoacrylate microbial sealant reduced the positive intraoperative culture rates in revision shoulder arthroplasty. METHODS: We retrospectively reviewed 55 patients who underwent revision shoulder arthroplasties. Intraoperative aerobic and anaerobic deep tissue culture results taken during the revisions were compared. Cultures were taken of the deep synovial tissue lining the prosthesis. Patients were divided into two groups: those who underwent standard preparations with adhesive, iodine-barrier drapes (Group SP) and those who had placement of cyanoacrylate microbial sealant in addition to the standard prep (Group MS). RESULTS: The prevalence of cases with positive cultures was 18% (seven of 40) in Group SP compared with 7% (one of 15) in Group MS. The prevalence of positive, anaerobic Propionibacterium acnes cultures was 13% in Group SP compared with 7% in Group MS. The prevalence of infections confirmed at revision surgery was 8% in Group SP versus 0% in Group MS. CONCLUSIONS: Our observations suggest application of a cyanoacrylate microbial sealant may reduce the prevalence of positive cultures and thereby subsequent infections in revision shoulder arthroplasties. LEVEL OF EVIDENCE: Level III, retrospective cohort study. See Guidelines for Authors for a complete description of levels of evidence.

Evaluation of the learning curve for reverse shoulder arthroplasty.

This purpose of this study was to quantify the surgical learning curve and provide guidelines to surgeons interested in teaching and performing reverse shoulder replacement. Sixty-two consecutive primary reverse shoulder replacements performed by a single surgeon were retrospectively reviewed. Using data from consecutive cases, surgical time was plotted against patient case order, and the linear regression slope was calculated. Case length slope analysis demonstrated a significantly negative slope with the first 18 cases, which subsequently leveled thereafter. The number of cases needed to arrive at this flat slope was defined as the proficiency point.The proficiency point was then verified using the measurable variables of baseplate screw number and glenosphere overhang by dividing the series into 2 groups: Group A included patients who had surgery prior to the proficiency point, and group B included patients who had surgery after the proficiency point. In group A, only 33% (6/18) had all 4 glenoid baseplate screws placed as compared to 66% (29/44) in group B (P=.02). Glenosphere overhang increased from a mean of 1.02 mm (+/-1.29 mm) in group A to 2.58 mm (+/-1.89 mm) in group B (P=.003).A learning curve of approximately 18 cases was found in this series based on the technical aspects of performing reverse shoulder replacement. This curve is likely even longer for lower volume shoulder surgeons. We recommend specialized training prior to performing this procedure.

Fenestrated cannulae with outflow reduces fluid gain in shoulder arthroscopy.

UNLABELLED: Soft tissue fluid retention is a common problem after arthroscopy, with as much as 2% of patients having complications develop. A fenestrated outflow cannula has been introduced to reduce interstitial swelling. We tested the ability of this outflow cannula design to reduce fluid weight gain. We enrolled 28 patients undergoing shoulder arthroscopy and randomized them into two groups using fenestrated outflow versus conventional cannulae. The conventional group had greater weight gain as a function of the procedure duration than the fenestrated outflow group (slope = 0.542 +/- 1.160 kg/hour versus 0.0144 +/- 0.932 kg/hour). The conventional group also had greater weight gain as a function of fluid volume than the fenestrated outflow group (slope = 0.022 +/- 0.038 kg/L versus 0.002 +/- 0.341 kg/L). Compared with conventional nonoutflow cannulae, fenestrated outflow cannulae with negative pressure reduced weight gain associated with longer arthroscopic surgeries and increased arthroscopic fluid volume. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Removal of well-fixed flanged humeral prostheses may require humeral expansion.

BACKGROUND: A flanged humeral stem design can be advantageous in achieving an interlock between the prosthetic and bone interface leading to a long-term stable loading pattern. The purpose of this study is to report a short case series involving revision of a flanged humeral prosthesis. Our hypothesis was that a greater percentage of the flanged prostheses undergoing revision would require some form of bone expansion to achieve stem removal compared to the nonflanged. METHODS AND RESULTS: In the period from October 2004 to July 2008, 43 patients underwent revision of a humeral prosthetic stem by a single surgeon. Of these, 6 prostheses were of a triflanged design. Of these six, five (83%) could not be removed with longitudinal force and required some expansion of the bone in order to achieve stem extraction. Of the nonflanged humeral stems, 3/37 (8%) required bone expansion to achieve extraction. Analysis of the 2 groups showed a statistical difference in the need for humeral expansion (P < .000001). CONCLUSIONS: Surgeons preparing to revise a flanged humeral stem should include expansion of the humeral shaft, by episiotomy or windowing, as part of their preoperative planning and informed consent of the patient.

Porcine small intestine submucosa xenograft augmentation in repair of massive rotator cuff tears.

In this prospective study, we evaluated the efficacy of using porcine small intestine submucosa (SIS) xenograft to augment the repair of massive rotator cuff tears. Our hypothesis was that SIS xenograft would help restore tendon tissue in the human model, as has been shown in several animal studies. Eleven patients were followed clinically for a mean of 26 months (range, 14-38 months). Mean University of California Los Angeles end-result scores improved from 13.9 before surgery to 25.7 after surgery, American Shoulder and Elbow Surgeons scores improved from 36.3 to 71.8, and the visual analog scale pain score decreased from 6.6 to 2.0. All findings were statistically significant (P<.01). At a mean of 25 months after surgery, magnetic resonance arthrography (MRA) showed the repairs partially or completely intact in 44% of shoulders. Intact repairs were thin and wispy. There were 3 complications, which included 1 infection and 2 localized skin reactions that resolved spontaneously. SIS xenograft did not reconstitute rotator cuff tissue or add to the quality of the rotator cuff repair. Given clinical concerns about localized reactions in this series and suboptimal MRA findings, use of SIS xenograft to augment rotator cuff repairs is not recommended.