Outcome of biceps suspensionplasty for recurrent multidirectional shoulder instability.

INTRODUCTION: Recurrent multidirectional shoulder instability after failed capsular repair/plication, is a challenging treatment problem. The long head of the biceps has been identified as a structure that may be utilized as a checkrein to stop abnormal anterior and inferior translation of the humeral head. The purpose of this study is to analyse the outcomes of biceps suspensionplasty (BS) in the treatment of recurrent shoulder instability. METHODS: A retrospective review identified patients with recurrent multidirectional instability that underwent BS as part of a revision shoulder stabilization procedure. Clinical records were reviewed for demographics, pain, complications, recurrent instability, reoperations, and range of motion. Patients were also administered ASES/SST/SANE/Rowe and Oxford instability questionnaire at minimum of 2-year clinical follow-up. RESULTS: Five patients (7 shoulders) were included with a mean follow-up of 3.2 years (2-7 years). Patients had an average of 1.6 prior procedures (1-3). Average patient age was 24.2 years (18.7-32.4 years) and all were female. Four shoulders were treated open while 3 were treated arthroscopically with a capsular shift and biceps suspension. Four shoulders also underwent capsular reconstruction with allograft. At final follow-up three shoulders had recurrent inferior subluxation, although all patients considered their shoulders to be much better (4) or somewhat better (3) and none have undergone repeat surgery. CONCLUSION: In our series of patients, we found BS may be useful as an adjunct to a revision capsular shift or reconstruction. While 42.8% of patients experienced recurrent subluxations, this high-risk population demonstrated encouraging subjective results and avoiding joint arthrodesis in the short-term.

Reconstruction of Acute Acromioclavicular (AC) Joint Dislocations with or without Tendon Graft: a Retrospective Comparative Study.

BACKGROUND: Reconstructions of acute acromioclavicular (AC) dislocations have been thought to result in superior outcomes than chronic dislocations. The use of tendon graft in reconstructions has demonstrated favorable biomechanical properties. To determine whether utilizing tendon graft during repair of acute AC dislocations results in superior outcomes and lower complication rate. METHODS: A retrospective review of AC reconstructions was conducted. Reconstructions performed within 3 weeks of injury were included. Inclusion criteria included age over 18, grade 3-5 AC joint separation, and no previous ipsilateral shoulder injury. Primary outcome measure was radiographic loss of reduction. Secondary outcomes included ASES and SANE scores. RESULTS: Of 47 reconstructions of acute AC joint separations, 35 utilized fixation without a tendon graft, while 12 underwent an anatomic reconstruction with tendon graft. Repairs without the use of graft resulted in 8 (23%) cases of loss of reduction, while tendon graft augmented repairs resulted in 5 (42%). This difference was not statistically significant (p = 0.22). No patients required reoperation. There was no statistical difference in the ASES and SANE scores between the two groups. Furthermore, we found no significant difference in ASES or SANE scores in patients who maintained reduction postoperatively versus those that lost reduction. CONCLUSION: A greater but not statistically significant rate of loss of reduction was observed in the group reconstructed with the use of a tendon graft. Further research is needed to determine whether the use of tendon graft is beneficial in the treatment of acute AC joint separations. LEVEL OF EVIDENCE: IV.

Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.

BACKGROUND: Opioids are commonly administered for the treatment of acute and chronic pain symptoms. The current health care system is struggling to deal with increasing medication abuse and rising mortality rates from overdose. Preoperative patient-targeted education on opioid use is an avenue yet to be explored. The purpose of the study was to determine whether preoperative narcotics education reduces consumption after arthroscopic rotator cuff repair (ARCR). METHODS: Patients undergoing primary ARCR at our institution were randomized to receiving opioid-related preoperative education or not. Patients filled out preoperative questionnaires detailing complete medical history and visual analog scale (VAS) for pain. Patients completed questionnaires regarding their opioid consumption and pain at their 2-week, 6-week, and 3-month follow-up. RESULTS: The study enrolled 140 patients. Patients in the study group consumed significantly less narcotics than the control group at the 3-month follow-up. Patients in the education group were 2.2 times more likely to discontinue narcotic use by the end of follow-up (odds ratio, 2.19; P = .03). In addition, patients with a history of preoperative narcotic use that were in the education group were 6.8 times more likely to discontinue narcotics by the end of follow-up (odds ratio, 6.8; P = .008). DISCUSSION/CONCLUSIONS: The findings of this study determined that preoperative education intervention significantly decreased the number of narcotic pills consumed at 3 months after ARCR. In addition, education resulted in earlier cessation of opioids; therefore, directed patient education can help alleviate the current opioid epidemic.

Preoperative Sterilization Preparation of the Shoulder: A Comparative Study Evaluating Gauze Sponge and Commercially Available Applicator Prep Stick.

BACKGROUND: Surgical site infection (SSI) remains a concern in shoulder surgery, especially during arthroplasty. While many studies have explored the characteristics and efficacy of different sterilizing solutions, no study has evaluated the method of application. The purpose of this study was to compare two popular pre-surgical preparatory applications (two 4 x 4 cm gauze sponges and applicator stick) in their ability to cover the skin of the shoulder. METHODS: Two orthopedic surgeons simulated the standard pre-surgical skin preparation on 22 shoulders of volunteer subjects. Each surgeon alternated between an applicator stick and two sterile 4x4 cm gauze sponges. Skin preparation was performed with a commercially available solution that can be illuminated under UV-A light. Advanced image-analysis software was utilized to determine un-prepped areas. A two-tailed paired t-test was performed to compare percentage of un-prepped skin. RESULTS: The applicator stick method resulted in a significantly higher percentage of un-prepped skin (27.25%, Range 10-49.3) than the gauze sponge method (15.37%, Range 5-32.8, P=0.002). Based on image evaluation, most un-prepped areas were present around the axilla. CONCLUSION: Based on our findings, the use of simple gauze sponges for pre-surgical preparatory application of sterilization solution may result in a lower percent of un-prepped skin than commercially available applicator stick. Orthopaedic surgeons and operating room staff should be careful during the pre-surgical sterile preparation of the shoulder, especially the region around the axilla, in order to reduce the potential risk of surgical site infection.Level of evidence: III.

Low Prevalence of Hip and Knee Arthritis in Active Marathon Runners.

BACKGROUND: Existing evidence on whether marathon running contributes to hip and knee arthritis is inconclusive. Our aim was to describe hip and knee health in active marathon runners, including the prevalence of pain, arthritis, and arthroplasty, and associated risk factors. METHODS: A hip and knee health survey was distributed internationally to marathon runners. Active marathoners who completed ≥5 marathons and were currently running a minimum of 10 miles per week were included (n = 675). Questions assessed pain, personal and family history of arthritis, surgical history, running volume, personal record time, and current running status. Multivariable analyses identified risk factors for pain and arthritis. Arthritis prevalence in U.S. marathoners was compared with National Center for Health Statistics prevalence estimates for a matched group of the U.S. RESULTS: Marathoners (n = 675) with a mean age of 48 years (range, 18 to 79 years) ran a mean distance of 36 miles weekly (range, 10 to 150 miles weekly) over a mean time of 19 years (range, 3 to 60 years) and completed a mean of 76 marathons (range, 5 to 1,016 marathons). Hip or knee pain was reported by 47%, and arthritis was reported by 8.9% of marathoners. Arthritis prevalence was 8.8% for the subgroup of U.S. marathoners, significantly lower (p < 0.001) than the prevalence in the matched U.S. population (17.9%) and in subgroups stratified by age, sex, body mass index (BMI), and physical activity level (p < 0.001). Seven marathoners continued to run following hip or knee arthroplasty. Age and family and surgical history were independent risk factors for arthritis. There was no significant risk associated with running duration, intensity, mileage, or the number of marathons completed (p > 0.05). CONCLUSIONS: Age, family history, and surgical history independently predicted an increased risk for hip and knee arthritis in active marathoners, although there was no correlation with running history. In our cohort, the arthritis rate of active marathoners was below that of the general U.S. POPULATION: Longitudinal follow-up is needed to determine the effects of marathon running on developing future hip and knee arthritis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Blood Glucose Levels in Diabetic Patients Following Corticosteroid Injections into the Subacromial Space of the Shoulder.

BACKGROUND: Corticosteroid injections are used to treat a variety of orthopedic conditions with the goal of decreasing pain and inflammation. Administration of systemic or local corticosteroids risks temporarily increasing blood glucose levels, especially diabetic patients. The purpose of this study is to quantify the effects of corticosteroid injections on blood glucose levels in diabetic patients with shoulder pathology. METHODS: Diabetic patients who regularly monitored their blood glucose levels and were indicated for a subacromial corticosteroid injection were included in this prospective investigation. The typical normal morning fasting glucose and most recent hemoglobin A1c level was recorded for each patient. After injection, patients were contacted daily to confirm their fasting morning glucose level for 10 days post-injection. RESULTS: Seventeen consecutive patients were enrolled. Patients with hemoglobin A1c of <7% had an average rise in blood glucose of 38 mg/dL compared to 98 mg/dL in the poorly controlled group after injection (P<0.001). Well-controlled patients' glucose levels returned to near baseline levels around post-injection day 8, while poorly controlled patients levels remained elevated. Similarly, insulin-dependent diabetic patients had an average increase in fasting glucose level of 99 mg/dL versus 50 mg/dL in non-insulin-dependent diabetic patients (P<0.001). CONCLUSION: After corticosteroid injection, patients with well-controlled diabetes experience smaller elevations and faster return to baseline glucose levels than patients with poor control. Insulin dependent diabetics experienced similar findings as patients with poor control. Future studies are needed to evaluate dosing to optimize the risks of blood glucose elevation while maintaining therapeutic benefit.

Pain Management After Outpatient Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Effective postoperative pain management after shoulder arthroscopy is a critical component to recovery, rehabilitation, and patient satisfaction. PURPOSE: This systematic review provides a comprehensive overview of level 1 and level 2 evidence regarding postoperative pain management for outpatient arthroscopic shoulder surgery. STUDY DESIGN: Systematic review. METHODS: We performed a systematic review of the various modalities reported in the literature for postoperative pain control after outpatient shoulder arthroscopy and analyzed their outcomes. Analgesic regimens reviewed include regional nerve blocks/infusions, subacromial/intra-articular injections or infusions, cryotherapy, and oral medications. Only randomized control trials with level 1 or level 2 evidence that compared 2 or more pain management modalities or placebo were included. We excluded studies without objective measures to quantify postoperative pain within the first postoperative month, subjective pain scale measurements, or narcotic consumption as outcome measures. RESULTS: A combined total of 40 randomized control trials met our inclusion criteria. Of the 40 included studies, 15 examined nerve blocks, 4 studied oral medication regimens, 12 studied subacromial infusion, 8 compared multiple modalities, and 1 evaluated cryotherapy. Interscalene nerve blocks (ISBs) were found to be the most effective method to control postoperative pain after shoulder arthroscopy. Increasing concentrations, continuous infusions, and patient-controlled methods can be effective for more aggressively controlling pain. Dexamethasone, clonidine, intrabursal oxycodone, and magnesium have all been shown to successfully improve the duration and adequacy of ISBs when used as adjuvants. Oral pregabalin and etoricoxib administered preoperatively have evidence supporting decreased postoperative pain and increased patient satisfaction. CONCLUSION: On the basis of the evidence in this review, we recommend the use of ISBs as the most effective analgesic for outpatient arthroscopic shoulder surgery.

Functional outcomes after bilateral arthroscopic rotator cuff repair.

BACKGROUND: Arthroscopic repair of rotator cuff tears is a common procedure performed by orthopedic surgeons. There is a well-known incidence of up to 35% of bilateral rotator cuff tear disease in patients who have a known unilateral tear. The majority of the literature focuses on outcomes after unilateral surgery. The purpose of this study was to determine if there are clinical differences in shoulders of patients who underwent staged bilateral rotator cuff repairs during their lifetime. METHODS: A retrospective review of all patients who underwent staged bilateral arthroscopic rotator cuff surgery at our institution was performed. All patients had at least 2 years of follow-up. Clinical outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Rowe measures were obtained. A subset of patients returned for clinical and ultrasound evaluation performed by an independent fellowship-trained musculoskeletal radiologist. RESULTS: Overall, 110 shoulders in 55 patients, representing 68% of all eligible patients, participated. No clinical or statistical difference was found in any outcome measure. ASES scores averaged 86.5 (36.7-100) in the dominant shoulder compared with 89.6 (23.3-100) in the nondominant shoulder (P = .42). Ultrasound was available on 34 shoulders and showed complete healing rate of 88%. The shoulders with retearing of the rotator cuff (12%) demonstrated clinically relevant lower ASES scores (72.5) compared with shoulders with confirmed healed repairs (86.2; P = .2). DISCUSSION: Patients who undergo staged bilateral rotator cuff repair can expect to have similarly good clinical outcomes regardless of hand dominance or chronologic incidence with excellent healing rates in both shoulders.