Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopedic Shoulder Arthroplasty: A Matched – Pair Analysis

Background There is minimal work defining the economic impact of resident participation in shoulder arthroplasty. Thus, this study quantified the opportunity cost of resident participation in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) by determining differences in operative time, relative value units (RVUs)/hour, and RVUs/case. Methods A retrospective analysis of shoulder arthroplasty procedures were identified from the ACS-NSQIP database from 2006 to 2014 using CPT codes. Demographic, comorbidity, preoperative laboratory data and surgical procedure were used to develop matched cohorts. Mean differences in operative time, RVUs/case and RVUs/hour between attending-only (AO) cases and cases with resident involvement (RI) were examined. Cost analysis was performed to identify differences in RVUs generated per hour in dollars/case. Results A total of 1786 AO and 1102 RI cases were identified. With the exception of PGY-3 and PGY-4 cases, RI cases had lower mean operative times compared to AO cases. The cost of RI was highest for PGY-3 ($199.87 per case) and PGY-4 ($9 .2 9) residents with all other postgraduate years providing a cost reduction. Discussion Involvement of residents was associated with shorter operative times leading to a savings of $29.64 per case. Involvement of intermediate-level (PGY-3) residents were associated with increased costs that ultimately decreased as residents became more senior.

Outcomes of day case shoulder replacement surgery in a stand-alone day care unit in the United Kingdom

Background: This review aims to compare the outcomes for day case shoulder replacement with in-patient shoulder replacement surgery in a district general hospital. Methods: Seventy-three patients had 82 shoulder arthroplasty procedures. Forty-six procedures were undertaken in a dedicated stand-alone day-case unit and 36 were undertaken as in-patient cases. Patient were followed up at 6 weeks, 6 months and annually. Results: There was no significant difference between the outcomes of shoulder arthroplasty procedures performed in the day case or in-patient settings making this a safe option for surgical care in a unit with an appropriate care pathway. Six complications in total were observed, three in each group. Operation time was statistically shorter for day cases by 25.1 min (95% CI - 36.5 to −13.7; d = −0.95, 95% CI −1.42 to 0.48). Estimated marginal means (EMM) revealed lower post-surgery oxford pain scores in day cases (EMM = 3.25, 95% CI 2.35, 4.16) compared with inpatients (EMM = 4.65, 95% CI 3.64 to 5.67). Constant shoulder scores were higher in day cases versus inpatients. Conclusion: Day case shoulder replacement is safe with comparable outcomes to routine inpatient care for patients up to ASA 3 classification with high satisfaction and excellent functional outcomes.

The role of preoperative opioid use in shoulder surgery—A systematic review

Background Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids. Methods EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies. Results Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively. Conclusion Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients. Level of evidence Level IV, Systematic review.

Long-Term Outcomes Following Manipulation Under Anaesthetic for Patients with Primary and Secondary Frozen ShoulderShoulder

Background Frozen Shoulder (FS) is a common, debilitating condition for which manipulation under anaesthetic (MUA) is a non-invasive and effective treatment option. Current literature evaluates short to medium-term outcomes, but there is a paucity of long-term (>10 years) studies. Knowledge of long-term outcomes is also needed to evaluate whether FS or its treatment pre-disposes to other shoulder pathology in the long-term. Methods A retrospective analysis of 398 shoulders undergoing MUA for FS between Jan 1999 and Jan 2010; 240 complete datasets were obtained. Outcomes were Oxford Shoulder Score (OSS), recurrence and development of other shoulder pathology (arthritis or rotator cuff tear). Results At long-term follow-up (mean 13.2 years), 71.3% had no symptoms (OSS 48), 16.6% had minor symptoms (OSS 42–47) and 12.1% had significant symptoms (OSS < 42). There were 4/240 (1.7%) self-reported recurrences > 5 years after initial MUA and 2/240 (0.8%) repeat MUAs. In the long-term 6.7% developed rotator cuff pathology and 3.8% shoulder OA. Discussion This study suggests that long-term outcome after MUA for FS is favourable. Late recurrence of FS is uncommon and the development of OA or rotator cuff pathology is no greater than that of the general population.

Diabetes status and postoperative complications for patients receiving open rotator cuff repair

Background Diabetic patients are known to have poor wound healing and worse outcomes following surgeries. The purpose of this study is to evaluate diabetes status and complications for patients receiving open rotator cuff repair. Methods Patients undergoing open rotator cuff repair from 2006 to 2018 were identified in a national database. Patients were stratified into 3 cohorts: no diabetes mellitus, non-insulin dependent diabetes mellitus (NIDDM), and insulin dependent diabetes mellitus (IDDM). Differences in demographics, comorbidities, and complications were assessed with the use of bivariate and multivariate analyses. Results Of 7678 total patients undergoing open rotator cuff repair, 6256 patients (81.5%) had no diabetes, 975 (12.7%) had NIDDM, and 447 (5.8%) had IDDM. Bivariate analyses revealed that IDDM patients had increased risk of mortality, extended length of stay, and readmission compared to non-diabetic patients ( p < 0.05 for all). IDDM patients had higher risks of major complications and readmission relative to NIDDM patients ( p < 0.05 for both). On multivariate analysis, there were no differences in any postoperative complications between the non-diabetic, NIDDM, and IDDM groups. Discussion Diabetes does not affect postoperative complications following open rotator cuff repairs. Physicians should be aware of this finding and counsel their patients appropriately. Level of Evidence: III

Regaining motion among patients with shoulder pathology - are all exercises equal?

Background Little information exists to guide the choice of exercise for regaining shoulder range of motion (ROM). The purpose of this study was to compare the maximal ROM reached, pain and difficulty associated with 4 commonly prescribed exercises. Methods Forty (9 females) patients with various shoulder disorders and a limited flexion ROM performed 4 exercises for regaining shoulder flexion ROM in a randomized order. Exercises included the self-assisted flexion, forward bow, table slide and rope-and-pulley. Participants were videotaped while performing all exercises and the maximal flexion angle reached during each exercise was recorded using Kinovea motion analysis freeware (Kinovea 0.8.15). Pain intensity and the perceived level of difficulty associated with each exercise were also recorded. Results The forward bow and table slide generated significantly greater ROM compared with the self-assisted flexion and rope-and-pulley (P ≤ 0.005). The self-assisted flexion was associated with a greater pain intensity compared with the table slide and rope-and-pulley (P = 0.002) and a greater perceived level of difficulty compared with the table slide (P = 0.006). Conclusions Due to the greater ROM allowed, and similar or even lower level of pain or difficulty, clinicians may wish to initially recommend the forward bow and table slide for regaining shoulder flexion ROM.

Salvaging the 'irreparable' tear: Superior Capsular Reconstruction augmented with partial cuff repair

Introduction Massive rotator cuff tears (MRCTs) have long posed a complex problem for both patients and surgeons. If not treated promptly, tendon retraction, fatty infiltration and muscle atrophy of the rotator cuff muscles occur. These lead to irreparable RCTs with poor functional outcomes. We describe our technique of superior capsular reconstruction (SCR) augmented with partial cuff repair and report on our short term outcomes Method Seven consecutive patients who underwent the procedure were recruited at our institution from January 2019 to December 2019. Medical records of these patients were reviewed looking at pre-operative symptoms and examination findings, imaging studies, intra-operative findings, the surgical technique employed, post-operative progress in terms of pain, affected shoulder range of movement and outcome scores. Results All patients showed complete tears of at least two tendons and were deemed irreparable intra-operatively. All patients exhibited Goutalier grade 2–4 wasting of the affected tendons on MRI and Patte grade 3 intra-operatively. At 12 months, the mean improvement shown in Constant score is 12.1 points, in University of California Los Angeles (UCLA) score is 9.4 points and in Oxford Shoulder Score is 17 points. Active forward flexion improved in all patients with a mean improvement of 40 degrees. Numerical Pain Rating Scale improved in all patients with a mean of 5.1 points. Conclusion Our case series shows good short-term outcomes can be achieved with SCR augmented with partial cuff repair. Notably, our SCR results showed encouraging results even for challenging revision rotator cuff repairs.

Large segmental defects in midshaft clavicle nonunion treated with autologous tricortical iliac crest bone graft

Background To evaluate the use of intercalary iliac crest bone graft in the treatment of clavicle nonunion with a large segmental bone defect (3–6 cm). Methods This retrospective study evaluated patients with large segmental bone defects (3–6 cm) after clavicle nonunion, treated with open reposition internal fixation and iliac crest bone graft between February 2003 and March 2021. At follow-up the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was administered. A literature search was performed to provide an overview of commonly used graft types per defect size. Results We included five patients treated with open reposition internal fixation and iliac crest bone graft for clavicle nonunion with a median defect size of 3.3 cm (range 3–6 cm). Union was achieved in all five, and all pre-operative symptoms resolved. The median DASH score was 23 out of 100 (IQR 8-24). An extensive literature search revealed that there are no studies describing the use of an used iliac crest graft for defects larger than 3 cm. Instead, a vascularized graft was typically used to treat defects sizes between 2.5 and 8 cm. Discussion An autologous non-vascularized iliac crest bone graft can be safely used and is reproducible to treat a midshaft clavicle non-union with a bone defect between 3 and 6 cm.

Agreement between the American Shoulder and Elbow Surgeons Society Standardized Shoulder Assessment score (ASES) and the Oxford Shoulder Score (OSS) in patients presenting with shoulder pathology: A cohort analysis of the Clinical Quality Registry for Outcomes in Shoulder and Elbow Pathology (CROSEP) registry

Background The choice of patient-reported outcome measure (PROM) used in shoulder studies varies based on clinician's preference and location. This creates difficulties when attempting to compare studies which have used different PROMs as their outcome measure. This study aims to assess the agreement between the American Shoulder and Elbow Surgeons score (ASES) and the Oxford Shoulder Score (OSS), and identify factors associated with agreement. Methods Patients with shoulder pathology were identified from a multi-cohort observational practice registry. 1050 paired ASES and OSS pre-treatment scores were prospectively collected. Linear regression was performed to assess the agreement between the PROMs. Mixed-effects analysis of variance was performed to assess the influence of factors associated with agreement. Results Regression for mean total and mean function ASES and OSS demonstrated good fit (adjusted R2 57.7%, P < 0.001; and 63.9%, P < 0.001). Mean pain subscore demonstrated a poorer fit (adjusted R2 39.4%, P < 0.001). Crosswalks to convert between mean scores were produced with reasonable precision. Veterans RAND 12-Item Health Survey score, age and diagnosis cohort influenced agreement. Conclusion Mean total and mean function ASES and OSS scores agree well with each other. This allows for a more informed comparison of studies using either PROMs as their outcome measure.