Arthroscopic Shoulder Procedures Research Articles

Three-Dimensional Morphological Analysis of the Suprascapular Notch in Patients with Arthroscopic Rotator Cuff Repair.

The morphology of the suprascapular notch (SSN) and the ossification of the superior transverse suprascapular ligament (STSL) are risk factors for injury of the suprascapular nerve (SN) during arthroscopic shoulder procedures. The purpose of the current study was to compare preoperative clinical and radiologic characteristics between patients with and without STSL ossification and to evaluate SSN morphology in patients who underwent arthroscopic rotator cuff repair using a 3-dimensional (3D) reconstructed model. Patients who underwent arthroscopic rotator cuff repair and were given a computed tomography (CT) scan from March 2018 to August 2019 were included in this study. Patients were divided into 2 groups: those without STSL ossification (group I) and those with STSL ossification (group II). Tear size of the rotator cuff and fatty infiltration of rotator cuff muscles were assessed in preoperative magnetic resonance imaging. The morphology of the SSN was classified following Rengachary's classification. The transverse and vertical diameters of the SSN and the distances from anatomical landmarks to the STSL were measured. All measurements were completed using a 3D CT reconstructed scapula model. A total of 200 patients were included in this study. One hundred seventy-eight patients (89.0%) without STSL ossification were included in group I, and 22 patients (11.0%) with STSL ossification were included in group II. Group II showed a significantly advanced age (61.0 ± 7.4 vs. 71.0 ± 7.3 years, p < 0.001) and a shorter transverse diameter of SSN (10.7 ± 3.1 mm vs. 6.1 ± 3.7 mm, p < 0.001) than group I. In the logistic regression analysis, age was an independent prognostic factor for STSL ossification (odds ratio, 1.201; 95% confidence interval, 1.112-1.296; p < 0.001). Patients in type VI showed significantly shorter transverse diameters than other types (p < 0.001). The patient with type I showed a significantly shorter distance from the articular surface of the glenoid to the SSN than those with other types (p < 0.001). In the 3D morphological analysis, age was the independent factor associated with STSL ossification in patients who underwent arthroscopic rotator cuff repair. Type VI showed significantly shorter transverse diameters than other types. Type I showed a significantly shorter distance from the articular surface of the glenoid to the SSN than other types.

How low can we go? A randomized controlled trial of low-quantity initial opioid prescriptions for shoulder surgery

Orthopedic surgeons are the third most frequent prescribers of opioid medications. Given the current opioid addiction crisis, it is critical to limit opioid prescriptions to the lowest effective dose. In this study, we investigated how the initial opioid prescription after shoulder surgery affects maximum possible opioid consumption. We hypothesized that fewer pills in the initial opioid prescription would lead to less opioid consumption, a lower refill request rate, and fewer post-surgery office contacts for pain. In this single-center, prospective, randomized controlled clinical trial, 74 adults who underwent shoulder arthroplasty, rotator cuff repair, or other arthroscopic shoulder procedures were enrolled from December 2020 to July 2022. Follow-up was completed by February 2023. Participants were randomly assigned to receive postoperative prescriptions of seven 5-mg oxycodone pills (n=20), 15 pills (n=29), or 23 pills (n=25). The primary outcome was maximum possible opioid consumption within 2weeks after surgery, calculated by assuming consumption of all pills in the initial prescription, as well as any refills. Secondary outcomes were the opioid prescription refill request rates, post-surgery pain-related telephone calls or messages to the provider's office ("office contacts") within 2weeks after surgery, and American Shoulder and Elbow Surgeons pain scores 2weeks after surgery. Baseline characteristics did not differ among groups except for mean age, which was younger in the 7-pill group (P=.047). Maximum possible opioid consumption increased with the number of pills initially prescribed, with means of 78 morphine milligram equivalents (MME) for the 7-pill group, 118 MME for the 15-pill group, and 199 MME for the 23-pill group (P<.001). None of the secondary outcome measures differed among groups. Refill request rates were 20% for the 7-pill group, 3.4% for the 15-pill group, and 12% for the 23-pill group (P=.20). The proportions of patients with at least 1 office contact were 35% in the 7-pill group, 45% in the 15-pill group, and 28% in the 23-pill group (P=.43). Mean American Shoulder and Elbow Surgeons pain scores were 49 in the 7-pill group, 44 in the 15-pill group, and 40 in the 23-pill group (P=.20). After shoulder surgery, an initial prescription of fewer opioid pills was associated with less maximum possible opioid consumption without an increase in the percentage of patients requesting opioid refills or contacting the provider's office for pain-related concerns. An initial postoperative prescription of fewer 5-mg oxycodone pills may be equally or more effective compared with larger quantities for most patients.

Comment on: “Comparison between supra-scapular nerve block combined with axillary nerve block and interscalene brachial plexus block for postoperative analgesia following shoulder arthroscopy”

I read the article that compared the interscalene block (ISB) with the shoulder block (ShB) which is a combination of supra-scapular and axillary nerve block for shoulder arthroscopy procedures published in the current issue and wish to present my reflections on that article as a "Letter to the Editor" manuscript.

The effect of intravenous tranexamic acid on visual clarity in arthroscopic shoulder surgery compared to epinephrine and a placebo: a double-blinded, randomized controlled trial

The addition of epinephrine in irrigation fluid and the intravenous or local administration of tranexamic acid have independently been reported to decrease bleeding, thereby improving surgeons' visualization during arthroscopic shoulder procedures. No study has compared the effect of intravenous tranexamic acid, epinephrine in the irrigation fluid, or the combination of both tranexamic acid and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. We hypothesized that intravenous tranexamic acid is more effective than epinephrine mixed in the irrigation fluid in improving visualization during shoulder arthroscopy, with no additive effect when both are used. Patients aged ≥18 years undergoing shoulder arthroscopy were randomized into one of 4 study arms: (1) saline irrigation fluid (placebo); (2) epinephrine (0.33 mL of 1:1000 per liter) mixed in irrigation fluid (EPI); (3) 1 g intravenous tranexamic acid (TXA); and (4) epinephrine and tranexamic acid combined (TXA+EPI). Visualization was rated intraoperatively on a scale from 0, indicating poor clarity, to 3, indicating excellent clarity, every 15 minutes and overall. The primary outcome measure was the overall rating of visualization. A stepwise linear regression was performed using visualization as the dependent variable and independent variables including presence or absence of epinephrine and tranexamic acid, surgery duration, complexity, mean arterial pressure, increase in pump pressure, and volume of irrigation fluid. One hundred twenty-eight patients (mean age 56 years) were randomized. Mean visual clarity for the placebo, TXA, EPI, and TXA+EPI groups were 2.0 (±0.6), 2.0 (±0.6), 2.6 (±0.5), and 2.7 (±0.5), respectively (P<.001). The presence or absence of epinephrine was the most significant predictor of visual clarity (P<.001). Tranexamic acid presence or absence had no effect. No adverse events were recorded in any of the groups. Intravenous tranexamic acid is not an effective alternative to epinephrine in irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries, and there is no additive effect when both are used.

Resilience of Patients Undergoing Knee and Shoulder Arthroscopy Procedures.

Resilience is a person's capacity to overcome adversity. The purpose was to determine what patient factors correlate with resilience using the Brief Resilience Score. We hypothesize that characteristics of female sex, younger age, Workers' Compensation status, and preoperative opioid use are predictors of a lower preoperative resilience score and that patients with positive psychosocial factors would have higher resilience scores. Eight hundred nine patients undergoing knee or shoulder arthroscopy were preoperatively categorized into low, normal, and high-resilience groups. Preoperative patient-reported outcome measures (PROMs) and demographics were assessed. Statistical analyses evaluated differences in demographics and PROMs between resilience groups. Analysis disclosed notable differences between low, normal, and high-resilience groups regarding demographics and PROMs. High resilience was seen in older patients, male patients, and patients with positive psychosocial factors. Low resilience scores were discovered in Workers' Compensation patients and those with a history of preoperative opioid use. No difference in resilience scores was observed between smokers and nonsmokers. Preoperative resilience score is associated with age, sex, preoperative opioid use, Workers' Compensation status, and smoking status of patients undergoing knee or shoulder arthroscopy.

Risk factors for 30-day readmission following shoulder arthroscopy: a systematic review.

Recently, there has been a rapid shift from open shoulder surgery to arthroscopic shoulder procedures for treating several shoulder pathologies. This shift is mainly due to reduced postoperative complications and 30-day readmission. Although the 30-day readmission rate is low, the risk still exists. One way to minimize the risk factors is to analyze all the risk factors contributing to the 30-day readmission following shoulder arthroscopy. Electronic databases such as PubMed, Google Scholar, and Cochrane library were searched. Studies were selected based on predefined inclusion and exclusion criteria. Newcastle-Ottawa score was used for the quality assessment of individual studies. Two reviewers extracted data from the selected studies. Results were evaluated through narrative analysis and presented as an odds ratio with 95% confidence interval. A meta-analysis was not possible due to the heterogeneity in the available data. A total of 12 studies evaluating 494,038 patients were selected in our review. All the studies have a low risk of bias (median=8). Significant factors predicting readmission included age, gender, COPD (chronic obstructive pulmonary disorder), steroid use, smoking, preoperative opioid use, higher American Society of Anesthesiologists (ASA) score (3 or higher), and general and regional anesthesia vs. regional anesthesia alone. Through our systematic review, we tried to identify risk factors that can predict 30-day readmission following shoulder arthroscopy. These include age > 65 years, COPD, steroid use, opioid use, and OR time > 90 mins. These high-risk patients could be triaged earlier by identifying these parameters, and effective pre and post-operative surveillance could minimize 30-day readmission risk following shoulder arthroscopy.

Preoperative Corticosteroid Injections Within 4 Weeks of Arthroscopic Shoulder Procedures Are Associated With Increased Postoperative Infection Rates

To refine the understanding of the effect of timing of corticosteroid injections (CSIs) and shoulder arthroscopy on postoperative infection. An insurance database was used to determine all patients who underwent shoulder arthroscopy for a 5-year period with an associated preoperative ipsilateral corticosteroid injection. Patients were stratified into cohorts based on timing of preoperative CSI: (1) 0-<2 weeks, (2) 2-<4 weeks, (3) 4-<6 weeks, and (4) 6-<8 weeks. Patients were pooled to include all patients who had a CSI less than 4 weeks and those longer than 4 weeks. A cohort of patients who never had a corticosteroid injection before undergoing arthroscopy were used as a control. All patients had a follow-up of 2 years. Multivariable regression analyses were performed using R Studio with significance defined as P<.05. Multivariate logistic regression showed a greater odds ratio (OR) for postoperative infection in patients who received CSI 0-<2 weeks before shoulder arthroscopy at 90 days (3.10, 95% confidence interval [CI] 1.62-5.57, P<.001), 1 year (2.51, 95% CI 1.46-4.12, P < .001), and 2 years (2.08, 95% CI 1.27-3.28, P= .002) compared with the control group. Patients who received CSI 2-<4 weeks before shoulder arthroscopy had greater OR for infection at 90 days (2.26, 95% CI 1.28-3.83, P= .03), 1 year (1.82, 95% CI 1.13-2,82, P= .01), and 2 years (1.62, 95% CI 1.10-2.47, P=.012). Patients who received CSI after 4 weeks had similar ORs of infection at 90 days (OR 1.15, 95% CI 0.78-1.69, P=.48) 1 year (OR 1.18, 95% CI 0.85-1.63 P= .33), and 2 years (OR 1.09, 95% CI 0.83-1.42, P= .54), compared with the control cohort. The present study shows the postoperative infection risk is greatest when CSIs are given within 2 weeks of shoulder arthroscopy, whereas CSIs given within 2-<4 weeks also portend increased risk, albeit to a lesser degree. The risk of postoperative infection is not significantly increased when CSIs are given more than 1 month before surgery. Level III, retrospective comparative, prognosis study.

Poster 176: Distal Mononeuropathy and Nerve Release after Arthroscopic Shoulder Surgery: A Matched Cohort Analysis

Objectives: Following arthroscopic shoulder procedures such as total shoulder arthroplasties, reverse total shoulder arthroplasties, and rotator cuff repairs, select patients have presented with symptomatic distal mononeuropathy (DMN) that require follow-up nerve release procedure(s). This occurrence may be secondary to operative complications such as limb traction, surgical dissection, hematoma formation, or interscalene block placement. Separately, many patients presenting for impending shoulder procedures have been found to have preexisting DMN that similarly require nerve release for management. This retrospective cohort study aims to compare the clinical outcomes of a cohort of patients who underwent peripheral nerve release (cubital/carpal tunnel) for DMN following recent shoulder surgery to a cohort with no prior history of a shoulder procedure before DMN presentation. Methods: From 2010 to 2020, CPT codes were used to identify a cohort of patients over the age of 18 who underwent a shoulder procedure (rotator cuff repair, total shoulder arthroplasty, reverse total shoulder arthroplasty, and shoulder stabilization) and had an ensuing nerve release procedure for DMN (open or endoscopic cubital or carpal tunnel release) within 2 years of that surgery. A second cohort of patients who underwent a nerve release procedure for DMN presentation (open or endoscopic cubital or carpal tunnel release) with no prior history of shoulder surgery were identified using CPT codes and subsequently matched to the first cohort by age, sex, and BMI in a 3:1 (control: case) ratio. Following this, chart review and Redcap surveys were used to collect: demographics, surgical history, electromyography/nerve conduction velocity (EMG/NCV) results, post-operative symptoms (numbness, weakness, pain), and patient-reported outcomes (ASES, SANE, DASH). EMG/NCV results were categorized as Mild/Moderate/Severe based on standard practices. T-tests and Mann-Whitney tests were used for statistical analysis between the two groups with significance set at P &lt; .05. Results: 120 patients are included in this analysis (28 case, 92 control). There was no statistical difference between the groups for mean age at surgery, sex, or BMI . Patients with prior shoulder surgery before DMN presentation had a nerve release at an average of 0.81 ± 0.61 years after shoulder surgery. Mean follow-up time after nerve release for all patients in both cohorts was 4.91 ± 2.11 years. The most common nerve release for DMN across both cohorts was open carpal tunnel release (n=86), followed by endoscopic carpal tunnel release (n=22), open cubital tunnel release (n=16), and endoscopic cubital tunnel release (n=2). There was no statistical difference in preoperative EMG/NCV results between patients in the case group (39.3% mild, 32.1% moderate, 28.6% severe) compared to patients in the control group (29.3% mild, 47.8% moderate, 22.8% Severe) (P=0.125). There was no difference between groups for preoperative ASES, SANE, and DASH (P≥0.188), or for postoperative ASES, SANE, and DASH (P≥0.170). Following nerve release, patients in the case group were found to have significantly more post-operative numbness/tingling (42.9%) than patients in the control group (18.5%) (P=0.017). There was no difference between groups in postoperative pain (P=0.075) or weakness (P=0.156) [Figure 1]. Residual post-operative numbness following nerve release, was more likely to occur in the forearm for patients in the case group (21.4%) than patients in the control group (6.52% of patients) (P=0.032) [Figure 2]. Although not significant, 65.2% of patients in the case group reported complete resolution of symptoms following nerve release procedure compared to 50% of patients in the control group (P=.219). Conclusions: Patients with a history of shoulder surgery prior to presentation of DMN are more likely to experience persistent numbness or tingling after nerve release surgery than patients without a history of shoulder surgery. These patients are also more likely to experience symptoms located in the forearm. However, patient-reported outcomes between patients undergoing nerve release surgery with a history of shoulder surgery and those without are similar. Surgeons should be aware of these findings for improved patient education regarding post-operative prognosis.

Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors Have No Significant Relationship With Postoperative Arthrofibrosis After Shoulder Arthroscopy

To determine the effect of perioperative angiotensin II receptor blocker (ARB) or angiotensin-converting enzyme inhibitors (ACEi) on postoperative arthrofibrosis, as defined by requiring manipulation under anesthesia (MUA) or new diagnosis of adhesive capsulitis (AC) following arthroscopic shoulder procedures. Patients were retrospectively identified using Current Procedural Terminology surgical billing codes to identify patients who underwent any shoulder arthroscopic procedure at a single urban academic institution from 2012 to 2020 with a minimum 2-year follow-up. Patients were excluded if <30 years old at time of surgery, as these patients rarely use ARB and ACEi medications, or if they had pre-existing AC. Demographics, active medication prescriptions at the time of surgery, and medical comorbidities were recorded. Multivariable logistic regression was performed to determine the effect of ARB/ACEi on subsequent MUA or AC by 90 days, 1 year, and 2 years. In total, 5,559 patients were included in the final analysis. A majority of the cohort (53.4%) underwent arthroscopic surgery between the ages of 50 to 69 years. Most patients were male (61.8%) and without obesity (67.3%). In total, 18.9% and 15.0% were taking an ARB or ACEi medication perioperatively, respectively. Within 2 years' postoperatively, 51 patients (0.9%) underwent subsequent ipsilateral MUA, and 174 patients (3.1%) developed AC. Patients taking ARBs had a 17.5% rate of postoperative arthrofibrosis within 2-years compared with 19.1% in those not on ARBs, although this difference was not significant (P= .58). Likewise, no significant difference was found between those taking ACEi versus not (15.0% vs 15.0%, P= .99). Individual generic ARB/ACEi subgroup analysis did not demonstrate any significant associations with rate of postoperative arthrofibrosis (P > .05). ARBs or ACEi did not significantly affect the rate of postoperative arthrofibrosis following shoulder arthroscopy, however female sex, diabetes mellitus, and Black/African American race were associated with an increased rate of necessitating MUA or developing AC within 2 years postoperatively. Level III, retrospective cohort study.

The Incidence of Carpal Tunnel Syndrome Diagnosis Increases after Arthroscopic Shoulder Surgery

Arthroscopic shoulder surgery has been identified as a potential risk factor for carpal tunnel syndrome (CTS). The purposes of this study were as follows: to (1) examine the percentage of patients who underwent arthroscopic shoulder procedures and later developed ipsilateral CTS within 1 year of the procedure, (2) determine the percentage of those patients with CTS who subsequently underwent an injection or release, and (3) examine comorbidities associated with developing CTS after surgery. Patients who underwent arthroscopic rotator cuff repair (RCR), labral repair, or biceps tenodesis were retrospectively identified in a national database. Within 1 year, we compared the rates of ipsilateral CTS diagnoses versus the contralateral side. The rates of comorbidities between those who did and did not develop CTS were also compared. Within 1 year, arthroscopic RCR patients (1.47% vs 1.00%; odds ratio [OR], 1.48; P < .001) and arthroscopic labral repair patients (0.76% vs 0.52%; OR, 1.47; P < .001) had a significantly higher rate of ipsilateral carpal tunnel diagnosis versus contralateral side diagnosis. Arthroscopic RCR patients were also significantly more likely to have ipsilateral carpal tunnel injection (0.16% vs 0.11%; OR, 1.45; P < .001) and release (0.46% vs 0.37%; OR, 1.24; P < .001). Patients who had an ipsilateral carpal tunnel diagnosis following arthroscopic RCR and labral repair were both significantly older (both P < .001), a higher percentage of women (both P<.001), and more likely to have had a preoperative nerve block (both P < .05). Both cohorts had significantly higher mean Elixhauser comorbidity Index (P < .001) and more comorbidities. This study demonstrated a significantly higher incidence of operative side CTS within 1 year following arthroscopic RCR and labral repairs. Arthroscopic RCR was also demonstrated to result in significantly higher rates of injections and carpal tunnel release. The cohort that developed ipsilateral CTS was older, had higher percentage of women, and had more comorbidities. Prognostic III.

Unanticipated costs associated with interscalene nerve catheters for shoulder surgery.

Regional anesthesia has become a mainstay of analgesia following shoulder arthroscopic and reconstructive procedures. Local anesthetic can be injected in the perineural space of the brachial plexus by a single shot or continuously by an indwelling catheter. Although previous studies have compared efficacy and direct cost of single shot to catheters, few have evaluated unanticipated costs of ongoing care or complications. Pulmonary complications can lead to unexpected admissions and emergency department visits. The purpose of the study was to identify unplanned hospital admissions or emergency department visits related to regional anesthesia after shoulder surgery and determine the additional associated costs. A series of 1888 shoulder surgeries were identified in 1856 unique patients at a single, large academic center. As part of an interscalene nerve catheter program, a continuous interscalene block (CIB) was given to 1728 patients, whereas 160 patients had a single-shot interscalene block (SSIB). A hospital-employed quality control nurse contacted all patients receiving a CIB at 1, 2, 7, and 14 days following surgery. All emergency department visits and readmissions were recorded, and the associated billing charges were reviewed for the inpatient and any outpatient visits immediately preceding or immediately following the readmission. The regional average Medicare fee schedule was used to determine a cost for these episodes of care. Of the 1728 patients who had CIB, 10 patients were readmitted following open or arthroscopic surgery or presented to the emergency department in the immediate postoperative period for pulmonary compromise. No patient in the SSIB group had an emergency department visit or readmission. The average age of the 10 patients with readmission was 60 years (7 females, 3 males). The majority were diagnosed with hypoxemia on admission (R09.02). Length of stay during readmission ranged from 0 to 4 days, with 1 patient requiring admission to the intensive care unit. The average cost of admission to the hospital or visit to the emergency department was $6849 (range, $1988-$19,483). These costs were primarily related to chest radiographs and electrocardiogram (9/10), chest computed tomography (CT) with contrast (3/10), and head CT (2/10). Although uncommon, unanticipated pulmonary complications after CIB can result in significant cost compared to SSIB. The indirect costs of pulmonary workup after readmission or emergency department workup may be overlooked if only considering direct costs, such as medication charges, medical supplies, and physician fees.

Interscalene block applied by an experienced anesthesiologist has a good anesthetic effect, a long duration of action, and less postoperative pain after arthroscopic shoulder procedures independent of surgery type and operation duration.

This study aims to evaluate the severity of postoperative pain and the time to the onset of pain after arthroscopic surgical treatment of rotator cuff tear or instability under interscalene block. Between October 2015 and June 2016, a total of 172 patients (82 males, 90 females; mean age: 47.9±16.9 years; range, 15 to 83 years) who underwent shoulder arthroscopy under interscalene block by a single surgeon were retrospectively analyzed. The relationship between the postoperative 24-h Visual Analog Scale (VAS), the time to the onset of pain with the type of surgical procedure (rotator cuff repair, n=101 or instability surgery, n=71), and the duration of surgery (<30 min n=92; ≥30 min n=80) was examined. No significant relationship was found between the type of surgical procedure, VAS scores, and the onset of pain after the block (p=0.577 and p=0.780, respectively). No significant relationship was found between the operation duration, and VAS, and the onset of pain after the block (p=0.570 and p=0.408, respectively). The mean duration until the start of postoperative pain was 734±313 (range, 60 to 1,440) min. There was no statistically significant difference in the need for rescue analgesics at the postoperative 24th h and the duration of surgery between the two groups (p=0.393 and p=0.675, respectively). Our study results show no significant difference in the time for the onset of postoperative pain and the VAS scores according to the characteristics of the surgical procedure, operation duration, or age and sex of the patient. Shoulder arthroscopy performed by experienced surgeons under interscalene block eliminates the need for analgesics within the first 12 h postoperatively.

Removal of Hydrus® microstent due to uveitis-glaucoma-hyphema syndrome.

Regional anesthesia has become a mainstay of analgesia following shoulder arthroscopic and reconstructive procedures. Local anesthetic can be injected in the perineural space of the brachial plexus by a single shot or continuously by an indwelling catheter. Although previous studies have compared efficacy and direct cost of single shot to catheters, few have evaluated unanticipated costs of on-going care or complications. Pulmonary complications can lead to unexpected admissions and emergency room visits. The purpose of the study was to identify unplanned hospital admissions or emergency room visits related to regional anesthesia after shoulder surgery and determine the additional associated costs.A series of 1888 shoulder surgeries were identified in 1856 unique patients at a single large academic center. As part of an interscalene nerve catheter program, a continuous interscalene block (CIB) was given to 1728 patients; whereas, 160 patients had a single shot interscalene block (SSIB). A hospital-employed quality control nurse contacted all patients receiving a CIB at one, two, seven, and fourteen days following surgery. All emergency room visits and readmissions were recorded, and the associated billing charges were reviewed for the inpatient and any outpatient visits immediately preceding or immediately following the readmission. The regional average Medicare fee schedule was used to determine a cost for these episodes of care.Of the 1728 patients who had CIB, ten patients were readmitted following open or arthroscopic surgery or presented to the emergency department in the immediate postoperative period for pulmonary compromise. No patient in the SSIB group had an emergency room visit or readmission. The average age of the ten patients with readmission was 60 years (7 females, 3 males). The majority were diagnosed with hypoxemia on admission (R09.02). Length of stay during readmission ranged from 0 to 4 days with one patient requiring admission to the ICU. The average cost of admission to the hospital or visit to the emergency room was $6,849 (range, $1,988 to $19,483). These costs were primarily related to chest X-Rays and EKG (9/10), chest CT with contrast (3/10), and head CT (2/10).Although uncommon, unanticipated pulmonary complications after CIB can result in significant cost compared to SSIB. The indirect costs of pulmonary workup after readmission or emergency room work-up may be overlooked if only considering direct costs, such as medication charges, medical supplies, and physician fees.

Paper 16: The Use of Intravenous Tranexamic Acid Does Not Improve Arthroscopic Visualization in Shoulder Surgery: A Randomized Controlled Trial

Objectives: Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon’s visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is an effective alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. Methods: The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. Unweighted means (SD) were calculated for visualization and mean arterial pressure (MAP) for each patient. Study group allocation was represented with epinephrine and tranexamic acid being coded in dichotomous variables (used or not used) for each patient. A step-wise linear regression was performed using visualization as the dependent variable and a series of independent variables considered for inclusion: epinephrine, tranexamic acid, surgery duration, complexity, mean arterial pressure, increase in pump pressure, and volume of irrigation fluid. All statistical tests were considered significant if p&lt;0.05. Results: One-hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Figure 1 presents the patient flow through the study. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p&lt;0.001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p&lt;0.001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Conclusions: Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone. [Figure: see text]

Improving visualization in shoulder arthroscopy.

Arthroscopic shoulder procedures are one of the most common procedures used to restore function through minimally invasive techniques. With the demand for shoulder arthroscopic procedures comes the need for safe, effective, and efficient surgery that maximizes patient outcomes while minimizing complications. Many variables contribute to visualization in shoulder arthroscopy including vascular anatomy, blood pressure control, arthroscopic pump systems, turbulence control, epinephrine, and tranexamic acid. Furthermore, patient positioning can have a dramatic effect on visualization with both the beach chair position and lateral decubitus positioning having various strengths and weaknesses depending on the intended procedure being performed. The purpose of this review is to examine the benefits and complications reported in the literature for improving visualization in shoulder arthroscopy.

Opportunity to Perform – Should Simulation-Based Surgical Training be Provided on Demand or on Supply?

Introduction The aim of the study was to assess the surgical case volume of residents before and after simulation-based training in hip fracture surgery provided on demand versus knee and shoulder arthroscopy provided on supply. Materials and Methods A retrospective analysis of surgical case volume in hip fracture surgery and arthroscopic shoulder and knee procedures 90 days before and after simulation-based training of either procedure. Sixty-nine orthopedic residents voluntarily participating in either simulation-based training. Hip fracture surgery simulation was provided on supply, ie, whenever 1–2 residents applied for the course, while the arthroscopic simulation course was supplied twice yearly. Results Thirty-four residents participated in hip fracture simulation on demand and 35 residents participated in arthroscopic simulation on supply. The surgical case volume of hip fracture osteosynthesis increased from median 2.5 (range: 0–21) to median 11.5 (1–17) from 90 days before to the 90 days after the simulation-based training on demand. The median difference was 6.5 procedures (p &lt; 0.0003). On the contrary, the surgical case volume in shoulder and knee arthroscopy was low both before and after the simulation on supply, ie, median 2 (0–22) before and median 1 (0–31) after. The median difference was 0 (p = 0.21). Conclusions Simulation on demand was associated with increased opportunities to perform in the clinical environment after the simulation-based training compared with simulation on supply. Simulation-based training should be aligned with the clinical rotation of the residents. Simulation on demand instead of supply on fixed dates may overcome this organizational issue of aligning training with the opportunity to perform.

Efficacy of surgeon-directed suprascapular and axillary nerve blocks in shoulder arthroscopy: a 3-arm prospective randomized controlled trial

The use of regional anesthesia in shoulder arthroscopy improves perioperative pain control, thereby reducing the need for opioids and their recognized side effects. Occasionally one type of block is not suitable for a patient's anatomy or comorbidities or requires a specially trained anesthetist to safely perform. The primary aim of this study is to compare the efficacy of 3 different nerve blocks for pain management in patients undergoing shoulder arthroscopy. A 3-arm, blinded, randomized controlled trial in patients undergoing elective, unilateral shoulder arthroscopic procedures between August 2018 and November 2020 was conducted at a single center. One hundred and thirty participants were randomized into 1 of 3 regional anesthesia techniques. The first group received an ultrasound-guided interscalene block performed by an anesthetist (US+ISB). The second group received an ultrasound-guided suprascapular nerve block and an axillary nerve block by an anesthetist (US+SSANB). The final group received a suprascapular nerve block without ultrasound and an axillary nerve block under arthroscopic guidance by an orthopedic surgeon (A+SSANB). Intraoperative pain response, analgesia requirements, and side effects were recorded. Visual analogue pain scores and opioid doses were recorded in the Post Anaesthesia Care Unit (PACU) and daily for 8 days following the procedure. Twelve patients withdrew from the study after randomization, leaving 39 participants in US+ISB, 40 in US+SSANB, and 39 in A+SSANB. The US+ISB group required significantly lower intraoperative opioid doses than US+SSANB and A+SSANB (P<.001) and postoperatively in PACU (P<.001). After discharge from hospital, there were no differences between all groups in daily analgesia requirements (P=.063). There was significantly more nerve complications with 6 patient-reported complications in the US+ISB group (P=.02). There were no reported differences in satisfaction rates between groups (P=.41); however, the A+SSANB group was more likely to report a wish to not have a regional anesthetic again (P=.04). The US+ISB group required lower opioid doses perioperatively; however, there was no difference between groups after discharge from PACU. The analgesia requirements between the US+ SSANB and A+ SSANB were similar intraoperatively and postoperatively. A surgeon-administered SSANB may be a viable alternative when an experienced regional anesthetist is not available.

Biomolecule-releasing bioadhesive for glenoid labrum repair through induced host progenitor cell responses.

Glenoid labral tears occur with repetitive dislocation events and are common injuries observed in shoulder arthroscopic procedures. Although surgery can restore shoulder anatomy, repair is associated with poor clinical outcomes, which may be attributed to the poor regenerative capability of glenoid labral fibrocartilage. Thus, this study was designed to assess whether in situ tissue regeneration via biomolecule-stimulated recruitment of progenitor cells is a viable approach for the regeneration of labral tears. We developed a click chemistry-based bioadhesive to improve labral repair and reduce local inflammatory responses due to trauma. Additionally, we previously identified the presence of progenitor cells in the human labrum, which can be recruited by platelet-derived growth factor (PDGF). Thus, we hypothesized that PDGF-releasing adhesives could induce the regenerative responses of progenitor cells at the injury site to improve labral healing. In a rat glenoid labral tear model, we evaluated the effect of PDGF-releasing adhesives on promoting progenitor cells to participate in labral tear healing. After 3 and 6 weeks, the labrum was histologically analyzed for inflammatory responses, progenitor cell recruitment, proliferation, and extracellular matrix (ECM) production (collagen and glycosaminoglycan). Our results showed that adhesives alone considerably reduced local inflammatory responses and labral tissue dissolution. PDGF-releasing adhesives significantly increased progenitor cell recruitment, proliferation, and ECM production. These results demonstrate that by accelerating autologous progenitor cell responses, PDGF-releasing adhesives represent a novel clinically relevant strategy to improve the healing of glenoid labral tears.

Buyer beware: analysis of changes to the 2021 Center for Medicare and Medicaid Services physician fee schedule for shoulder surgeons Medicare physician fee schedule changes

BackgroundBecause of budget neutrality rules in the United States Congress, the rates for reimbursable medical expenses with Medicare have been on a recent and consistent decline. The Center for Medicare and Medicaid Services (CMS) continued to proceed with cuts to the 2021 physician fee schedule. There has been an overall 3.3% decrease in the valuation of work relative value units per CMS guidelines. Conversely, CMS has increased the value of certain in office evaluation and management (E/M) services and changed the criteria for level of visit based on complexity of decision-making. The direct effects of these changes to shoulder and elbow surgeons are unknown. This study evaluates the effect of these changes in Medicare reimbursement from 2020 to 2021 among a group of high-volume shoulder and elbow surgeons. MethodsBilling data were queried for 9 fellowship-trained shoulder & elbow surgeons at a high-volume surgical practice from 2020 to 2021. Office-based E/M and surgical codes for shoulder arthroplasty and other common shoulder and elbow codes were used. We compared volume data and change to reimbursement using the 2020 and 2021 Medicare physician fee schedule. The impact of increased E/M billing levels using the new 2021 CMS criteria was also calculated and compared between years. ResultsComparing 2020 to 2021, there was a 18.7% decrease in level 3 visits (17,208 vs. 13,990) and a corresponding 371% increase in level 4 visits billed (1138 vs. 5362). Evaluating the overall impact of this shift on reimbursement from office-based E/M codes, there was a significant increase with an average of $57,954 per surgeon (range = $20,394-$118,916) for this group of 9 surgeons. However, surgical reimbursement for most commonly performed arthroscopic and open shoulder and elbow procedures decreased for 5 of 9 surgeons, with an average decrease of $13,015 (range = −$80,980 to $44,246). When arthroplasty reimbursements were combined with those for other common procedures, there was a decreased surgical reimbursement, totaling $117,135 for all surgeons combined. ConclusionIn this practice of 9 high-volume shoulder and elbow surgeons, a significant decrease in CMS reimbursement related to surgical procedural reimbursement from 2020 to 2021 was experienced. However, increasing the rates of E/M reimbursement and the augmented visit level rules helped offset and exceed the lost revenue from surgical procedures. Caution must be taken: this one time increase in office-based billing coupled with continued annual cuts to surgical procedure valuation is not a sustainable model moving forward. Level of EvidenceLevel IV; Retrospective Case Series; Economic Model.

Serious adverse event rates and reoperation after arthroscopic shoulder surgery: population based cohort study

ObjectiveTo provide clinicians and patients with accurate risk estimates of serious adverse events after common elective shoulder arthroscopic procedures, including reoperation within one year.DesignPopulation based cohort study.SettingHospital Episode Statistics for...