Orthopaedic Shoulder Research Articles

Orthopaedic Shoulder and Elbow Fellowship Directors in the United States Have Substantial Research Output but Lack Diversity

To investigate the characteristics of shoulder and elbow fellowship directors (FDs). FDs for shoulder and elbow fellowship programs in the United States were identified. Demographic, educational, and professional background data were collected from available curricula vitarum, institutional biographies, and the Scopus database. Data collected included age, sex, race/ethnicity, training locations, graduation years, advanced degrees, current institutional information, and personal research H-index. Thirty current orthopaedic shoulder and elbow FDs were identified. The mean Scopus H-index was 25.5. The mean age of FDs was 52.1 years. In total, 29 FDs (96.7%) were male and 1 (3.3%) was female. In addition, 25 of the 30 (83.3%) were White (83.3%), 4 were Asian, and 1 (3.3%) was Hispanic. Two (6.7%) had a military affiliation. Mean time from fellowship training graduation to FD appointment was 13.5 years. Mean number of years as FD was 6.1 years, whereas the number of years tenure with an FD-affiliated institution was 13.0 years. Mean calendar years for completion of orthopaedic residency training and fellowship training were 1998 and 2000, respectively. The residencies that produced the most future FDs were Hospital of the University of Pennsylvania (n= 2) and University of Nebraska Medical Center/Creighton University Health Foundation (n= 2). The fellowship that produced the most future FDs was Columbia University (n= 6). Moderate correlation was found between age and Scopus H-index (r= 0.48; P= .04) and years as FD and Scopus H-index (r= 0.42; P= .03). Women and minorities are under-represented in leadership positions in shoulder and elbow surgery. Shoulder and elbow FDs have the highest H-index of any subspecialty reported in the orthopaedic literature. Research productivity is an important qualification when considering the characteristics of shoulder and elbow FDs. Fellowship directors can have a profound influence on current and future orthopaedic surgeons. It is important to identify the traits that characterize current fellowship directors to have a better understanding of who we choose as leaders in our field.

Can deep learning reduce the time and effort required for manual segmentation in 3D reconstruction of MRI in rotator cuff tears?

Background/PurposeThe use of MRI as a diagnostic tool has gained popularity in the field of orthopedics. Although 3-dimensional (3D) MRI offers more intuitive visualization and can better facilitate treatment planning than 2-dimensional (2D) MRI, manual segmentation for 3D visualization is time-consuming and lacks reproducibility. Recent advancements in deep learning may provide a solution to this problem through the process of automatic segmentation. The purpose of this study was to develop automated semantic segmentation on 2D MRI images of rotator cuff tears by using a convolutional neural network to visualize 3D models of related anatomic structures.MethodsMRI scans from 56 patients with rotator cuff tears (T2 Linear Coronal MRI; 3.0T, 512 mm × 512 mm, and 2.5-mm slice thickness) were collected. Segmentation masks for the cuff tendon, muscle, bone, and cartilage were obtained by four orthopedic shoulder surgeons, and these data were revised by a shoulder surgeon with more than 20 years’ experience. We performed 2D and 3D segmentation using nnU-Net with secondary labels for reducing false positives. Final validation was performed in an external T2 MRI dataset (10 cases) acquired from other institutions. The Dice Similarity Coefficient (DSC) was used to validate segmentation quality.ResultsThe use of 3D nnU-Net with secondary labels to reduce false positives achieved satisfactory results, even with a limited amount of data. The DSCs (mean ± SD) of the cuff tendon, muscle, bone, and cartilage in the internal test set were 80.7% ± 9.7%, 85.8% ± 8.6%, 97.8% ± 0.6%, and 80.8% ± 15.1%, respectively. In external validation, the DSC of the tendon segmentation was 82.74±5.2%.ConclusionAutomated segmentation using 3D U-Net produced acceptable accuracy and reproducibility. This method could provide rapid, intuitive visualization that can significantly facilitate the diagnosis and treatment planning in patients with rotator cuff tears.

Malpractice against shoulder surgeons: what the data say.

Thousands of orthopedic surgeons in the United State face medical malpractice claims annually; however, little is known regarding the common causes for litigation against shoulder surgeons. In addition, the current analysis does not take into consideration how surgical frequency affects the litigation likelihood. The purpose of our investigation was to identify the most common causes of litigation against shoulder surgeons in the United States adjusting for surgical frequency. The VerdictSearch database was used using the search terms "medical malpractice," "shoulder," and "NOT cancer." Results were queried, and all studies pertaining to orthopedic shoulder surgery included. Data gathered included cause of lawsuit, indemnity paid, type of surgery performed, results of the cases, verdict or settlement, and, if applicable, technical error. A query of a multisurgeon institutional database was conducted to determine how frequently surgeries were performed. Then the frequency of litigation was adjusted by the procedure frequency to determine which surgery has the greatest likelihood to be litigated relative to rotator cuff surgery. Forty-five cases were included in our study. After adjusting for the procedure frequency, the most likely procedure to be litigated, relative to rotator cuff repair, was manipulation under anesthesia (MUA), 251 times more likely to be litigated, and washout/lavage procedures, 17 times more likely to be litigated. Injection and total shoulder arthroplasty were 23 and 14 times less likely to be litigated relative to rotator cuff repair, respectively. In addition, the average age of the patients was 47 years, and 53% of the cases involved a male plaintiff. The most commonly litigated procedures were rotator cuff repair (42%), MUA (13%), and humeral open reduction and internal fixation (9%). The most commonly cited symptoms for litigation against shoulder surgeons were pain (60%) and loss of range of motion (40%). Of the 45 cases, 44% ended in physician loss, with the average indemnity paid via verdict being $1,118,714 vs. $416,875 for settlement. This study identifies that MUA and lavage/washout procedures are much more likely to be litigated relative to rotator cuff repair. Rotator cuff repair is actually one of the least likely procedures to be litigated. Furthermore, settlement may represent a method of decreasing the indemnity paid for malpractice cases for which surgeons are implicated.

Business Articles in Shoulder and Elbow Surgery Support Outpatient Total Shoulder Arthroplasty and Identify Factors Impacting Surgery Cost

Objectives: Review business related shoulder and elbow articles in tope general orthopaedic journals and compare to top shoulder and elbow subspecialty journals. Design: Literature review. Intervention: General orthopaedic vs subspecialty journals. Main outcome measurement: Publication type, subject, methods Results: There were a total of 21 shoulder and elbow related business articles across JBJS, B&JJ, CORR, and AAOS during the study time period. That accounts for 0.3% of total publications (21/6098) and 8% of the business publications (21/261) in these journals over this 5 year span. Shoulder and elbow business publications accounted for a wide range of editorial space, ranging from 0% of CORR business publications to 11% of BJ&J publications. Across the five shoulder and elbow surgery journals of interest, there were 57 business related articles published for the 5-year duration. The Journal of Shoulder and Elbow Surgery accounted for 77% of these publications (44/57). Business articles represented 0.8% of articles in the fine shoulder and elbow publications (57/7155) over the study time period. Conclusions: This analysis demonstrates the tendency of shoulder and elbow oriented orthopaedic journals to publish a higher percentage of business articles related to shoulder and elbow surgery compared to general orthopaedics journal. The composition of these business articles demonstrates the recent focus on cost analysis of outpatient shoulder arthroplasty as well as factors that drive cost of shoulder and elbow procedures. The subject of shoulder and elbow business related articles in these journals over the last 5 years demonstrates that this field is increasingly interested in outpatient procedures and identifying ways to safely improve cost efficiency. Level of Evidence: IV review Keywords: Orthopaedic business, shoulder and elbow, cost, value based care, finance, shoulder arthroplasty, total shoulder. (J Ortho Business 2022; Volume 2, Issue 3:pages 18-31)

Factors influencing surgical management of proximal humerus fractures: do shoulder and trauma surgeons differ?

Proximal humerus fractures (PHFs) are managed with open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), or nonoperatively. Given the mixed results in the literature, the optimal treatment is unclear to surgeons. The purpose of this study was to survey orthopedic shoulder and trauma surgeons to identify the patient- and fracture-related characteristics that influence surgical decision-making. We distributed a 23-question closed-response email survey to members of the American Shoulder and Elbow Surgeons and Orthopaedic Trauma Association. Questions posed to respondents included demographics, surgical planning, indications for ORIF and arthroplasty, and the use of surgical augmentation with ORIF. Numerical and multiple-choice responses were compared between shoulder and trauma surgeons using unpaired t-tests and χ2 tests, respectively. Respondents included 172 shoulder and 78 trauma surgeons. When surgery is indicated, most shoulder and trauma surgeons treat 2-part (69%) and 3-part (53%) PHFs with ORIF. Indications for managing PHFs with arthroplasty instead of ORIF include an intra-articular fracture (82%), bone quality (76%), age (72%), and previous rotator cuff dysfunction (70%). In patients older than 50 years, 90% of respondents cited a head-split fracture as an indication for arthroplasty. Both shoulder and trauma surgeons preferred RSA for treating PHFs presenting with a head-split fracture in an elderly patient (94%), pre-existing rotator cuff tear (84%), and pre-existing glenohumeral arthritis with an intact cuff (75%). Similarly, both groups preferred ORIF for PHFs in young patients with a fracture dislocation (94%). In contrast, although most trauma surgeons preferred to manage PHFs in low functioning patients with a significantly displaced fracture or nonreconstructable injury nonoperatively (84% and 86%, respectively), shoulder surgeons preferred either RSA (44% and 46%, respectively) or nonoperative treatment (54% and 49%, respectively) (P<.001). Similarly, although trauma surgeons preferred to manage PHFs in young patients with a head-split fracture or limited humeral head subchondral bone with ORIF (98% and 87%, respectively), shoulder surgeons preferred either ORIF (54% and 62%, respectively) or HA (43% and 34%, respectively) (P<.001). ORIF and HA are preferred for treating simple PHFs in young patients with good bone quality or fracture dislocations, whereas RSA and nonoperative management are preferred for complex fractures in elderly patients with poor bone quality, rotator cuff dysfunction, or osteoarthritis. The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research.

Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ?

Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons. An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics. A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P=.003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P=.412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P=.009). A greater proportion of trauma surgeons began passive range of motion (ROM) <2 weeks after 2-part fractures (70% vs. 41%, P<.001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P<.001) and 4-part fractures (65% vs. 43%, P=.020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of >12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of <6 weeks vs. no restrictions and >12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs. <2 weeks or >6 weeks for 2-part fractures, but not 4-part fractures. Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.

National and geographic trends in Medicare reimbursement rates for orthopedic shoulder and upper extremity surgery from 2000 to 2020.

There is a paucity of information regarding financial trends in orthopedic upper extremity surgery. If progress is to be made in advancing agreeable reimbursement models, a more comprehensive understanding of these trends is needed. The purpose of this study was to assess national and geographic trends in Medicare reimbursement rates for shoulder and elbow surgical procedures over the past 2 decades. The 10 most billed Common Procedural Terminology (CPT) codes for both orthopedic shoulder surgery and elbow/upper arm surgery were determined. Medicare reimbursement data for these CPT codes were compiled between 2000 and 2020 and adjusted for inflation. The percentage change for each procedure and the average change in reimbursement each year were analyzed. Data from 2000, 2010, and 2020 were organized by state. The total percent change in physician fee and the percent change per year were tabulated for each CPT code using inflation-adjusted data and averaged by state. From 2000 to 2020, when corrected for inflation, shoulder and elbow procedures decreased on average by 29.3% and 24.5%, respectively. Shoulder procedures experienced a greater numerical yet statistically insignificant decline in mean reimbursement percent decrease (P = .16), average percent decrease per year (P = .11), a more negative compound annual growth rate (P = .14), and a greater R-squared value as compared with elbow and upper arm procedures. For shoulder procedures, the average percent difference in inflation-adjusted Medicare reimbursement rates from 2000 to 2020 varied from -22.6% in Alaska to -34.1% in Michigan; division data varied from -27.8% in the Mountain Division to -31.2% in the East North Central Division; and region data varied from -28.3% in the West to -30.5% in the Northeast. For elbow and upper arm procedures, the average percent difference in inflation-adjusted Medicare reimbursement rates from 2000 to 2020 varied from -17.6% in Alaska to -29.8% in Michigan; division data varied from -23.0% in the Mountain Division to -26.7% in the East North Central Division; and region data varied from -23.5% in the West to -25.7% in the Northeast. Inflation-adjusted Medicare reimbursement in upper extremity surgery has decreased markedly between 2000 and 2020. The degree of decrease varies geographically. If access to quality and sustainable surgical orthopedic care is to persist in the United States, increased awareness of these trends is important. The trends identified in this study can serve to customize regional health care policymaking.

The reliability of the Neer classification for proximal humerus fractures: a survey of orthopedic shoulder surgeons.

BackgroundThe Neer classification is among the most widely used systems to describe proximal humerus fractures (PHF) despite the poor interobserver agreement. The purpose of this study was to verify whether or not blinded shoulder surgeons and trainees agree with the authors of articles published in the highest impact-factor orthopedic journals.MethodsAll articles regarding PHF published between 2017 and 2019 in the top 10 orthopedic journals as rated by impact factor were searched. Articles were included if the authors used the Neer classification to describe at least 1 PHF in the figures. Figures were extracted without the legend, and X-rays ± computed tomography scan images were included when available. An international survey was conducted among 138 shoulder surgeons who were asked to record the Neer classification for each de-identified radiograph in the publications. The type of fracture mentioned in the legend of the published figure was considered as the gold standard.ResultsSurvey participants agreed with the published article authors in 55% of cases overall (range 6%-96%, n = 35). The most common response disagreed with the article authors in 13 cases (37%), underestimating the number of parts in 11 of 13 cases. The interobserver agreement between the 138 responders was fair (k = 0.296). There was an association between the percentage of concordant answers and greater experience (number of years of shoulder surgery practice) of the responders (P = .0023). The number of parts, the number or type of available imaging modalities, and the geographic origin of participants did not influence the agreement between responders and authors.DiscussionIn more than one-third of cases, specialized shoulder surgeons disagree with article authors when interpreting the Neer classification of de-identified images of PHF in published manuscripts. Morphologic classification of PHF as the sole basis for treatment algorithms and surgical success should be scrutinized.

Radial shock-wave therapy for frozen shoulder patients with type 2 diabetes mellitus: a pilot trial comparing two different energy levels.

Extracorporeal shock-wave therapy (ESWT) is highly recommended for the management of orthopedic shoulder pathologies. Yet, the clinical relevance of the dose difference effect of radial ESWT approaches in the management of frozen shoulder patients with type 2 diabetes mellitus remains uncertain. The aim was to examine the short-term effects of medium-and high-energy levels of radial ESWT (rESWT) in the treatment of frozen shoulder patients with type 2 diabetes mellitus. Prospective clinical pilot study. This study was conducted in an outpatient clinic. Thirty-nine patients who had frozen shoulder untreated for at least 3 months, diagnosed with type 2 diabetes mellitus for ≥3 years were included. The patients were randomly allocated to receive either high-energy rESWT (hrESWT), or medium-energy rESWT (mrESWT) or placebo at 8 Hz twice a week for six weeks. The primary outcome measure was pain, evaluated by the Visual Analog Scale (VAS) Score. Secondary outcome measures were function evaluated by the Shoulder Pain and Disability Index (SPADI) Score, and shoulder active range of motion (AROM). The mechanical properties of the deltoid and trapezius muscles were assessed using the MyotonPRO (Myoton AS, Tallinn, Estonia). The mrESWT resulted in statistically significant reductions in night pain at 6 weeks (η<inf>p</inf>2=0.27, P=0.003). Significantly improved function (SPADI scores: -35.42±21.29 vs.-29.59±22.60; η<inf>p</inf>2=0.39, P˂0.001) was found in both hrESWT and mrESWT group by 6 weeks. Significantly higher mean shoulder AROM values were recorded for external rotation (η<inf>p</inf>2=0.53, P<0.001), and internal rotation (η<inf>p</inf>2=0.21, P=0.020), in the hrESWT group at the 6th week. A significantly improved resting tone (η<inf>p</inf>2=0.58) and stiffness of deltoid muscle (η<inf>p</inf>2=0.62) were found in the mrESWT group (P<0.001). The trapezius muscle resting tone reduced with hrESWT (η<inf>p</inf>2=0.17, P=0.033). Regardless of the energy levels, rESWT appears to be an effective therapeutic intervention for frozen shoulder patients with type 2 diabetes mellitus in the short-term results. Our results suggest that this rESWT can be a useful strategy for the rehabilitation of frozen shoulder patients with type 2 diabetes mellitus. This is the first study on dose difference effectiveness in terms of the clinical significance of rESWT which is key to transfer research evidence into practice.

How Should Antibiotics Be Used in Primary and Revision Hip and Knee Arthroplasty? An Introduction

Joint arthroplasty is a highly successful surgical treatment for symptomatic arthritis of the hip and knee. Despite excellent pain relief and prosthesis survival of approximately 90% at 20 years, complications occur [[1]Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)Hip, Knee & Shoulder Arthroplasty: 2021 Annual Report. AOA, Adelaide2021: 1-432https://aoanjrr.sahmri.com/annual-reports-2021Google Scholar]. Deep periprosthetic joint infection (PJI) is among the top 2 causes of failure around the world after primary and revision, hip and knee replacement at both short-term and long-term follow-up [1Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)Hip, Knee & Shoulder Arthroplasty: 2021 Annual Report. AOA, Adelaide2021: 1-432https://aoanjrr.sahmri.com/annual-reports-2021Google Scholar, 2Meyer J.A. Zhu M. Cavadino A. Coleman B. Munro J.T. Young S.W. Infection and periprosthetic fracture are the leading causes of failure after aseptic revision total knee arthroplasty.Arch Orthop Trauma Surg. 2021; 141: 1373-1383Crossref PubMed Scopus (9) Google Scholar, 3Le D.H. Goodman S.B. Maloney W.J. Huddleston J.I. Current modes of failure in TKA: infection, instability, and stiffness predominate.Clin Orthop Relat Res. 2014; 472: 2197-2200Crossref PubMed Scopus (183) Google Scholar]. In distinction to many other problems, such as dislocation and polyethylene wear that can be directly influenced by improvements in surgical technique and prosthesis design, surgeons may find it more frustrating to reduce surgical site infections. It is important to remember that appropriate use of prophylactic antibiotics, introduced over 50 years ago, remains the single most effective intervention available [[4]Burke J.F. The effective period of preventive antibiotic action in experimental incisions and dermal lesions.Surgery. 1961; 50: 161-168PubMed Google Scholar]. In our well-intentioned pursuit of completely eliminating PJI we can sometimes fall victim to the more is better philosophy. Indeed, over the past few years we have seen the introduction of new delivery methods, dosing schedules, and adjunctive products that encourage us to expand our use of prophylactic antibiotics without conclusive evidence. Additionally, our own success has led us to implement change before results from level 1A studies are available. Although PJI remains a persistent concern, the absolute rate of PJI after hip and knee arthroplasty remains low. Consequently, proving the value of new interventions remains problematic due to the large number of patients and extended follow-up duration required for definitive studies [[5]Thompson K.M. Oldenburg W.A. Deschamps C. Rupp W.C. MD Smith C.D. Chasing zero: the drive to eliminate surgical site infections.Ann Surg. 2011; 254: 430-436Crossref PubMed Scopus (65) Google Scholar]. Furthermore, the distinctions among prophylactic, treatment, and suppressive use of antibiotics have become blurred at times. It is important to remember that overuse of antibiotics has potentially significant consequences including the emergence of antibiotic resistance at the individual and societal levels, and individual patient side effects that can have serious consequences, such as acute kidney injury and allergic reaction [[6]Kheir M.M. Dilley J.E. Ziemba-Davis M. Meneghini R.M. The AAHKS clinical research award: extended oral antibiotics prevent periprosthetic joint infection in high-risk cases: 3855 patients with 1-Year follow-up.J Arthroplasty. 2021; 36: S18-S25Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar]. In this series of papers, drawn from presentations from the AAHKS Annual Meeting Symposium: Antibiotic Use in Primary and Revision Total Hip and Knee Arthroplasty, we will discuss the most effective uses of antibiotics before, during, and after surgery in order to reduce deep PJI. Each paper, authored by an expert in the field, will summarize the published data and clinical guidelines pertinent to the topic and distill the information to pragmatic advice that is ready for use in your practice. Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for Clarke

Retention Stitches: A Concept of Wound Closure of Knee Arthroplasty in Obese Patients.

Knee joint arthroplasty is a commonly performed procedure. However, number of obese patients undergoing total knee arthroplasty is on a rise. In such cases, post closure using routine techniques, there have been an increasing number of cases of wound dehiscence and complications like persistent discharge and delayed healing. To overcome this problem, the author has come up with an innovative technique in closure. 27 patients, who were obese, were included in the study and operated at Orthopaedic Arthroscopic Knee and Shoulder clinic. The patients were evaluated pre operatively clinically and planned for retention stitches for closure. Same technique was followed for closure in all the patients. Suture removal was done at 2weeks and patients were followed up for a period of 6months for any complications. In 27 patients undergoing retention stitches post total knee arthroplasty, patients were followed up for a mean period of 14months, with minimum being 6months and maximum being 5years. Patients showed no complications such as wound dehiscence, discharge, localised skin necrosis or cut-through of stitches. Retention stitches in knee arthroplasty is an innovative, ideal, yet easily replicable method of wound closure in obese patients, especially with BMI > 30 (Obesity grade 1 or more). Patients undergo better and uneventful wound healing, which is of paramount importance in a surgery like this. In all these patients, the rehabilitation post surgery is also similar to the other patients, hence not affecting the outcome. The online version contains supplementary material available at 10.1007/s43465-021-00596-y.

High Patient Satisfaction with Examination by Advanced Practice Physiotherapists in an Orthopaedic Outpatient Shoulder Clinic: A Cross-Sectional Study Using Quantitative and Qualitative Methods.

Purpose: To evaluate patients' satisfaction with being examined and diagnosed in an orthopaedic outpatient shoulder clinic, determine whether a difference exists between levels of satisfaction among patients examined by advanced practice physiotherapists (APPs) and orthopaedic surgeons (OSs), and explore patients' experiences with being examined by APPs. Method: One hundred and thirty-three patients participated in a cross-sectional questionnaire study using the Visit-Specific Satisfaction Instrument (VSQ-9). Primary outcome was satisfaction with "The visit overall" (item 9). Nine patients participated in semi-structured interviews, which were thematically analyzed. Results:There was no significant difference in satisfaction with "The visit overall" between patients examined by an OS (median: 75, 1st-3rd quartiles: 75-100) and an APP (median: 100, 1st-3rd quartiles: 75-100). The VSQ-9 total score was not significantly different between groups, but some items regarding direct interaction with the health provider were scored significantly higher in the APP group. Patients were particularly satisfied with APPs' ability to explain during the consultation. Conclusions: The results showed high levels of satisfaction with examinations performed by both OSs and APPs with no difference between groups concerning "The visit overall." From a patient perspective, the results support the use of APPs to examine and diagnose selected patients in an orthopaedic outpatient shoulder clinic.

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

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. 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. 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. 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.

Patients' perception of physical therapy after shoulder surgery.

BackgroundFormal physical therapy (PT) traditionally has been a critical part of postoperative recovery, but recently, because of cost containment, coverage of PT has become limited. Alternatives to formal PT have been proposed, including telerehabilitation, internet-based PT (IBPT), and home-based physician-guided PT. The purpose of this study was to understand patient perceptions of PT, the benefits, perception of improvements, access to PT, and alternative forms of PT after shoulder surgery.MethodsEighty patients who underwent orthopedic shoulder surgery were anonymously surveyed at one institution. Demographics, PT access, number of PT sessions, insurance, copayment, patients’ perceptions of improvement, and their opinion about IBPT were collected. Answers were designed using Likert-scale or open-ended questions. Descriptive statistics were used to report survey data. Analyses were performed based on demographic variables using independent t-test, chi-square tests, and analysis of variance.ResultsPatients attended an average of 16.3 ± 13.8 PT sessions, with 65% ± 32.2 attributing average improvement to their sessions. Average copay was $18 ± 20.8 per session, which 56.1% agreed was reasonable. Almost all patients (94.8%) agreed their therapist took time to educate them. Half (52.5%) disagreed that successful PT could be achieved by IBPT, and 68.6% of patients responded they would not consider using IBPT even after a few in-person sessions.ConclusionPatients have a positive perception of their therapist, cost, number of sessions, and utility of PT to impact improvements after orthopedic shoulder surgery. For IBPT to be a viable alternative, it should involve close engagement of a physical therapist given patients’ perceptions of PT.

Comparative Studies in the Shoulder Literature Lack Statistical Robustness: A Fragility Analysis

PurposeEvidenced-based decision-making is rooted in comparative clinical studies; however, a small number of outcome event reversals have the potential to change study significance. The purpose of this study was to determine the utility of applying fragility analysis to comparative studies in the published orthopaedic shoulder literature.MethodsComparative clinical shoulder research studies reporting 1:1 dichotomous categorical data were analyzed in 6 leading orthopaedic journals between 2006 and 2016. Statistical significance was defined as a P value of less than .05. The fragility index (FI) for each study outcome was determined by the number of event reversals required to change the P value to either greater or less than 0.05, thus changing the study conclusions. The associated fragility quotient (FQ) was determined by dividing the FI by the total population comprising a particular outcome.ResultsOf the 23,897 studies screened, 3,591 met search criteria, with 198 comparative studies ultimately included for analysis, 67 of which were randomized controlled trials. There were 357 total outcome events with 74 reported as significant and 283 as not significant. The FI was 4 (IQR 2-6) with an associated FQ of 0.066 (interquartile range [IQR] 0.038-0.102). There was no difference in statistical fragility between randomized and nonrandomized trials with both revealing a FI of 4 and FQ of 0.068 (IQR 0.044-0.107) and 0.065 (IQR 0.031-0.101), respectively.ConclusionsThis current analysis reveals that comparative shoulder studies published in six leading orthopaedic journals are at risk of statistical fragility. As such, contemporary clinical shoulder literature may not be as robust as traditionally perceived with the reversal of only a few outcome events required to change study significance. Therefore, we advocate the reporting of both FI and FQ in addition to the P value as statistical complements to all comparative investigations to provide a more comprehensive understanding of trial stability and significance in the published shoulder literature.Clinical RelevanceComparative study designs are commonly employed in shoulder research. Several studies in both the general medical and orthopaedic literature have identified a lack of statistical robustness through comprehensive fragility analysis. Our findings demonstrate the P value may be an inadequate independent statistical metric requiring the complement of a FI and FQ to aid in the interpretation and understanding of study significance for clinical decision-making.

Concept and simulation of an alternative design for an orthopaedic shoulder implant

For a first-time glenohumeral arthritis patient, total shoulder arthroplasty (TSA) is an option where the shoulder joint is replaced with an artificial humeral head that articulates against a cup attached to the glenoid. A patient with rotator cuff deficiency can undergo reverse total shoulder arthroplasty (RTSA) where the components are switched. Presented here is a concept design at simulation stage which offers a platform-based implant where either a system can be assembled and implanted for TSA or a reverse system for RTSA. Platform components and the glenoid baseplate have been designed as part of this concept stage. Modular components are also described as part of the concept, which can influence a patient’s range of motion (ROM), as well as the effect of implant positioning within the patient. A 42 mm hemisphere is used as the articulating component providing a good balance between ROM, joint load and deltoid force. The most suitable material concluded for the concept design TSA was as follows: grade 5 Ti–6Al–4V for the humeral stem and baseplate and CoCrMo with cross-linked polyethylene (XLPE) for the metal-on-polymer bearing surface. Finite element analysis concluded that the concept prosthesis is able to withstand an impact force of six times bodyweight from a forward fall. A dynamic fatigue test concluded that the expected lifetime of the concept polymer bearing surface is 33 years.

Patients prefer physician-provided durable medical equipment over third-party vendors: a patient satisfaction survey

Background: The purpose of the study was to compare patient satisfaction between patients receiving durable medical equipment (DME) at home from a third-party vendor versus directly from their physician’s office. Methods: A prospective 10-question patient satisfaction survey study was provided to 66 consecutive adult patients who met the inclusion criteria of receiving DME after orthopaedic shoulder or knee surgery using either an in-office (n=31 patients) or third party (n=35 patients) DME delivery program. Survey questions were graded on a 1 to 5 Likert scale that assessed the ease of obtaining DME, comfort with delivery method, ease of scheduling fitting, education about DME use and postoperative instructions, concerns about cost, and satisfaction with overall care. Categorical questions evaluated preference of same-day delivery method, patient perceived adequacy of answering of all DME-related questions, and whether cryotherapy was utilized postoperatively. Results: All patients (100%; 31 of 31) who received DME in-office reported they would use the same program for their next DME delivery. Six (17.1%; 6 of 35) patients who received DME from a third-party vendor preferred to use the same method in the future (P=0.0001). Scheduling DME fittings was easier in the in-office setting compared with a third-party vendor (P=0.05). Conclusions: Patients receiving their DME in the office from their physician were significantly more likely to prefer using the in-office setting again and reported fit-scheduling to be easier when compared with patients using a third-party vendor. DME can be provided by physicians in the office setting without negatively impacting patient satisfaction. Level of Evidence: Level II.

Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement: A Pragmatic, Double-Blind Randomized Controlled Trial (SExSI Trial)

Background: A strong recommendation against subacromial decompression surgery was issued in 2019. This leaves nonoperative care as the only treatment option, but recent studies suggest that the dose of strengthening exercise is not sufficient in current nonoperative care. At this point, it is unknown if adding more strengthening to current nonoperative care is of clinical value. Purpose: To assess the effectiveness of adding a large dose of shoulder strengthening to current nonoperative care for subacromial impingement compared with usual care alone. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In this double-blinded, pragmatic randomized controlled trial, we randomly allocated 200 consecutive patients referred to orthopaedic shoulder specialist care for long-standing shoulder pain (>3 months), aged 18 to 65 years and diagnosed with subacromial impingement using validated criteria, to the intervention group (IG) or control group (CG). Outcome assessors were blinded, and participants were blinded to the study hypothesis as well as to the treatment method in the other group. The CG received usual nonoperative care; the IG underwent the same plus an add-on intervention designed to at least double the total dose of shoulder strengthening. The primary outcome was the Shoulder Pain and Disability Index (SPADI; 0-100) at 4-month follow-up, with 10 points defined as the minimal clinically important difference. Secondary outcomes included shoulder strength, range of motion, health-related quality of life, and the Patient Acceptable Symptom State (PASS). Results: Intention-to-treat and per-protocol analyses showed no significant or clinically relevant between-group differences for any outcome. From baseline to 4-month follow-up, SPADI scores improved in both groups (intention-to-treat analysis; IG, –22.1 points; CG, –22.7 points; between-group mean difference, 0.6 points [95% CI, –5.5 to 6.6]). At 4 months after randomization, only 54% of the IG and 48% of the CG (P = .4127) reached the PASS. No serious adverse events were reported. Conclusion: Adding a large dose of shoulder strengthening to current nonoperative care for patients with subacromial impingement did not result in superior shoulder-specific patient-reported outcomes. Moreover, approximately half of all randomized patients did not achieve the PASS after 4 months of nonoperative care, leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem. Registration: NCT02747251 (ClinicalTrials.gov identifier)

The impact of state-mandated opioid prescribing restrictions on prescribing patterns surrounding reverse total shoulder arthroplasty.

BackgroundOrthopedic surgeons are the third-highest prescribers of opioid medications, and the recent opioid crisis has placed more scrutiny on physicians and their prescribing habits. House Bill 21, a new law limiting the prescription of opioid medications, was signed in Florida on July 1, 2018 and similar laws have been passed in a number of other states as well. The purpose of this study was to understand the effect of new legal mandates on opioid prescribing patterns and dependence rates for patients undergoing reverse shoulder arthroplasty.MethodsA retrospective review of 143 patients who underwent primary reverse shoulder arthroplasty from 2017 to 2019 was performed. There were 87 patients in the pre-legislation group (group 1), compared to 56 in the post-legislation group (group 2). Demographics data and opioid prescriptions provided 90 days before and after surgery were obtained using the physician drug monitoring database. Descriptive statistics and Student's t-tests were used to examine differences.ResultsPreoperatively, both groups received similar numbers of pills and total morphine equivalents (TMEs; group 1: 47.3 pills and 59.9 TMEs, group 2: 30.9 pills and 24.8 TMEs) (P = .292, P = .081). Group 1 had 88.5% of patients fill an opioid prescription postoperatively, compared to 50.9% of group 2 (P < .001). Postoperatively, initial opioid prescriptions were higher in average pills for group 1 (26 pills with an average of 375.6 TMEs) compared to group 2 (18 pills with an average of 199.6 TMEs) (P < .001, P = .122). For the entire postoperative course, patients in group 1 filled prescriptions for an average of 1740.7 TMEs and 84 pills, compared to 461.9 TMEs and 32 pills in group 2 (P = .035, P < .001). In the cohort, 17.8% of group 2 had multiple recorded opioid prescriptions, compared to 70.1% of group 1. There were also significant differences observed in postoperative dependence rates, with 23.0% in group 1 compared to 12.5% in group 2 (P = .043).ConclusionsState-mandated opioid prescribing restrictions have been successful in decreasing opioid prescribing and dependence rates for orthopedic shoulder patients. Further efforts are required to reduce preoperative prescriptions involving chronic shoulder pathology as current legislature has not had an impact on this. Legislative changes may be an effective way to help reduce abuse and opioid dependence in shoulder arthroplasty patients; however, further research is needed.

Trends in the most cited articles in shoulder surgery, 1900–2019

BackgroundOur purpose was to identify the 100 most cited articles in the shoulder surgery literature published in past decade and to compare them with the 100 most cited “classic” shoulder surgery articles to identify trends in the topics of shoulder research. MethodsUsing the term “shoulder,” we searched the Clarivate Analytics’ Web of Science Core Collection database for 2 periods: 2010 through 2019 (“contemporary group,” n = 12,394) and 1900 through 2009 (“classic group,” n = 8790). We used the database sort function to order articles by number of citations. Titles, abstracts, and, when necessary, full text were screened to determine relevance to orthopedic shoulder topics until the 100 most cited articles were determined for each group. We analyzed the following article characteristics: title, author(s), publication year, journal, geographic origin, article type (clinical vs basic research), study design, and level of evidence (for clinical articles). P < .05 was considered significant. ResultsThe 3 journals with the most articles in the contemporary group were the American Journal of Sports Medicine (AJSM) (28%), the Journal of Shoulder and Elbow Surgery (JSES) (28%), and the Journal of Bone and Joint Surgery, American volume (JBJS Am) (23%). The top 3 journals in the classic group were JBJS Am (45%), AJSM (16%), and JSES (15%). The 3 most frequent topics in the contemporary group were rotator cuff tear (43%), instability (14%), and fractures (10%); those in the classic group were pathoanatomy (29%), rotator cuff (28%), and instability (17%). Compared with the classic group, the contemporary group had more articles on outcomes of common shoulder procedures, including rotator cuff repair (25% vs. 17%), arthroplasty (21% vs. 15%), arthroscopy (17% vs. 11%), reverse shoulder arthroplasty (13% vs. 7%), and the Latarjet procedure (7% vs. 2%). More articles reporting complications were found in the contemporary (9%) than in the classic (2%) group (P = .03). The contemporary group contained articles on topics not found in the classic group, such as platelet-rich plasma (8%), scaffolds (3%), infection (3%), Cutibacterium acnes (2%), stem cells (2%), superior capsular reconstruction (2%), bony increased offset reversed shoulder arthroplasty (2%), opioid issues (1%), and tendon transfer (1%). ConclusionThe most cited studies from 1900 to 2009 and 2010 to 2019 reported on the rotator cuff and shoulder instability. The most cited articles from 2010 to 2019 reflect the development of shoulder arthroscopy, shoulder arthroplasty, treatment of surgical complications, and augmentation or biologic interventions for rotator cuff repair. Level of evidenceLevel IV; Review Article