Undergoing Shoulder Surgery Research Articles

Reply to Letter to the Editor: "Correlation Between Patient-reported and Clinician-measured Shoulder Range of Motion in Patients Undergoing Shoulder Surgery".

Reply to Letter to the Editor: "Correlation Between Patient-reported and Clinician-measured Shoulder Range of Motion in Patients Undergoing Shoulder Surgery".

Cross-cultural adaptation and test-retest reliability assessment of a Swedish version of the exercise adherence rating scale in patients after shoulder surgery

Background Adherence to prescribed home exercise is an important predictor for the long-term effectiveness of exercise therapy and therefore important to evaluate. The Exercise Adherence Rating Scale (EARS) is a valid and reliable tool to assess exercise adherence behavior, but it is not translated into Swedish. This study aimed to translate EARS into Swedish and to explore the psychometric properties in terms of test-retest reliability, internal consistency as well and possible floor-/ceiling effects. Materials and Methods A translation and cultural adaptation process followed international guidelines and resulted in EARS-Sv. A total of 30 patients who had undergone shoulder surgery were included in the study and filled out EARS-Sv at two different time points. The test-retest reliability was evaluated through the weighted kappa coefficient and Intraclass Correlation Coefficient (ICC). Cronbach’s alpha was used to assess internal consistency. Floor-/ceiling effects were calculated. Results The test–retest reliability of the questionnaire was good with ICC (0.79, CI 95%) and moderate with weighted kappa-coefficient (MD= 0.58). Cronbach’s alpha was considered good (0.88). A ceiling effect was registered in all 6 items of EARS-Sv. Conclusion EARS-Sv has moderate to good test-retest reliability and good internal consistency in patients who have undergone shoulder surgery.

Osteoporosis Management for Shoulder Surgeons.

The aim of this review is to aggregate currently available literature as it pertains to treating surgical shoulder pathology in patients with osteoporosis. Emerging data surrounding perioperative use of anti-osteoporosis medications for patients undergoing shoulder surgery have not shown definitively favorable or unfavorable outcomes. Similar evaluations in animal studies have shown promising results as a biologic augment to tendon and bone healing, especially with newer, anabolic agents. The mainstay of bone health management remains pre-operative evaluation, using opportunistic radiographic and CT based validated measurements, along with optimization of risk factors. Surgical techniques continue to incorporate implants that perform well in osteopenic bone. Promising pre-clinical studies have identified anabolic anti-osteoporosis medications as viable biologic augments to shoulder surgery, which has not been borne out in any clinical studies at this time.

United States opioid prescribing trends after shoulder surgery and their correlation with opioid misuse

BACKGROUNDOrthopedic surgery has been highlighted as a contributor to the opioid epidemic. There is a paucity of literature focused specifically on opioid prescribing trends following shoulder surgery. Our aims were to describe national and regional trends in opioid prescribing following total shoulder arthroplasty (TSA), proximal humerus fracture fixation, and rotator cuff repair (RCR), and to correlate opioid prescribing trends after shoulder surgery with regional heroin use and new opioid misuse diagnoses. METHODSThis is a retrospective study of 218,577 patients from a commercial insurance dataset who had undergone orthopedic shoulder procedures from 2014-2020. Opioid prescription data within 90-day postop were converted to morphine milligram equivalents (MME). Multivariate modelling was used to evaluate independent associations between MME’s prescribed and subsequent new postoperative diagnosis of opioid dependence. Additionally, longitudinal mixed effects modeling was employed to understand aggregated prescriber habits by state over time and the subsequent effects on estimates of state heroin use and drug overdose deaths. RESULTSFrom 2014 to 2020, the mean number of MMEs prescribed nationally decreased by over 50% for TSA, proximal humerus fracture fixation, and RCR. Over the study period, most states demonstrated an overall downtrend of 90-day opioid prescribing for these procedures.Individuals with a new opioid misuse diagnosis following shoulder surgery were found to be younger (SMD=0.27, p<0.001), have increased comorbidities (SMD=0.38, p<0.001), and increased MME’s prescribed (SMD=0.94, p<0.001). Increased comorbidity score (OR=3.28, p<0.001) and increased 90-day MME’s prescribed (OR=1.05, p<0.001) were all found to increase the odds ratio of a postoperative opioid misuse diagnosis in patient’s undergoing shoulder surgery, while increased age (OR=0.97, p<0.001) and patient’s undergoing RCR (OR=0.79, p=0.001) were found to have a decreased odds ratio of developing a new opioid misuse diagnosis.The predictors of regional heroin use included the within-state 90-day MMEs prescribed (p=0.002). The predictors of drug overdose death included year (p<0.001), but did not include type of surgery or 90-day MMEs. CONCLUSIONOrthopedic surgeons successfully reduced the number of opioids prescribed nationally after shoulder surgeries by over 50% during our study period with similar trends seen at the state level. Our data indicate a relationship between increased opioid prescribing after shoulder surgery and heroin use. This study highlights that while progress has been made, there is evidence that opioid prescribing following shoulder surgery is associated with the more widespread opioid epidemic, and that more research is needed to further lower postoperative opioid misuse in the future.

Cryo-Pneumatic Compression Results in a Significant Decrease in Opioid Consumption After Shoulder Surgery: A Multicenter Randomized Controlled Trial.

The management of pain after shoulder surgery typically includes the use of cryotherapy and the prescription of opioid analgesics. Much focus has been placed lately on the opioid epidemic, which in part is fueled by excessive prescription of opioid medication. Previous studies have found a combination of cryotherapy and compression effective at reducing analgesic consumption and increasing recovery in patients undergoing knee and spine surgery; however, efficacy in patients undergoing shoulder surgery has not been evaluated. To evaluate the effectiveness of a cryo-pneumatic compression device on postoperative shoulder pain, narcotic use, and quality of life when compared with standard care cryotherapy. Randomized controlled trial; Level of evidence, 2. In total, 200 patients older than 18 years scheduled for unilateral shoulder surgery were enrolled. Patients were randomized to receive either postoperative cryo-pneumatic compression or standard care. The intervention group received a cryo-pneumatic device, while the standard care group received the treating surgeon's preferred method of postoperative care, including standard cryotherapy. Narcotic use was evaluated by the number of oral morphine milligram equivalents consumed during the postoperative period, as well as the time to cessation of narcotic use. Patient-reported outcome measures consisted of a numeric rating scale pain score, 36-item Short Form Survey, patient experience assessed using the net promoter score, and adverse events. Outcomes were evaluated at 2, 6, and 12 weeks postoperatively. Patients receiving cryo-pneumatic compression reported a significant decrease in opioid consumption when compared with standard care (oral morphine milligram equivalents median, 56.1 vs 112; P = .02468). A significant increase in self-reported function was seen in the cryo-pneumatic compression group at 2 weeks when compared with standard care (mean, 61.2 vs 54.2; P = .0412). In patients undergoing unilateral shoulder surgery, the use of cryotherapy with pneumatic compression, when compared with standard care, resulted in significantly decreased opioid consumption as well as increased function at 2 weeks. NCT04185064 (ClinicalTrials.gov identifier).

Ultrasound Guided Subscapularis and Subomohyoid Plane Blocks versus Interscalene Block with Levobupivacaine for Analgesia in Shoulder Surgery

Abstract Background Now Shoulder surgery is a common procedure, particularly as it is associated with reduced hospitalization times, even though the technique may lead to moderate and severe postoperative pain. In recent years, various studies have been carried out that demonstrated the need for valid anaesthetic techniques that allow adequate control of postoperative pain and also favour early mobilization and rehabilitation. Subscabularis and subomohyoid plane blocks allow pain control after shoulder surgery while decreasing the need of opioids and pain medication after surgery. In contrast to interscalene brachial plexus block, subscabularis and subomohyoid plane blocks carry minor risks of intrathecal injection or post operative respiratory distress. Aim of the Work to compare analgesic efficacy of ultrasound guided subomohyoid and subscapularis plane blocks versus interscalene block using levobupivacaine in both techniques for pain control after shoulder surgery. Patients and Methods This exploratory randomized clinical trial study was conducted in Ain Shams University hospital after approval of the anesthesia department and the local ethics and research committee over 6 months and after obtaining a written informed consent. Sixty patients underwent shoulder surgery under general anesthesia were included in the study their ages range between 21 and 65 years old and classified as ASA I and II. The patients were randomly divided using computer generated randomization and opaque sealed envelopes into two groups 30 patients in each (n = 30). Results In this study we find that combined subscapularis plane and sub-omohyoid injections may serve as an alternative to interscalene block for shoulder analgesia, with less complications. The present study shows no difference in the demographic data between the two groups (p-value &amp;gt;0.05). Also there was no statistically significant difference in the surgery duration between the two groups. But the duration of subomohyoid and subscapularis plane block was longer than the duration of interscalene block, the Mean± SD is (10.80±2.64 minutes) for subomohyoid and subscapularis plane blocks while interscalene block duration is (5.33±1.56 minutes) so there was astatically significant difference P-value &amp;lt;0.001. Conclusion Subscapularis plane and subomohyoid plane blocks can be used as an alternative shoulder analgesia with minor risks.

Correlation between the optimal screening for prediction of referral and outcome yellow flag tool and patient-reported legacy outcome measures in patients undergoing shoulder surgery

BackgroundThe Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) Tool is a 10-item multidimensional screening tool utilized to evaluate pain-related psychological traits in individuals with musculoskeletal pain conditions. The validity of postoperatively collected OSPRO-YF is unclear. This study sought to assess validity of the OSPRO-YF by comparing it to PRO scores in both pre- and postoperative settings. HypothesisThe authors hypothesized that OSPRO-YF overall score would correlate with shoulder and global function PROs at pre- and postoperative timepoints. MethodsA review of 101 patients undergoing shoulder surgery by one sports medicine orthopedic surgeon at a large academic institution was conducted. 90 and 54 patients had complete pre- and postoperative PRO responses. OSPRO-YF, American Shoulder and Elbow Surgeons Evaluation Form (ASES), and Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) were routinely administered before and after surgery at the senior author’s clinic visits. Concurrent validity of OSPRO-YF at either timepoint was assessed by comparing scores with PROs cross-sectionally using Pearson correlations and multiple comparison corrections. ResultsPreoperatively, higher OSPRO-YF total score was associated with greater concurrent PROMIS-CAT Pain Interference (r=0.43; p<0.01) and Depression (r=0.36; p=0.05) and lower ASES (r=-0.34; p<0.01). Higher postoperative OSPRO-YF was also associated with greater concurrent PROMIS-CAT Pain Interference (r=0.43; p<0.01) and Depression (r=0.36; p<0.01) and lower ASES (r=-0.34; p=0.01). ASES had strong correlation with SANE and Pain scores at both pre- and postoperative timepoints. SANE was not significantly associated with OSPRO-YF total score or number of YFs at either timepoints. ConclusionThe study findings support the clinical validity of the 10-item OSPRO-YF tool when administered before or after shoulder surgery. For patients exhibiting suboptimal recovery or those identified as high risk at initial screening, assessment of pain-related psychological distress postoperatively may be particularly beneficial in guiding rehabilitation.

Paper 06: Lower Socioeconomic Status is Associated with Recurrent Shoulder Instability Before Surgical Shoulder Stabilization

Objectives: Social determinants of health (SDOH) are comprised of a patient’s environmental conditions including social and economic factors, which influence access to health care and resources. Growing evidence in orthopaedic surgery has revealed that SDOH factors lead to differential access to care and ultimately health disparities after surgery. For shoulder instability, previous literature has demonstrated that the number of previous dislocations before a stabilization procedure increases the risk of recurrent instability after the procedure. The purpose of this study was to investigate the impact of SDOH on the number of dislocation events before surgical intervention. Methods: A retrospective review of patients who underwent shoulder stabilization surgery at a health system in a large metropolitan area between January 1, 2021 and April 13, 2023 were identified. Patients’ demographic and social determinants variables were extracted using the electronic medical record. Social Vulnerability Index (SVI) socioeconomic subscore and Area of Deprivation Index (ADI) were collected using online mapping data based on patient zip codes. The number of dislocation events and the time they occurred were determined using clinical charts. Operative variables collected included the date of surgery to determine the time from clinical presentation to surgery and the procedure performed. Univariate linear regression analysis was used to evaluate potential predictors of increasing time to presentation and increasing time to surgery. Univariate logistic regression analysis was also performed of all potential predictors of having &gt;1 dislocation event. A multivariate model was then created using all predictors with a P value &lt; 0.05 in the univariate models. Results: There were 106 patients who underwent shoulder surgery for instability, including arthroscopic and open stabilization, and had complete social determinant data, with 54% (n = 57) identifying as White, 29% (n = 31) as Black/African American, and 17% (n = 18) as other. A total of 38 (35.8%) patients suffered 1 dislocation (single dislocation cohort) before undergoing surgery, and 68 (64.2%) experienced &gt; 1 dislocation (recurrent cohort) before surgery. No significant variables were associated with increasing time to presentation or surgery. Univariate logistic regression revealed that decreasing age (odds ratio [OR] 0.94 [95% confidence interval (CI) 0.89- 0.99]; P = 0.02), decreasing body mass index (BMI) (OR 0.90 [95% CI 0.83-0.98]; P = 0.02), increasing SVI (OR 1.21 [95% CI 1.05-1.38]; P = 0.006), and increasing area deprivation index (ADI) (third tercile compared to first, OR 6.04 [95% CI 2.05-17.8]; P = 0.003) were associated with increased odds of having &gt; 1 instability event before surgical intervention. There was no association with race found in terms of number of dislocations before surgery. Multivariate logistic regression modeling revealed that decreasing BMI (OR 0.87 [95% CI 0.78-0.98]; P = 0.02) and increasing ADI (third tercile compared to first tercile, OR 7.46 [95% CI 1.26-44.2]; P = 0.02) were associated with increased odds of having &gt; 1 instability event before shoulder instability surgery. Conclusions: Lower socioeconomic status, as measured by ADI, is an independent predictor of a higher likelihood of recurrent instability before shoulder stabilization surgery. Recognizing these relationships may motivate surgeons to create pathways to prevent these treatment disparities among shoulder instability patients. Further studies are required to examine if these SDOH variables lead to disparities in postoperative outcomes.

Correlation Between Patient-Reported and Clinician-Measured Shoulder Range of Motion in Patients Undergoing Shoulder Surgery.

There has been increasing interest in remote measures of patients' health, both in the clinical and research settings. This study sought to evaluate correlations between patient-reported and clinician-measured (CM) shoulder range of motion (ROM). ROM measures including elevation, abduction, and internal rotation were recorded by a patient-reported picture-based survey and clinician measurement during each patient visit. A total of 13,842 visits over a 16-year period met inclusion criteria. Spearman correlation was performed to determine the correlation between patient-reported and CM elevation, abduction, and internal rotation. A subgroup analysis was conducted to evaluate motion in patients who underwent arthroplasty and arthroscopy. Patients were 52.4% male with a median age of 67 years (range, 18 to 96). PR and CM shoulder ROM were gathered at 13,842 patient visits. Strong correlations between PR and CM elevation (r = 0.70) and internal rotation (r = 0.66) were found, as well as a moderate correlation between PR and CM abduction (r = 0.59). Strong correlations were found between all three PR and CM measures of motion in the arthroplasty subgroup (elevation r = 0.74, abduction r = 0.63, and internal rotation r = 0.64). There is a strong correlation between patient-reported and CM shoulder elevation and internal rotation, as well as a moderate correlation between PR and CM abduction. This allows for a method of assessing patient motion without requiring an in-person visit. Level III Retrospective Cohort Study.

Assessing changes in regional cerebral hemodynamics in adults with a high-density full-head coverage time-resolved near-infrared spectroscopy device.

Cerebral oximeters have the potential to detect abnormal cerebral blood oxygenation to allow for early intervention. However, current commercial systems have two major limitations: (1)spatial coverage of only the frontal region, assuming that surgery-related hemodynamic effects are global and (2)susceptibility to extracerebral signal contamination inherent to continuous-wave near-infrared spectroscopy (NIRS). This work aimed to assess the feasibility of a high-density, time-resolved (tr) NIRS device (Kernel Flow) to monitor regional oxygenation changes across the cerebral cortex during surgery. The Flow system was assessed using two protocols. First, digital carotid compression was applied to healthy volunteers to cause a rapid oxygenation decrease across the ipsilateral hemisphere without affecting the contralateral side. Next, the system was used on patients undergoing shoulder surgery to provide continuous monitoring of cerebral oxygenation. In both protocols, the improved depth sensitivity of trNIRS was investigated by applying moment analysis. A dynamic wavelet filtering approach was also developed to remove observed temperature-induced signal drifts. In the first protocol ( years; five females, five males), hair significantly impacted regional sensitivity; however, the enhanced depth sensitivity of trNIRS was able to separate brain and scalp responses in the frontal region. Regional sensitivity was improved in the clinical study given the age-related reduction in hair density of the patients ( years; 14 females, 13 males). In five patients who received phenylephrine to treat hypotension, different scalp and brain oxygenation responses were apparent, although no regional differences were observed. The Kernel Flow has promise as an intraoperative neuromonitoring device. Although regional sensitivity was affected by hair color and density, enhanced depth sensitivity of trNIRS was able to resolve differences in scalp and brain oxygenation responses in both protocols.

Minimal important clinical difference values are not uniformly valid in the active duty military population recovering from shoulder surgery

There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of 2 different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operating characteristic (ROC) curve-based MCIDs and baseline-adjusted ROC curve MCIDs. All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROM battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Patient Reported Outcome Management Information System (PROMIS) physical function (PF), PROMIS pain interference (PI), and the Warfighter Readiness Survey. Standard anchor-based and baseline-adjusted ROC curve MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval [CI] either completely negative or positive). A total of 117 patients (136 operations) were identified, comprising 83% males with a mean age of 35.7±10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC curve MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC curve MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7. When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC curve analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC curve method was more effective at discerning changes across a battery of PROMs among the same cohort.

Midterm Outcomes of Surgical Reconstruction and Spontaneous Recovery of Upper-Extremity Paralysis Following Acute Flaccid Myelitis.

Acute flaccid myelitis (AFM) is a disabling, poliomyelitis-like illness that mainly affects children. Although various surgical interventions are performed for intractable paralysis due to AFM, the timing of surgery and its long-term outcomes have yet to be established, especially for shoulder reconstruction. This study aimed to analyze the midterm outcomes of nonsurgically and surgically treated upper-extremity AFM and the factors influencing shoulder functional outcomes after surgical reconstruction. We retrospectively examined 39 patients with AFM in 50 upper extremities between 2011 and 2019. The degree of spontaneous recovery of completely paralyzed muscles was evaluated at a median of 3, 6, and 37 months after the onset of paralysis. Twenty-seven patients with 29 extremities underwent surgery involving nerve transfer, muscle-tendon transfer, or free muscle transfer for shoulder, elbow, and hand reconstruction. Patients with complete paralysis of shoulder abduction at 6 months did not show later recovery. Twenty-two patients with 24 extremities underwent shoulder surgery, and all but 1 were followed for at least 24 months after surgery. Although postoperative shoulder abduction recovery was similar between transfer of the spinal accessory nerve and of the contralateral C7 nerve root to the suprascapular nerve, the outcomes obtained with spinal accessory nerve transfer had more variability, likely related to latent spinal accessory nerve paralysis, shoulder instability related to pectoralis major paralysis, and the type of paralysis. Shoulder abduction recovery was also greatly affected by scapulothoracic joint movement. In contrast, the outcomes of the elbow flexion and hand reconstructions were more consistent and acceptable. All patients had loss of shoulder abduction, and restoration of shoulder function was less predictable and depended on the quality of the donor nerves and recovery of the synergistic muscles. Strict donor nerve selection and additional nerve transfer for shoulder reconstruction are imperative for satisfactory outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Opioid use and disposal at 2 weeks post-surgery: Brief communication regarding excess opioids and disposal habits.

To measure the number of unused prescription opioids and disposal habits of patients following orthopedic shoulder surgery. A prospective observational study. Academic orthopedic sports medicine department. Sixty-seven patients undergoing shoulder surgery. Nine-question opioid use questionnaire. Responses to an opioid use questionnaire were collected at 2 weeks post-surgery. Outcomes of interest included the amount of initial opioid prescription used and the disposal of excess opioids. Sixty-seven patients completed the opioid use questionnaire. Forty-six (68.7 percent) patients reported having excess opioids at 2 weeks. Of the 46 patients with excess opioids, 57 percent disposed of the excess, and 43 percent planned to keep their opioids. Two-thirds of the patients reported having excess opioids, highlighting the issue of an overabundance of unused prescription opioids in America. Utilization of opioid-free pain management strategies and drug disposal kits should be explored to reduce the number of unused and improperly disposed opioids.

Impact of Resident Involvement on 30-Day Postoperative Outcomes in Orthopedic Shoulder Surgery.

The literature concerning resident involvement in shoulder surgery is limited. The purpose of this study was to examine whether resident involvement across all orthopedic shoulder surgeries is associated with adverse 30-day outcomes. Utilizing the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent shoulder surgery with or without a resident present were analyzed. Independent t-test and chi-square or Fischer's exact test were used appropriately. A logistic regression model was used to calculate adjusted odds ratios. This study examined 5,648 patients: 3,455 patients in the "Attending alone" group and 2,193 in the "Attending and resident in the operating room" group. Resident presence in the operating room was not associated with increased complications, except for bleeding transfusions (OR 1.71, CI 1.32-2.21, P ≤ 0.001). This study demonstrates that resident involvement in orthopedic shoulder surgery does not present an increased risk for 30-day complications when compared to surgeries performed with the attending surgeon alone.

The effect on the incidence of rebound pain of the application of anterior suprascapular nerve block added to interscalene brachial plexus block for shoulder surgery: A randomized controlled study

This study aimed to compare the incidence of rebound pain applied with anterior suprascapular nerve block (ASSB) added to interscalene brachial plexus block (ISB) as postoperative analgesia in shoulder surgery. This prospective, observer-blinded, randomized study involved 60 patients who were to undergo shoulder surgery. The patients were divided into two groups: group ISB (n=30) received ISB block, while group ISB+ASSB (n=30) received ASSB in addition to ISB. The primary outcome was to determine the occurrence of rebound pain. Secondary outcomes were numerical rating scale (NRS) values of postoperative pain at 6, 8, 12, 16, 18, 24, and 48 hours, 48-hour opioid consumption, sleep scale for the postoperative night and subsequent 6 nights, and the quality of recovery (QoR) scale evaluated on postoperative days 1 and 7. No statistically significant difference was found between the ISB group (56.7%) and the ISB+ASSB group (40%) in the incidence of rebound pain following the resolution of peripheral nerve block (PNB) (p=0.196). The ISB+ASSB group had a significantly longer time to PNB wear off (14.77±2.07 ) compared to the ISB group (12.87±1.94) (p=0.001). The postoperative day 1 QoR-15 values were significantly better in the ISB+ASSB group (122.60±10.79) than in the ISB group (116.33±11.48) (p=0.031). Sleep evaluation on the postoperative night showed a significant difference between the groups; ISB+ASSB (3[2-3])–ISB (2[1-3]). The addition of ASSB to ISB did not have a sufficient effect with respect to the incidence of postoperative rebound pain following shoulder surgery. However, there was seen to be a positive effect on prolonging the PNB and on the QoR day 1 values.

Osteoporosis in the setting of rotator cuff repair: A narrative review

Osteoporosis and osteopenia are frequently found in patients undergoing shoulder surgery, especially rotator cuff repair, and it is anticipated that this link will become more common as more elderly people have operations on their shoulders. For orthopedic surgical candidates who are at high risk, preoperative screening may identify those who might benefit from early intervention and prevent any associated adverse events. The major complications include repair failure and revision surgery. Antiresorptive medication preoperatively has shown good results in vivo. However, when used in the clinical setting, the efficacy remains controversial. Surgical management may include repair augmentation and placing the anchors in the posteromedial part of the greater tuberosity. Level of evidence IV.

Chronological changes in the rate of surgical field contamination in the shoulder joint

BackgroundIn shoulder surgery, low-virulence bacteria such as Cutibacterium acnes and coagulase-negative staphylococci can cause postoperative infection. However, the degree of sterility during surgery after disinfection is not known, and the efficacy of double skin preparation for such bacteria is unclear. This study aimed to evaluate chronological changes in the surgical field contamination rate in the shoulder joint and to compare single and double skin preparation. MethodsIn total, 126 shoulders in 121 patients undergoing shoulder surgery (64 men, 62 women; mean age 64 years) were enrolled. Patients were divided into two groups: single skin preparation, where the site was painted with 10% povidone iodine, and double skin preparation, where the site was treated with 1% chlorhexidine gluconate/83% isopropyl alcohol and painted 10% povidone iodine. Swab samples from the axillary and proximal areas in the surgical field were collected chronologically before starting surgery and at 30, 60, and 120 min after starting surgery (MAS). The contamination rate of each sample was compared and detected species were evaluated. ResultsThe contamination rate for the axillary area was 48.4%, 85.9%, 95.3%, and 97.1% in the single-preparation group and 32.3%, 72.6%, 87.1%, and 91.2% in the double-preparation group before starting surgery and 30, 60, and 120 MAS, respectively, and that the proximal area was 12.5%, 26.6%, 29.7%, and 35.3% in the single-preparation group and 16.1%, 19.4%, 27.4%, and 38.2% in the double-preparation group, respectively. Significant differences were not seen between the groups by area or time point. Most detected species were Cutibacterium acnes and coagulase-negative staphylococci. ConclusionsThe incidence of surgical field contamination in shoulder joint was high from immediately after starting surgery. In the axillary area, the contamination rates exceeded 70% from 30 MAS in both groups. Measures against infection should be instituted considering these findings when performing shoulder surgery.

Risk factors of liposomal bupivacaine failure in managing postoperative pain following shoulder surgery

BackgroundAmidst a national opioid crisis, increased focus has been placed on reducing opioid consumption. Novel multimodal pain protocols including the use of liposomal bupivacaine (LB) have shown success in minimizing opioid usage after orthopedic surgery. There is disputing evidence of the effectiveness of LB use in shoulder surgery and the purpose of our study was to analyze the risk factors and determinants of LB failure for postoperative pain control after orthopedic shoulder surgeries. MethodsA retrospective review of 121 patients undergoing shoulder surgery treated by 2 fellowship-trained shoulder surgeons at a single institution was performed from 2018-2020. All patients received a standardized multimodal pain management protocol that included an LB interscalene block. Local infiltration of LB was also administered at closure. Visual analog scales (VASs) were administered at 24, 48, 72 hours, and 7 days postoperatively. LB failure was defined as visual analog scale score >7 any time within the 7-day postoperative period. Twenty-one patients were included in the liposomal bupivacaine failure (LBF) group and 100 in the liposomal bupivacaine success (LBS) group. Patient demographics, pain scores, and opioid consumption were compared between groups. ResultsBaseline characteristics were comparable, except the LBF cohort had a greater proportion of females (P = .03). The LBF group had 20% of patients with a history of chronic opioid use compared to none in the LBS group (P = .003). Logistic regression showed strong and independent associations between failure of LB and performing surgeon, chronic opioid use, gender, and history of prior surgery. Patients in the LBF group had an average of 20 total morphine equivalents 7-14 days following surgery compared to 0 total morphine equivalents (P = .002) in the LBS group, and an average of 2.9 opioid prescriptions within the first 6 months compared to 1.7 in the LBS group (P = .028). ConclusionPerforming surgeon, gender, history of opioid use, and prior surgeries were all identified as strong, independent predictor variables of LB failure. In this study, performing surgeon is likely indicative of the impact of differences in patient education on postoperative pain expectations and alternate treatments. We recommend that surgeons incorporate further preoperative patient education, and to take into account, the specific risk factors when deciding to incorporate LB into their multimodal postoperative pain management plan for patients undergoing shoulder surgery.

A High Rate of Return to Running Is Seen After Both Arthroscopic and Open Shoulder Surgery

To determine the percentage of patients who report the ability to run 1 mile at various time points after arthroscopic and open shoulder surgery. We performed a retrospective review of prospectively collected data for all active-duty military patients aged 18 to 45 years who underwent shoulder surgery at a single institution over a 2-year period. The rehabilitation protocol discouraged running before 3 months, but all patients were able to return to unrestricted running at 3 months postoperatively. Patients were excluded if they lacked 1-year follow-up data. Parameters collected included demographic information and validated patient-reported outcome measures at the preoperative and short-term postoperative visits, as well as patients' ability to run at least 1 mile postoperatively. A total of 126patients were identified who underwent shoulder surgery with return-to-running data. Compared with baseline, significant improvements in patient-reported outcomes were shown at 1 and 2 years postoperatively (P= .001). The percentage of patients reporting the ability to run 1 mile postoperatively was 59% at 3 months, 74% at 4.5 months, 79% at 6 months, 83% at 12 months, and 91% at 24 months. There was no significant difference in patients undergoing shoulder surgery for instability versus non-instability diagnoses or in patients undergoing open versus arthroscopic anterior stabilization. All 11 patients unable to return to running at final follow-up had chronic lower-extremity diagnoses limiting their running ability. Young military athletes undergoing arthroscopic and open shoulder surgery have a high rate of early return to running. Approximately 60% of patients report the ability to run 1 mile at 3 months postoperatively, and three-quarters of patients do so at 4.5 months. Age, sex, military occupation, underlying diagnosis or type of surgery did not influence the rate of return to running after shoulder surgery. Level IV, therapeutic case series.

Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction: early experience

Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients, however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting. A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale (AMS) scores, Cookie Tests, and the requirement for subsequent neuroma resection and nerve grafting. Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie Test for elbow flexion. Thirteen patients either passed the Cookie Test or scored AMS 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie Test. Two patients did not have sufficient follow to assess elbow flexion. Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.