Journal of Shoulder and Elbow Surgery最新文献

Background: Reverse shoulder arthroplasty (RSA) for fracture currently shares a single current procedural terminology (CPT) code with RSA for arthropathy despite potential differences in patient factors, procedural demands, postoperative care and needs, and overall hospital systems' resource utilization. We hypothesize that patients indicated for RSA for fracture will have greater medical complexity, require longer operative duration, have higher complication rates, demonstrate inferior functional outcomes, and require greater healthcare cost expenditures compared to a cohort undergoing RSA for rotator cuff arthropathy.

Methods: 383 RSAs were retrospectively reviewed from January 2011 to December 2020. Demographics, comorbidities, operative time, financial charge and cost data, length of stay (LOS), discharge disposition, and all-cause revisions were assessed. Visual analog scale (VAS) pain score and active range of motion (AROM) were evaluated at 2, 6, and 12 months postoperatively.

Results: 197 total RSA were included with 28 for fracture and 169 for arthropathy indications after exclusions. RSA operative time was longer for fractures with an average of 143.2±33.7 minutes compared to 108.2±33.9 minutes for arthropathy (p=0.001). Average cost per patient for RSA for proximal humerus fracture was $2,489 greater than cost for RSA for elective indications; however, no statistically significant difference was noted between average costs (p=0.126). LOS was longer for RSA for fracture compared to arthropathy with a mean of 4.0 ± 3.6 days versus 1.8 ± 2.3 days (p=0.004). The fracture group was 3.6 times more likely to be discharged to a skilled nursing facility or inpatient rehab (32% versus 9%, p=0.002). Early and late all-cause revisions were similar between groups. Differences in postoperative AROM for fracture versus arthropathy were significant for active forward flexion (aFF) at 2 months (95.5±36.7°, 117.0±32.3°) and 6 months (110.9±35.2°, 129.2±28.3°) (p=0.020) as well as active adducted external rotation (aER) at 6 months (20.0±20.9°, 33.1±12.3°) (p=0.007) and at 12 months (23.3±18.1°, 34.5±13.8°) (p=0.012). No difference in VAS pain scores were noted between fracture and arthropathy groups at any time point.

Discussion: RSA for fractures versus arthropathy have substantial differences in patient characteristics, surgical complexity, and hospital resource utilization. This is of importance given the currently available CPT code does not differentiate indications for RSA, especially if intending to accurately document surgical care delivered.

Introduction: The surgical treatment of anterior shoulder instability with arthroscopic cortical-button Latarjet procedure has been the subject of very few medium and long-term studies. The aim of this study was to analyze the clinical and radiological results of arthroscopic cortical-button Latarjet procedure with minimum 5 years follow-up.

Method: This is a monocentric retrospective study including 40 patients who have undergone shoulder stabilization with primary arthroscopic cortical-button Latarjet procedure and been reviewed with minimum 5 years follow-up. The average age at the time of surgery was 26.6 years (16 - 59; ± 10) and 92.5% were sporty individuals. The average ISI score was 6 points (2- 9; ± 1,6). The clinical evaluation involved active range of motion measurement, apprehension test, Rowe and Walch-Duplay scores, SSV and Net Promoter Score. Radiologically, evolution of the bone graft and degenerative arthritis of the shoulder joint were analyzed at the last follow-up.

Results: At an average follow-up of 71 months (60 - 97; ± 12), 3 patients (7.5%) experienced recurrence as a dislocation or subluxation, which was responsible for revision in 1 case. Moreover, apprehension persisted in 6 (16%) patients. There were no significant restrictions in recovery of active ranges of motion, including external rotation. Return to sports was effective in 94.6% of cases. The average Rowe and Walch-Duplay scores were 87 points (15 - 100; ± 20) and 88 points (15 - 100; ± 19) respectively. SSV was 91% (10 - 100; ± 16) and NET Promoter Score was 9.3 points (5 - 10; ± 1,3). Radiologically, degenerative arthritis occurred in 18.7% of patients, mainly asymptomatic stage 1 (9.4%). Bone healing was acquired in 72% of cases and partial lysis of the bone block in 41%.

Conclusion: At an average follow-up of 6 years, arthroscopic cortical-button Latarjet procedure effective, enabling return to sport in 95% of cases. Onset of asymptomatic arthritis seems similar to conventional techniques but justifies a more long-term follow-up.

Background: In nonoperative treated proximal humeral fractures (PHF), uncertainty remains regarding functional outcome. Therefore, the aim was to identify predictors of functional outcome following nonoperative treatment of PHF and to develop predictive models.

Methods: Adults with a nonoperatively treated PHF involving the surgical neck were followed for 1 year. Radiographic parameters included fracture configuration, displacement, bone quality, and the critical shoulder angle (CSA). The neck-shaft angle (NSA) and humeral head offset assessed displacement. The greater tuberosity index (GTI) addressed greater tuberosity (GT) displacement relative to the articular surface while the impingement index addressed GT-displacement relative to the acromion. Multivariate regression models determined predictors of impaired function as measured by Constant Score (CS), flexion, and external rotation (ER). Recursive partitioning created a decision tree model over dichotomized functional outcome that combined flexion and ER (good = flexion ≥ 120° and ER ≥ 40°).

Results: In 272 consecutive patients (mean age: 66 years, 69% women and 31% men), mean functional outcomes were a CS of 74 points, 138° flexion, and 50° ER. Older age was a predictor for impaired CS, flexion, and ER (p < 0.001), while sex only influenced CS (p = 0.040). Every 10% increase in GTI assessed on the Y-view explained a decrease of 3 CS points, 7° of flexion, and 5° of ER (p < 0.001). Every 10° of varus angulation assessed on anterior-posterior (ap) views in internal rotation resulted in a decrease of 1 CS point and 4° of flexion (p ≤ 0.004). Subgroups of combined important GT-displacement (GTI ≥ 1.15) with age > 76 years or < 119° varus angulation demonstrated the worst function. Linear prediction models estimated flexion, ER, and CS with a mean difference of 10°, 3°, and 3 points, respectively. The decision tree model predicted good function with 80% accuracy (positive predictive value = 81%; negative predictive value = 78%).

Conclusion: Demographic and radiographic predictors were identified allowing for accurate functional prognosis of nonoperatively treated PHF involving the surgical neck. A combined assessment of the ap-view in internal rotation and Y-view is sufficient for accurate function prediction. The identified subgroups resulting in good or impaired function, and the predictive models may be useful for patient counseling and guidance of treatment-related expectations.

Introduction: In recent years, several studies have evaluated the effect of Medicaid insurance status on total shoulder arthroplasty (TSA) outcomes and have presented discordant findings. The purpose of this study is to determine if Medicaid status is an independent predictor of all-cause complications, readmission, revision, and mortality following elective primary TSA using a large, national administrative claims database.

Methods: The Nationwide Readmissions Database (NRD) was queried to identify patients who underwent elective primary TSA from 2016 to 2020. Patients were propensity score matched in a 1:1 proportion based on age, sex, and discharge weight, yielding 15,374 Medicaid cases and 15,448 control cases. Patient demographic and discharge information, preoperative comorbidities, and postoperative outcomes were compared with bivariate analysis. Binary logistic regression was performed to account for the influence of variables other than Medicaid status on postoperative outcomes.

Results: Medicaid patients had higher rates of preoperative comorbidities, higher Charlson-Deyo Comorbidity Index scores, and lower household incomes than matched controls. Compared to controls, Medicaid patients undergoing TSA had higher odds of adverse clinical outcomes, including all-cause complications, readmission, and mortality within 180 days, along with other specific medical and implant-related complications including broken hardware, dislocation, prosthetic loosening, and surgical site infection. Medicaid status was independently predictive of increased rates of all-cause complications within 180 days, readmission within 180 days, dislocation, pneumonia, sepsis, and decreased rates of prosthetic loosening. Medicaid patients had an increased mean cost of $1,396 and increased mean length of stay of 0.4 days.

Conclusion: Medicaid status was independently predictive of readmission, complications, and mortality within 180 days of primary TSA, as well as other specific medical and surgical complications. Medicaid patients experience higher admission costs and longer hospital stays compared to those with other insurance types. Medicaid status is a risk factor for adverse clinical outcomes, and orthopedic surgeons need to consider the multitude of disparities that Medicaid patients experience when determining surgical options, treatment plans, and hospital disposition.

Background: Increasingly, patients are turning to artificial intelligence (AI) programs such as ChatGPT to answer medical questions either before or after consulting a physician. Although ChatGPT's popularity implies its potential in improving patient education, concerns exist regarding the validity of the chatbot's responses. Therefore, the objective of this study was to evaluate the quality and accuracy of ChatGPT's answers to commonly asked patient questions surrounding total shoulder arthroplasty (TSA).

Methods: Eleven trusted healthcare websites were searched to compose a list of the 15 most frequently asked patient questions about TSA. Each question was posed to the ChatGPT user interface, with no follow-up questions or opportunity for clarification permitted. Individual response accuracy was graded by three board-certified orthopedic surgeons using an alphabetical grading system (i.e., A-F). Overall grades, descriptive analyses, and commentary were provided for each of the ChatGPT responses.

Results: Overall, ChatGPT received a cumulative grade of B-. The question responses surrounding general/preoperative and postoperative questions received a grade of B- and B-, respectively. ChatGPT's responses adequately responded to patient questions with sound recommendations. However, the chatbot neglected recent research in its responses, resulting in recommendations that warrant professional clarification. The interface deferred specific questions to orthopedic surgeons in 8/15 questions, suggesting its awareness of its own limitations. Moreover, ChatGPT often went beyond the scope of the question after the first two sentences, and generally made errors when attempting to supplement its own response.

Conclusion: Overall, this is the first study to our knowledge to utilize AI to answer the most common patient questions surrounding TSA. ChatGPT achieved an overall grade of B-. Ultimately, while AI is an attractive tool for initial patient inquiries, at this time it cannot provide responses to TSA-specific questions that can substitute the knowledge of an orthopedic surgeon.

Introduction: Rotator cuff injury diagnosis involves comprehensive clinical, physical, and imaging assessments, with MRI being pivotal for detecting and classifying these injuries. However, the absence of a universally accepted classification system necessitates a more precise approach, advocating for the use of three-dimensional (3D) modeling to better understand and categorize rotator cuff tears.

Methodology: This research was conducted as a prospective, single-institution study on 62 patients exhibiting full-thickness rotator cuff tears. Utilizing preoperative 1.5T MRI, the study aimed to create a more detailed classification system based on volumetric and surface area measurements. Advanced 3D modeling software was employed to transform MRI data into precise 3D representations, facilitating a more accurate analysis of the lesions.

Results: The study unveiled a novel classification system rooted in volumetric and surface area assessments, revealing significant discrepancies in the existing two-dimensional classifications. Approximately 45% of the cases demonstrated inconsistencies between traditional classifications and 3D measurements. Notably, medium-sized lesions were often overestimated, while small and large lesions were consistently underestimated in their severity. The volumetric and surface area-based classifications provided a more accurate depiction, highlighting the limitations of relying solely on coronal plane assessments in MRI. Comparative analysis confirmed the improved accuracy of the 3D method.

Conclusion: The integration of 3D imaging and volumetric analysis offers novel advancement in diagnosing and classifying rotator cuff injuries. This study's findings challenge the conventional reliance on 2D MRI, proposing a more detailed and accurate classification system that enhances the precision of surgical planning and potentially improves patient outcomes. The incorporation of comprehensive 3D assessments into the diagnostic process represents a significant step forward in the orthopedic imaging field.

Background: The decision to withdraw or continue antiplatelet and anticoagulant drugs would be balanced on the bleeding risk and the cardiovascular risk. The purpose of this study was to investigate perioperative bleeding in reverse shoulder arthroplasty (RSA) to determine the impact of oral antiplatelet and anticoagulant medications in the absence of drug withdrawal. The hypothesis was that the continuation of antiplatelet and anticoagulant drugs would increase postoperative bleeding but to a limited extent.

Methods: During the study period, RSA cases were prospectively included and retrospectively reviewed. Cases of revision for arthroplasty, proximal fracture, and cemented stem fixation were excluded. Cases with dual therapy of aspirin and clopidogrel and cases with heparin bridges were also excluded. Age, gender, height, weight, American Society of Anesthesiologists physical status anesthesia risk (ASA), smoking status, preoperative diagnosis, preoperative blood sampling data within one month of surgery (estimated glomerular filtration rate (eGFR), Prothrombin Time-International Normalized Ratio (PT-INR), and activated partial thromboplastin time (APTT)), surgical time, stem length (standard or short stem), and use of tranexamic acid were identified. The presence of diabetes mellitus, rheumatoid arthritis, and hypertension were confirmed as comorbidities. Hemoglobin (Hb) and hematocrit (Ht) values were recorded preoperatively and on the third postoperative day, and estimated blood loss was calculated by Gross formula using the change in preoperative Ht and postoperative day 3 Ht values. Multiple regression models were used to determine predictors of the estimated blood loss. P values less than .05 were considered statistically significant.

Results: 315 RSA cases were analyzed (172 females, a mean age of 77.2 years). The estimated blood loss was 819 ml. The regression equation was statistically significant (P < .0001, R²=0.21), and aspirin, direct oral anticoagulants (DOAC), tranexamic acid, height, and surgery time were statistically significant explanatory variables, showing the predicted changes in bleeding volume for each drug were +283 ml for aspirin, +180 ml for DOAC, and -237 ml for tranexamic acid, respectively. Warfarin and cilostazol were not employed due to P values and Akaike's Information Criterion. Two blood transfusions (without antiplatelet or anticoagulant medications) were administered. One patient on aspirin had a cardiovascular event.

Conclusions: The current study showed that the use of aspirin and DOAC were significant predictors of increased perioperative blood loss, but the amount of increase was in the acceptable range, suggesting that continued antiplatelet and anticoagulant were relatively safe in primary RSA. Administration of tranexamic acid was shown to reduce bleeding significantly.

Background: Proximal humeral fractures (PHF) are one of the most common fragility fractures and there is accumulating evidence that even displaced PHFs should be treated conservatively. The treatment should be as effective and standardized as possible regardless of the hospital district of the patient. The aim of this study was to describe possible regional variation in incidence and treatment methods of PHFs in Finland.

Methods: The study included all Finnish inhabitants aged 16 years and older with PHF diagnosis between 1997 and 2019. All records are based on data from two national registers. The fractures and operations were organized according to hospital district of the patient and annual incidences of PHFs, and different treatment methods were calculated for each hospital district.

Results: Between 1997 and 2019, 79,053 PHFs were identified. 64,117 of PHFs were treated conservatively and 14,936 operatively. The incidence of conservative treatment corresponded closely to the fracture incidence per hospital district. Internal fixation (IF) incidence generally increased towards the end of the first half of the study period and declined thereafter, and hemiarthroplasty (HA) was replaced by total shoulder arthroplasty (TSA) as the most common type of arthroplasty by the end of the period. We found regional variation in the incidence of PHFs, with a low of 61.4 per 10⁵ in Åland, and a high of 97.7 per 10⁵ in East-Savo.

Conclusions: In Finland, the treatment of PHFs did not differ fundamentally between hospital districts and a general evidence-based shift in treatment practice was shown. We found regional variation in the incidence of PHFs, and it seems that the higher incidence of PHFs is concentrated in the Eastern Finland.