Background: Various surgical techniques can be used to repair acute distal biceps tendon (DBT) tears; however, it is unknown which type of repair or implant has the greatest biomechanical strength and presents the lowest risk of type 2 failure. Purpose: To identify associations between the type of implant or construct used and the biomechanical performance of DBT repairs in a review of human cadaveric studies. Study Design: Systematic review and meta-regression. Methods: We systematically searched the EMBASE and Medline (PubMed) databases for biomechanical studies that evaluated DBT repair performance in cadaveric specimens. Two independent reviewers extracted data from 14 studies that met our inclusion criteria. The pooled data set was subjected to meta-regression with adjusted failure load (AFL) as the primary outcome variable. Procedural parameters, such as number of sutures, cortices, locking stitches, and whipstitches, served as covariates. Adjusted analysis was performed to determine the differences among implant types. The alpha level was set at .05. Results: When using no implant (bone tunnels) as the referent, no fixation type or procedural parameter was significantly better at predicting AFL. Cortical button fixation had the highest AFL (370 N; 95% CI, −2 to 221). In an implant-to-implant comparison, suture anchor alone was significantly weaker than cortical button (154 N; 95% CI, 30 to 279). Constructs using a cortical button and interference screw were not stronger (as measured by AFL) than those using a cortical button alone. The presence of a locking stitch added 113 N (95% CI, 29 to 196) to the AFL. The use of cortical button instead of interference screws or bone tunnels was associated with lower odds of type 2 failure. Avoiding locking stitches and using more sutures in the construct were also associated with lower odds of type 2 failure. Conclusion: Cortical button fixation is associated with greater construct strength than is suture anchor repair and a lower risk of type 2 failure compared with interference screw fixation or fixation without implants. The addition of an interference screw to cortical button fixation was not associated with increased strength. The presence of a locking stitch added 113 N to the failure load but also increased the odds of type 2 failure.

Rotator cuff pathology is one of the most common reasons for patients to seek orthopaedic consultation. Although in many cases these issues can be resolved with proper conservative management, many of these patients benefit from surgical treatment. The goal of this instructional course lecture is to identify factors that can potentially lead to worse outcomes following repair, describe the history and techniques behind transosseous anchorless repairs, discuss subscapularis tears and their management, and to analyze the most current data regarding double-row rotator cuff repairs. Rotator cuff tears managed surgically have been proven to provide significant pain relief and improved function; however, surgical intervention in patients with significant risk factors for failure can lead to substantial disability for the patient.

Abstract Background Preoperative opioid use has been associated with higher pain scores and lower functional outcomes after total shoulder arthroplasty (TSA), but the association between preoperative opioid use and readmission, revision surgery and cost following TSA is less well-known. The purpose of this study is to determine the association between preoperative opioid use and readmission, revision surgery and cost after total shoulder arthroplasty. Methods Using the Marketscan© administrative claims database, we identified patients from 2010–2015 who underwent primary TSA using Current Procedural Terminology codes. 5,621 patients aged 18–64 were identified who had 6-months of continuous coverage preoperatively and one year of continuous coverage postoperatively. Patients who were using opioids up until the 30-day period prior to surgery were classified as preoperative opioid users. Our primary outcomes were rates of 90-day all-cause hospital readmission, 1-year rates of revision surgery, and 1-year healthcare payments. Logistic regression and a generalized linear model were used to analyze binomial and payment data, respectively. All models were controlled for age, gender and Charlson comorbidity index. Results Mean age of patients was 57 ± 5.6 years, 42% were females. Average length of stay was 1.7 ± 1.2 days. 28% of patients were using opioids preoperatively. Preoperative opioid use was associated with significantly increased odds of 90-day readmission (OR 2.6, p Conclusions Preoperative opioid use is associated with increased rates of readmission and revision surgery following TSA. Patients undergoing TSA have significantly higher total healthcare costs and a modest increase in length of hospital stay. Level of evidence Level II

BACKGROUND:Minimal clinically important differences (MCIDs) at 1 year after subpectoral biceps tenodesis are unknown for the American Shoulder and Elbow Surgeons (ASES) scale, Subjective Shoulder Value (SSV), and visual analog scale (VAS) for pain. Our objectives were to determine MCIDs for these measures at 1 year after biceps tenodesis and to identify preoperative factors that predict attainment of MCIDs. METHODS:We included 52 patients who underwent arthroscopic débridement, decompression, and mini-open biceps tenodesis from 2016-2018. We analyzed age, sex, body mass index value, arm dominance, diagnosis, range of shoulder motion, and preoperative and 1-year postoperative ASES, SSV, and VAS scores. MCIDs were calculated using a distribution-based method of one-half the standard deviation. Preoperative thresholds predictive of MCIDs were calculated with univariate logistic regression. Multiple logistic regression was used to determine factors that predict MCIDs. Significance was set at a 2-tailed P value of <.05. RESULTS:MCIDs for the ASES, SSV, and VAS were 13, 12, and 1.6 points, respectively. Preoperative ASES score <59 predicted MCID on the ASES (P = .03); VAS score >3 predicted MCID on the VAS (P < .01); external shoulder rotation >40° predicted MCID on the SSV (P = .02); and age >41 years predicted MCID on the VAS (P = .02). CONCLUSION:At 1 year after débridement, decompression, and biceps tenodesis, MCIDs were 13, 12, and 1.6 points for the ASES, SSV, and VAS, respectively. Patients most likely to attain MCIDs were those aged >41 years, those with the most preoperative pain, and those with the poorest preoperative shoulder function.

Opioids are prescribed routinely for pain after total shoulder arthroplasty (TSA). This study was designed to characterize opioid use after elective primary TSA and identify predictors of long-term postoperative opioid use. The authors used the MarketScan administrative claims database to identify 5676 adults who underwent elective primary TSA between 2010 and 2015 and had 1 year or more of continuous insurance enrollment, including prescription drug coverage, postoperatively. Long-term postoperative opioid use was defined as filling prescriptions totaling a 120-day or greater supply during the 3- to 12-month postoperative period. The authors performed univariate regression analysis with age, sex, US region, anatomic or reverse TSA, anxiety, chronic obstructive pulmonary disease, congestive heart failure, depression, diabetes, history of drug abuse, hypertension, obesity, osteoporosis, history of myocardial infarction, and current tobacco use. Variables that were significant at P <.05 were included in multivariate logistic regression. Overall, 16% of patients had long-term postoperative opioid use, which was strongly predicted by the multivariate model (area under the curve, 0.77; P <.001). The strongest predictors in the multivariate analysis were preoperative opioid use (odds ratio [OR], 4.7; 95% CI, 4.0–5.5), history of drug abuse (OR, 2.5; 95% CI, 1.3–4.9), depression (OR, 1.9; 95% CI, 1.6–2.3), anxiety (OR, 1.4; 95% CI, 1.2–1.7), surgery performed in the Western United States (OR, 1.8; 95% CI, 1.3–2.4), and reverse TSA (OR, 1.5; 95% CI, 1.2–1.8). Most patients do not have long-term opioid use after elective primary TSA. Strong predictors of long-term postoperative opioid use are preoperative opioid use, history of drug abuse, depression, anxiety, reverse TSA, and surgery performed in the Western United States. [ Orthopedics . 2021;44(1):58–63.]

Objectives: Smoking has been associated with poor cuff healing and worse long-term outcomes in patients undergoing rotator cuff repair. The effects of smoking on short-term complications following open rotator cuff repair are not well defined. The purpose of this study is to analyze the effects of smoking on 30-day outcomes following open rotator cuff repair. Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open rotator cuff repair from 2011 to 2016. Patients who were current smokers (within 1 year prior to surgery) were identified and compared with nonsmokers. Demographic data and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of smoking on complications after surgery. Results: We identified 5,157 patients who underwent open rotator cuff repair, of which 18% (946 patients) were current smokers (within 1 year of surgery). Smokers were younger (54.4 years versus 61.5 years, P < 0.001) and were more likely to be male (60.8% versus 56.9%, P = 0.03). Compared with nonsmokers, smokers had a similar rate of comorbidities (P = 0.35) and similar preoperative functional status (P = 0.53), but had higher mean American Society of Anesthesiologists (ASA) class (P < 0.001). Logistic regression revealed that smoking was an independent predictor for any complication (OR 1.9, P = 0.03), any venous thromboembolic event (OR 4.6, P = 0.01), and pulmonary embolism (OR 6.4, P = 0.02). Conclusion: Patients who smoke are at increased risk for short-term complications after open rotator cuff repair. Smoking is independently associated with increased rate of postoperative venous thromboembolic events such as pulmonary embolism. This further highlights the importance of preoperative smoking cessation in patients undergoing open rotator cuff repair.

CASE The expandable intramedullary cage (Conventus Orthopaedics) may treat 3- and 4-part proximal humerus fractures. Cage removal for symptomatic avascular necrosis with humeral head collapse requiring conversion to arthroplasty can be challenging because the cage's collapsing mechanism becomes inoperable after fracture consolidation. We present cage explantation followed by reverse total shoulder prosthesis placement in a 54-year-old man who underwent plate/cage fixation for a 3-part proximal humerus fracture 10 months earlier. CONCLUSION The proximal humeral cage can be extracted safely while preserving adequate bone stock for subsequent arthroplasty. Additional time and exposure are necessary compared with removing a locking plate alone.

BACKGROUNDHip fractures are associated with 1-year mortality rates as high as 19% to 33%. Nonwhite patients have higher mortality and lower mobility rates at 6 months postoperatively than white patients. Studies have extensively documented racial disparities in hip fracture outcomes, but few have directly assessed racial disparities in the timing of hip fracture care.QUESTIONS/PURPOSESOur purpose was to assess racial disparities in the care provided to patients with hip fractures. We asked, (1) do racial disparities exist in radiographic timing, surgical timing, length of hospital stay, and 30-day hospital readmission rates? (2) Does the hospital type modify the association between race and the outcomes of interest?METHODSWe retrospectively reviewed the records of 1535 patients aged 60 years or older who were admitted to the emergency department and treated surgically for a hip fracture at one of five hospitals (three community hospitals and two tertiary hospitals) in our health system from 2015 to 2017. Multivariable generalized linear models were used to assess associations between race and the outcomes of interest.RESULTSAfter adjusting for patient characteristics, we found that black patients had a longer mean time to radiographic evaluation (4.2 hours; 95% confidence interval, -0.6 to 9.0 versus 1.2 hours; 95% CI, 0.1-2.3; p = 0.01) and surgical fixation (41 hours; 95% CI, 34-48 versus 34 hours 95% CI, 32-35; p < 0.05) than white patients did. Hospital type only modified the association between race and surgical timing. In community hospitals, black patients experienced a 51% (95% CI, 17%-95%; p < 0.01) longer time to surgery than white patients did; however, there were no differences in surgical timing between black and white patients in tertiary hospitals. No race-based differences were observed in the length of hospital stay and 30-day hospital readmission rates.CONCLUSIONSAfter adjusting for patient characteristics, we found that black patients experienced longer wait times to radiographic evaluation and surgical fixation than white patients. Hospitals should consider evaluating racial disparities in the timing of hip fracture care in their health systems. Raising awareness of these disparities and implementing unconscious bias training for healthcare providers may help mitigate these disparities and improve the timing of care for patients who are at a greater risk of delay.LEVEL OF EVIDENCELevel III, therapeutic study.

Abstract Hip fractures are associated with significant morbidity and mortality. Delaying surgery for more than 24 hours after presentation results in more complications, higher 30-day mortality rate, and longer stays in the hospital. As such, high-quality care should be provided consistently to an increasingly diverse patient population. We determined if race characteristics influence the quality of care provided to patients with hip fractures. We conducted a retrospective analysis on patients at our institution between January 2015 and December 2017. Patients were categorized as white, Black, Asian, and other. The primary outcome variable was the time between presentation to surgery. Other outcomes included length of hospital stay and narcotic pain medication consumption in the first 24 hours postoperatively. Adjusted analysis was performed, controlling for sex, age, body mass index (BMI), American Society of Anesthesiologists’ (ASA) classification of health, and Charlson Comorbidity Index (CCI). There were 1544 hip fracture patients included in the study. The majority of patients were white (84.1%) followed by Black (7.6%), Asian (4.5%), and other (3.7%). Most patients were female (69.6%). After adjusting for patient characteristics, Black patients experienced a significantly greater delay to surgery after presentation than white patients (42.1 vs. 34.9 hours). In addition, Black patients experienced significantly longer length of hospital stays compared to their white counterparts (6.9 vs. 5.8 days). Racial disparities in the quality of care provided to hip fracture patients persist even after adjusting for patient characteristics. Addressing these disparities can possibly enhance outcomes for minority patients.

Abstract Background Previous studies have found an association between functional status and outcomes following hip and knee arthroplasty. The purpose of this study was to evaluate the effect of dependent functional status on outcomes after total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent primary TSA (anatomic or reverse) for glenohumeral osteoarthritis from January 1, 2011 to December 31, 2016. Patients whose preoperative functional status was dependent were compared with independent patients. Demographic data, length of hospital stay, and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of functional status on postoperative complications and readmission. Results A total of 12,982 patients underwent primary TSA (anatomic or reverse) and 3.2% had a dependent functional status. Dependent patients had higher rate of comorbidities, higher mean American Society of Anesthesiologists class, longer hospital stays, and higher complication rates (including pneumonia, urinary tract infection, and blood transfusion). Logistic regression revealed that dependent functional status was an independent predictor for occurrence of any complication (odds ratio 2.0, P Conclusion Patients with dependent functional status preoperatively are at increased risk for short-term complications and readmission within 30 days following primary TSA. Level of evidence : Level III