Background: Humeral shaft fractures account for approximately 3% of orthopedic injuries each year. While the standard treatment is nonoperative management, surgery is performed in cases where fixation is required to restore alignment and optimize healing. The success of these procedures depends on a number of factors, including fracture characteristics, intraoperative fixation, and patient characteristics. This study was undertaken to better understand the effect of nicotine dependence on surgical outcomes following humeral shaft fracture surgical management. The study hypothesis was that complications and reoperations would be higher in patients with nicotine dependence undergoing humeral shaft fracture repair. Methods: The TriNetX US Collaborative Network was queried for all adult patients diagnosed with a humeral shaft fracture undergoing either fixation via a plate and screw construct or intramedullary fixation between 2005 and 2025. Cohorts were defined by inclusion or exclusion of the International Classification of Diseases (ICD) code for nicotine dependence prior to surgery. Statistical analysis was performed after propensity score matching to determine differences in postoperative outcomes between cohorts. We looked at incidence of pulmonary embolism, upper extremity deep vein thrombosis, postoperative infection, sepsis, and disruption of wound up to 90 days postop, and incidence of postoperative infection, nonunion, and reoperation between 3 months and 1 year postop. Results: The risk ratio was significantly elevated for those with nicotine dependence for a number of outcomes: 1.630 (1.213, 2.190) for postoperative early infection, 1.645 (1.102, 2.455) for disruption of wound, 1.822 (1.194, 2.780) for late infection, 1.907 (1.364, 2.668) for nonunion, and 1.810 (1.246, 2.628) for reoperation. No significant differences in risk were found between cohorts for pulmonary embolism, upper extremity deep vein thrombosis, or sepsis. Conclusion: Nicotine dependence prior to surgical fixation of humeral shaft fractures is associated with a 60-110% increased risk for surgical complications including postoperative infection, wound disruption, nonunion and reoperation. These findings emphasize the importance of preoperative risk stratification and advising smoking cessation in order to optimize surgical outcomes for this patient population.

Background:Arthroscopic rotator cuff repair (ARCR) is the most common form of operative intervention utilized in the treatment of rotator cuff tears. Retear rates following ARCR have been reported to range from 7% to 94%. This study was undertaken to better understand the effects of various medical comorbidities and age on rotator cuff retear risk following ARCR. Methods:The TriNetX US Collaborative Network was queried for all patients treated with ARCR from 2013 to 2022 with recurrence of rotator cuff tear within 1 year. Cohorts were defined by inclusion of medical comorbidities at time of ARCR including hypertension, hyperlipidemia, chronic ischemic heart disease, type 2 diabetes mellitus, smoking history, and chronic kidney disease. Patient age groups in 10-year increments were also examined. Propensity score matching was performed for comorbid groups to adjust for age and comorbidities. Relative risk was calculated for each comorbidity and age group. Results:There were a total of 98,844 patients who underwent ARCR for complete rotator cuff tear from 2012 to 2023 with an overall retear percentage of 16.3% within 1 year of surgery. Hypertension, hyperlipidemia, and smoking history were significant risk factors of retear after propensity score matching. Chronic ischemic heart disease, chronic kidney disease, and type 2 diabetes mellitus were not significant risk factors of retear after propensity score matching. It was also noted that relative risk of retear increased as patient age increased; patients aged 81-90 having the highest likelihood of retear (relative risk: 1.206), with a retear rate of 19.6%. Conclusion:Medical comorbidities and advanced age can increase the risk of rotator cuff retear following ARCR. Understanding how these common comorbidities affect retear rate following ARCR can better inform orthopedic surgeons of potential risks and optimize postoperative outcomes.

BACKGROUND:As the utilization of shoulder and elbow procedures increases, it is not clear whether the hospital reimbursement for these cases has proportionally increased in the United States. This study investigated trends in reimbursement for shoulder and elbow hospitalizations. METHODS:The Centers for Medicare and Medicaid Services Inpatient Utilization and Payment Public Use Files from 2015 to 2022 were retrospectively queried for all diagnosis-related groups (DRGs) (483, 507, 508, 510, 511, and 512) related to shoulder and elbow procedures, including primary and revision upper extremity arthroplasty cases. After adjusting for inflation to 2022 US dollars with the US Consumer Price Index, the mean, median, and standard deviation of the Medicare payments were determined to analyze the total number of procedures performed each year and over the study period. These same calculations were also performed for the submitted charges by hospital for the reported hospital expenses. A multiple linear mixed-model regression analysis and an analysis of covariance were performed to assess the change in reimbursement and charges over time for each code and the proportional rate of change between codes, respectively. RESULTS:The inflation-adjusted average Medicare payment for DRG 483 per procedure decreased by $1295.57 (-7.2%) from $17,874.69 in 2015 to $16,579.12 in 2022. The inflation-adjusted average submitted charge for DRG 483 per procedure increased by $16,453.29 (19.1%) from $86,314.46 in 2015 to $102,767.76 in 2022. The inflation-adjusted Medicare payments for DRG 483 significantly decreased year-over-year over the study period (P < .001), showing consistent declines across years relative to the reference year. CONCLUSION:The decrease in reimbursement for DRG 483, including revision upper extremity arthroplasty procedures, shows that fewer resources have been allocated for shoulder and elbow hospitalizations. These results necessitate further examination of Medicare payment algorithms to accurately account for case complexity in allocating fair reimbursement to hospitals for upper extremity procedures.

BACKGROUND:Preoperative opioid users experience worse outcomes and higher complication rates compared to opioid-naïve patients following shoulder arthroplasty. This study evaluates the effects of socioeconomic status, as measured by the Distressed Communities Index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery. METHODS:A retrospective review of patients who underwent primary shoulder arthroplasty (Current Procedural Terminology code 23472) from 2014 to 2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index, DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents was gathered. RESULTS:Individuals from distressed communities used more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations, respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared with prosperous, comfortable, and mid-tier, respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs. 21.3%, P < .001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs. 21.7%, P = .002). CONCLUSIONS:Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.

Osteology: The 3 bones that comprise the elbow joint (distal humerus, proximal ulna, and proximal radius) allow it to function as a trochoginglymus joint, providing both flexion/extension as well as pronation-supination. Distal humerus: transitions from the shaft to the medial and lateral columns, which support the articular surface (Figure 1-1) Lateral column Lateral supracondylar ridge: attachment of brachioradialis (BR) and extensor carpi radialis longus anteriorly and triceps posteriorly (Figure 1-2) Avascular zone between BR and triceps marks the lateral column for surgical exposure Lateral epicondyle: attachment of common extensor-supinator tendon and lateral ulnar collateral ligament (LUCL) posteriorly Tendinitis of extensor carpi brachialis brevis (deep in common extensor mass) is cause of lateral epicondylitis 1 (Figure 1-3) Lateral epicondyle debridement: must stay anterior to LUCL to avoid creating posterior rotatory instability Medial column The medial supracondylar ridge is more narrow than lateral, thus more prone to fracture The medial epicondyle is more prominent than the lateral, serves as attachment of medial ulnar collateral ligament and flexor-pronator mass Figure 1-1 (A) The articular surfaces of the elbow joint. Note the anterior capsular attachment to the coronoid. This also demonstrates the more anterior/distal projection of the medial trochlea, which creates the valgus carrying angle in elbow extension. (B) Osteology of the distal humerus. Note the coronoid fossa and olecranon fossa anteriorly and posteriorly, respectively. The lateral view demonstrates the anterior angulation of the distal humerus to aid in full flexion. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9781003524243/e2a244c3-6295-4c82-b6fb-c3937c885478/content/fig1-1.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> Supracondylar process is seen in 1% to 3% of patients, attachment for ligament of Struthers may cause median nerve impingement (pronator syndrome) 2 Articular surfaces: angulated 30 degrees anteriorly, matches 30 degrees posterior angulation of greater sigmoid notch of the ulna Trochlea: articulates with greater sigmoid notch of ulna, 300 degrees covered with articular cartilage, medial portion is more distal than lateral, bordered anterosuperiorly by coronoid fossa and posterosuperiorly by olecranon fossa Figure 1-2 Superficial view of the lateral humerus demonstrates the fascial layer of the common extensor mass, the anconeus, and the triceps at the top of the figure. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9781003524243/e2a244c3-6295-4c82-b6fb-c3937c885478/content/fig1-2.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> Figure 1-3 The superficial layer of the common extensor mass is reflected to demonstrate the deeper layer containing the tendinous insertion of the extensor carpi radialis brevis. This is the tendon affected by lateral epicondylitis at the tendon's insertion to the lateral epicondyle. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9781003524243/e2a244c3-6295-4c82-b6fb-c3937c885478/content/fig1-3.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> Capitellum: articulates with radial head, spheroidal in shape, thick cartilage layer (approximately 2 mm) anteriorly Proximal ulna: subcutaneous along posteromedial aspect of forearm (Figure 1-4) Olecranon process: posterior and proximal portion of the ulna, serves as an attachment site for the triceps tendon Coronoid process: anterior portion of ulnohumeral articulation, serves as a buttress to maintain anterior stability of the joint, attachment site of the brachialis tendon and anterior joint capsule Greater sigmoid notch: cartilage-covered grooved surface that articulates with the trochlea of the distal humerus and allows flexion and extension of the joint, 30 degrees of posterior angulation to match that of the trochlea Lesser sigmoid notch: distal-lateral to the greater sigmoid notch, small cartilage-covered groove that articulates the ulna with the radial head Can serve as an alignment landmark for reconstruction or replacement of radial head fractures 3 Supinator crest: raised area distal and posterior to lesser sigmoid notch, attachment site of lateral collateral ligament and important landmark for reconstruction of this structure Proximal radius: primary role is to allow pronation and supination of the elbow Radial head: Central depression that articulates with the capitellum, the radial head should always point at the capitellum on x-ray at all ranges of motion. There is a 240-degree rim of articular cartilage around the radial head that articulates with the Figure 1-4 Osteology of the proximal ulna. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9781003524243/e2a244c3-6295-4c82-b6fb-c3937c885478/content/fig1-4.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> lesser sigmoid notch (proximal radioulnar joint); the remaining 120 degrees does not articulate and thus is a safe zone for hardware placement. The safe zone can be identified using distal radius landmarks such as the arc between the radial styloid and Lister tubercle. 4 Radial tuberosity: medial aspect of the proximal radius and serves as the attachment site of the distal biceps tendon Radial neck: distal to the radial head, transition point to the shaft, has 15 degrees of valgus angulation that should be taken into account during radial head replacement 3

Maintaining the reduction of a transverse humeral shaft fracture can be particularly challenging while applying a compression plate for definitive fixation. Nitinol compression staples are being increasingly utilized in orthopedic surgery due to their unique ability to apply continuous compression between staple legs at body temperature. We have found them to be particularly useful in the maintenance of the reduction of transverse humeral shaft fractures before compression plate application. This simple technique allows for the removal of reduction clamps and precise plate placement. We describe our technique for using nitinol compression staples to augment fracture fixation in transverse humeral shaft fractures as well as our experience using this technique in a case series of 4 patients.

This article assesses the shoulder surgery literature relating to unplanned hospital readmissions following primary total shoulder arthroplasty (TSA). With increasing demand for TSA and the challenges posed by unplanned hospital readmissions, it is essential to have a concrete understanding of the risk factors and implications of readmissions. Patient Intrinsic and Extrinsic factors such as patient demographics, comorbidities, and surgical variables contribute to readmission risk. Despite low overall readmission rates, the negative patient health, financial, and resource burdens of unplanned readmissions remain significant. This study emphasizes the importance of developing targeted interventions to minimize readmission risks and improve patient outcomes.

PURPOSE:Subacromial decompression (SAD) has historically been described as an essential part of the surgical treatment of rotator cuff disorders. However, investigations throughout the 21st century have increasingly questioned the need for routine SAD during rotator cuff repair (RCR). Our purpose was to assess for changes in the incidence of SAD performed during RCR over a 12-year period. In addition, we aimed to characterize surgeon and practice factors associated with SAD use. METHODS:Records from two large tertiary referral systems in the United States from 2010 to 2021 were reviewed. All cases of RCR with and without SAD were identified. The outcome of interest was the proportion of SAD performed during RCR across years and by surgeon. Surgeon-specific characteristics included institution, fellowship training, surgical volume, academic practice, and years in practice. Yearly trends were assessed using binomial logistic regression modeling, with a random effect accounting for surgeon-specific variability. RESULTS:During the study period, 37,165 RCR surgeries were performed by 104 surgeons. Of these cases, 71% underwent SAD during RCR. SAD use decreased by 11%. The multivariable model found that surgeons in academic practice, those with lower surgical volume, and those with increasing years in practice were significantly associated with increased odds of performing SAD. Surgeons with fellowship training were significantly more likely to use SAD over time, with the greatest odds of SAD noted for sports medicine surgeons (odds ratio = 3.04). CONCLUSIONS:Although SAD use during RCR appears to be decreasing, multiple surgeon and practice factors (years in practice, fellowship training, volume, and academic practice) are associated with a change in SAD use. CLINICAL RELEVANCE:These data suggest that early-career surgeons entering practice are likely driving the trend of declining SAD. Despite evidence suggesting limited clinical benefits, SAD remains commonly performed; future studies should endeavor to determine factors associated with practice changes among surgeons.

Background: As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. Methods: A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. Results: Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-na & imath;ve (P <.001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-na & imath;ve patients (P <.001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-na & imath;ve (P <.001). Conclusion: This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA. Level of evidence: Level III; Retrospective Cohort Study; Prognosis Study (c) 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

INTRODUCTION:The opioid epidemic in the United States has contributed to a notable economic burden and increased mortality. Total shoulder arthroplasty (TSA) has become more prevalent, and opioids are commonly used for postoperative pain management. Prolonged opioid use has been associated with adverse outcomes, but the role of surgeons in this context remains unclear. This study aims to investigate the incidence and risk factors of prolonged opioid utilization after primary TSA. METHODS:After obtaining institutional review board approval, a retrospective review of 4,488 primary total shoulder arthroplasties from 2014 to 2022 at a single academic institution was conducted. Patients were stratified by preoperative and postoperative opioid use, and demographic, clinical, and prescription data were collected. Prescriptions filled beyond 30 days after the index operation were considered prolonged use. Multivariate analysis was conducted to determine the independent risk factors associated with prolonged opioid utilization. RESULTS:Among 4,488 patients undergoing primary TSA, 22% of patients developed prolonged opioid use with 70% of prolonged users being opioid-exposed preoperatively. Independent risk factors of prolonged use include patient age younger than 65 years (Odds Ratio (OR) 1.02, P < 0.001), female sex (OR 1.41, P < 0.001), race other than Caucasian (OR 1.36, P = 0.003), undergoing reverse TSA (OR 1.28, P = 0.010), residing in an urban community (OR 1.33, P = 0.039), preoperative opioid utilization (OR 6.41, P < 0.001), preoperative benzodiazepine utilization (OR 1.93, P < 0.001), and increased postoperative day 1-30 milligram morphine equivalent (OR 1.003, P < 0.001). DISCUSSION:Nearly 22% of patients experienced prolonged opioid use, with preoperative opioid exposure being the most notable risk factor in addition to postoperative prescribing patterns and benzodiazepine utilization. Surgeons play a crucial role in opioid management, and understanding the risk factors can help optimize benefits while minimizing the associated risks of prolonged opioid use. Additional research is needed to establish standardized definitions and strategies for safe opioid use in orthopaedic surgery.

BACKGROUND:The OPTimisE intervention was developed to address uncertainty regarding the most effective physiotherapy treatment strategy for people with Lateral Elbow Tendinopathy (LET). OBJECTIVES:To assess the feasibility of conducting a fully-powered randomised controlled trial (RCT) evaluating whether the OPTimisE intervention is superior to usual physiotherapy treatment for adults with LET. DESIGN:A mixed-methods multi-centred, parallel pilot and feasibility RCT, conducted in three outpatient physiotherapy departments in the UK. METHOD:Patients were independently randomised 1:1 in mixed blocks, stratified by site, to the OPTimisE intervention or usual care. Outcomes were assessed using pre-defined feasibility progression criteria. RESULTS:50 patients were randomised (22 Female, 28 Male), mean age 48 years (range 27-75). Consent rate was 71% (50/70), fidelity to intervention 89% (16/18), attendance rate in the OPTimisE group 82% (55/67) vs 85% (56/66) in usual care, outcome measure completion 81% (39/48) at six-month follow-up. There were no related adverse events. Patients and physiotherapists reported that the OPTimisE intervention was acceptable but suggested improvements to the trial design. 49 patients were recruited from physiotherapy referrals vs one from primary care records. Outcome measure return rates were higher when completed online (74%) compared to postal questionnaire (50%). Exploratory analysis showed improvements in both groups over time. CONCLUSIONS:It is methodologically feasible to conduct a fully powered RCT comparing the clinical and cost-effectiveness of the OPTimisE intervention versus usual physiotherapy treatment. Considering the similar improvements observed in both groups, careful consideration is needed regarding the priority research question to be addressed in future research.

Introduction: Increasingly, unicompartmental knee arthroplasty (UKA) is being performed on an outpatient basis, with the growing utilization of ambulatory surgery centers (ASCs). The purpose of this study was to compare the costs of UKAs performed in an ASC to UKAs done in a hospital, either on an outpatient or inpatient basis. Methods: This study involved three matched groups, each with 50 consecutive patients, undergoing UKA either on an outpatient basis in an ASC or a community hospital, or who were admitted overnight to the same community hospital. Identical perioperative analgesic regimens and care protocols were used in each group. The primary outcomes evaluated included direct facility costs. Secondary outcomes were postoperative complications and readmissions. Results: Average age, gender ratio, and comorbidities were similar in all three cohorts. Only two patients in the study experienced complications and these were without secondary adverse consequences. Mean costs were substantially reduced when UKAs were performed in an ASC ($9,025) compared to a community hospital on either an outpatient ($12,032) or inpatient basis ($14,542).Conclusion: UKA can be safely performed in the outpatient setting, in appropriately selected patients, at substantial cost savings, particularly when performed in an ASC.

BackgroundSalvage reverse shoulder arthroplasty (RSA) for failed proximal humerus fractures (PHFs) fixation and hemiarthroplasty (HA) may maximize outcomes in the absence of tuberosity healing or a chronically torn rotator cuff. The purpose of this systematic review was to examine the improvement in clinical outcomes for patients after revision RSA was performed for failed PHFs fixation or HA.MethodsAn electronic database search of SCOPUS, PubMed, Embase, MEDLINE, SPORTDiscus, CINAHL, and ClinicalTrials.gov was performed. A meta-analysis was carried out to determine weighted mean outcome differences between two primary intervention cohorts (failed fixation: open reduction and internal fixation, intramedullary nail, or K-wire vs. failed HA).ResultsFifteen studies were included (primary fixation: 208 patients; HA: 162 patients). Patients improved meaningfully in all clinical outcomes after revision surgery (constant: 18.5-48.3; abduction: 44-95; forward flexion: 47-107; external rotation: 5-10), with a 16.2% complication and 9.4% revision rate. The failed fixation group performed significantly better than the failed HA group in postoperative constant (fixation: 53.3 vs. HA: 45.1, p = 0.016) and shoulder abduction (fixation: 102 vs. HA: 87, p = 0.026).ConclusionsRSA is a successful revision intervention for primary PHF operative failures with the greatest benefit for failures of primary fixation versus HA.

Background: Socioeconomic status (SES) has been shown to affect outcomes following total shoulder arthroplasty (TSA), but little is known regarding how SES and the communities in which patients reside can affect postoperative health care utilization. With the growing use of bundled payment models, understanding what factors put patients at risk for readmission and the ways in which patients utilize the health care system postoperatively is crucial for preventing excess costs for providers. This study helps surgeons predict which patients are high-risk and may require additional surveillance following shoulder arthroplasty.Methods: A retrospective review of 6170 patients undergoing primary shoulder arthroplasty (anatomic and reverse; Current Procedural Terminology code 23472) from 2014-2020 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, patient zip code, and Charlson Comorbidity Index were attained. Patients were classified according to the Distressed Communities Index (DCI) score of their zip code. The DCI combines several metrics of socioeconomic well-being to generate a single score. Zip codes are then classified by scores into 5 categories based on national quin-tiles. The primary outcome of interest was 90-day readmissions. Secondary outcomes included number of postoperative medication prescriptions, patient telephone calls to the office, and follow-up office visits.Results: Among all patients undergoing total shoulder arthroplasty, individuals from distressed communities were more likely than their prosperous counterparts to experience an unplanned readmission (odds ratio = 1.77, P = .045). Patients from comfortable (relative risk [RR] = 1.12, P < .001), midtier (RR = 1.13, P < .001), at-risk (RR = 1.20, P < .001), and distressed (RR = 1.17, P < .001) communities were all more likely to use more medications compared to those from prosperous communities. Likewise, those from comfortable (RR = 0.92, P < .001), midtier (RR = 0.88, P < .001), at-risk (RR = 0.93, P = .008), and distressed (RR = 0.93, P = .033) communities, respectively, were at a lower risk of making calls compared to prosperous communities.Conclusions: Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively. This study revealed that patient socioeconomic distress is more associated with readmission than race following TSA. Increased awareness and employing strategies to maintain and ultimately improve communication with patients offers a potential solution to reduce excessive health care utilization, benefiting both patients and providers alike. Level of evidence: Level III; Retrospective Cohort Comparison; Prognosis Study (c) 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: As demand for shoulder arthroplasty grows, adequate cost containment is of importance. Given the historical use of bundle payments for lower extremity arthroplasty, it is reasonable to anticipate that such programs will be universally implemented in shoulder arthroplasty. This project evaluates how patient demographics, medical comorbidities, and surgical variables affect episode-of-care costs in an effort to ensure accurate reimbursement scales and equitable access to care. Methods: Consecutive series of primary total shoulder arthroplasty (anatomic and reverse) procedures were retrospectively reviewed at a single academic institution from 2014 to 2020 using claims cost data from Medicare and a private insurer. Patient demographics, comorbidities, and clinical outcomes were collected. A stepwise multivariate regression was performed to determine the independent effect of comorbidities and demographics on 90-day episode-of-care costs. Results: Overall, 1,452 shoulder arthroplasty patients were identified (1,402 Medicare and 50 private payer patients). The mean 90-day cost for Medicare and private payers was $25,822 and $31,055, respectively. Among Medicare patients, dementia ($3,407, P = 0.003), history of stroke ($3,182, P = 0.005), chronic pulmonary disease ($1,958, P = 0.007), anemia ($1,772, P = 0.039), and heart disease ($1,699, P = 0.014) were associated with significantly increased costs. Demographics that significantly increased costs included advanced age ($199 per year in age, P < 0.001) and elevated body mass index ($183 per point, P < 0.001). Among private payers, hyperlipidemia ($6,254, P = 0.031) and advanced age ($713 per year, P < 0.001) were associated with an increase in total costs. Conclusion: Providers should be aware that certain demographic variables and comorbidities (history of stroke, dementia, chronic pulmonary disease, anemia, heart disease, advanced age, and elevated body mass index) are associated with an increase in total costs following primary shoulder arthroplasty. Further study is required to determine whether bundled payment target costs should be adjusted to better compensate for specific comorbidities. Level of Evidence: Level IV case series.

Background: In late 2019 and early 2020, a novel coronavirus, COVID-19 (coronavirus disease 2019), spread across the world, creating a global pandemic. In the state of Pennsylvania, non-emergent, elective operations were temporarily delayed from proceeding with the normal standard of care. The primary purpose of this study was to determine the proportion of patients who required prescription pain medication during the surgical delay. Secondarily, we sought to determine the proportion of patients who perceived their surgical pro-cedure as non-elective and to evaluate how symptoms were managed during the delay.Materials and methods: A single institutional database was used to retrospectively identify all shoulder and elbow surgical procedures scheduled between March 13 and May 6, 2020. Charts were manually reviewed. Patients who underwent non-shoulder and elbow-related procedures and patients treated by surgeons outside of Pennsylvania were excluded. Patients whose surgical procedures were postponed or canceled were administered a survey evaluating how symptoms were managed and perceptions regarding the delay. Preoperative functional scores were collected. Statistical analysis was performed to determine associations between procedure status, preoperative functional scores, perception of surgery, and requirement for prescription pain medication.Results: A total of 338 patients were scheduled to undergo shoulder and elbow surgery in our practice in Pennsylvania. Surgery was performed as initially scheduled in 89 of these patients (26.3%), whereas surgery was postponed in 179 (71.9%) and canceled in 70 (28.1%). The average delay in surgery was 86.7 days (range, 13-299 days). Responses to the survey were received from 176 patients (70.7%) in whom surgery was postponed or canceled. During the delay, 39 patients (22.2%) required prescription pain medication. The surgical procedure was considered elective in nature by 73 patients (41%). One hundred thirty-seven patients (78%) would have moved forward with surgery if performed safely under appropriate medical guidelines. Lower preoperative American Shoulder and Elbow Sur-geons scores (r = -0.36, P < .001) and Single Assessment Numeric Evaluation scores (r = -0.26, P = .016) and higher preoperative visual analog scale scores (r = 0.28, P = .009) were correlated with requiring prescription pain medication. Higher preoperative Amer-ican Shoulder and Elbow Surgeons scores were positively correlated with perception of surgery as elective (r = 0.4, P < .001). Conclusion: Patients undergoing elective shoulder and elbow surgical procedures during the COVID-19 (coronavirus disease 2019) pandemic experienced a delay of nearly 3 months on average. Fewer than half of patients perceived their surgical procedures as elective procedures. Nearly one-quarter of patients surveyed required extra prescription pain medicine during the delay. This study elucidates the fact that although orthopedic shoulder and elbow surgery is generally considered "elective,"it is more important to a majority of pa-tients. These findings may also be applicable to future potential mandated surgical care delays by other third-party organizations.Level of evidence: Descriptive Epidemiology Study; Chart Review and Patient Survey Design (c) 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Abstract Background Physiotherapy is recommended for people with tennis elbow, but whilst a wide array of treatments is available, the optimal approach remains uncertain. We have therefore recently developed an optimised physiotherapy treatment package for tennis elbow based on a synthesis of the evidence, patient input and clinical consensus. It consists of detailed advice and education, a structured progressive exercise programme and provision of a counter-force elbow brace. Here, we report the protocol for our multicentre pilot and feasibility randomised controlled trial (RCT) designed to (a) examine the feasibility of our optimised physiotherapy treatment package and (b) to pilot trial processes for a future fully powered RCT to test clinical and cost-effectiveness compared with usual physiotherapy treatment. Methods A multicentre pilot and feasibility RCT will be conducted across three sites in England, recruiting up to 50 patients (or for a maximum of 12 months). Participants with tennis elbow, identified from physiotherapy clinic waiting lists and general practice surgeries, will be randomly allocated to receive the optimised physiotherapy treatment package or usual physiotherapy care. Analysis will focus on feasibility measures including consent rate, intervention fidelity, follow-up rate and outcome completion rate. A nested qualitative study will explore the acceptability of the study processes and patient and physiotherapist experiences of the new optimised intervention. Discussion This study will determine the feasibility of a new optimised physiotherapy treatment package for people with tennis elbow and pilot the processes for a future fully powered RCT. In the longer term, this treatment package may provide superior clinical outcomes for patients, in terms of pain and quality of life, and be more cost-effective for the health service. Trial registration Registered with the ISRCTN database 19/7/2021, https://www.isrctn.com/ISRCTN64444585

Background: The short-term results of total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon in patients with glenoid bone loss have previously been reported. The purpose of this study was to investigate the mid-to long-term clinical and radiographic outcomes of these patients.Methods: We identified a cohort of patients who underwent total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon between 2010 and 2019 for severe glenoid dysplasia and/or glenoid bone loss. Patients with a minimum of 2 years' follow-up were evaluated regarding preoperative and postoperative range of motion, radiographic findings, visual analog scale pain scores, and Single Assessment Numeric Evaluation scores.Results: Overall, 39 shoulders in 33 patients were treated with an inlay glenoid component for severe glenoid bone loss. Four patients were lost to follow-up, and 1 patient died with a well-functioning implant in place. The final cohort included 34 shoulders in 28 patients (46.4% female patients [13 of 28] and 53.6% male patients [15 of 28]) with a mean age of 66.9 years (range, 58-81 years) and mean follow-up period of 68.3 months. Of the 34 cases, 5 were revision cases. One patient died following 2-year follow-up. Of the shoulders, 10 were classified as Walch type A2, 4 were classified as Walch type B3, and 15 were classified as Walch type C; 5 shoulders were unable to be classified. We observed statistically significant increases in range of motion (forward elevation, 38.1 degrees [P < .001]; external rotation, 18.8 degrees [P < .001]) and improvement in the Single Assessment Numeric Evaluation score (from 26.6 to 81.0, P < .001). Two patients underwent conversion to reverse shoulder arthroplasty at 2.2 and 1.7 years postoperatively.Conclusion: Inlay glenoid components provide a low rate of revision and improved clinical and functional outcomes at mid-to long-term follow-up.Level of evidence: Level IV; Case Series; Treatment Study (c) 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background:The goal of this study was to determine if there is an association between glenohumeral synovitis and early post-operative pain after arthroscopic rotator cuff repair.Methods:Fifty patients with symptomatic rotator cuff tears were prospectively enrolled prior to RCR. Baseline ASES score, VAS Pain score, forward elevation, and external rotation were recorded. Intra-operatively, synovitis was graded on a scale of zero to six as based on a previously validated scoring system. VAS Pain scores were obtained from patients post-operatively on days one through 14, week 6, and 3 months.Results:Average intra-operative synovitis score was 2.4 ± 1.6. No significant correlation was found between synovitis score and pre-operative forward elevation (P=0.171), external rotation (P=0.126), VAS Pain (P=0.623), or ASES (P=0.187) scores. No significant correlation was found between synovitis score and post-operative VAS Pain level at any time point. There was a moderate correlation between both pre-operative VAS Pain and ASES scores and post-operative VAS Pain in the first post-operative week. Workers' compensation patients had worse pain at 3 months post-operatively compared to non-workers compensation patients (P=0.038).Conclusion:This study reveals that macroscopically assessed glenohumeral synovitis does not have any significant correlation with pre-operative or post-operative pain in patients undergoing arthroscopic rotator cuff repair; although higher pre-operative pain levels, worse pre-operative ASES scores, and workers compensation status do influence post-operative pain levels in arthroscopic rotator cuff repair.

Introduction: Given the rising demand for shoulder arthroplasty, understanding risk factors associated with unplanned hospital readmission is imperative. No study to date has examined the influence of patient and hospital-specific factors as a predictive model for 90-day readmissions within a bundled payment cohort after primary shoulder arthroplasty. The purpose of this study was to determine predictive factors for 90-day readmissions after primary shoulder arthroplasty within a bundled payment cohort. Methods: After obtaining IRB approval, a retrospective review of a consecutive series of Medicare patients undergoing primary shoulder arthroplasty from 2014 to 2020 at a single academic institution was conducted. Patient demographic data, surgical variables, medical comorbidity profiles, medical risk scores, and social risk scores were collected. Postoperative variables included length of hospital stay, discharge location, and 90-day readmissions. Multivariate analysis was conducted to determine the independent risk factors of 90-day readmission. Results: Overall, 3.6% of primary shoulder arthroplasty patients (127/3,523) were readmitted within 90 days. Readmitted patients had a longer hospital course (1.75 versus 1.45 P = 0.006), higher comorbidity profile (4.64 versus 4.24 P = 0.001), higher social risk score (7.96 versus 6.9 P = 0.008), and higher medical risk score (10.1 versus 6.96 P < 0.001) and were more likely to require a home health aide or be discharged to an inpatient rehab facility or skilled nursing facility (P = 0.002). Following multivariate analysis, an elevated medical risk score was associated with an increased risk of readmission (odds ratio = 1.05, P < 0.001). Discussion: This study demonstrates medical risk scores to be an independent risk factor of increased risk of 90-day hospital readmissions after primary shoulder arthroplasty within a bundled payment patient population. Additional incorporation of medical risk scores may be a beneficial adjunct in preoperative prediction for readmission and the potentially higher episode-of-care costs. Level of Evidence: Level III, retrospective cohort.