BACKGROUND:To compare patient-reported outcomes, range of motion, and rates of revision surgery between male and female patients undergoing primary anatomic total shoulder arthroplasty (aTSA). METHODS:A systematic review was performed using the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A literature search was performed on June 1, 2024, using the PubMed, Embase, and Scopus library databases for human clinical studies reporting postoperative outcomes and revision rates following aTSA between male and female patients. Preoperative and postoperative outcome scores and revision rates were stratified by patient sex and quantitatively compared. The quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies criteria. RESULTS:Six studies met the inclusion criteria, totaling 4525 patients. Males (n = 2288) had a mean age of 68.3 years and females (n = 2237) had a mean age of 67.4 years (mean difference, 2.02; P = .43). Males demonstrated significantly greater improvement in postoperative American Shoulder and Elbow Surgeons scores (mean difference 2.18, P < .001) and visual analog scale pain scores (mean difference 0.40, P < .001) compared to females. Females demonstrated higher rates of postoperative complications (10.1% vs. 7.3%, risk ratio 1.43, P < .001) and revision surgeries (6.2% vs. 3.7%, risk ratio 1.87, P = .03). CONCLUSION:Males undergoing aTSA demonstrate significantly greater improvements in postoperative American Shoulder and Elbow Surgeons and visual analog scores than females. Females have higher rates of postoperative complications and revision surgery. These findings highlight the necessity for tailored preoperative counseling, perioperative management, and postoperative care strategies. Further investigation is needed to determine the clinical significance of these difference and to identify modifiable biological and social risk factors to improve results in female patients.

Arthroscopic biceps tenodesis is a safe and reliable treatment for managing intra-articular biceps tendon pathology. This Technical Note describes an arthroscopic biceps tenodesis technique with a single double loop-and-tack knotless suture anchor.

Background: It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation. Methods: Current Procedural Terminology codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services. Procedures were grouped into arthroscopic and open categories. Publicly available data from Centers for Medicare and Medicaid Services was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018 to 2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018 to 2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons. Results: A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (P < .01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (P = .838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (P = .064 and P = .005, respectively). Conclusion: Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care. Level of evidence: Level IV; Economic Study (c) 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background: Although both anatomic (ATSA) and reverse total shoulder arthroplasty (rTSA) have been popularized as a means of treating individuals with degenerative shoulder conditions, the indications for each can vary widely among providers. Although surgeons with differing fellowship training commonly perform these procedures, it is not understood how fellowship training influences choice of implant. Methods: A national database was queried to identify surgeons performing ATSA and rTSA. For all surgeons who performed more than 10 cases between 2010 and 2022, fellowship data were individually collected via an online search. For each fellowship group, rates of ATSA and rTSA were identified using International Classification of Diseases procedural codes. Those who underwent revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Primary outcome measures included the proportion of primary and revision ATSAs and rTSAs by fellowship in addition to the rate of rTSA performed for a primary diagnosis of glenohumeral osteoarthritis. Results: A total of 131,974 patients met the inclusion criteria and were retained for this study. The proportion of rTSAs increased from 50.1% of all primary shoulder arthroplasty cases in 2011 to 72.0% in 2022. After adjusting for age and comorbidities, Sports Medicine fellowship-trained (Sports) surgeons opted for primary rTSA over ATSA at a significantly higher rate than Shoulder and Elbow fellowship-trained (Shoulder) surgeons and surgeons who completed another type of fellowship or no fellowship (Other). Sports surgeons also chose rTSA more frequently for the diagnosis of glenohumeral osteoarthritis than Shoulder surgeons. Surgeons in the Other cohort were more likely to perform primary ATSA rather than rTSA in comparison with surgeons in the Shoulder and Sports cohorts. Sports surgeons were responsible for the greatest increase in the percentage of all shoulder arthroplasty procedures from 2010 to 2022 (28.4%-40.4%), whereas the Other group decreased by a comparable amount (45.9%-32.4%) over the same period. Conclusions: Surgeons who have completed a Sports Medicine fellowship choose rTSA over ATSA at a higher rate than Shoulder and Elbow surgeons, both for all indications and for a primary diagnosis of glenohumeral osteoarthritis. Those who have no fellowship training or fellowship training outside of Sports Medicine and Shoulder and Elbow surgery have the highest percentage of ATSAs in their arthroplasty practice. Revision ATSA and revision rTSA represent a larger percentage of overall case volume for Shoulder and Elbow surgeons. Level of evidence: Level III; Epidemiology Study; Cross-Sectional Design (c) 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background: Total shoulder arthroplasty is performed by orthopedic surgeons with various fellowship training backgrounds. Whether surgeons performing shoulder arthroplasty with different types of fellowship training have differing rates of complications and reoperaMethods: The PearlDiver Mariner database was retrospectively queried from the years 2010 to 2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Fellowship was determined and verified via online search. Only surgeons who performed a minimum of 10 cases were selected; and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90-day, 1-year, and 5-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was Results: In total, 150,385 patients met the inclusion criteria and were included in the study. Analysis of surgical trends revealed that Sports Medicine and Shoulder and Elbow fellowship-trained surgeons are performing an increasing percentage of all shoulder arthroplasty over time, with each cohort exhibiting an 11.3% and 4.2% increase from 2010 to 2022, respectively. The geographic region with the highest proportion of cases performed by Sports Medicine surgeons was the West, while the Northeast has the highest proportion of cases performed by Shoulder and Elbow surgeons. Shoulder and Elbow surgeons operated on patients that were significantly younger and had fewer comorbidities. Both Shoulder and Elbow and Sports Medicine surgeons had lower rates of postoperative complications at 90 days, 1 year, and 5 years in comparison to surgeons who completed another type of fellowship or no fellowship. Across each time point, the rates of individual complications between Sports Medicine and Shoulder and Elbow were comparable, but the pooled complication rate was lowest in the Shoulder and Elbow cohort. Conclusion: Surgeons who have completed either a Sports Medicine or Shoulder and Elbow fellowship are performing an increasing proportion of shoulder arthroplasty over time. Sports Medicine and Shoulder and Elbow-trained surgeons have significantly lower complication rates at 90 days, 1 year, and 5 years postoperatively. The individual complication rates between Sports Medicine and Shoulder and Elbow are comparable, but Shoulder and Elbow have the lowest pooled complication rates overall. Level of evidence: Level III; Retrospective Cohort Comparison using Large Database; Prognosis Study (c) 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

The presence of a Hill-Sachs lesion is a known risk factor for recurrent shoulder instability. Many procedures have been described for the treatment of off-track Hill-Sachs lesions; however, each of these techniques is fraught with potential disadvantages and complications. In this Technical Note and accompanying video, we describe our technique for arthroscopic treatment of a Hill-Sachs lesion with talus osteochondral allograft. This technique recreates native humeral head anatomy with a highly congruent graft without altering the biomechanics of the glenohumeral joint.

Background Cutibacterium acnes (C. acnes), formerly Propionibacterium acnes (P. acnes), is the most common pathogen responsible for postoperative shoulder infections. Prevention of shoulder infection is crucial to improving patient outcomes, prolonging implant longevity, and reducing costs. The purpose of this study is to evaluate the effectiveness of various prophylactic treatments for C. acnes in the shoulder. Methods A systematic review of 15 randomized controlled trials was conducted to evaluate the effectiveness of various skin preparation methods in the reduction of C. acnes for patients undergoing shoulder surgery. Three electronic databases were queried as follows: PubMed, Embase, and the Cochrane Library databases. Data extraction for this study was performed by three independent reviewers, and only level I studies were included. Outcomes were assessed based on the effectiveness of the method used; side effects were also analyzed. Results Fifteen studies were included in this review. Seven studies utilized a regimen of at-home treatment in the days leading up to culture sampling, while the other eight studies administered treatment just prior to sampling. Seven studies found their respective treatment methods to be statistically significant. No preparation methods applied immediately prior to sampling showed conclusive superiority. The application benzoyl peroxide in the days prior to sampling showed significantly lower rates of colonization when compared to control groups in five separate studies. Conclusion There remains no consensus on the optimal skin preparation method immediately prior to surgery, however, acne cream applied in the days leading up to surgery has been shown to significantly reduce the bacterial load of C. acnes. While BPO appears to be the superior method of prophylactic treatment, it is also associated with higher rates of complications and skin reactions following treatment; thus, caution is warranted. Further studies should investigate whether this reduction in bacterial load translates to meaningfully lower rates of periprosthetic joint infections.

Background: Hamstring injuries are commonly considered the number one reason for delayed return to play and return to sport (RTS) across several sport disciplines. Traditionally, they are treated conservatively. However, recent literature has shown surgical intervention to improve recovery and expedite RTS. One potential explanation behind this phenomenon is conservative treatment does not address the disrupted length-tendon relationship, which can cause hamstring re-injury. Indications: Operative indications for tendon excision include patients with distal semitendinosus avulsions tear with retraction, especially patients who had already failed conservative management. Elite athletes with distal hamstring tears who have experienced a delayed RTS or desired activity level should also be considered for distal hamstring excision. Technique Description: A distal 4-cm incision, which was longitudinal in line with the semitendinosus, was made over the posterior knee at the measured level of the avulsed tendon stump, 2 cm proximal to the knee flexion crease. Blunt dissection was used for the subcutaneous layers, and the overlying hypertrophic and fibrotic tendon sheath was sharply incised. The torn and retracted tendon tissue was exteriorized. An allis clamp was used to provide tension on the distal semitendinosus, and mobilization of the avulsed tendon was performed. Sheath tissue surrounding the injured tendon was removed. The stump was whipstitched to provide further traction, and the hypertrophied portion of the tendon was excised. An open tendon stripper was implemented to exercise both limbs of the semitendinosus. The subcutaneous tissue and skin were closed, and an incisional wound vac was placed. Discussion/Conclusion: Distal avulsion tears of semitendinosus tendons can lead to unsatisfactory results with conservative treatment, with delayed RTS and recurrence of symptoms. Resection of hamstring tendon tissue may eliminate the recurrence of injury, along with inflammation, fibrosis, and hemorrhage associated with retraction reinjuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Suprascapular nerve (SSN) entrapment is a rare but significant cause of posterior shoulder pain and weakness. Compression of the nerve at the level of the spinoglenoid notch leads to weakness and atrophy of the infraspinatus. A detailed history and physical examination along with appropriate workup are paramount to arrive at this diagnosis. Surgical decompression is indicated in cases refractory to conservative management. In this technical note, we describe our technique for open decompression of the SSN at the spinoglenoid notch. This approach permits direct visualization of the SSN and allows for a safe, reliable, and thorough decompression.

Background:In 2020, the American Society of Shoulder and Elbow Therapists (ASSET) published an evidence-based consensus statement outlining postoperative rehabilitation guidelines following anatomic total shoulder arthroplasty (TSA). Purpose:The purpose of this study was to (1) quantify the variability in online anatomic TSA rehabilitation protocols, and (2) assess their congruence with the ASSET consensus guidelines. Methods:This study was a cross-sectional investigation of publicly available, online rehabilitation protocols for anatomic TSA. A web-based search was conducted in April 2022 of publicly available rehabilitation protocols for TSA. Each collected protocol was independently reviewed by two authors to identify recommendations regarding immobilization, initiation, and progression of passive (PROM) and active range of motion (AROM), as well as the initiation and progression of strengthening and post-operative exercises and activities. The time to initiation of various components of rehabilitation was recorded as the time at which the activity or motion threshold was permitted by the protocol. Comparisons between ASSET start dates and mean start dates from included protocols were performed. Results:Of the 191 academic institutions included, 46 (24.08%) had publicly available protocols online, and a total of 91 unique protocols were included in the final analysis. There were large variations seen among included protocols for the duration and type of immobilization post-operatively, as well as for the initiation of early stretching, PROM, AROM, resistance exercises, and return to sport. Of the 37 recommendations reported by both the ASSET and included protocols, 31 (83.78%) were found to be significantly different between groups (p\<0.05). Conclusion:Considerable variability was found among online post-operative protocols for TSA with substantial deviation from the ASSET guidelines. These findings highlight the lack of standardization in rehabilitation protocols following anatomic TSA. Level of Evidence:3b.

BACKGROUND:Lateral unicompartmental knee arthroplasty (UKA) is an effective treatment for isolated lateral compartment osteoarthritis. However, due to the rarity of the procedure, long-term outcomes and survivorship are poorly understood. We report the clinical and radiographic outcomes after lateral UKA. METHODS:We retrospectively reviewed a consecutive series of patients who underwent lateral UKA by a single fellowship-trained arthroplasty surgeon from 2001 to 2021 with a minimum 2 year follow up. There were 161 knees in 153 patients (average age 69 years) that met inclusion criteria, with a mean follow up of 10.0 years (range 0.05 to 22.2). All patients underwent the procedure via a minimally invasive lateral parapatellar approach with a fixed-bearing implant. Patient demographics, complications, radiographic findings, patient-reported outcomes, and the need for revision surgery were evaluated. Survivorship was defined with the end point as revision of components. RESULTS:There were 8 patients (5.0%) who underwent conversion to total knee arthroplasty for lateral UKA implant failure or progression of arthritis. There were 3 patients (1.9%) who underwent ipsilateral medial UKA due to medial compartment arthritis progression with preserved mechanical alignment and patellofemoral joint. There were 8 additional procedures that did not require implant changes, including 5 irrigation and debridements for acute periprosthetic joint infection (3.1%), 2 wound closures for dehiscence (1.3%), and one loose body removal (0.6%). CONCLUSIONS:Lateral UKA showed a survivorship rate of 98.0% at 5 years, 96.0% at 10 years, and 94.5% at 15 years. When including patients who underwent additional surgery for the progression of arthritis, survivorship was 97.4% at 5 years, 95.4% at 10 years, and 91.3% at 15 years. Lateral UKA should be seen as a durable treatment option for isolated lateral compartment osteoarthritis.

Background: Osteoporosis is common among patients undergoing primary total hip arthroplasty (THA). This study aimed to evaluate the effect of bisphosphonate treatment on osteoporotic patients undergoing primary THA. Methods: Using a national database, 30,137 patients who had osteoporosis before primary elective THA were identified during 2010 to 2020. Patients undergoing nonelective THA and those using corticosteroids or other medications for osteoporosis were excluded. Bisphosphonate users and bisphosphonate naive patients were matched 1:1 based on age, sex, Elixhauser comorbidity index, and a history of obesity, rheumatoid arthritis, tobacco use, and alcohol abuse. Kaplan-Meier and multivariate analyses were used to compare 2-year outcomes between groups. Results: Among matched cohorts of 9,844 patients undergoing primary THA, bisphosphonate use was associated with a significantly higher 2-year rate of periprosthetic fracture (odds ratio 1.29, 95% confidence interval 1.04 to 1.61, P = .022). There was a trend toward increased risk of any revision with bisphosphonate use (odds ratio 1.19, confidence interval 1.00 to 1.41, P = .056). Rates of infection, aseptic loosening, dislocation, and mortality were not statistically different between bisphosphonate users and bisphosphonate-naive patients. Conclusion: In osteoporotic patients, bisphosphonate use before primary THA is an independent risk factor for periprosthetic fracture. Additional longer-term data are needed to determine the underlying mechanism for this association and identify preventative measures. (c) 2023 Elsevier Inc. All rights reserved.

IntroductionProximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques.Materials and MethodsAdult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating characteristic (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified.ResultsA total of 7,473 patients were included (72.1% male, mean age 66.2 ± 13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean: 0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE: 0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009).ConclusionsPredictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification.

Background Increased surgeon volume has been demonstrated to correlate with improved outcomes after orthopedic surgery. However, there is a lack of data demonstrating the effect of surgeon volume on outcomes after total shoulder arthroplasty. Methods The PearlDiver Mariner database was retrospectively queried from the years 2010-2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472 (Total Shoulder Arthroplasty). Patients under 40 years of age, those undergoing revision arthroplasty and cases of bilateral arthroplasty were excluded. Additionally, cases with a history of fracture, infection, or malignancy prior to surgery were excluded. Only surgeons who performed a minimum of 10 cases were selected and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90 day, 1-year, and 2-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at p≤0.00082 Results A total of 155,560 patients met inclusion criteria and were retained for analysis. The 90th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90th percentile (n=340) operated on 68,531 patients whereas surgeons below the 90th percentile (n=3,038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship (p<0.001) and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine (p<0.001). Low-volume surgeons operated on patients with higher baseline comorbidities (CCI: 2.01 vs 1.85, p<0.001). After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure (p<0.001), anemia (p<0.001), and UTI (p<0.001). All cause readmission (0.90, p<0.001), reoperation at 90 days (OR 0.75, p<0.001) and reoperation at 1 year (OR: 0.86, p<0.001) were significantly lower among high-volume surgeons. High-volume surgeons exhibited lower rates of various complications including prosthetic joint infection (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001), periprosthetic fracture (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001) and all complications (90d: p<0.001; 1yr: p<0.001). Conclusion Surgeons who perform a high volume of total shoulder arthroplasty are more likely to operate on healthier patients than surgeons who perform a lower volume of cases. When compared to low-volume surgeons, and after adjusting for age, gender, and CCI, high-volume surgeons have a significantly lower overall complication rate. Despite this lower complication rate, high-volume surgeons are responsible for a decreasing portion of shoulder arthroplasty since 2016.

Objectives: To compare the overall cost of sports medicine procedures for Medicare beneficiaries in both ambulatory surgery centers (ASC) and hospital outpatient department (HOPD) settings. Secondary aims were to compare facility fees, surgeon fees, Medicare payments, and patient payments between ASCs and HOPDs. Methods: Publicly available data from The Centers for Medicare & Medicaid Services (CMS) was accessed via the Medicare Procedure Price Lookup Tool. Current Procedural Terminology (CPT) codes were used to identify sports medicine procedures approved for the outpatient setting by CMS. Facility fees, surgeon fees, total costs, Medicare payment, and patient payment were extracted. Descriptive statistics were used to calculate means and standard deviations. Cost differences were analyzed using Mann Whitney U tests. Results: Sixty-two CPT codes were identified. Shoulder procedures (n=25) at ASCs had lower total costs (3,622±1,156 vs 6,262±1,759; p<0.001), facility fees (2,777±1,020 vs 5,416±1,606; p<0.001), Medicare payments (2,898±928 vs 5,009±1,407 p<0.001), and patient payments (724±232 vs 1,252±352; p<0.001) compared to HOPDs. Knee procedures (n=31) at ASCs had lower total costs (4,236±2,741 vs 6,668±3,341; p=0.006), facility fees (3,408±2,507 vs 5,840±3,116; p=0.006), Medicare payments (3,389±2,193 vs 5,458±2,955; p=0.006), and patient payments (847±548 vs 1,209±429; p=0.011). Hip procedures (n=6) at ASCs had lower total costs (3,583±698 vs 6,671±1,451; p=0.025), facility fees (2,725±6689 vs 5,813±1,431; p=0.025), Medicare payments (2,866±558 vs 5,336±1,161; p=0.025), and patient payments (716±139 vs 1,333±290; p=0.025). Conclusions: Sports medicine procedures performed at ASCs for Medicare recipients were found to have overall average total cost savings of 40% compared to those performed at HOPDs (42% savings for shoulder, 36% for knee, and 46% for hip procedures). ASC use conferred lower facility fees, patient payments, and Medicare payments in all cohorts. These results inform surgeons, patients, and insurance officials of the cost-effectiveness of outpatient surgical facilities for Medicare recipients undergoing sports medicine procedures.

Entrapment of the axillary nerve is a rare cause of shoulder pain and dysfunction. In quadrilateral space syndrome (QSS), compression of the axillary nerve leads to posterior and lateral shoulder pain with weakness in abduction and external rotation. A detailed history, physical exam, and imaging work-up are paramount to arriving at this diagnosis. In this technical note and accompanying video, we report a case of QSS caused by fibrous bands and describe our technique for arthroscopic decompression of the axillary nerve.

Patellar instability in patients with a dysplastic trochlea can be challenging to treat without addressing the trochlea directly. Trochleoplasty allows the surgeon to target a root osseous cause of instability and is an effective treatment option in well -selected patients. This chapter explores the variations in trochleoplasty techniques and offers an overview of recently published data associated with this surgery. Oper Tech Sports Med 31:151037 (c) 2023 Elsevier Inc. All rights reserved.

Background: Patients use the Internet to learn information about injuries, yet online content remains largely unstudied. This study analyzed patient questions posed online regarding ulnar collateral ligament (UCL) tears or UCL surgical management. Methods: Three separate search strings about UCL tear and UCL surgery were queried on the Google search engine. The 300 most commonly asked questions were compiled for each topic and associated webpage information was collected from the “People also ask” section. Questions were categorized using the Rothwell classification and webpages by Journal of the American Medical Association (JAMA) benchmark criteria. Results: The most frequent UCL tear questions were “how long does it take to heal a torn UCL?” and “what is nonsurgical treatment for the UCL?” The most frequent UCL surgery question was “can you retear your UCL after surgery?” The Rothwell classification of questions for UCL tear/UCL surgery was 55%/32% policy, 38%/57% fact, and 7%/11% value with highest subcategories being indications/management (46%/25%) and technical details (24%/25%). The most common webpages were academic (39%/29%) and medical practice (24%/26%). Mean JAMA score for all 600 webpages was low (1.2), with journals (mean = 3.4) having the highest score. Medical practice (mean = 0.5) and legal websites (mean = 0.0) had the lowest JAMA scores. Only 30% of webpages provided UCL-specific information. Conclusion: Online UCL patient questions commonly pertain to technical details and injury management. Webpages suggested by search engines contain information specific to UCL tears and surgery only one-third of the time. The quality of most webpages provided to patients is poor, with minimal source transparency.

Medial patellofemoral ligament (MPFL) reconstruction is the most commonly performed surgery for treatment of lateral patellar instability. It may be used in isolation or in conjunction with a variety of different procedures depending on the individual patient's specific risk factors for instability. Indicating the correct patient involves a thorough history, physical examination, and proper imaging. Careful surgical technique and a detailed understanding of both topographic and radiographic anatomy is critical to successful reconstruction. MPFL reconstruction has been shown to be a safe and effective technique for treatment for lateral patellar instability. Oper Tech Sports Med 31:151035 (c) 2023 Elsevier Inc. All rights reserved.

BACKGROUND:Synovial fluid analysis is an essential tool in diagnosing periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, concern exists that aspiration may introduce infection into a noninfected joint. Therefore, the purpose of this study was to evaluate the incidence of iatrogenic PJI following diagnostic knee aspiration done within 6 months of the primary TKA.METHODS:Between 2017 and 2021, the senior surgeon performed over 4,000 primary TKAs and aspirated 155 knees in 137 patients for whom there was a suspicion for PJI within 6 months of their primary TKA. There were 22 knees diagnosed as infected from the initial aspiration and therefore were excluded from the study. The remaining 133 aspirates in 115 patients who were negative for infection were followed for 6 months for signs and symptoms of PJI to elucidate whether aspiration introduced infection into an initially noninfected joint.RESULTS:There were 70 of 133 knees (52.6%) aspirated between 0 and 6 weeks after index TKA, 40 of 133 (30.1%) between 6 weeks and 3 months, and 23 of 133 (17.3%) between 3 and 6 months. At final follow-up, none of the 133 initially noninfected knees exhibited evidence of subsequent iatrogenic PJI or had subsequent surgery for infection.CONCLUSION:While joint aspiration is a procedure with inherent risks, this study shows that the rate of iatrogenic PJI is extremely low (0%). Therefore, if infection is suspected, the surgeon should consider joint aspiration, even in the initial postoperative period, as the risk for introducing infection is far outweighed by the risk of missing an infection.