Faculty Bibliography

BACKGROUND:The aims of this study were to examine variances in inpatient opioid consumption after total shoulder arthroplasty (TSA) and to determine factors influencing inpatient opioid utilization. METHODS:The sample included patients undergoing elective TSA at a tertiary-level institution between January 2016 and April 2018. Opioid consumption during the inpatient stay was converted into morphine milligram equivalents (MMEs), accounting for dosage and route of administration. The MMEs were calculated per patient encounter and used to calculate mean opioid consumption. Bivariate linear regression analysis was performed to assess the impact of patient-related factors and surgery-related factors on inpatient opioid consumption. RESULTS:Altogether 20 surgeons performed 622 TSAs. The average opioid dose per encounter was 47.4 ± 65.7 MME/d. MMEs prescribed varied significantly among surgeon providers (P < .01). Pre-existing psychiatric disorders (P = .00012), preoperative opioid use (P = .0013), highest quartile of median household income (P = .048), current-smoker status (P < .001), age < 60 years (P < .01), and general anesthesia (vs. regional anesthesia, P = .005) were associated with significant inpatient opioid consumption after TSA. Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences. CONCLUSION/CONCLUSIONS:There is considerable variation in inpatient opioid consumption after TSA at the same institution. Knowledge of modifiable and nonmodifiable risk factors that increase inpatient opioid consumption will help to optimize multimodal analgesia protocols for TSA.

Introduction: There is no current standard by which culture specimens from revision shoulder arthroplasty should be handled, processed, cultured, and reported. Due to the relatively low numbers of cases multicenter study may provide information to form consensus recommendations. However, assimilation of multicenter data requires comparable methodologies. The objective of this study was to document and evaluate the extent of variability between surgeons and institutions. Methods: An 11-question survey was sent to 20 shoulder surgeons as part of the American Shoulder and Elbow Surgeons Periprosthetic Joint Infection Multicenter Workgroup. Questions addressed how samples are handled in the operating room by surgeons, processing of tissue samples and explants by laboratories, number of media, culture incubation durations, and culture reporting. Results: Common practices regarding specimen handling and processing were identified including prolonged culture incubation times >13 days (94% of participants). However, substantial variation in handling of tissue and explant specimens, number and type of media used, and reporting of results were identified. The majority of surgeons reported using a sterile instrument to harvest each individual tissue specimen (10/17, 59%), more so than using any available instrument (4/17, 24%) or washing and re-using the same instrument (3/17, 18%). Half of the institutions require a time limit by which samples must be processed in the laboratory (8/16, 50%). Nine institutions (9/16, 56%) report cultures in a semiquantitative manner, while 7 (44%) report cultures in a binary fashion. Five institutions reported having performed a negative control study, and the rate of positive cultures ranged between 0% and 17%. The majority of positive cultures from the negative controls contained Cutibacterium (92%). Discussion: Specimen handling, processing, culturing, and reporting varies widely between institutions. Due to the risk of false positives as demonstrated by negative control studies, surgeons should be cognizant of potential sources of contamination at the specimen handling level in the operating room and specimen processing level in the laboratory. Given the challenges in interpretation of positive cultures in revision shoulder arthroplasty, further studies are needed to determine whether assimilation of data across institutions is acceptable or whether a standard culturing methodology across institutions is necessary. Level of Evidence: V

The glenoid is considered a weak link in total shoulder arthroplasty because failure on the glenoid side is one of the most common reasons for revision of total shoulder arthroplasty. Glenoid wear is commonly seen in glenohumeral arthritis and compromises glenoid bone stock and also alters the native version and inclination of the glenoid. It is critical to recognize glenoid wear and correct it intraoperatively to avoid component malposition, which can negatively affect the survivorship of the glenoid implant. The end point of correction for the glenoid wear in shoulder arthroplasty is controversial, but anatomic glenoid component positioning is likely to improve long-term survivorship of the total shoulder arthroplasty. Preoperative three-dimensional (3-D) computer planning software, based on CT, is commercially available. It allows the surgeon to plan implant type (anatomic versus reverse), size, and position on the glenoid, and also allows for templating deformity correction using bone graft and/or augments. Guidance technology in the form of computer-assisted surgery (CAS) and patient-specific instrumentation (PSI) allows the surgeon to execute the preoperative plan during surgery with a greater degree of accuracy and precision and has shown superiority to standard instrumentation. However, the proposed benefits of this technology including improved glenoid survivorship, reduced revision arthroplasty rate and cost-effectiveness have not yet been demonstrated clinically. In this review, we present the current evidence regarding PSI and CAS in managing glenoid deformity in total shoulder arthroplasty.

BACKGROUND:Nonsteroidal anti-inflammatory drugs (NSAIDs) are being increasingly employed as a part of multimodal non-opioid strategies to treat postoperative pain. In the present study, we sought to review the effects of short-term NSAID use on musculoskeletal soft-tissue healing. METHODS:We performed a scoping review of all studies that included the use of NSAIDs and their effect on healing of soft tissues, which for the purpose of this review refers to non-osseous musculoskeletal tissue such as ligament, tendon, labrum, and meniscus. The inclusion criteria encompassed all studies (human, animal, and in vitro) that evaluated the effect of NSAIDs on soft-tissue healing. Subgroup analyses, wherever applicable, were conducted on the basis of the type of NSAID (cyclooxygenase [COX]-specific or nonspecific) and the type of study (human, animal, or in vitro). Relevant metadata from each study were abstracted, and descriptive statistics were used to summarize the results. RESULTS:A total of 44 studies met the inclusion criteria, including 3 human studies, 33 animal studies, and 8 in vitro studies. These studies included 4 different NSAIDs in the human subgroup, 16 different NSAIDs in the animal subgroup, and 7 different NSAIDs in the in vitro subgroup. The majority of reported studies (including 1 of 2 human studies, 10 of 14 animal studies, and 3 of 3 in vitro studies) demonstrated that COX-2-selective inhibitors had negative impact on soft-tissue healing. In contrast, the majority of human and animal studies (2 of 2 and 19 of 30, respectively) demonstrated that nonselective COX inhibitors had no negative effect on the healing of labrum, tendons, and ligaments. The majority of in vitro studies demonstrated that NSAIDs have a harmful effect on biological processes involved in tendon-healing and regeneration (tenocyte proliferation, collagen and glycosaminoglycan synthesis). CONCLUSIONS:Current limited evidence demonstrates that selective COX-2 inhibitors can negatively affect healing of musculoskeletal soft tissue after surgical repair. In contrast, the majority of studies demonstrate that nonselective COX inhibitors have no negative effect on musculoskeletal soft-tissue healing. Additional high-quality human clinical trials are necessary to provide more definitive conclusions.

INTRODUCTION/BACKGROUND:Management of the subscapularis during shoulder arthroplasty is controversial. The purpose of this study was to compare the biomechanical performance of subscapularis peel (SP) and lesser tuberosity osteotomy (LTO) in a cadaveric model. METHODS:The subscapularis and proximal humerus were dissected from all soft tissues in 21 fresh-frozen human cadaveric shoulders and randomized to undergo SP, LTO, or standard subscapularis tenotomy (ST, control). For SP and LTO, six #5 sutures were passed through eyelets in the implant (on lateral border and through drill holes in bicipital groove [2] and under trunion [4]). Double-row repair was performed using two lateral row transosseous sutures and four medial row sutures through the tendon (SP) or osseotendinous junction (LTO). Biomechanical properties and mode of failure were tested. RESULTS:There were no significant differences in elongation amplitude, cyclic elongation, or maximum load to failure between the three groups (P > 0.05). Mean stiffness was significantly higher in LTO (P = 0.009 vs. SP and ST). In the ST group, 7/7 specimens failed at the tendon-suture interface. For SP, 4/7 failed at the tendon-suture interface, one at the suture-bone interface, one fractured around the implant stem, and one at the knots. For LTO, 3/7 failed at the tendon-suture interface, two at the suture-bone interface and two fractured around the implant stem. CONCLUSIONS:In this cadaveric model, subscapularis repair via ST, SP, and LTO techniques was biomechanically equivalent. Additional studies are needed to confirm these findings and determine the influence of biologic healing on healing rates and clinical outcomes. LEVEL OF EVIDENCE/METHODS:N/a, biomechanical laboratory study.

BACKGROUND:Reducing intraoperative wound contamination is a critical preventive strategy for reducing the risk of prosthetic joint infection in shoulder arthroplasty. The aim of this study was to investigate the potential microbial colonization of subscapularis tagging sutures during shoulder arthroplasty. METHODS:In this prospective study, 50 consecutive patients undergoing primary shoulder arthroplasty (anatomic or reverse) were enrolled. Patients with revision shoulder arthroplasty and proximal humeral fractures were excluded. Nonabsorbable, braided tagging sutures were placed through the subscapularis tendon prior to tenotomy. A similar nonabsorbable, braided suture (control) was placed in a sterile container on the back table, open to the operating room environment. Subscapularis tagging sutures (experimental specimens) and control sutures were collected prior to subscapularis tenotomy repair and submitted for aerobic and anaerobic cultures. Cultures were held for 21 days to account for extended growth of slow-growing bacteria. RESULTS:A total of 12 of 50 experimental and 16 of 50 control sutures had positive cultures. Staphylococcus epidermidis and Cutibacterium acnes were the 2 most commonly isolated organisms. Active tobacco use (P = .038) and procedure length (P = .03) were significantly associated with positive cultures. No significant association between positive subscapularis tagging suture cultures and positive control cultures was found (P = .551). Patient age, sex, body mass index, and significant medical comorbidities were not significantly associated with positive cultures. DISCUSSION/CONCLUSIONS:Subscapularis tagging sutures are a potential source of microbial contaminant in shoulder arthroplasty, and we recommend exchanging the tagging suture with a suture opened immediately prior to subscapularis repair.

HYPOTHESIS/OBJECTIVE:The aim of this meta-analysis was to compare the safety, efficacy, and opioid-sparing effect of liposomal bupivacaine (LB) vs. nonliposomal local anesthetic agents (NLAs) for postoperative analgesia after shoulder surgery. METHODS:A systematic literature review of randomized controlled clinical studies comparing the efficacy of LB with NLAs in shoulder surgery was conducted. Seven level I and II studies were included in the meta-analysis, and shoulder surgical procedures included arthroscopic rotator cuff repair and shoulder arthroplasty. Bias was assessed using The Cochrane Collaboration's tool. The primary outcome measures were visual analog scale pain scores and opioid consumption 24 and 48 hours after shoulder surgery. Subgroup analysis was performed for the method of LB administration (interscalene nerve block vs. local infiltration). RESULTS:A total of 7 studies (535 patients) were included in the final meta-analysis comparing LB (n = 260) with NLAs (n = 275). No significant difference was found between the LB and NLA groups in terms of visual analog scale pain scores at 24 hours (95% confidence interval, -1.02 to 0.84; P = .86) and 48 hours (95% confidence interval, -0.53 to 0.71; P = .78). Both groups had comparable opioid consumption at both 24 hours (P = .43) and 48 hours (P = .78) postoperatively and with respect to length of stay (P = .87) and adverse events (P = .97). Subgroup analysis demonstrated comparable efficacy irrespective of the method of administration of LB. CONCLUSION/CONCLUSIONS:LB is comparable to NLAs with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after arthroscopic rotator cuff repair and total shoulder arthroplasty.

OBJECTIVE:A major factor that impacts the long-term outcome and complication rates of total shoulder arthroplasty is the preoperative posterior glenoid bone loss quantified by glenoid retroversion. The purpose of this study was to assess if glenoid retroversion varies significantly at different glenoid heights in Walch B2 and B3 glenoids. MATERIALS AND METHODS/METHODS:Patients with B2 and B3 glenoid types were included following retrospective review of 386 consecutive CT shoulder studies performed for arthroplasty preoperative planning. True axial CT reconstructions were created using a validated technique. Two readers independently measured the glenoid retroversion angles according to the Friedman method using the "intermediate" glenoid at three glenoid heights: 75% (upper), 50% (equator), and 25% (lower). The variances between the three levels for a given patient were calculated. RESULTS:Twenty-nine B2 and 8 B3 glenoid types were included. There was no significant difference in variance of glenoid version among the three levels in B2 or B3 groups. The mean variance in retroversion degree between equator-lower, upper-equator, and upper-lower glenoid was - 0.4, 0.3, and - 0.2 for B2; and - 0.2, 1.9, and 1.9 for B3 glenoid, respectively. The level of inter-reader agreement was fair to good for variance at equator-lower, and good to excellent for upper-equator and upper-lower glenoid. CONCLUSIONS:Glenoid version can be accurately measured at any level between 25 and 75% of glenoid height for Walch B2 and B3. We recommend that the glenoid equator be used as the reference to assure consistent and reliable version measurements in this group of patients.

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. More than 800 experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form the International Consensus Group. The shoulder workgroup reached consensus on 27 questions related to culture techniques, inflammatory markers, and diagnostic criteria used to evaluate patients for periprosthetic shoulder infection. This document contains the group's recommendations and rationale for each question related to evaluating periprosthetic shoulder infection.