The Impact of the COVID-19 Pandemic on Racial Disparities in Patients Undergoing Total Shoulder Arthroplasty in the United States

INTRODUCTION: The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the US and to determine whether these disparities were affected by the COVID-19 pandemic. METHODS: Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April-December from 2019-2020. Utilization was assessed for White/Black/Hispanic/Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age/sex/CMS-Hierarchical Condition Categories (HCC) score, dual enrollment (proxy for socioeconomic status), time fixed effects, and Core-based Statistical Area (CBSA) fixed effects was used to study difference across groups. RESULTS: In 2019, TSA volume/1000 beneficiaries was 1.51 for White and 0.57 for non-White, a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P\u3c0.01). There was an overall 14% decrease in TSA volume/1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference;8.7%,p = 0.02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%,p = 0.05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture. CONCLUSIONS: During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA while disparities were less apparent for proximal humerus fracture

Shoulder Surgery Postoperative Immobilization: An International Survey of Shoulder Surgeons

Background: There is currently no consensus on immobilization protocols following shoulder surgery. The aim of this study was to establish patterns and types of sling use for various surgical procedures in the United States (US) and Europe, and to identify factors associated with the variations. Methods: An online survey was sent to all members of the American Shoulder and Elbow Society (ASES) and European Society for Surgery of the Shoulder and Elbow (ESSSE). The survey gathered member data, including practice location and years in practice. It also obtained preferences for the type and duration of sling use after the following surgical procedures: arthroscopic Bankart repair, Latarjet, arthroscopic superior/posterosuperior rotator cuff repair (ARCR) of tears 3 cm, anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA), and isolated biceps tenodesis (BT). Relationships between physician location and sling type for each procedure were analyzed using Fisher’s exact tests and post-hoc tests using Bonferroni-adjusted p-values. Relationships looking at years in practice and sling duration preferred were analyzed using Spearman’s correlation tests. Results: In total, 499 surgeons with a median of 15 years of experience (IQR = 9–25) responded, with 54.7% from the US and 45.3% from Europe. US respondents reported higher abduction pillow sling use than European respondents for the following: Bankart repair (62% vs. 15%, p p p 3 cm (84% vs. 61%, p p p p p = 0.006). European respondents reported higher simple sling use than US respondents for the following: Bankart repair (74% vs. 31%, p p p 3 cm (34% vs. 13%, p p p p p p p = 0.014) and >3 cm (r = −0.20, p p p = 0.049) and without subscapularis repair (r = −0.19, p = 0.022. Thus, the more experienced surgeons tended to recommend shorter durations of post-operative sling use. US surgeons reported longer post-operative sling durations for Bankart repair (4.8 vs. 4.1 weeks, p p p 3 cm (5.9 vs. 5.1 weeks, p p p = 0.031), and isolated BT (3.7 vs. 3.3 weeks, p = 0.012) than Europe respondents. No significant differences between regions within the US and Europe were demonstrated. Conclusions: There is considerable variation in the immobilization advocated by surgeons, with geographic location and years of clinical experience influencing patterns of sling use. Future work is required to establish the most clinically beneficial protocols for immobilization following shoulder surgery. Level of Evidence: Level IV

Diagnostic Performance of Advanced Metal Artifact Reduction MRI for Periprosthetic Shoulder Infection

BACKGROUND The diagnosis of periprosthetic shoulder infection (PSI) in patients with a painful arthroplasty is challenging. Magnetic resonance imaging (MRI) may be helpful, but shoulder implant-induced metal artifacts degrade conventional MRI. Advanced metal artifact reduction (MARS) improves the visibility of periprosthetic bone and soft tissues. The purpose of our study was to determine the reliability, repeatability, and diagnostic performance of advanced MARS-MRI findings for diagnosing PSI. METHODS Between January 2015 and December 2019, we enrolled consecutive patients suspected of having PSI at our academic hospital. All 89 participants had at least 1-year clinical follow-up and underwent standardized clinical, radiographic, and laboratory evaluations and advanced MARS-MRI. Two fellowship-trained musculoskeletal radiologists retrospectively evaluated the advanced MARS-MRI studies for findings associated with PSI in a blinded and independent fashion. Both readers repeated their evaluations after a 2-month interval. Interreader reliability and intrareader repeatability were assessed with κ coefficients. The diagnostic performance of advanced MARS-MRI for PSI was quantified using sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC). When applying the International Consensus Meeting (ICM) 2018 criteria, of the 89 participants, 22 (25%) were deemed as being infected and 67 (75%) were classified as being not infected (unlikely to have PSA and not requiring a surgical procedure during 1-year follow-up). RESULTS The interreader reliability and intrareader repeatability of advanced MARS-MRI findings, including lymphadenopathy, joint effusion, synovitis, extra-articular fluid collection, a sinus tract, rotator cuff muscle edema, and periprosthetic bone resorption, were good (κ = 0.61 to 0.80) to excellent (κ > 0.80). Lymphadenopathy, complex joint effusion, and edematous synovitis had sensitivities of >85%, specificities of >90%, odds ratios of >3.6, and AUC values of >0.90 for diagnosing PSI. The presence of all 3 findings together yielded a PSI probability of >99%, per logistic regression analysis. CONCLUSIONS Our study shows the clinical utility of advanced MARS-MRI for diagnosing PSI when using the ICM 2018 criteria as the reference standard. Although the reliability and diagnostic accuracy were high, these conclusions are based on our specific advanced MARS-MRI protocol interpreted by experienced musculoskeletal radiologists. Investigations with larger sample sizes are needed to confirm these results. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence

Artificial Intelligence in the Management of Rotator Cuff Tears

Technological innovation is a key component of orthopedic surgery. Artificial intelligence (AI), which describes the ability of computers to process massive data and “learn” from it to produce outputs that mirror human cognition and problem solving, may become an important tool for orthopedic surgeons in the future. AI may be able to improve decision making, both clinically and surgically, via integrating additional data-driven problem solving into practice. The aim of this article will be to review the current applications of AI in the management of rotator cuff tears. The article will discuss various stages of the clinical course: predictive models and prognosis, diagnosis, intraoperative applications, and postoperative care and rehabilitation. Throughout the article, which is a review in terms of study design, we will introduce the concept of AI in rotator cuff tears and provide examples of how these tools can impact clinical practice and patient care. Though many advancements in AI have been made regarding evaluating rotator cuff tears—particularly in the realm of diagnostic imaging—further advancements are required before they become a regular facet of daily clinical practice

Increased prevalence of lower extremity soft tissue injuries and surgeries in patients with anorexia nervosa and bulimia nervosa

PURPOSE: An abundance of literature exists linking eating disorders and fracture risk. However, no studies, to our knowledge, have investigated the impact of eating disorders on lower extremity soft tissue injury or surgery risk. The purpose of this study was to determine if anorexia nervosa and bulimia nervosa are associated with prevalence of lower extremity soft tissue injuries and surgeries. METHODS: Patients with anorexia nervosa or bulimia nervosa over 2010-2020 were identified through the International Classification of Diseases (ICD) codes in the PearlDiver Claims Database. Patients were matched by age, gender, comorbidities, record dates, and region to control groups without anorexia or bulimia. Soft tissue injuries were identified through ICD codes, and surgeries were identified through Current Procedural Terminology codes. Differences in relative prevalence were analyzed using chi-square analysis. RESULTS: Patients with anorexia had a significantly increased prevalence of meniscus tears (RR = 1.57, CI 1.22-2.03,  = 0.001) or deltoid ligament sprains (RR = 1.83, CI 1.10-3.03,  = 0.025), and patients with bulimia had a significantly increased prevalence of meniscus tears (RR = 1.98, CI 1.56-2.51,  \u3c 0.001), medial collateral ligament sprains (RR = 3.07, CI 1.72-5.48,  \u3c 0.001), any cruciate ligament tears (RR = 2.14, CI 1.29-3.53,  = 0.004), unspecified ankle sprains (RR = 1.56, CI 1.22-1.99,  \u3c 0.001), or any ankle ligament sprains (RR = 1.27, CI 1.07-1.52,  = 0.008). Patients with anorexia had a significantly increased prevalence of anterior cruciate ligament reconstructions (RR = 2.83, CI 1.12-7.17,  = 0.037) or any meniscus surgeries (RR = 1.54, CI 1.03-2.29,  = 0.042), and patients with bulimia had a significantly increased prevalence of partial meniscectomies (RR = 1.80, CI 1.26-2.58,  = 0.002) or any meniscus surgeries (RR = 1.83, CI 1.29-2.60,  \u3c 0.001). CONCLUSIONS: Anorexia and bulimia are associated with increased prevalence of soft tissue injuries and surgeries. Orthopedic surgeons should be aware of this risk, and patients presenting to clinics should be informed of the risks associated with these diagnoses and provided with resources promoting recovery to help prevent further injury or surgery

The “Sandwich Tenodesis”: An Arthroscopic Technic for Combined Soft-Tissue and Bony Fixation of the Long Head of the Biceps

Pathology of the long head of the biceps can contribute to substantial shoulder pain. After nonoperative treatment has failed, either open or arthroscopic tenotomy or tenodesis can be recommended depending on age, occupation, function, and cosmetic preference. While classic tenodesis techniques rely on tendon-to-bone fixation, multiple studies have shown superior healing results for fixation between similar types of tissue, such as tendon-to-tendon. In this technique, we present the “sandwich technique,” performed entirely arthroscopically. A single 4-strand anchor with bioabsorbable screw is used to provide 2 types of fixation. Two strands are first used to lasso-loop the long head of the biceps to the bicipital groove, providing bone-to-tendon fixation. The other strands are then used to anchor rotator interval tissue to the tendon, providing a similar tissue or tendon-to-tendon patch augmentation

Survey of Expert Opinion Regarding Peri-operative Management of Shoulder Arthroplasty

Total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (rTSA) surgery have gained popularity for their ability to address a range of shoulder pathologies. Despite increasing data on shoulder arthroplasty management and outcomes, a “gold standard” for perioperative care has yet to be defined, including preoperative optimization and postoperative rehab. We surveyed the members of the American Shoulder and Elbow Society (ASES) regarding perioperative management of shoulder arthroplasty patients in three main domains: preoperative optimization, intraoperative protocols, and postoperative patient care. To this end, we hypothesized that fewer than 50% of perioperative management questions would garner 75% or more agreement. We also hypothesized that incorporating preoperative optimization, particularly for BMI, hemoglobin A1c, and the use of planning software, would correlate with a surgeon’s stage in career/practice volume