Does the use of peri-articular anesthetic cocktail provide adequate pain control following shoulder arthroplasty?

Purpose: Interscalene nerve block (INB) and liposomal bupivacaine (LB) have been previously found to provide adequate pain control following shoulder arthroplasty. We hypothesized that local infiltration of a peri-articular cocktail (LIC) would provide equivalent pain control compared to INB and LB at a decreased cost. Methods: Eighty-six patients undergoing primary shoulder arthroplasty were consented for participation. Patients were treated with either LIC (200 mg of 0.5% ropivacaine/1 mg epinephrine/30 mg ketorolac), local infiltration of LB (20mL bupivacaine/20mL saline), or preoperative INB. The primary outcome of the study was postoperative average visual analog scale (VAS) scores accessed for 4 days. Secondary outcomes included opioid consumption, length of stay, and complications. Results: A total of 29 patients receiving LIC, 26 receiving LB and 31 receiving INB were included in the study. Patients who received LIC had a significantly lower mean VAS on post-operative day (POD) 0 when compared to INB (2.46 vs. 3.95, phttps://scholarlycommons.henryford.com/merf2019clinres/1029/thumbnail.jp

Comparison of pre- and post-operative shoulder muscle EMG profiles in reverse total shoulder arthroplasty patients

Background: Deltoid muscle function is central in reverse total shoulder arthroplasty (RTSA) function; however, there is limited information available regarding changes in deltoid activity before and after surgery. Few tests exist to evaluate specific muscle metrics pre and post operatively. Surface Electromyographic (EMG) is non-invasive and allows for observation of motions with multifaceted analysis of movement with minimal patient demand. Understanding the changes in shoulder muscle activation, namely in the deltoid, in patients pre and post-RTSA can further advance understanding of the procedure and rehabilitation efforts. Methods: Nine individuals were recruited for this study: all patients underwent RTSA by a single fellowship trained shoulder and elbow surgeon. Participants executed shoulder abduction, forward flexion, internal and external rotation at slow, medium and fast speeds as well as static maximum contraction of these motions against force at each EMG testing session. EMG activation of the anterior, middle and posterior aspects of the deltoid, upper and middle trapezius, supraspinatus, infraspinatus, teres major and teres minor was recorded on the surgical shoulder preoperatively, and 6 weeks, 3 months and 6 months postoperatively. Delsys EMG acquisition software linked to Bluetooth sensors captured shoulder motion. Statistical comparisons between pre-RTSA and post-RTSA shoulders, as well as consecutive post-RTSA shoulders were performed using one-way ANOVA (p\u3c0.05). Results: Analysis pending- will be fully available at the symposium. Preliminary data show an overall significant increase in concentric muscle activity (RMS) of the anterior and lateral deltoid during abduction when comparing: 6 week post-RTSA patients (6w-RTSA) to pre-RTSA and 6w-RTSA to 3 month post-RTSA (3m-RTSA). Furthermore, there was a significant increase in frequency (PSD) in anterior and lateral deltoid during abduction when comparing the same groups. There were no significant changes in RMS or PSD when comparing 3m to 6m-RTSA during abduction. During forward flexion in the sagittal plane, an overall significant increase in RMS and PSD of the anterior and lateral deltoid was observed in 3m-RTSA compared to pre-RTSA. Deltoid muscle activation time significantly decreased for abduction and forward flexion at medium and fast speeds when comparing 6w-RTSA to 3m-RTSA and 3m-RTSA to 6m-RTSA. There was an insignificant increase in posterior deltoid activation during external rotation when comparing 6w- to 3m-RTSA. Conclusion: Post-RTSA patients showed increased concentric muscle activity and muscle fiber frequency in the anterior and lateral deltoid muscle fibers when compared with pre-RTSA patients during abduction, forward flexion and external rotation. Some degree of increase in deltoid activation was seen when comparting specific post-RTSA groups. Overall, these findings suggest the deltoid muscle has an increased role in abduction, forward flexion and external rotation in RTSA patients

Rockwood Grade-III Acromioclavicular Joint Separation: A Cost-Effectiveness Analysis of Treatment Options

Background: The treatment of Rockwood Grade-III acromioclavicular (AC) joint separation has been widely disputed since the introduction of the classification system. The present literature does not reach consensus on whether operative or nonoperative management is more advantageous, nor does it effectively distinguish between operative measures. We hypothesized that nonoperative treatment of Rockwood Grade-III AC joint separation would be more cost-effective when compared with surgical options. Methods: We created a decision-tree model outlining the treatment of Rockwood Grade-III separations using nonoperative management or hook-plate, suture-button, or allograft fixation. After nonoperative intervention, the possible outcomes predicted by the model were uneventful healing, delayed operative management, a second round of sling use and physical therapy, or no reduction and no action; and after operative intervention, the possible outcomes were uneventful healing, loss of reduction and revision, and depending on the implant, loss of reduction and no action, or removal of the implant. A systematic review was conducted, and probabilities of each model state were averaged. A cost-effectiveness analysis was conducted both through rollback analysis yielding net monetary benefit and through incremental cost-effectiveness ratios (ICERs). Thresholds of $50,000/quality-adjusted life-year (QALY) and$100,000/QALY were used for ICER analysis. Furthermore, a sensitivity analysis was utilized to determine whether differential probabilities could impact the model. Results: Forty-five papers were selected from a potential 768 papers identified through our literature review. Nonoperative treatment was used as our reference case and showed dominance over all 3 of the operative measures at both the $50,000 and$100,000 ICER thresholds. Nonoperative treatment also showed the greatest net monetary benefit. Nonoperative management yielded the lowest total cost ($6,060) and greatest utility (0.95 QALY). Sensitivity analysis showed that allograft fixation became the favored technique at a willingness-to-pay threshold of$50,000 if the rate of failure of nonoperative treatment rose to 14.6%. Similarly, at the $100,000 threshold, allograft became dominant if the probability of failure of nonoperative treatment rose to 22.8%. Conclusions: The cost-effectiveness of nonoperative treatment is fueled by its notably lower costs and overall high rates of success in Grade-III separations. It is important to note that, in our analysis, the societal cost (measured in lost productivity) of nonoperative treatment neared that of surgical treatment, but the cost from the health-care system perspective was minimal. Physicians should bear in mind the sensitivity of these conclusions and should consider cost-effectiveness analyses in their decision-making guidelines. Level of Evidence: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence

Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament Lesion With Capsular Plication in the Lateral Decubitus Position

Humeral avulsion of the glenohumeral ligament (HAGL) lesions can lead to persistent shoulder instability. While rare, HAGL lesions may present as a concomitant injury following shoulder dislocation events. Traditionally, an open approach has been used to repair the inferior glenohumeral ligament and restore shoulder stability. Modern arthroscopic techniques and instrumentation have permitted a minimally invasive approach for treating HAGL lesions. While technically demanding, arthroscopic repair of HAGL lesions has demonstrated favorable outcomes with less soft-tissue disruption. The following Technical Note describes a safe and effective method for the arthroscopic repair of HAGL lesions. Our technique highlights the use of the lateral decubitus position, a 70° arthroscope, a curved anchor device, and a 90° SutureLasso device

Patient-Reported Outcomes Measurements Information System (PROMIS) upper extremity and pain interference do not significantly predict rotator cuff tear dimensions

BACKGROUND: Proper diagnosis of rotator cuff tears is typically established with magnetic resonance imaging (MRI); however, studies show that MRI-derived measurements of tear severity may not align with patient-reported pain and shoulder function. The purpose of this study is to investigate the capacity for the Patient-reported Outcomes Measurements Information System (PROMIS) computer adaptive tests to predict rotator cuff tear severity by correlating preoperative tear morphology observed on MRI with PROMIS upper extremity (UE) and pain interference (PI) scores. This is the first study to investigate the relationship between tear characteristics and preoperative patient-reported symptoms using PROMIS. Considering the essential roles MRI and patient-reported outcomes play in the management of rotator cuff tears, the findings of this study have important implications for both treatment planning and outcome reporting. METHODS: Two PROMIS-computer adaptive test forms (PROMIS-UE and PROMIS-PI) were provided to all patients undergoing rotator cuff repair by one of three fellowship-trained surgeons at a single institution. Demographic information including age, sex, race, employment status, body mass index, smoking status, zip code, and preoperative PROMIS-UE and -PI scores was prospectively recorded. A retrospective chart review of small to large full- or partial-thickness rotator cuff tears between May 1, 2017 and February 27, 2019 was used to collect each patient\u27s MRI-derived tear dimensions and determine tendon involvement. RESULTS: Our cohort consisted of 180 patients (56.7% male, 43.3% female) with an average age of 58.9 years (standard deviation, 9.0). There was no significant difference in PROMIS-UE or -PI scores based on which rotator cuff tendons were involved in the tear (P \u3e .05). Neither PROMIS-UE nor PROMIS-PI significantly correlated with tear length or retraction length of the supraspinatus tendon (P \u3e .05). The sum of tear lengths in the anterior-posterior and medial-lateral directions was weakly correlated with PROMIS-UE (P = .042; r = -0.152, r = .031) and PROMIS-PI (P = .027; r = 0.165, r = 0.012). CONCLUSION: Rotator cuff tear severity does not significantly relate to preoperative PROMIS-UE and -PI scores. This finding underscores the importance of obtaining a balanced preoperative assessment of rotator cuff tears that acknowledges the inconsistent relationship between rotator cuff tear characteristics observed on MRI and patient-reported pain and physical function

PROMIS CAT Forms Demonstrate Responsiveness in Patients Following Reverse Total Arthroplasty Across Numerous Health Domains

Aim: The purpose of this study was to investigate the responsiveness of three PROMIS CAT domains in patients undergoing reverse shoulder arthroplasty. Background: To better optimize the administration and postoperative tracking of patients using PROM, the Patient-Reported Outcomes Measurement Information System (PROMIS) was established by the National Institutes of Health. PROMIS CAT domains have been since validated in multiple orthopedic interventions of the shoulder, however, no one to date has studied the responsiveness of PROMIS CAT domains in a cohort of patients undergoing reverse shoulder arthroplasty. Methods: Patients undergoing reverse shoulder arthroplasty by a board-certified shoulder and elbow surgeon were included in this study. PROMIS CAT Upper Extremity Physical Function (“PROMIS-UE”), Pain Interference (“PROMIS-PI”), and Depression (“PROMIS-D”) scores were collected preoperatively and at five postoperative timepoints. Patient-centric demographic factors, range of motion, and clinical characteristics were also reviewed and analyzed for association with PROMIS scores. Results: 104 patients undergoing primary reverse shoulder arthroplasty were included in this study. The patient cohort consisted of 52 males (50.0%), an average age of 70.3 years (standard deviation, 11.2), and a BMI of 30.2 (standard deviation, 6.1). All three PROMIS domains showed significant improvement as early as 6 weeks after surgery, with values of 32.4 ± 6.6, 56.2 ± 7.5, and 44.6 ± 8.6, for PROMIS-UE, PROMIS-PI, and PROMIS-D, respectively. Significant improvements were noted for each postoperative timepoint thereafter, with 1-year follow up values as follows: 42.1 ± 8.7, 52.5 ± 8.6, and 43.6 ± 9.5 for PROMIS-UE, PROMIS-PI, and PROMIS-D, respectively. Moderate correlations were identified with postoperative PROMIS-UE and abduction (r=0.439, p\u3c0.01), as well as postoperative PROMIS-PI and PROMIS-D (r=0.502, p\u3c0.01). Conclusions: PROMIS CAT forms demonstrate responsiveness in patients undergoing reverse shoulder arthroplasty

Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery

Background: There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear. Purpose/Hypothesis: The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship-trained orthopaedic surgeons were included in the study. Preoperative PROMIS-Upper Extremity (PROMIS-UE), PROMIS-Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors. Results: Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI ( Conclusion: Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups

PROMIS MCID and SCB Achievement in Rotator Cuff Repair

The purpose of this study was to establish threshold score changes to determine minimal clinically important difference (MCID) and substantial clinical benefit (SCB) in PROMIS computer adaptive test (CAT) scores following rotator cuff repair (RCR). Patients undergoing arthroscopic RCR were identified over a 24-month period. PROMIS CAT forms for upper extremity physical function (PROMIS-UE), pain interference (PROMIS-PI), and depression (PROMIS-D) were utilized. Analysis of variance testing with post hoc least significant difference pairwise comparisons and Tukey’s B subset analysis were used in determining if anchor question responses showed statistically significant differences between answers. These findings were used to establish two clinically significant outcome (CSO) groups, MCID and substantial clinical benefit (SCB). Patients were then dichotomized into two separate analyses, no MCID achievement compared with MCID achievement and no SCB achievement compared with SCB achievement. Of the 198 eligible patients, 168 patients (84.8%) were included in analysis. Receiver operating curve analysis determined delta PROMIS-UE values of 5.8 and 9.7 (area under the curve (AUC) = 0.906 and 0.949, respectively) and delta PROMIS-PI values of -11.4 and -12.9 (AUC = 0.875 and 0.938, respectively) to be excellent threshold predictors of MCID and SCB achievement. On average, 81.1%, 65.0%, and 54.5% of patients achieved MCID for PROMIS-UE, PROMIS-PI, and PROMIS-D while 70.7%, 60.7%, and 37.7% of patients in the cohort respectively achieved SCB

Shoulder muscle activation pattern recognition based on sEMG and machine learning algorithms

BACKGROUND AND OBJECTIVE: Surface electromyography (sEMG) has been used for robotic rehabilitation engineering for volitional control of hand prostheses or elbow exoskeleton, however, using sEMG for volitional control of an upper limb exoskeleton has not been perfectly developed. The long-term goal of our study is to process shoulder muscle bio-electrical signals for rehabilitative robotic assistive device motion control. The purposes of this study included: 1) to test the feasibility of machine learning algorithms in shoulder motion pattern recognition using sEMG signals from shoulder and upper limb muscles, 2) to investigate the influence of motion speed, individual variability, EMG recording device, and the amount of EMG datasets on the shoulder motion pattern recognition accuracy. METHODS: A novel convolutional neural network (CNN) structure was constructed to process EMG signals from 12 muscles for the pattern recognition of upper arm motions including resting, drinking, backward-forward motion, and abduction motion. The accuracy of the CNN models for pattern recognition under different motion speeds, among individuals, and by EMG recording devices was statistically analyzed using ANOVA, GLM Univariate analysis, and Chi-square tests. The influence of EMG dataset number used for CNN model training on recognition accuracy was studied by gradually increasing dataset number until the highest accuracy was obtained. RESULTS: Results showed that the accuracy of the normal speed CNN model in motion pattern recognition was 97.57% for normal speed motions and 97.07% for fast speed motions. The accuracy of the cross-subjects CNN model in motion pattern recognition was 79.64%. The accuracy of the cross-device CNN model in motion pattern recognition was 88.93% for normal speed motion and 80.87% for mixed speed. There was a statistical difference in pattern recognition accuracy between different CNN models. CONCLUSION: The EMG signals of shoulder and upper arm muscles from the upper limb motions can be processed using CNN algorithms to recognize the identical motions of the upper limb including drinking, forward/backward, abduction, and resting. A simple CNN model trained by EMG datasets of a designated motion speed accurately detected the motion patterns of the same motion speed, yielding the highest accuracy compared with other mixed CNN models for various speeds of motion pattern recognition. Increase of the number of EMG datasets for CNN model training improved the pattern recognition accuracy

Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery

Background: There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear. Purpose/Hypothesis: The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship–trained orthopaedic surgeons were included in the study. Preoperative PROMIS–Upper Extremity (PROMIS-UE), PROMIS–Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors. Results: Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI (R = –0.61; P \u3c.001), and a negligible correlation was found between the PROMIS-UE and PROMIS-D (R = –0.28; P \u3c.001). When stratified by patient demographic factors, the correlation between the PROMIS-UE and PROMIS-PI was stronger in female patients compared with male patients (R = –0.77 vs –0.46, respectively; P \u3c.001 for both), stronger in black patients compared with white patients (R = –0.72 vs –0.56, respectively; P \u3c.001 for both), and highest in current tobacco users (R = –0.80; P \u3c.001). Conclusion: Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups