Aims. The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures. Patients and Methods. Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses. Results. A total of 98 769 patients were included; 35 701 patients were opioid-naïve, 11 621 used opioids continuously for six months before surgery, and 4558 used opioids continuously for at least six months but did not obtain any prescriptions in the three months before surgery. Among opioid-naïve patients, between 0.76% and 4.53% used opioids chronically postoperatively. Among chronic preoperative users, between 42% and 62% ceased chronic opioids postoperatively. A three-month opioid-free period preoperatively led to a rate of cessation of chronic opioid use between 82% and 93%, as compared with between 31% and 50% with continuous preoperative use (p < 0.001 for significant changes in opioid use before and after surgery in each procedure). Between 5.6 and 20.0 preoperative chronic users ceased chronic use for every new chronic opioid user. Risk factors for chronic postoperative use included chronic preoperative opioid use (odds ratio (OR) 4.84 to 39.75; p < 0.0001) and depression (OR 1.14 to 1.55; p < 0.05 except total hip arthroplasty). With a three-month opioid-free period before surgery, chronic preoperative opioids elevated the risk of chronic opioid use only mildly, if at all (OR 0.47 to 1.75; p < 0.05 for total shoulder arthroplasty, rotator cuff repair, and carpal tunnel release). Conclusion. Chronic preoperative opioid use increases the risk of chronic postoperative use, but an opioid-free period before surgery decreases this risk compared with continuous preoperative use. Cite this article: Bone Joint J 2019;101-B:1570–1577

Aims. To investigate the impact of the Charlson and Elixhauser comorbidity indices on patient-reported outcomes measures (PROMs) following shoulder arthroplasty. Methods. Patients undergoing total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or hemiarthroplasty (HA) from 2016 to 2018 were identified, along with the Charlson and Elixhauser comorbidities listed as their secondary diagnoses in the electronic medical records. Patients were matched to our institution’s registry to obtain their PROMs, including shoulder-specific (American Shoulder and Elbow Society (ASES) and Shoulder Activity Scale (SAS)) and general health scales (12-Item Short Form Survey (SF-12) and Patient-Reported Outcomes Measurement Information System-Pain Interference). Linear regression models adjusting for age and sex were used to evaluate the association between increasing number of comorbidities and PROM scores. A total of 1,817 shoulder arthroplasties were performed: 1,017 (56%) TSA, 726 (40%) RSA, and 74 (4%) HA. The mean age was 67 years (SD 10), and 936 (52%) of the patients were female. Results. The most common comorbidities were obesity (1,256, 69%) and hypertension (990, 55%). Patients with more comorbidities had lower ASES and SAS scores at baseline (p < 0.001). Elixhauser comorbidities continued to negatively impact ASES and SAS scores at one year (p = 0.002) and two-year follow-up (p = 0.002). Patients with more comorbidities reported greater pain interference on PROMIS at baseline (p = 0.007), but not at two years. Higher number of Charlson comorbidities were associated with lower scores on the SF-12 mental component at baseline (p < 0.001) and two years (p = 0.020). Higher number of Elixhauser comorbidities were associated with lower SF-12 physical component scores at baseline (p < 0.001) and two years (p = 0.004). Conclusion. Higher number of comorbidities was associated with lower baseline scores and worse outcomes on both shoulder-specific and general health PROMs. The presence of specific comorbidities may be used during shared decision-making to manage expectations for patients undergoing shoulder arthroplasty. Cite this article: Bone Joint J 2021;103-B(5):964–970

Aims. Accurate measurement of the glenoid version is important in performing total shoulder arthroplasty (TSA). Our aim was to evaluate the Ellipse method, which involves formally defining the vertical mid-point of the glenoid prior to measuring the glenoid version and comparing it with the ‘classic’ Friedman method. Methods. This was a retrospective study which evaluated 100 CT scans for patients who underwent a primary TSA. The glenoid version was measured using the Friedman and Ellipse methods by two senior observers. Statistical analyses were performed using the paired t-test for significance and the Bland-Altman plot for agreement. Results. The mean glenoid version was -3.11° (-23.8° to 17.9°) using the Friedman method and -1.95° (-29.8° to 24.6°) using the Ellipse method (p = 0.002). In 16 patients the difference between methods was greater than 5°, which we considered to be clinically significant. There was poor agreement between methods with relatively large 95% limits of agreement. There was excellent inter-rater agreement between the observers for the Ellipse method and similarly, the intrarater agreement was excellent with a repeatability coefficient of 0.94. Conclusion. We recommend the use of the Ellipse modification to define the mid glenoid point prior to measuring the glenoid version in patients undergoing TSA. Cite this article: Bone Joint J 2020;102-B(2):232–238

We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components. Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt > 5° or subsidence > 5 mm), the presence of radiolucent lines and a Constant score of < 30 as the endpoints. There were two re-operations not involving revision of the implants and the survival rate of the prosthesis was 100.0% for the follow-up period, with an absolute Constant score of > 30 as the endpoint the survival rate was 98%. Radiological glenoid loosening was 9% after five years, and 33% after nine years. There was an incidence of 8% of radiolucent lines in more than three of six zones in the immediate post-operative period, of 37.0% after the first year which increased to 87.0% after nine years. There was no correlation between the score of Boileau and the total Constant score at the latest follow-up, but there was correlation between glenoid loosening and pain (p = 0.001). We found that total shoulder replacement had an excellent mid-term survivorship and clinical outcome. The surgical and cementing techniques were related to the decrease in radiolucent lines around the glenoid compared with earlier studies. One concern, however, was the fact that radiolucent lines increased over time and there was a rate of glenoid loosening of 9% after five years and 33% after nine years. This suggests that the design of the glenoid component, and the implantation and cementing techniques may need further improvement

Aims. The aim of this study was to evaluate the clinical and radiological outcome of using an anatomical short-stem shoulder prosthesis to treat primary osteoarthritis of the glenohumeral joint. Patients and Methods. A total of 66 patients (67 shoulders) with a mean age of 76 years (63 to 92) were available for clinical and radiological follow-up at two different timepoints (T1, mean 2.6 years, . sd. 0.5; T2, mean 5.3 years,. sd. 0.7). Postoperative radiographs were analyzed for stem angle, cortical contact, and filling ratio of the stem. Follow-up radiographs were analyzed for timing and location of bone adaptation (cortical bone narrowing, osteopenia, spot welds, and condensation lines). The bone adaptation was classified as low (between zero and three features of bone remodelling around the humeral stem) or high (four or more features). Results. The mean Constant score improved significantly from 28.5 (. sd. 11.6) preoperatively to 75.5 (. sd. 8.5) at T1 (p < 0.001) and remained stable over time (T2: 76.6, . sd. 10.2). No stem loosening was seen. High bone adaptation was present in 42% of shoulders at T1, with a slight decrease to 37% at T2. Cortical bone narrowing and osteopenia in the region of the calcar decreased from 76% to 66% between T1 and T2. Patients with high bone adaptation had a significantly higher mean filling ratio of the stem at the metaphysis (0.60, . sd. 0.05 vs 0.55, . sd. 0.06; p = 0.003) and at the diaphysis (0.65 . sd. 0.05 vs 0.60 . sd. 0.05; p = 0.007). Cortical contact of the stem was also associated with high bone adaptation (14/25 shoulders, p = 0.001). The clinical outcome was not influenced by the radiological changes. Conclusion. Total shoulder arthroplasty using a short-stem humeral component resulted in good clinical outcomes with no evidence of loosening. However, approximately 40% of the shoulders developed substantial bone loss in the proximal humerus at between four and seven years of follow-up. Cite this article: Bone Joint J 2018;100-B:603–9

The October 2013 Shoulder & Elbow Roundup. 360 . looks at: Deltoid impairment not necessarily a contra-indication for shoulder arthroplasty; The tricky radiograph; Not so asymptomatic cuff tears; Total shoulder arthroplasty: kinder on the glenoid; Barbotage for calcific tendonitis; What happens to the arthritic glenoid?; Two screws a screw too few?; Sloppy hinge best for elbow arthroplasty

B. Mollon, S. A. Mahure, D. Y. Ding, J. D. Zuckerman, Y. W. Kwon. The influence of a history of clinical depression on peri-operative outcomes in elective total shoulder arthroplasty. Bone Joint J 2016;98-B:818–824

Aims. In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder. Patients and Methods. All patients who underwent primary arthroplasty of the shoulder at our institution between 1970 and 2012 were included in the study. There were 4636 patients with 1167 cemented humeral components and 3469 cementless components. Patients with the two types of fixation were matched for nine different covariates using a propensity score analysis. A total of 551 well-balanced pairs of patients with cemented and cementless components were available after matching for comparison of the outcomes. The clinical outcomes which were analysed included loosening of the humeral component determined at revision surgery, periprosthetic fractures, post-operative infection and operating time. Results. The overall five-, ten-, 15- and 20-year rates of survival were 98.9%, 97.2%, 95.5%, and 94.4%, respectively. Survival without loosening at 20 years was 98% for cemented components and 92.4% for cementless components. After propensity score matching including fixation as determined by the design of the component, humeral loosening was also found to be significantly higher in the cementless group. Survival without humeral loosening at 20 years was 98.7% for cemented components and 91.0% for cementless components. There was no significant difference in the risk of intra- or post-operative fracture. The rate of survival without deep infection and the mean operating time were significantly higher in the cemented group. Conclusion. Both types of fixation give rates of long-term survival of > 90%. Cemented components have better rates of survival without loosening but this should be weighed against increased operating time and the risk of bony destruction of the proximal humerus at the time of revision of a cemented humeral component. Cite this article: Bone Joint J 2017;99-B:666–73

Aims. Radiostereometric analysis (RSA) allows an extremely accurate measurement of early micromotion of components following arthroplasty. . Patients and Methods. In this study, RSA was used to measure the migration of 11 partially cemented fluted pegged glenoid components in patients with osteoarthritis who underwent total shoulder arthroplasty using an improved surgical technique (seven men, four women, mean age 68). Patients were evaluated clinically using the American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores and by CT scans two years post-operatively. . Results. There were two patterns of migration, the first showing little, if any, migration and the second showing rotation by > 6° as early as three months post-operatively. At two years, these two groups could be confirmed on CT scans, one with osseointegration around the central peg, and the second with cystic changes. Patients with osteolysis around the central peg were those with early migration and those with osseointegration had minimal early migration. Both groups,however,had similar clinical results. . Conclusion. Rapid early migration associated with focal lucency and absence of osseointegration was observed in three of 11 glenoid components, suggesting that lack of initial stability leads to early movement and failure of osseointegration. Cite this article: Bone Joint J 2017;99-B:674–9

The August 2013 Shoulder & Elbow Roundup. 360 . looks at: the sternoclavicular joint revisited; surgical simulators: more than just a fancy idea?; arthroscopic tennis elbow release; costly clavicle stabilisation; a better treatment for tennis elbow?; shock news: surgeons and radiologists agree; overhead athletes and SLAP repair; and total shoulder arthroplasty more effective than hemiarthroplasty

Aims

The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery.

Aims. The purpose of the present study was to evaluate the impact of intravenous tranexamic acid on the reduction of blood loss, transfusion rate, and early post-operative clinical outcome in total shoulder arthroplasty. Patients and Methods. A randomised, placebo-controlled trial which included 54 patients undergoing unilateral primary stemless anatomical or stemmed reverse total shoulder arthroplasty was undertaken. Patients received either 100 ml saline (placebo, n = 27), or 100 ml saline together with 1000 mg of tranexamic acid (TXA, n = 27) intravenously prior to skin incision and during wound closure. Peri-operative blood loss via an intra-articular drain was recorded and total blood loss was calculated. The post-operative transfusion rate was documented. Assessment of early clinical parameters included the visual analogue scale for pain (VAS), documentation of haematoma formation and adverse events. Results. Mean peri-operative blood drainage (placebo: 170 ml versus TXA: 50 ml, p = 0.001) and calculated mean total blood loss (placebo: 1248.2 ml versus TXA: 871.0 ml, p = 0.009) were significantly lower in the TXA group. No transfusions were necessary during the study period in either group. Mean VAS for pain significantly decreased from pre-operative (VAS 7) to the early post-operative period (VAS 1.7, p < 0.001). Significant differences regarding mean post-operative pain between placebo (VAS 2.0) and TXA (VAS 1.3) were detected (p = 0.05). The occurrence of haematomas was significantly more frequent in the placebo (59.3%, n = 16) than in the TXA group (25.9%, n = 6, p = 0.027). Whereas only mild haematomas developed in the TXA group, in the placebo group a total of 22.2% (n = 6) developed either moderate or severe haematomas. No adverse events associated with administration of TXA occurred. Conclusion. Intravenous administration of TXA successfully reduced mean peri-operative blood drainage, total estimated blood loss, pain during the first post-operative days, and haematoma formation in total shoulder arthroplasty. Cite this article: Bone Joint J 2017;99-B:1073–9

In a prospective study between 2000 and 2005, 22 patients with primary osteoarthritis of the shoulder had a total shoulder arthroplasty with a standard five-pegged glenoid component, 12 with non-offset humeral head and ten with offset humeral head components. Over a period of 24 months the relative movement of the glenoid component with respect to the scapula was measured using radiostereometric analysis. Nine glenoids needed reaming for erosion. There was a significant increase in rotation about all three axes with time (p < 0.001), the largest occurring about the longitudinal axis (anteversion-retroversion), with mean values of 3.8° and 1.9° for the non-offset and offset humeral head eroded subgroups, respectively. There was also a significant difference in rotation about the anteversion-retroversion axis (p = 0.01) and the varus-valgus (p < 0.001) z-axis between the two groups. The offset humeral head group reached a plateau at early follow-up with rotation about the z-axis, whereas the mean of the non-offset humeral head group at 24 months was three times greater than that of the offset group accounting for the highly significant difference between them

The October 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomized, placebo-controlled trial; Superior capsular reconstruction partially restores native glenohumeral loads in a dynamic model; Gene expression in glenoid articular cartilage varies in acute instability, chronic instability, and osteoarthritis; Intra-articular injection versus interscalene brachial plexus block for acute-phase postoperative pain management after arthroscopic shoulder surgery; Level of pain catastrophizing rehab in subacromial impingement: secondary analyses from a pragmatic randomized controlled trial (the SExSI Trial); Anterosuperior versus deltopectoral approach for primary reverse total shoulder arthroplasty: a study of 3,902 cases from the Dutch National Arthroplasty Registry with a minimum follow-up of five years; Assessment of progression and clinical relevance of stress-shielding around press-fit radial head arthroplasty: a comparative study of two implants; A number of modifiable and non-modifiable factors increase the risk for elbow medial ulnar collateral ligament injury in baseball players: a systematic review.

The use of artificial intelligence (AI) is rapidly growing across many domains, of which the medical field is no exception. AI is an umbrella term defining the practical application of algorithms to generate useful output, without the need of human cognition. Owing to the expanding volume of patient information collected, known as ‘big data’, AI is showing promise as a useful tool in healthcare research and across all aspects of patient care pathways. Practical applications in orthopaedic surgery include: diagnostics, such as fracture recognition and tumour detection; predictive models of clinical and patient-reported outcome measures, such as calculating mortality rates and length of hospital stay; and real-time rehabilitation monitoring and surgical training. However, clinicians should remain cognizant of AI’s limitations, as the development of robust reporting and validation frameworks is of paramount importance to prevent avoidable errors and biases. The aim of this review article is to provide a comprehensive understanding of AI and its subfields, as well as to delineate its existing clinical applications in trauma and orthopaedic surgery. Furthermore, this narrative review expands upon the limitations of AI and future direction.

Cite this article: Bone Joint Res 2023;12(7):447–454.

Aims

The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry.