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Affiliation(s)
- Frederick M Azar
- Campbell Clinic, Inc, University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Jennewine BR, Throckmorton TW, Pierce AS, Miller AH, Azar AT, Sharp CD, Azar FM, Bernholt DL, Brolin TJ. Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update. J Shoulder Elbow Surg 2024; 33:900-907. [PMID: 37625693 DOI: 10.1016/j.jse.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. METHODS A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. RESULTS A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. CONCLUSIONS There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.
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Affiliation(s)
- Brenton R Jennewine
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Andrew S Pierce
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Andrew H Miller
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adrian T Azar
- College of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
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Polio WP, Hajek B, Brolin TJ, Mihalko WM, Singhal K, Hughes S, Nelson A, Hayes T, Chiu CY, Bernholt DL, Azar FM, Throckmorton TW. Muscle activation patterns during active external rotation after reverse total shoulder arthroplasty: an electrophysiological study of the teres minor and associated musculature. J Shoulder Elbow Surg 2024; 33:583-592. [PMID: 37778657 DOI: 10.1016/j.jse.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Preoperative teres minor insufficiency has been identified as a risk factor for poor restoration of external rotation (ER) after reverse total shoulder arthroplasty (RTSA). However, there has been little investigation regarding muscle activation patterns generating ER. This prospective study sought to determine the timing and activation levels of the shoulder girdle musculature during ER in well-functioning RTSAs with an intact teres minor using a lateralized design. METHODS Patients who underwent RTSA ≥1 year previously with functional ER, an American Shoulder and Elbow Surgeons (ASES) score >70, superior rotator cuff deficiency, and an intact teres minor were identified. Electrophysiological and kinematic analyses were performed during ER in the modified neutral position (arm at side with 90° of elbow flexion) and in abduction (AB) (shoulder abducted 90° with 90° of elbow flexion). Dynamometer-recorded torque and position were pattern matched to electromyography during ER. The root-mean-square and integrated electromyography (in microvolts × milliseconds with standard deviation [SD]), as well as median frequency (MF) (in hertz with SD), were calculated to determine muscle recruitment. Pair-wise t test analysis compared muscle activation (P < .05 indicated significance). RESULTS After an a priori power analysis, 16 patients were recruited. The average ASES score, visual analog scale pain score, and ASES subscore for ER in AB ("comb hair") were 87.7, 0.5, and 2.75 of 3, respectively. In AB, muscle activation began with the upper trapezius, middle trapezius, and latissimus dorsi, followed by the anterior deltoid activating to neutral. With ER beyond neutral, the teres major (9.6 μV × ms; SD, 9.2 μV × ms) initiated ER, followed by the teres minor (14.1 μV × ms; SD, 18.2 μV × ms) and posterior deltoid (11.1 μV × ms; SD, 9.3 μV × ms). MF analysis indicated equal contributions of the teres major (1.1 Hz; SD, 0.5 Hz), teres minor (1.2 Hz; SD, 0.4 Hz), and posterior deltoid (1.1 Hz; SD, 0.4 Hz) in ER beyond neutral. In the modified neutral position, the upper trapezius and middle trapezius were not recruited to the same level as in AB. For ER beyond neutral, the teres major (9.5 μV × ms [SD, 9 μV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), teres minor (11.4 μV × ms [SD, 15.1 μV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), and posterior deltoid (8.5 μV × ms [SD, 8 μV × ms]; MF, 1.2 Hz [SD, 0.3 Hz]) were activated in similar sequence and intensity as AB. No differences in muscle activation duration or intensity were noted among the teres major, teres minor, and posterior deltoid (P > .05). CONCLUSION Active ER after RTSA is complex and is not governed by a single muscle-tendon unit. This study establishes a sequence, duration, and intensity of muscle activation for ER in well-functioning RTSAs. In both tested positions, the teres major, teres minor, and posterior deltoid function equally and sequentially to power ER.
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Affiliation(s)
- William P Polio
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Blake Hajek
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - William M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Kunal Singhal
- Department of Physical Therapy, College of Rehabilitation Sciences, University of St. Augustine for Health Sciences, Austin, TX, USA
| | - Shannon Hughes
- Department of Physical Therapy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alexis Nelson
- College of Graduate Health Sciences in the Biomedical Sciences Program, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tristan Hayes
- Biostats, Epidemiology, and Research Design (BERD) Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Chi-Yang Chiu
- Biostats, Epidemiology, and Research Design (BERD) Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
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Jennewine BR, James NF, Polio WP, Naser AM, Nieboer MJ, Schoch BS, Throckmorton TW, Bernholt DL, Azar FM, Brolin TJ. Superior humeral head osteophytes are associated with rotator cuff insufficiency in glenohumeral osteoarthritis: a retrospective analysis. Eur J Orthop Surg Traumatol 2024; 34:893-900. [PMID: 37770594 DOI: 10.1007/s00590-023-03727-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/04/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE The primary goal of this study was to investigate whether superior humeral head osteophyte (SHO) size is associated with rotator cuff insufficiency, including rotator cuff tear (RCT), supraspinatus tendon thickness, and fatty infiltration of the rotator cuff muscles. METHODS Patients ≥ 18 years who were diagnosed with glenohumeral osteoarthritis were retrospectively reviewed. SHO size was determined by radiograph. MRI measured SHO and RCT presence, type, and size; supraspinatus tendon thickness; and fatty infiltration of rotator cuff musculature. RESULTS A total of 461 patients were included. Mean SHO size was 1.93 mm on radiographs and 2.13 mm on MRI. Risk ratio for a RCT was 1.14. For each 1-mm increase in SHO size on radiograph, supraspinatus tendon thickness decreased by 0.20 mm. SHO presence was associated with moderate-to-severe fatty infiltration of the supraspinatus with a risk ratio of 3.16. CONCLUSION SHOs were not associated with RCT but were associated with higher risk of supraspinatus FI and decreased tendon thickness, which could indicate rotator cuff insufficiency. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Brenton R Jennewine
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN, 38104, USA
| | - Nicholas F James
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN, 38104, USA
| | - William P Polio
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN, 38104, USA
| | - Abu Mohd Naser
- Division of Epidemiology, Biostatistics, and Environmental Health, University of Memphis, Memphis, TN, USA
| | - Micah J Nieboer
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN, 38104, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN, 38104, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN, 38104, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN, 38104, USA.
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Kim A, Goodloe JB, Garcia-Lopez E, Klott JD, Dopke KM, Feeley B, Miller MD, Azar FM, Gallo RA. How to Recognize, Correct, and Avoid Intraoperative Complications During Anterior Cruciate Ligament Reconstructions. Instr Course Lect 2024; 73:765-777. [PMID: 38090939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Technical complications are a leading cause of graft failure following anterior cruciate ligament reconstructions. Complications can occur during any phase of the procedure, from graft harvesting to tunnel preparation to graft fixation. Predicting potential causes of technical difficulty and developing strategies to avoid potential pitfalls can limit the number of intraoperative complications. If adverse events do occur intraoperatively, prompt recognition and treatment can lead to favorable outcomes. It is important to discuss strategies to understand potential complications and develop tactics to avoid and correct adverse events that can occur during anterior cruciate ligament reconstruction.
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Affiliation(s)
- Frederick M Azar
- Campbell Clinic, Inc, University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery & Biomedical Engineering, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Eason RR, Joyce MR, Throckmorton TW, Azar FM, Bernholt DL, Naser AM, Brolin TJ. Comparison of triamcinolone and methylprednisolone efficacy and steroid flare reaction rates after shoulder corticosteroid injection: a prospective interrupted time series study. J Shoulder Elbow Surg 2023; 32:2214-2221. [PMID: 37348782 DOI: 10.1016/j.jse.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND A corticosteroid flare reaction is a well-described phenomenon that causes significant pain and dysfunction. The paucity of literature impedes decision making regarding which corticosteroid to use for shoulder injection. The purpose of this study was to compare methylprednisolone acetate (MPA) and triamcinolone acetonide (TA) injections in the glenohumeral joint and/or subacromial space in terms of efficacy and the incidence of steroid flare reactions. METHODS In this prospective, interrupted time series, parallel study, patients received injections in the glenohumeral joint and/or subacromial space. MPA and TA were used during 2 discrete 3-month periods. The injections consisted of 2 mL of lidocaine, 2 mL of bupivacaine, and 80 mg of either MPA or TA. Visual analog scale (VAS) pain scores were recorded immediately before injection; 1-7 days after injection; and 3, 6, and 12 months after injection. The primary outcome was the incidence of a steroid flare reaction, defined as a post-injection increase in the VAS score by ≥2 points. The secondary outcome was injection failure, defined as a post-injection VAS score greater than the baseline score or the need for another intervention. We used linear mixed models with a patient-level random intercept to identify the mean VAS score change for TA injections in the first week after injection. RESULTS MPA or TA shoulder injections were administered in 421 patients; of these patients, 15 received bilateral-joint injections whereas 406 received a single-joint injection, for a total of 436 injections (209 MPA and 227 TA injections). Pain scores in the first week after injection were available for 193 MPA and 199 TA injections. Significantly more patients in the MPA cohort reported flare reactions compared with the TA cohort (22.8% vs. 4.0%, P < .001) during the first week after injection. In the first week after injection, the mean VAS score of patients receiving TA injections was 1.05 (95% confidence interval, 0.47-1.63) lower than that of patients receiving MPA injections when adjusted for age, sex, race, pain type, surgeon type, and injection site. At 3 months, surveys for 169 MPA and 172 TA injections were completed, with no significant difference in the rate of injection failure for MPA vs. TA (42.6% vs. 36.1%, P = .224). Treatment failure rates were significantly higher for MPA than for TA at 6 months (78.44% vs. 62.5%, P < .001) but not at 12 months (81.18% vs. 81.42%, P = .531.) CONCLUSION: TA injections resulted in a >5-fold reduction in steroid flare reactions, with statistically superior 6-month efficacy rates, compared with MPA injections. This study supports TA as a more viable corticosteroid option for shoulder injection.
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Affiliation(s)
- Robert R Eason
- Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Myles R Joyce
- Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Abu Mohd Naser
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
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Azar FM. Perioperative Pain Management. Orthop Clin North Am 2023; 54:xv-xvi. [PMID: 37718089 DOI: 10.1016/j.ocl.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Affiliation(s)
- Frederick M Azar
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee, Health Science Center, Memphis, TN 38104, USA.
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Affiliation(s)
- Frederick M Azar
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee, Health Science Center, Memphis, TN 38104, USA.
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Affiliation(s)
- Frederick M Azar
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Affiliation(s)
- Frederick M Azar
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee Health Science Center, Memphis, TN, USA.
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Marois AJ, Achecar A, Azar FM, Bernholt DL, Brolin TJ, Throckmorton TW. Grit Score is Predictive of Increased Risk for Opioid Prescription Refill Following Primary Arthroscopic Rotator Cuff Repair. J Surg Orthop Adv 2023; 32:177-181. [PMID: 38252605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
The grit score is used to measure passion and perseverance for long-term goals. We hypothesized that higher grit scores would predict improved 90-day outcomes and reduced opioid requirements after primary arthroscopic rotator cuff repair (RCR). Included were 103 patients. The median grit score was 3.9 (2.2-5.0). There was no statistically significant association between grit and morphine milligram equivalents prescribed or patient-reported pain control. Higher grit score was associated with a significant reduction in opioid prescription refill at 6 weeks, though this association was not seen at 2 or 12 weeks. The odds of requiring opioid medication 6 weeks after RCR increased 3.5 times per each 1.0 unit decrease in grit score. Patients with higher levels of grit, especially a score over 4.0, have a less difficult postoperative course after RCR. The grit score may help identify patients who are at increased risk for prolonged opioid use after RCR. (Journal of Surgical Orthopaedic Advances 32(3):177-181, 2023).
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Affiliation(s)
- Anthony J Marois
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee - Campbell Clinic, Memphis, Tennesse
| | - Adam Achecar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee - Campbell Clinic, Memphis, Tennesse
| | - Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee - Campbell Clinic, Memphis, Tennesse
| | - David L Bernholt
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee - Campbell Clinic, Memphis, Tennesse
| | - Tyler J Brolin
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee - Campbell Clinic, Memphis, Tennesse
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee - Campbell Clinic, Memphis, Tennesse
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Affiliation(s)
- Frederick M Azar
- University of Tennessee Health Science Center, Campbell Clinic Department of Orthopaedic, Surgery and Biomedical Engineering, Memphis, Tennessee 38104, USA; Campbell Clinic Foundation, 1211 Union Avenue, Suite 510, Memphis, TN 38104..
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Calkins TE, Baessler AM, Throckmorton TW, Black C, Bernholt DL, Azar FM, Brolin TJ. Safety and short-term outcomes of anatomic vs. reverse total shoulder arthroplasty in an ambulatory surgery center. J Shoulder Elbow Surg 2022; 31:2497-2505. [PMID: 35718256 DOI: 10.1016/j.jse.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/26/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone. METHODS Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone. RESULTS Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001). CONCLUSION Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.
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Affiliation(s)
- Tyler E Calkins
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Aaron M Baessler
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Carson Black
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Jones CA, Throckmorton TW, Murphy J, Eason RR, Joyce M, Bernholt DL, Azar FM, Brolin TJ. Opioid-sparing pain management protocol after shoulder arthroplasty results in less opioid consumption and higher satisfaction: a prospective, randomized controlled trial. J Shoulder Elbow Surg 2022; 31:2057-2065. [PMID: 35803549 DOI: 10.1016/j.jse.2022.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/19/2022] [Accepted: 05/30/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The opioid epidemic has become a central focus in health care. In an effort to reduce opioid use, orthopedic surgeons use multimodal strategies to control postoperative pain. However, no clear consensus exists on ideal pain management strategies after shoulder arthroplasty, and most protocols are opioid-driven. This study sought to determine if patients undergoing shoulder arthroplasty using a postoperative opioid-sparing pain-control regimen would have equivalent pain scores and satisfaction as patients using a traditional opioid-based regimen. METHODS Patients undergoing primary anatomic or reverse total shoulder arthroplasty were prospectively enrolled and randomized into an opioid-sparing (OS) or a traditional opioid-based (OB) postoperative pain protocol. Both groups received opioid education, periarticular injection with liposomal bupivacaine, and preoperative and postoperative multimodal management (acetaminophen, celecoxib, and gabapentin). The OB group was discharged with 40 oxycodone tablets and standard icing, whereas the OS group received ketorolac during admission, continuous cryotherapy, and discharged with 10 oxycodone tablets for rescue. Patients were queried regarding levels of pain and opioid consumption at days 1-7 and at 2, 6, and 12 weeks postoperatively. Patient satisfaction was recorded at 1, 2, 6, and 12 weeks. Range of motion (ROM), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numerical Evaluation (SANE) scores were assessed preoperatively and at 12 weeks postoperatively. Complications, readmissions, and reoperations were recorded. RESULTS In 78 patients, no difference in VAS pain scores were seen at any time between groups. The OS group consumed less oral morphine equivalents (OME) from inpatient hospitalization to 12 weeks postoperatively (P < .05). Total OME consumption was reduced by 213% for the OS vs. the OB group (112 vs. 239; P < .0001). The OS group consumed fewer opioid pills at all time points (P < .05). A 395% reduction in number of opioid pills consumed in the first 12 weeks postoperatively was seen in the OS vs. the OB group (4.3 vs. 17.0; P < .0001). Significantly more patients in the OS group discontinued opioids by 2 weeks postoperatively (86.1% vs. 58.5%; P = .011), and 94.4% in the OS group discontinued opioids by 6 weeks postoperatively. The OS group was more satisfied with pain management at 1 and 6 weeks (P = .05). No difference in ROM, ASES or SANE scores, complications, readmissions, or reoperations were seen between groups. CONCLUSIONS This study demonstrated a nearly 4-fold reduction in opioid pain pill consumption and earlier cessation of opioids with an OS pain management protocol. Patients also reported higher satisfaction with this pain management strategy.
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Affiliation(s)
- Caleb A Jones
- University of Tennessee Health Science Center, Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA
| | - Thomas W Throckmorton
- University of Tennessee Health Science Center, Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA
| | - Jeff Murphy
- Murphy Statistical Services, Warsaw, IN, USA
| | | | - Myles Joyce
- Campbell Clinic Foundation, Memphis, TN, USA
| | - David L Bernholt
- University of Tennessee Health Science Center, Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA
| | - Frederick M Azar
- University of Tennessee Health Science Center, Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA
| | - Tyler J Brolin
- University of Tennessee Health Science Center, Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA.
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Affiliation(s)
- Frederick M Azar
- The University of Tennessee Health Science Center, Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN, USA.
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Hillesheim RA, Kumar P, Brolin TJ, Bernholt DL, Sethi PM, Kowalsky MS, Azar FM, Throckmorton TW. Response to Chen et al: Comparing efficacy of different analgesia modalities after arthroscopic rotator cuff repair: methodology is important. J Shoulder Elbow Surg 2022; 31:e361-e362. [PMID: 35304282 DOI: 10.1016/j.jse.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Richard A Hillesheim
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Padam Kumar
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Paul M Sethi
- Orthopedic & Neurosurgical Specialists, ONS Foundation, Greenwich, CT, USA
| | - Marc S Kowalsky
- Orthopedic & Neurosurgical Specialists, ONS Foundation, Greenwich, CT, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
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18
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Affiliation(s)
- Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee/Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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19
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Affiliation(s)
- Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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20
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Baessler A, Smith PJ, Brolin TJ, Neel RT, Sen S, Zhu R, Bernholt D, Azar FM, Throckmorton TW. Preoperative opioid usage predicts markedly inferior outcomes 2 years after reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:608-615. [PMID: 34474138 DOI: 10.1016/j.jse.2021.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse total shoulder arthroplasty (RTSA) has proved to be a highly effective treatment for rotator cuff-deficient conditions and other end-stage shoulder pathologies. With value-based care emerging, identifying predictive factors of outcomes is of great interest. Although preoperative opioid use has been shown to predict inferior outcomes after anatomic total shoulder arthroplasty and rotator cuff repair, there is a paucity of data regarding its effect on outcomes after RTSA. We analyzed a series of RTSAs to determine the influence of preoperative opioid use on clinical and radiographic outcomes at a minimum of 2 years' follow-up. METHODS A retrospective review of primary RTSA patient data revealed 264 patients with ≥2 years of clinical and radiographic follow-up. Patients were classified as preoperative opioid users (71 patients) if they had taken narcotic pain medication for a minimum of 3 months prior to surgery or as opioid naive (193 patients) at the time of surgery. Assessments included preoperative and postoperative visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, strength, and range of motion, as well as complications and revisions. Radiographs were analyzed for signs of loosening or mechanical failure. The Mann-Whitney U and Fisher exact tests were used for comparisons between groups. Statistical significance was set at P < .05. RESULTS The mean patient age was 69.9 years, and the mean follow-up time was 2.8 years. Opioid users were significantly younger (66.1 years vs. 70.7 years, P < .001) at the time of surgery and had significantly higher preoperative rates of mood disorders, chronic pain disorders, and disability status (all P < .05). Postoperatively, opioid users had inferior visual analog scale pain scores (2.59 vs. 1.25, P < .001), American Shoulder and Elbow Surgeons scores (63.2 vs. 75.2, P < .001), active forward elevation (P < .001), and internal and external rotational shoulder strength (all P < .05) compared with opioid-naive patients. Periprosthetic radiolucency (8.45% vs. 2.07%, P = .026) and subsequent revision arthroplasty (14.1% vs. 4.66%, P = .014) occurred more frequently in opioid users than in opioid-naive patients. Both groups improved from baseline preoperatively to most recent follow-up in terms of functional outcomes and pain. CONCLUSION Preoperative opioid use portended markedly inferior clinical outcomes in patients undergoing RTSA. Additionally, opioid users had significantly increased rates of periprosthetic radiolucency and revision. Preoperative opioid use appears to be a significant marker for adverse outcomes after RTSA.
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Affiliation(s)
- Aaron Baessler
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Patrick J Smith
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Robert T Neel
- University of Tennessee Health Science Center School of Medicine, Memphis, TN, USA
| | - Saunak Sen
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rongshun Zhu
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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21
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McClatchy SG, Heise GM, Mihalko WM, Azar FM, Smith RA, Witte DH, Stanfill JG, Throckmorton TW, Brolin TJ. Effect of deltoid volume on range of motion and patient-reported outcomes following reverse total shoulder arthroplasty in rotator cuff-intact and rotator cuff-deficient conditions. Shoulder Elbow 2022; 14:24-29. [PMID: 35154397 PMCID: PMC8832705 DOI: 10.1177/1758573220925046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/12/2020] [Accepted: 04/14/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Deltoid muscle function is paramount to the success of reverse total shoulder arthroplasty. The purpose of this study was to investigate the role of deltoid volume on shoulder range of motion and patient-reported outcomes following reverse total shoulder arthroplasty in rotator cuff-intact and rotator cuff-deficient conditions. METHODS Retrospective review of records identified 107 patients who met inclusion criteria. The rotator cuff integrity was evaluated by two musculoskeletal-trained radiologists. Volumetric deltoid measurements were calculated from preoperative computed tomography or magnetic resonance imaging scans. Satisfactory outcomes were defined as forward elevation of at least 135°, external rotation of at least 35°, and American Shoulder and Elbow Surgeons and Single Assessment Numerical Evaluation scores of at least 70. RESULTS Mean total deltoid muscle volume was significantly higher in patients with satisfactory forward elevation (57.8 ± 18.1 cm³) versus unsatisfactory forward elevation (48.6 ± 19.5 cm³) (p = 0.013). When separated by rotator cuff integrity, total deltoid volume was significantly higher (p = 0.030) in patients who achieved satisfactory forward elevation in the rotator cuff-deficient group but not the rotator cuff-intact group (p = 0.533). DISCUSSION Preoperative deltoid volume directly correlated with achieving satisfactory forward elevation after reverse total shoulder arthroplasty in rotator cuff-deficient conditions and may be one factor in determining the ability to achieve satisfactory outcomes in the rotator cuff-deficient patient.
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Affiliation(s)
- Samuel G McClatchy
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, Memphis, USA
| | - Griffin M Heise
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, Memphis, USA
| | - William M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, Memphis, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, Memphis, USA
| | - Richard A Smith
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, Memphis, USA
| | | | | | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, Memphis, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, Memphis, USA,Tyler J Brolin, University of Tennessee—Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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22
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Pharr ZK, Bowman EN, Blickenstaff BE, Hubler AK, Brolin TJ, Throckmorton TW, Azar FM. Frozen Shoulder Manipulation with the FEAR Technique: A Retrospective Case Series with Minimum Two-Year Follow-up. J Surg Orthop Adv 2022; 31:96-99. [PMID: 35820094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Conservative treatment of adhesive capsulitis fails in up to 30% of patients. Manipulation under anesthesia (MUA) has been shown to be safe and effective, although complications (iatrogenic fracture, glenohumeral dislocation, rotator cuff tears, nerve injuries) have been reported. This study details a novel technique, FEAR (Forward elevation, Extension, Adduction/abduction, and internal and external Rotation), and its results. Medical records review identified 100 patients with a diagnosis of adhesive capsulitis who had at least 6 weeks of physical therapy, with or without corticosteroid injection, with persistence of pain and loss of motion loss. An Institutional Review Board approved phone survey obtained Single Assessment Numeric Evaluation (SANE) scores, visual analog scale (VAS) scores, functional scores, and range of motion, with 43 available for survey. At average 5-year follow-up, 81% had excellent (≥ 90) scores and 77% were pain-free. Patients with diabetes and male patients had significantly lower SANE scores at follow-up. (Journal of Surgical Orthopaedic Advances 31(2):096-099, 2022).
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Affiliation(s)
| | - Eric N Bowman
- Vanderbilt Health, Department of Orthopaedic Surgery, Franklin, Tennessee
| | - Baylor E Blickenstaff
- Marshall University Joan C Edwards School of Medicine, Department of Orthopaedics, Huntington, West Virginia
| | - Adam K Hubler
- University of Tennessee Health Science Center, School of Medicine, Department of Radiation Oncology, Memphis, Tennessee
| | - Tyler J Brolin
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, Tennessee
| | - Thomas W Throckmorton
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, Tennessee
| | - Frederick M Azar
- University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, Tennessee
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23
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Azar FM. [Not Available]. Orthop Clin North Am 2022; 53:xvii-xviii. [PMID: 34799029 DOI: 10.1016/j.ocl.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick M Azar
- Professor, Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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24
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Hillesheim RA, Kumar P, Brolin TJ, Bernholt DL, Sethi PM, Kowalsky MS, Azar FM, Throckmorton TW. Periarticular liposomal bupivacaine mixture injection vs. single-shot interscalene block for postoperative pain in arthroscopic rotator cuff repair: a prospective randomized controlled trial. J Shoulder Elbow Surg 2021; 30:2691-2697. [PMID: 34537339 DOI: 10.1016/j.jse.2021.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/04/2021] [Accepted: 08/10/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The pain control efficacy, postoperative opioid requirements, and costs among patients undergoing major shoulder surgery using different perioperative analgesia modalities have been topics of active debate. Several studies have compared periarticular injection (PAI) to interscalene block (ISB) in shoulder arthroplasty, but there is a paucity of data comparing them in arthroscopic rotator cuff repair. METHODS Patients aged 18-80 years with full-thickness rotator cuff tears and undergoing primary arthroscopic rotator cuff repair at 2 different shoulder centers were screened and subsequently randomized to receive either periarticular injection (PAI) of liposomal bupivacaine mixed with 0.25% bupivacaine (n = 41) or single-shot interscalene nerve block (ISB) (n = 36). Visual analog scale (VAS) pain scores, oral morphine equivalent (OME) use, Single Assessment Numerical Evaluation (SANE) scores, and costs were collected. Differences with P <.05 were considered statistically significant. RESULTS Day of surgery VAS score and OME usage were significantly reduced with ISB vs. PAI (0.69 vs. 4.65, P < .001, and 18.66 vs. 34.39, P < .001, respectively). There were no significant differences between groups regarding VAS score on postoperative days (PODs) 1-3; however, OME usage on PODs 1 (50.5 vs. 38.8, P = .03) and 2 (48.1 vs. 37.8, P = .04) was significantly more in the ISB group. At POD 3, VAS score (4.13 vs. 3.97, P = .60) and OME use (28.60 vs. 31.16, P = .51) were similar. At 6 and 12 weeks, there were also no significant differences between groups regarding VAS and OME use. There was no difference in SANE score at 12 weeks following surgery between groups and no difference between average 12-week cumulative OME use between groups. The average charge for the PAI was $455, and the average charge for ISB was $745. CONCLUSION Both ISB and PAI provide acceptable pain control following arthroscopic rotator cuff repair. Patients have less pain on the day of surgery with ISB, but rebound pain is significant after the block wears off, resulting in substantially increased opioid use in the first 2 PODs. However, cumulative opioid use between groups was similar. There were also no significant differences at the end of the 12-week episode of care in any of the other variables studied. The charge per patient for PAI is approximately $300 less than ISB. Thus, PAI may offer surgeons and patients an effective postoperative analgesic modality as an alternative to ISB.
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Affiliation(s)
- Richard A Hillesheim
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA
| | - Padam Kumar
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Tyler J Brolin
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA
| | - David L Bernholt
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA
| | - Paul M Sethi
- Orthopedic & Neurosurgical Specialists, ONS Foundation, Greenwich, CT, USA
| | - Marc S Kowalsky
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Frederick M Azar
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA
| | - Thomas W Throckmorton
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA.
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25
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Baessler AM, Brolin TJ, Azar FM, Sen S, Chang M, Falkner D, Zmistowski BM, Routman HD, Namdari S, Gulotta LV, Throckmorton TW. Development and validation of a predictive model for outcomes in shoulder arthroplasty: a multicenter analysis of nearly 2000 patients. J Shoulder Elbow Surg 2021; 30:2698-2702. [PMID: 34284093 DOI: 10.1016/j.jse.2021.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Guiding expectations following shoulder arthroplasty is important in improving patient satisfaction. The purpose of this study was to develop a predictive model to calculate 2-year American Shoulder and Elbow Surgeons (ASES) scores in shoulder arthroplasty patients from a comprehensive set of preoperative patient factors and types of arthroplasty performed. METHODS This retrospective multicenter study included 1947 shoulder arthroplasties performed from 2010 to 2015 at 3 high-volume centers. Twenty-six variables were evaluated for an association with 2-year ASES scores, and variables with P < .20 in our pair-wise analysis were used to develop a predictive model. The prediction root-mean-square error was calculated. External validation was performed using data from 233 patients who underwent shoulder arthroplasty performed by a separate shoulder surgeon at a center not involved with creation of the predictive model. RESULTS A total of 1947 patients were analyzed, and their data were used to construct the predictive model. Variables most associated with 2-year ASES scores were patient age, preoperative ASES score, disability, chronic obstructive pulmonary disease, alcohol use, anatomic vs. reverse total shoulder arthroplasty, and primary vs. revision shoulder arthroplasty. By use of cross validation, the prediction error was 20.1, the proportion of variance explained was 25.3%, the mean absolute error was 15.9, and the C statistic for the linear regression model was 0.66. After external validation, the mean difference between predicted and actual 2-year ASES scores was 12.7 points, within the accepted minimal clinically important difference after shoulder arthroplasty. DISCUSSION Data from nearly 2000 shoulder arthroplasties allowed the development and validation of a model to predict 2-year ASES scores following shoulder arthroplasty. The model was accurate within the minimal clinically important difference in 85% of patients.
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Affiliation(s)
- Aaron M Baessler
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Saunak Sen
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Michael Chang
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dmitri Falkner
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Surena Namdari
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lawrence V Gulotta
- Department of Orthopedic Surgery, Hospital for Special Surgery-Weill Cornell Medical School, New York, NY, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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26
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Affiliation(s)
- Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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27
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Affiliation(s)
- Frederick M Azar
- Department of Orthopaedic Surgery &Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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28
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Azar FM. Hot Topics in Orthopedics. Orthop Clin North Am 2021; 52:xv-xvi. [PMID: 33752843 DOI: 10.1016/j.ocl.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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29
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Affiliation(s)
- Frederick M Azar
- University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery &, Biomedical Engineering, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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30
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Power I, Throckmorton TW, Smith RA, Azar FM, Brolin TJ. Pulmonary Comorbidities Are Associated with Increased Major Complication Rates Following Indwelling Interscalene Nerve Catheters for Shoulder Arthroplasty. Orthop Clin North Am 2020; 51:527-532. [PMID: 32950222 DOI: 10.1016/j.ocl.2020.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pulmonary comorbidities and ASA physical status class III and IV can significantly increase the rate of major complications after ISC placement. Patients with an underlying pulmonary comorbidity or lung disease (chronic obstructive pulmonary disease, asthma, or obstructive sleep apnea) have a 2.2-fold increased risk of having any complication and a 2.4-fold increased risk of having a major pulmonary complication compared to those without pulmonary comorbidities. Patients with pulmonary comorbidities may benefit from alternative pain management strategies to avoid complications in the early postoperative period.
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Affiliation(s)
- Ian Power
- Orthopedic Associates P.A., Farmington, NM, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Richard A Smith
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Abstract
Ultra-low-velocity knee dislocations are historically rare but increasingly common events. They occur most frequently in obese, morbidly obese, and super obese patients during everyday activities, but they can be as severe or more severe than high-velocity knee dislocations. Ultra-low-velocity knee dislocations frequently are associated with neurovascular injury and other complications. Diagnosis, early reduction, and identification and treatment of vascular injuries are critical to reducing the risk of limb ischemia and possibly amputation. Given the size of the limb, maintenance of reduction in these patients almost always requires external fixation. Although surgery on morbidly obese patients may be technically challenging, surgical reconstruction leads to improved subjective and objective results and is recommended.
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Affiliation(s)
- Patrick J Smith
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN
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32
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Affiliation(s)
- Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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33
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Wright RW, Armstrong AD, Azar FM, Bednar MS, Carpenter JE, Evans JB, Flynn JM, Garvin KL, Jacobs JJ, Kang JD, Lundy DW, Mencio GA, Murray PM, Nelson CL, Peabody T, Porter SE, Roberson JR, Saltzman CL, Sebastianelli WJ, Taitsman LA, Van Heest AE, Martin DF. The American Board of Orthopaedic Surgery Response to COVID-19. J Am Acad Orthop Surg 2020; 28:e465-e468. [PMID: 32324709 PMCID: PMC7195847 DOI: 10.5435/jaaos-d-20-00392] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Indexed: 02/01/2023] Open
Abstract
The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.
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Affiliation(s)
- Rick W Wright
- From the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Wright), Department of Orthopaedic Surgery, Penn State Hershey Medical Center, Hershey, PA (Dr. Armstrong), Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee/Campbell Clinic, Memphis, TN (Dr. Azar), Department of Orthopaedic Surgery and Rehabilitation, Stritch School of Medicine, Loyola University-Chicago, Maywood, IL (Dr. Bednar), Orthopaedic Surgery, University of Michigan, Ann Arbor, MI (Dr. Carpenter), Public Member, Cedar Rapids, IA (Mr. Evans), Orthopaedic Surgery, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA (Dr. Flynn), Department of Orthopaedic Surgery, University of Nebraska, Omaha, NE (Dr. Garvin), Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL (Dr. Jacobs), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Kang), Resurgens Orthopaedics, Atlanta, GA (Dr. Lundy), Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Mencio), Department of Orthopedic Surgery and Neurosurgery, Mayo Clinic, Jacksonville, FL (Dr. Murray), Hospital of the University of Pennsylvania, Philadelphia, PA (Dr. Nelson), Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Evanston, IL (Dr. Peabody), Department of Orthopaedic Surgery, Prisma Health-Upstate, Greenville, SC (Dr. Porter), Orthopaedics, Emory University, Atlanta, GA (Dr. Roberson), Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT (Dr. Saltzman), Orthopaedic Surgery and Rehabilitation, Penn State Health System, State College, PA (Dr. Sebastianelli), University of Washington, Harborview Medical Center, Seattle, WA (Dr. Taitsman), Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Van Heest), and American Board of Orthopaedic Surgery, Chapel Hill, NC (Dr. Martin), and Wake Forest School of Medicine, Winston-Salem, NC (Dr. Martin)
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34
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Affiliation(s)
- Frederick M Azar
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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35
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Walters JD, George LW, Walsh RN, Wan JY, Brolin TJ, Azar FM, Throckmorton TW. The effect of current and former tobacco use on outcomes after primary reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:244-251. [PMID: 31427230 DOI: 10.1016/j.jse.2019.05.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to determine the influence of current and former tobacco use on minimum 2-year clinical and radiographic outcomes after reverse total shoulder arthroplasty (RTSA). METHODS Review of primary RTSA patient data identified 186 patients with at least 2 years of follow-up. Patients were classified as nonsmokers (76 patients), former smokers (89 patients), or current smokers (21 patients). Assessment included preoperative and postoperative visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, strength, range of motion, complications, revisions, and narcotic use. Radiographs were analyzed for signs of loosening or mechanical failure. RESULTS Overall mean age of the patients was 70 (48-87) years, and mean follow-up was 2.6 (2.0-5.7) years. Smokers (62.1 years) were significantly younger than nonsmokers (70.7 years) and former smokers (70.8 years; P = .00002). All patients had significant improvements in pain, American Shoulder and Elbow Surgeons score, strength, and forward flexion range of motion; however, smokers had higher visual analog scale pain scores (mean, 2.5) than nonsmokers (mean, 1.8) or former smokers (mean, 1.0; P = .014). Otherwise, no differences were found regarding any of the postoperative parameters (P > .05). CONCLUSIONS Aside from increased patient-reported pain, current tobacco use does not appear to negatively affect outcomes after primary RTSA. The RTSA design obviates the need for a functioning rotator cuff, possibly mitigating tobacco's negative effects previously demonstrated in rotator cuff repair and anatomic total shoulder arthroplasty. Former users obtained outcomes similar to those of nonusers, suggesting that tobacco use is a modifiable risk factor to achieve optimal pain relief after RTSA.
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Affiliation(s)
- Jordan D Walters
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - L Watson George
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Ryan N Walsh
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Jim Y Wan
- Department of Biostatistics and Epidemiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Affiliation(s)
- Frederick M Azar
- Professor, University of Tennessee-, Campbell Clinic, Department of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Kester B, Kouk S, Minhas SV, Azar FM, Bosco J. Effect of Shoulder Stabilization on Career Length and Performance in National Basketball Association Athletes. Bull Hosp Jt Dis (2013) 2019; 77:223-229. [PMID: 31785133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Untreated episodes of shoulder instability can have major consequences on athletic careers. Operative shoulder stabilization reduces the rate of recurrent instability and allows for high rates of return to sport (RTS). Basketball players who experience an episode of instability have high rates of recurrence, though little is known about postoperative player performance. The purpose of this study was to identify the impact of shoulder instability and surgical stabilization on player performance and career lengths in the National Basketball Association (NBA). METHODS NBA players who had episodes of shoulder instability between 1994-2014 were identified using the NBA Injury Surveillance and Analytics Database. Players were stratified according to operative versus nonoperative treatment of shoulder instability. Two demographic- and performance-matched controls were chosen for each test subject. Univariate analyses were used to compare pre- and postoperative player performance metrics. Survival analysis was used to assess the effect of shoulder surgery on postoperative career lengths. RESULTS Fifty athletes were identified, 46 (92.0%) returned to play in the NBA. Compared to controls, there was no significant difference in postoperative performance according to either 1- or 3-year averages. Survival analysis demonstrated no significant difference in postoperative career lengths between athletes with a history of shoulder surgery for instability and matched controls. CONCLUSION NBA players return to professional basketball in high numbers following orthopedic surgery for shoulder instability. Shoulder instability may not be a career-altering event, as there are highly effective methods of shoulder stabilization available to athletes.
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Azar FM. Arthritis and Related Conditions. Orthop Clin North Am 2019; 50:xv-xvi. [PMID: 31466670 DOI: 10.1016/j.ocl.2019.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick M Azar
- University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Azar FM. Unique or Select Procedures. Orthop Clin North Am 2019; 50:xv-xvi. [PMID: 31189499 DOI: 10.1016/j.ocl.2019.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick M Azar
- University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Azar FM. Surgical Considerations for Osteoporosis, Osteopenia, and Vitamin D Deficiency. Orthop Clin North Am 2019; 50:xi. [PMID: 30850084 DOI: 10.1016/j.ocl.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick M Azar
- Campbell Clinic, University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Fournier MN, Brolin TJ, Azar FM, Stephens R, Throckmorton TW. Identifying appropriate candidates for ambulatory outpatient shoulder arthroplasty: validation of a patient selection algorithm. J Shoulder Elbow Surg 2019; 28:65-70. [PMID: 30100176 DOI: 10.1016/j.jse.2018.06.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/12/2018] [Accepted: 06/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Outpatient total shoulder arthroplasty (TSA) is increasing in frequency, but the selection of patients who are appropriate outpatient joint candidates remains challenging. We propose an algorithm for selecting outpatient TSA candidates, with validation by a cohort of patients from an ambulatory surgery center (ASC). METHODS We identified 61 patients who had primary anatomic and reverse TSA. The selection algorithm, which stratifies patients referable to their age and cardiopulmonary comorbidities, was used to choose patients for outpatient surgery. Complications, including cardiopulmonary, thromboembolic, and postoperative wound problems, were recorded. RESULTS All 61 patients were discharged from the ASC on the day of surgery. There were no cardiopulmonary events requiring intervention or hospital admission. One patient (2%) required a secondary operation, 3 patients (5%) experienced acute surgical complications, 3 patients (5%) had transient postoperative nausea, and 4 patients (7%) had additional complications within the 90-day episode of care. CONCLUSIONS This study is the first to propose a patient selection method for outpatient TSA. Using this algorithm for patient selection produced a low rate of perioperative complications and no hospital admissions. We suggest this algorithm provides an evidence-based method for the standardization of outpatient TSA candidate selection.
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Affiliation(s)
- Matthew N Fournier
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Raj Stephens
- Metropolitan Anesthesia Alliance, Germantown, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Thompson KM, Smith RA, Brolin TJ, Azar FM, Throckmorton TW. Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared with indwelling interscalene catheter in total elbow arthroplasty. J Shoulder Elbow Surg 2018; 27:2257-2261. [PMID: 30340926 DOI: 10.1016/j.jse.2018.07.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 07/02/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative pain control, short-term and long-term narcotic consumption, complication rates, and costs of indwelling interscalene catheter (ISC) were compared with a liposomal bupivacaine (LBC) mixture in patients undergoing primary total elbow arthroplasty. METHODS Forty-four consecutive patients were identified, the first 28 with an ISC and the later 16 with intraoperative LBC injection that also included ketorolac and 0.5% bupivacaine. Medical records were reviewed for visual analog scale scores for pain, oral morphine equivalent (OME) use, complications, and facility charges. RESULTS Average visual analog scale scores at 24 hours, 2 weeks, 6 weeks, and 12 weeks were not significantly different. Mean OME use was significantly greater in the LBC group at 24 hours but less at 12 weeks, although this difference was not statistically significant. Twelve anesthetic-related complications occurred in the ISC group (1 major and 11 minor); 10 patients (36%) had at least 1 complication. The major complication was respiratory failure requiring emergent tracheostomy. Minor complications included leaking pump/catheters, catheters inadvertently pulled out early, global hand paresthesias, forearm paresthesias, and pain at the catheter site. There were no anesthetic-related complications in the LBC group. The average charge for the LBC mixture was $327.10; charges for ISC, including equipment and anesthesia fees, were $1472.42. CONCLUSIONS An LBC mixture provides similar pain relief with fewer complications at a lower cost than indwelling ISC after total elbow arthroplasty. Although the OME use in the LBC group was almost double that of the ISC group at 24 hours, there was no difference at later time points.
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Affiliation(s)
- Kirk M Thompson
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Richard A Smith
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Azar FM. Quality, Value, and Patient Safety in Orthopedic Surgery. Orthop Clin North Am 2018; 49:xvii. [PMID: 30224016 DOI: 10.1016/j.ocl.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick M Azar
- University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Nelson CG, Brolin TJ, Ford MC, Smith RA, Azar FM, Throckmorton TW. Five-year minimum clinical and radiographic outcomes of total shoulder arthroplasty using a hybrid glenoid component with a central porous titanium post. J Shoulder Elbow Surg 2018. [PMID: 29526600 DOI: 10.1016/j.jse.2018.01.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND To determine the effectiveness of hybrid glenoid components in reducing the frequency of glenoid component loosening, we evaluated clinical and radiographic outcomes at a minimum 5-year follow-up in 45 shoulders that underwent total shoulder arthroplasty (TSA) using a system with a central porous titanium post to augment the cemented peripheral pegs. METHODS Function and pain were evaluated with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment score, visual analog scale, active shoulder range of motion, and strength. Postoperative radiographs were analyzed for radiolucent lines, progressive loosening, and at-risk signs. RESULTS The mean American Shoulder and Elbow Surgeons score improved from 40.4 to 83.7 (P < .0001) and the mean visual analog scale from 5.9 to 0.8 (P < .0001). Forward elevation improved from 113° to 151° (P < .001), internal rotation from 49° to 60° (P = .035), and mean external rotation from 36° to 50° (P = .0006). Radiographs showed glenoid component radiolucency in 29 shoulders. Radiolucencies were confined to the area under the glenoid faceplate in 6 and were only around the central post in 13. Nine TSAs (20%) demonstrated 2 or more columns of involvement but were not judged to be at-risk. One implant (2.2%) had glenoid component failure and was revised to a hemiarthroplasty. CONCLUSION Anatomic TSA using a hybrid glenoid component with a central porous titanium post demonstrated a low rate of mechanical failure and a rate of radiolucent lines comparable to reports of all polyethylene implants. Further evaluations are needed to demonstrate the long-term durability of these implants and to determine the significance and fate of the radiolucent lines, particularly relative to the central post.
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Affiliation(s)
- Clay G Nelson
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Marcus C Ford
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Richard A Smith
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Affiliation(s)
- Frederick M Azar
- Campbell Clinic, University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Affiliation(s)
- Frederick M Azar
- Campbell Clinic, Inc, University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery & Biomedical Engineering, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Weller WJ, Azzam MG, Smith RA, Azar FM, Throckmorton TW. Liposomal Bupivacaine Mixture Has Similar Pain Relief and Significantly Fewer Complications at Less Cost Compared to Indwelling Interscalene Catheter in Total Shoulder Arthroplasty. J Arthroplasty 2017; 32:3557-3562. [PMID: 28390888 DOI: 10.1016/j.arth.2017.03.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/20/2017] [Accepted: 03/07/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The efficacy and costs of indwelling interscalene catheter (ISC) and liposomal bupivacaine (LBC), with and without adjunctive medications, in patients with primary shoulder arthroplasty are a source of current debate. METHODS In 214 arthroplasties, 156 patients had ISC and 58 had LBC injections that were mixed with morphine, ketorolac, and 0.5% bupivacaine with epinephrine. Charts were reviewed for visual analog scale pain scores, oral morphine equivalent (OME) usage, major complications, and costs. RESULTS Visual analog scale scores were not significantly different at 24 hours or at 2, 6, and 12 weeks. Average OME consumption at 24 hours was significantly more with LBC, but was not significantly different at 12 weeks. Relative risk of a major complication was nearly 4 times higher with ISC than with LBC. The average cost for the LBC mixture was $289.04, and for ISC, including equipment and anesthesia fees, was $1559.42. CONCLUSION The intraoperative LBC mixture provided equivalent pain relief with significantly fewer major complications and at markedly lower cost than ISC. LBC required almost twice as much OME to attain the same level of pain relief at 24 hours, but there was no significant difference in the cumulative amount of outpatient narcotic use.
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Affiliation(s)
- William J Weller
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
| | - Michael G Azzam
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
| | - Richard A Smith
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
| | - Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee
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Affiliation(s)
- Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Brolin TJ, Mulligan RP, Azar FM, Throckmorton TW. Neer Award 2016: Outpatient total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total shoulder arthroplasty in a hospital: a matched cohort study. J Shoulder Elbow Surg 2017; 26:204-208. [PMID: 27592373 DOI: 10.1016/j.jse.2016.07.011] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/09/2016] [Accepted: 07/01/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent emphasis on safe and efficient delivery of high-quality health care has increased interest in outpatient total joint arthroplasty. The purpose of this study was to evaluate the safety of outpatient total shoulder arthroplasty (TSA) by comparing episode-of-care complications in matched cohorts of patients with anatomic TSA as an outpatient or inpatient procedure. METHODS Thirty patients with outpatient TSA at a freestanding ambulatory surgery center (ASC) were compared with an age- and comorbidities-matched cohort of 30 patients with traditional inpatient TSA to evaluate 90-day episode-of-care complications, including hospital admissions or readmissions and reoperations. Two-tailed t-tests were used to evaluate differences, and differences of P < .05 were considered statistically significant. RESULTS No significant differences were found between the ASC and hospital cohorts regarding average age, preoperative American Society of Anesthesiologists score, operative indications, or body mass index. No patient required reoperation. There were no hospital admissions from the ASC cohort and no readmissions from the hospital cohort. Minor complications in the ASC cohort were arthrofibrosis in 2 patients and mild asymptomatic anterior subluxation in 1 patient; the only major complication was in an outpatient who fell 11 weeks after surgery and disrupted his subscapularis repair. Three minor complications in the hospital cohort were mild asymptomatic anterior subluxation, blood transfusion, and superficial venous thrombosis. The complication rates (13% vs. 10%) were not significantly different. CONCLUSIONS Outpatient TSA is a safe alternative to hospital admission in appropriately selected patients. Further investigation is warranted to evaluate the longer term outcomes and cost-effectiveness of outpatient TSA.
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Affiliation(s)
- Tyler J Brolin
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Ryan P Mulligan
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Azar FM. Controversies in Fracture Care. Orthop Clin North Am 2017; 48:xiii. [PMID: 27886688 DOI: 10.1016/j.ocl.2016.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick M Azar
- Professor, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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