Hattrup, Steven J.

Objectives: Non-steroidal anti-inflammatory drugs (NSAID) are widely used for pain control in musculoskeletal conditions. The purpose of this study was to determine if long-term use of NSAIDs increases the incidience of rotator cuff tears. Methods: A retrospective comparative study using a national insurance database was performed. All patients who had a diagnosis of long-term NSAID use with active records in the database for at least 1 year or 2 years were identified. These patients were matched 1:1 to controls without NSAID use based on age, gender, and Elixhauser comorbidity index. Rotator cuff tendon tear rates were compared between each group. Sub-group analyses in the following age-ranges for each sex was also done: 35-45, 46-55, 56-65, 66-75. Results: A total of 499,240 patients who had a history of long-term NSAID use were evaluated. 10,180 patients sustained a rotator cuff tear compared to 7,471 control patients (2.04% vs. 1.50%, respectively), with an adjusted OR of 1.18 (95% CI: 1.14-1.21; P<0.001). Male chronic NSAID users in the 46 to 55 age range had higher rates of rotator cuff tears compared to control patients of the same demographics (OR: 1.41; 95% CI 1.30 – 1.52; P<0.001). Female chronic NSAID users in the 46 to 55 age range had higher rates of rotator cuff tears compared to control patients of the same demographics (OR: 1.40; 95% CI 1.31 – 1.49; P<0.001). Comparable results were seen in the 56-65 age range for both males and females. Further, chronic NSAID users (n=1,888; 18.5%) underwent rotator cuff repair at higher rates compared to controls (n=1,223; 16.4%). Conclusions: Long-term NSAID use significantly increases the rates of rotator cuff tendon tears at the 1-year and 2-year follow-up periods, which is particularly notable in the middle-aged population. These findings suggest that middle aged patients with long-term NSAID use may be at a higher risk for rotator cuff tendon tears.

Purpose The purpose of this investigation is to assess the incidence of rotator cuff tears in cases of calcific tendonitis and evaluate for differences in the incidences of rotator cuff tears by magnetic resonance imaging (MRI) between calcific lesions of different morphology, size, or location. Methods This single‐center study involved a retrospective chart review searching for patients from January 2010 to April 2017 with a diagnosis of calcific tendonitis of the shoulder based on review of all MRI reads done on patients with shoulder pain. Anteroposterior radiographic and MRI studies were reviewed by a musculoskeletal radiologist to assess calcific tendonitis morphology, size, distance from cuff insertion, and any rotator cuff tear. An additional radiologist evaluated calcific tendonitis size, morphology, and location to evaluate the reliability of these variables. Results In the final cohort of 318 shoulders with calcific tendonitis, the incidence of concomitant rotator cuff tears was 56%. Of all 177 tears, 164 (93%) were partial‐thickness and 13 (7%) were complete. Type III calcification morphology (cloudy with soft contour) was most frequently associated with rotator cuff tears and demonstrated an increased odds of tear by a factor of 1.8 (CI 95% 1.1‐2.9).There was no statistical difference regarding calcification size or location prognosticating rotator cuff tears or tear thickness. Intraclass correlation coefficients for calcification size, morphology, and location were 0.78, 0.30, and 0.50, respectively. Conclusions The incidence of rotator cuff tears in cases of calcific tendonitis in this cohort of patients who underwent MRI is higher than previously reported. Cloudy‐appearing calcified lesions showed a significant association with rotator cuff tears with an odds ratio of 1.8. Specific locations or sizes of calcified lesions do not appear to be reliable factors to predict concomitant rotator cuff tears. Interobserver agreement for these radiographic variables ranged from fair to substantial and prompt a cautious interpretation of these results. Level of Evidence IV Retrospective Case Series.

Background: The number of total shoulder arthroplasty (TSA) procedures performed annually is increasing as a result of an aging population and an increased access to subspecialty-trained upper extremity arthroplasty surgeons. An up-to-date analysis of the incidence of, risk factors for, and reasons for 90-day readmissions in primary anatomic TSA has yet to be performed. Purpose: To characterize 90-day readmissions on a national level. An understanding of these data will help to predict resource utilization and expenses in shoulder arthroplasty. Study Design: Case-control study; Level of evidence, 3. Methods: All adult patients undergoing elective primary TSA in 2014 who were included in the National Readmission Database were included in the analysis. Two cohorts were created according to 90-day readmission status. Multivariable analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified, and total hospital resource utilization was calculated. Results: An estimated 26,023 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. There was no difference in comorbidity burden between the cohorts. Medicare payer status (odds ratio [OR], 1.63; 95% CI, 1.00-2.65; P = .05), transfer to a skilled nurse facility (OR, 1.50; 95% CI, 1.05-2.14; P = .02), and chronic obstructive pulmonary disease (OR, 1.32; 95% CI, 1.04-1.66; P = .02) were identified as predictors of 90-day readmission. Female sex decreased odds of 90-day readmission (OR, 0.72; 95% CI, 0.59-0.87; P = .001). Ninety-day readmissions were associated with significant cost increases ( P < .001). The most common identifiable reason for related readmissions was a hardware-related complication at all time points. Conclusion: While uncommon, 90-day readmissions after primary TSA are associated with significant patient morbidity and ultimately substantial hospital costs. Truncating readmission analysis at a 30-day period will miss most arthroplasty-related hospital readmissions.

Background: There has been a surge in interest with regard to the utility of liposomal bupivacaine as part of a perioperative pain management protocol. The current study was proposed to critically assess the efficacy of liposomal bupivacaine as a local anesthetic for pain relief following orthopaedic procedures. Methods: A systematic review of prospective, randomized trials involving liposomal bupivacaine was performed using searches of the PubMed, Embase, and Cochrane databases. The primary outcomes of interest included postoperative subjective pain scores and narcotic consumption. The length of stay and postoperative mobility were reviewed as secondary outcomes. Results: Twenty-seven studies met inclusion criteria and were included for review. Twelve of 17 studies concluded that periarticular or local infiltrative liposomal bupivacaine offered no additive benefit compared with other local anesthetic injections. Peripheral nerve blocks without liposomal bupivacaine conferred more optimal pain relief and decreased narcotic consumption in the immediate postoperative period when compared with liposomal bupivacaine, with no differences thereafter. Twelve studies listed a conflict of interest related to the drug manufacturer (Pacira Pharmaceuticals). Eight of these studies (67%) demonstrated clinical superiority of liposomal bupivacaine when compared with the study control. In the 15 studies that did not show a conflict of interest, only 1 study (7%) demonstrated therapeutic superiority with use of periarticular liposomal bupivacaine when compared with a historical cohort that received no local or regional anesthesia. Conclusions: Current prospective, randomized controlled trials in patients undergoing orthopaedic surgery fail to support the routine use of liposomal bupivacaine compared with other local injectable analgesics, particularly in the setting of knee replacement surgery. We were unable to find consistent support for the potential of superior pain relief and narcotic use reduction with the use of liposomal bupivacaine. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Summary This randomised, double‐blind, placebo‐controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean ( SD ) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti‐emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

Instability after arthroplasty of the shoulder is difficult to correct surgically. Soft-tissue procedures and revision surgery using unconstrained anatomical components are associated with a high rate of failure. The purpose of this study was to determine the results of revision of an unstable anatomical shoulder arthroplasty to a reverse design prosthesis. Between 2004 and 2007, 33 unstable anatomical shoulder arthroplasties were revised to a reverse design. The mean age of the patients was 71 years (53 to 86) and their mean follow-up was 42 months (25 to 71). The mean time to revision was 26 months (4 to 164). Pain scores improved significantly (pre-operative visual analogue scale (VAS) of 7.2 (sd 1.6); most recent VAS 2.2 (sd 1.9); p = 0.001). There was a statistically significant increase in mean active forward elevation from 40.2° (sd 27.3) to 97.0° (sd 36.2) (p = 0.001). There was no significant difference in internal (p = 0.93) or external rotation (p = 0.40). Radiological findings included notching in five shoulders (15%) and heterotopic ossification of the inferior capsular region in three (9%). At the last follow-up 31 shoulders (94%) were stable. The remaining two shoulders dislocated at 2.5 weeks and three months post-operatively, respectively. According to the Neer rating system, there were 13 excellent (40%), ten satisfactory (30%) and ten unsatisfactory results (30%). Revision of hemiarthroplasty or anatomical total shoulder replacement for instability using a reverse design prosthesis gives good short-term results. Cite this article: Bone Joint J 2013;95-B:668–72.

In a review of the Mayo Clinic files, 17 biopsy-proven cases of metastatic tumors of the foot and ankle were found; 4 additional cases were considered to have metastatic disease on the basis of clinical and radiographic evidence but no histological confirmation was available. Lung, kidney, and colon were the most common sites of the primary tumors. The patients survived as long as 28 months after discovery of the metastasis. Treatment consisted of individualized combinations of orthotics, surgery, and radiotherapy to maintain mobility. In 9 of these 17 cases, no primary lesion was identified at the time the metastasis was diagnosed. Metastatic tumors of the foot present special problems in diagnosis and management.

During a 4-year period, one of the authors (M.B.W.) performed 16 nerve reconstructions by interfascicular grafting in the lower extremities of 13 patients. Three patients were excluded from the study: one was lost to follow-up and two had less than 1-year follow-up. At an average follow-up of 30 months, the results of 13 procedures in 10 patients were evaluated. Results were good after five procedures, fair after five, and poor after three. Superior results were evident with shorter graft lengths and after nerve transection injuries.

Rupture of the Achilles tendon is a relatively infrequent injury that is often missed by the initial treating physician. The diagnosis can be established on the basis of the physical examination with weakness of plantarflexion, a palpable gap in the tendon, and a positive squeeze test. Special diagnostic studies are rarely necessary. In the majority of cases, the etiologic basis for the rupture appears to be a combination of intratendon degeneration and mechanical stress. Conservative treatment of an acute rupture by immobilization with a cast provides satisfactory results. For the younger, more athletic patient, surgical repair should be considered.