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Although there is increased utilization of stemless humeral implants in anatomic total shoulder arthroplasty (TSA), there are inadequate objective metrics to evaluate bone quality sufficient for fixation. Our goals are to: (1) compare patient characteristics in patients who had plans for stemless TSA but received stemmed TSA due to intraoperative assessments and (2) propose threshold values of bone density, using the deltoid tuberosity index (DTI) and proximal humerus Hounsfield units (HU), on preoperative X-ray and computed tomography (CT) to allow for preoperative determination of adequate bone stock for stemless TSA.This is an observational study conducted at an academic institution from 2019 to 2021, including consecutive primary TSAs templated to undergo stemless TSA based on 3-dimensional CT preoperative plans. Final implant selection was determined by intraoperative assessment of bone quality. Preoperative X-ray and CT images were assessed to obtain DTI and proximal humeral bone density in HU, respectively. A receiver operating characteristic curve was used to analyze the potential of preoperative X-ray and CT to classify patients as candidates for stemless TSA.A total of 61 planned stemless TSAs were included, with 56 (91.8%) undergoing stemless TSA and 5 (8.2%) undergoing stemmed TSA after intraoperative assessment determined that the bone quality was inadequate for stemless fixation. There were no significant differences between the 2 groups in terms of gender (P = .640), body mass index (P = .296), and race (P = .580). The stem cohort was significantly older (mean age 69 ± 12 years vs. 59 ± 10 years, P = .029), had significantly lower DTI (1.45 ± 0.13 vs. 1.68 ± 0.18, P = .007), and had significantly less proximal humeral HU (-1.4 ± 17.7 vs. 78.8 ± 52.4, P = .001). The receiver operating characteristic curve for DTI had an area under the curve (AUC) of 0.86, and bone density in HU had an AUC of 0.98 in its ability to distinguish patients who underwent stemless TSA vs. short-stem TSA. A threshold cutoff of 1.41 for DTI resulted in a sensitivity of 98% and a specificity of 60%, and a cutoff value of 14.4 HU resulted in a sensitivity of 95% and a specificity of 100%.Older age, lower DTI, and less proximal humeral bone density in HU were associated with the requirement to switch from stemless to short-stem humeral fixation in primary TSA. Preoperative DTI had good ability (AUC of 0.86) and preoperative HU had excellent ability (AUC of 0.98) to categorize patients as appropriate for stemless TSA. This can help surgeons adequately plan humeral fixation using standard preoperative imaging data.

Multimodal pain regimens in total shoulder arthroplasty (TSA) now include regional anesthetic techniques. Historically, regional anesthesia for extended postoperative pain control in TSA was administered using a continuous interscalene catheter (CIC). Liposomal bupivacaine (LB) is used for its potential for similar pain control and fewer complications compared with indwelling catheters. We evaluated the efficacy of interscalene LB compared with a CIC in postoperative pain control for patients undergoing TSA.This was a retrospective cohort study at a tertiary-care academic medical center including consecutive patients undergoing primary anatomic or reverse TSA from 2016 to 2020 who received either single-shot LB or a CIC for perioperative pain control. Perioperative and outcome variables were collected. The primary outcome was postoperative pain control, whereas the secondary outcome was health care utilization.The study included 565 patients, with 242 in the CIC cohort and 323 in the LB cohort. Demographic characteristics including sex (P = .99) and race (P = .81) were similar between the cohorts. The LB cohort had significantly lower mean pain scores at 24 hours (3 vs. 2, P .001) and 36 hours (3 vs. 2, P .001) postoperatively. The CIC cohort showed a higher percentage of patients experiencing a pain score of 9 or 10 postoperatively (29% vs. 17%, P = .001), whereas the LB cohort had a significantly greater proportion of opioid-free patients (32% vs. 10%, P .001). Additionally, a greater proportion of CIC patients required opioid escalation to patient-controlled analgesia (7% vs. 2%, P = .002). The CIC cohort experienced a greater length of stay (2.3 days vs. 2.1 days, P = .01) and more 30-day emergency department visits (5% vs. 2%, P = .038).LB demonstrated lower mean pain scores at 24 and 36 hours postoperatively and lower rates of severe postoperative pain. Additionally, LB patients showed significantly higher rates of opioid-free pain regimens. These results suggest that as part of a multimodal pain regimen in primary shoulder arthroplasty, LB may provide greater reductions in pain and opioid use when compared with CICs.

To compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries.The MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sampleWe identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (Single-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured.Level III, retrospective cohort study.

BACKGROUND: Shoulder arthroplasty is increasingly performed for patients with symptoms of glenohumeral arthritis. Advanced imaging may be used to assess the integrity of the rotator cuff preoperatively because a deficient rotator cuff may be an indication for reverse shoulder arthroplasty (RSA) rather than anatomic total shoulder arthroplasty (TSA). However, the cost-effectiveness of advanced imaging in this setting has not been analyzed. QUESTIONS/PURPOSES: In this cost-effectiveness modeling study of TSA, all patients underwent history and physical examination, radiography, and CT, and we compared (1) no further advanced imaging, (2) selective MRI, (3) MRI for all, (4) selective ultrasound, and (5) ultrasound for all. METHODS: A simple chain decision model was constructed with a base-case 65-year-old patient with a 7% probability of a large-to-massive rotator cuff tear and a follow-up of 5 years. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness to pay of both USD 50,000 and 100,000 per quality-adjusted life year (QALY) used, in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. Diagnostic test sensitivity and specificity were extracted from published systematic reviews and meta-analyses, and patient utilities were obtained using the Cost-Effectiveness Analysis Registry from the Center for the Evaluation of Value and Risk in Health. Final patient states were categorized as either inappropriate or appropriate based on the actual rotator cuff integrity and type of arthroplasty performed. Additionally, to evaluate the real-world impact of intraoperative determination of rotator cuff status, a secondary analysis was performed where all patients indicated for TSA underwent intraoperative rotator cuff examination to determine appropriate implant selection. RESULTS: Selective MRI (ICER of USD 40,964) and MRI for all (ICER of USD 79,182/QALY) were the most cost-effective advanced imaging strategies at a willingness to pay (WTP) of USD 50,000/QALY gained and 100,000/QALY gained, respectively. Overall, quality-adjusted life years gained by advanced soft tissue imaging were minimal: 0.04 quality-adjusted life years gained for MRI for all. Secondary analysis accounting for the ability of the surgeon to alter the treatment plan based on intraoperative rotator cuff evaluation resulted in the no further advanced imaging strategy as the dominant strategy as it was the least costly (USD 23,038 ± 2259) and achieved the greatest health utility (0.99 ± 0.05). The sensitivity analysis found the original model was the most sensitive to the probability of a rotator cuff tear in the population, with the value of advanced imaging increasing as the prevalence increased (rotator cuff tear prevalence greater than 12% makes MRI for all cost-effective at a WTP of USD 50,000/QALY). CONCLUSION: In the case of diagnostic ambiguity based on physical exam, radiographs, and CT alone, having both TSA and RSA available in the operating room appears more cost-effective than obtaining advanced soft tissue imaging preoperatively. However, performing selective MRI to assess rotator cuff integrity to indicate RSA or TSA is cost-effective if surgical preparedness, patient expectations, and implant availability preclude the ability to switch implants intraoperatively. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

collection and preservation of private and official papers from different levels of government is an accepted and regular activity of archivists, manuscript librarians, and similar professional workers. In their endless hunt for new collections, these people employ all the arts of wit, guile, and appeals to uour sacred trust to generations yet unborn." In spite of all their rhetoric, their sophisticated approaches, and considerable publicity about their successes, plus the benefits of these conquests to the historical resources of the Nation, there is as yet a persistent, unsolved problem. That problem is to find and take into custody more of the personal papers of senior officials in government, at all levels, whose careers were wholly in the 20th century. It would be gratuitous to subject this audience to a long explanation of the reasons for the problem. Any one of you who has done any collecting at this level has heard the refrain. You have gone to the offices and homes of potential donors and have been greeted with something like the following: "I have nothing of any value among my personal papers, which have been stored in the cellar of my country place on Long Island since I left office in 1904." With the passage and ravages of time, that may indeed be an accurate description of the papers! If that quotation is not evocative enough, there is always this one: "Yes, I have a few things, and I shall consider depositing them after I have had a chance to sort them out and get rid of the junk. Just as soon as I get time I will get to it." So it goes. Men and women of brilliance, common sense, and not infrequently considerable respect for the study of history, faced with the pressure of daily business and their personal involvement as participants in the events of their times, procrastinate until they are no longer in control of their papers. Each day the archivist whose job it is to collect such papers grows a little older, a little wiser, and a little more nervous when he hears of a fire within a hundred miles of one of these unprotected, unsorted caches. The raw stuff of future histories is locked away in thousands of private files, and the one profession whose obligation is to protect and preserve it for the future is frequently, sometimes permanently, frustrated in acquiring and caring for that material. The reasons for this frustration are many and some are very individualized. At all points when dealing with these potential donors