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As the utilization and success of reverse total shoulder arthroplasty (RTSA) have continued to grow, so have its surgical indications. Despite the adoption of RTSA for the treatment of glenohumeral osteoarthritis (GHOA) with an intact rotator cuff and irreparable massive rotator cuff tears (MCTs) without arthritis, the literature remains sparse regarding the differential outcomes after RTSA among these varying indications. Thus, the purpose of this study was to examine the postoperative clinical outcomes of RTSA based on indication. A retrospective review of 2 large institutional databases was performed to identify all patients who underwent RTSA between 2015 and 2019 with minimum 2-year follow-up. Patients were stratified by indication into 3 cohorts: GHOA, rotator cuff tear arthropathy (CTA), and MCT. Baseline demographic characteristics were collected to determine differences between the 3 cohorts. Clinical outcomes were measured preoperatively and postoperatively, including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation score, and visual analog scale pain score. Multivariate linear regression was performed to determine the factors independently predictive of the postoperative ASES score. A total of 625 patients (383 with GHOA, 164 with CTA, and 78 with MCTs) with a mean follow-up period of 33.4 months were included in the analysis. Patients with GHOA had superior ASES scores (85.6 ± 15.7 vs. 76.6 ± 20.8 in CTA cohort [ P <.001] and 75.9 ± 19.9 in MCT cohort [ P <.001]), Single Assessment Numeric Evaluation scores (86 ± 20.9 vs. 76.7 ± 24.1 in CTA cohort [ P <.001] and 74.2 ± 25.3 in MCT cohort [ P <.001]), and visual analog scale pain scores (median [interquartile range], 0.0 [0.0-1.0] vs. 0.0 [0.0-2.0] in CTA cohort [ P <.001] and 0.0 [0.0-2.0] in MCT cohort [ P <.001]) postoperatively. Postoperative active forward elevation (P <.001) and improvement in active external rotation (P <.001) were greatest in the GHOA cohort compared with other indications. Multivariate linear regression demonstrated that the factors independently associated with the postoperative ASES score included a diagnosis of GHOA (β coefficient, 7.557 [ P <.001]), preoperative ASES score (β coefficient, 0.114 [ P =.009]), female sex (β coefficient, −4.476 [ P =.002]), history of surgery (β coefficient, −3.957 [ P =.018]), and postoperative complication (β coefficient, −13.550 [ P <.001]). RTSA for the treatment of GHOA generally has superior patient-reported and functional outcomes when compared with CTA and MCTs without arthritis. Long-term follow-up is needed to identify the lasting implications of such outcome differences. [ABSTRACT FROM AUTHOR]

Acromion and scapular spine fractures (ASFs) following reverse total shoulder arthroplasty (RSA) have been reported at a rate of 3.9%. The location of the fracture has been shown to be an important factor in determining the outcomes of nonoperative treatment, with medial fractures having worse outcomes than lateral fractures. As the debate between operative and nonoperative treatment continues, a more precise understanding of the location of the fracture is necessary for effective management. The purpose of this study was to use 3-dimensional computed tomography (CT) reconstruction to characterize the exact location of ASFs after RSA. A retrospective review of 2 separate institutional shoulder and elbow repositories was performed. Patients with post-RSA ASFs documented by post-fracture CT scans were included. The query identified 48 patients who sustained postoperative ASFs after RSA between July 2008 and September 2021. CT scans of patients with ASFs were segmented using Mimics software. Eight patients were excluded because of poor image quality. Each bone model was manipulated using 3-Matic Medical software to align the individual scapula with an idealized bone model to create a view of scapular fracture locations on a normalized bone model. This model was used to classify the fractures using the modified Levy classification. The study cohort consisted of 40 patients with a diagnosis of postoperative ASF after RSA. The median age at the time of surgery was 76 years (interquartile range, 73-79 years). The cohort comprised 32 women (80%) and 8 men (20%), with a median body mass index of 27.8. Only 10 patients (25%) had a previous diagnosis of osteoporosis and 6 (13%) had a diagnosis of inflammatory arthritis; 53% of patients underwent RSA owing to rotator cuff tear arthropathy. The distribution of fracture locations was similar within the cohort. However, lateral fractures were slightly more prevalent. The most common fracture location was the type I zone, with 12 fracture lines (29%). There were 11 fracture lines (26%) in the type IIa zone, 10 (23%) in the type IIb zone, 0 in the type IIc zone, and 9 (21%) in the type III zone. ASFs after RSA occur in 4 predictable clusters. No fractures appeared to distinctly cluster in the type IIc zone, which may not represent a true fracture zone. Understanding the distribution of these fractures will help to enable the future design of implants and devices to stabilize the fractures that require fixation. [ABSTRACT FROM AUTHOR]

Subscapularis management is a critical component to the success of anatomic total shoulder arthroplasty (TSA). Failure to heal the subscapularis can result in pain, weakness, loss of function, and revision. However, not all patients have poor outcomes. The purpose of this study is to compare patients with normal and dysfunctional subscapularis function following TSA in regard to (1) patient-reported outcome measures (PROMs); (2) range of motion (ROM) and strength; (3) achievement of minimal clinically important differences (MCIDs); and (4) specific functional internal rotation tasks. A retrospective review of patients treated with TSA for osteoarthritis with a minimum 2-year follow-up was performed to identify patients with subscapularis dysfunction. Subscapularis dysfunction was diagnosed when any degree of weakness in internal rotation was detected on physical examination (positive belly press sign). These patients were case controlled matched on a 1:3 ratio to patients with normal subscapularis function based on age and sex. PROMs, measured active motion, revision rates, patient satisfaction, and postoperative radiographic findings were compared. Population-specific institutional anchor-based MCID values were used to compare the improvement in PROM. Of the 668 patients included, 34 patients (5.1%) demonstrated evidence of subscapularis dysfunction. Mean follow-up for the normal subscapularis function cohort was 63.4 ± 29.7 and 58.7 ± 26.8 for the dysfunctional subscapularis cohort. Patients with subscapularis dysfunction demonstrated significantly worse postoperative Simple Shoulder Test, Single Assessment Numerical Evaluation, visual analog scale (VAS) function, VAS pain, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores with higher rates of unsatisfactory results when compared to patients with normal subscapularis function. Abduction, elevation, internal rotation ROM, along with supraspinatus and external rotation strength were also significantly worse in the dysfunctional group. Similarly, these patients were more likely to have decreased ability to perform functional internal rotation tasks, with only 47% of the patients being able to reach the small of their back compared to 85% with normal subscapularis function. Radiographically, the dysfunctional cohort demonstrated higher rates of anterior subluxation (56% vs. 7%; P <.001) and glenoid loosening (24% vs. 5%; P =.004). Similarly, revision rates were significantly higher for patients with subscapularis dysfunction (8 patients, 23.5%). Nonetheless, the dysfunctional subscapularis cohort demonstrated improvements in VAS pain (4.0 ± 3.7) and ASES (46.4 ± 35.9) scores that exceeded MCID thresholds. Patients who develop subscapularis dysfunction after TSA have significantly worse PROMs, ROM, functional tasks of internal rotation, and radiographic outcomes, as well as increased rates of revision. Although patients show worse outcomes and high revision rates compared with their normal-functioning counterparts, these patients maintained improvement above MCID thresholds for pain and function at a mean 5-year follow-up. [ABSTRACT FROM AUTHOR]

Use of standard-length anatomic total shoulder (TSA) humeral stems has been associated with high rates of medial calcar bone loss. Calcar bone loss has been attributed to stress shielding, debris-induced osteolysis, and undiagnosed infection. Short stem and canal-sparing humeral components may provide more optimal stress distribution and thus lower rates of calcar bone loss related to stress shielding. The purpose of this study is to determine whether implant length will affect the rate and severity of medial calcar resorption. A retrospective review was performed on TSA patients treated with three different-length humeral implants (canal-sparing, short, and standard-length designs). Patients were matched 1:1:1 based on both gender and age (±4 years), resulting in 40 patients per cohort. Radiographic changes in medial calcar bone were evaluated and graded on a 4-point scale, from the initial postoperative radiographs to those at 3 months, 6 months, and 12 months. The presence of any degree of medial calcar resorption demonstrated an overall rate of 73.3% at one year. At 3 months, calcar resorption was observed in 20% of the canal-sparing cohort, while the short and standard designs demonstrated resorption in 55% and 52.5%, respectively (P =.002). At 12 months, calcar resorption was seen in 65% of the canal-sparing design, while both the short and standard designs had a 77.5% rate of resorption (P =.345). The severity of calcar resorption for the canal-sparing cohort was significantly lower at all time points when compared to the short stem (3 months, P =.004; 6 months, P =.003; 12 months, P =.004) and at 3 months when compared to the standard-length stem (P =.009). Patients treated with canal-sparing TSA humeral components have significantly lower rates of early calcar resorption with less severe bone loss when compared to patients treated using short and standard-length designs. [ABSTRACT FROM AUTHOR]

Iron deficiency anemia (IDA) is associated with decreased bone mineral density and osteoporosis; however, studies investigating the effects of IDA in patients undergoing primary total shoulder arthroplasty (TSA) have not been well studied. The purpose of this study is to utilize a nationwide administrative claims database to investigate whether patients with diagnosed IDA undergoing primary TSA have higher rates of 1) in-hospital length of stay (LOS); 2) medical complications; and 3) implant-related complications. A retrospective review from 2005 to 2014 was conducted using the Medicare Standard Analytical Files. Patients with IDA undergoing primary TSA were identified and matched to controls without IDA, in a 1:5 ratio by age, sex, and medical comorbidities. Outcomes analyzed included in-hospital LOS and 90-day medical and implant-related complications. Mann–Whitney U tests compared in-hospital LOS, and multivariate logistic regression was used to calculate odds ratios (ORs) on the effects of IDA on postoperative complications after adjusting for age, sex, and Elixhauser Comorbidity Index. A total of 17,689 patients with IDA and 88,445 without IDA participated in the matched-cohort analysis, with no differences in age, gender, and comorbidities (P =.99). IDA patients were found to have significantly longer in-hospital LOS (3-days vs. 2-days, P <.0001). IDA patients were also found to have significantly higher odds of 90-day implant-related complications (OR: 1.65, P <.0001), such as periprosthetic joint infections (OR: 1.80, P <.0001) and 90-day medical complications (OR: 2.87, P <.0001), including blood transfusions (OR: 10.37, P <.0001). Patients with IDA undergoing primary TSA have significantly longer in-hospital LOS, and medical and implant-related complications. Patients were 10 times more likely to undergo a blood transfusion and 2 times more likely to have a periprosthetic fracture. [ABSTRACT FROM AUTHOR]

End-stage glenohumeral joint arthritis is common in patients with inflammatory arthritis. Reverse shoulder arthroplasty (RSA) and anatomic total shoulder arthroplasty (TSA) are both indicated in this setting. RSA is often considered based on the impacts of long-standing inflammatory arthritis including glenoid and humeral bone erosion and rotator cuff insufficiency. However, acromial and scapular spine fractures following RSA have been reported more commonly in these patients, which can have a significant impact on outcomes. Currently, no study has directly compared the efficacy and complication rates of RSA vs. TSA in patients with inflammatory arthritis. This study aimed to investigate differences in clinical outcomes and complications in patients undergoing RSA vs. TSA with glenohumeral inflammatory arthritis. We performed a retrospective review of 86 patients with inflammatory arthritis treated with primary RSA (n = 43) or TSA (n = 43) with a minimum of 2 years' follow-up. American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, visual analog scale scores for pain and function, active range of motion, and patient self-ratings of upper-extremity normality (Subjective Assessment of Normal Evaluation [SANE]) were collected preoperatively and at minimum 2-year follow-up. Radiographic classification of preoperative glenoid and humeral bone loss was performed, and postoperative complications were observed. Revision and complication details were compared. The study cohort had an average age of 72.1 years (range, 31-92 years) and average follow-up period of 51.6 months (range, 22-159 months). Both the RSA and TSA cohorts demonstrated improvements in patient-reported outcome measures and ranges of motion; however, patients treated with TSA showed a greater postoperative final Simple Shoulder Test score (P <.001), visual analog scale score for function (P =.0347), active elevation (P =.0331), active external rotation (P <.001), active internal rotation (P =.005), and Single Assessment Numeric Evaluation (SANE) score (P =.0161). Analysis of complication rates demonstrated no statistically significant difference between cohorts. Four acromial fractures occurred in the RSA group. When RSA patients who sustained acromial fractures were removed from the analysis, there were minimal differences in outcomes between the RSA and TSA cohorts. TSA in patients with inflammatory arthritis leads to improved clinical outcomes but higher early revision rates when compared with RSA. RSA outcomes are negatively impacted by a high rate of postoperative acromial fractures. [ABSTRACT FROM AUTHOR]

Postoperative fracture of the acromion is a complication uniquely more common after reverse shoulder arthroplasty (RSA) than other forms of shoulder arthroplasty. There is limited knowledge regarding the etiology of these fractures or the anatomic risk factors. The purpose of this study is to identify associations of the acromioclavicular (AC) joint and relative humeral and glenoid positioning on the occurrence of acromial fractures after RSA. A retrospective case-controlled study was performed on primary RSA patients treated by a single surgeon from September 2009 to September 2019. Patients with a postoperative acromion fracture were matched in a 3:1 ratio based on gender, indication, and age to those without a fracture and with a 2-year minimum follow-up. Preoperative and the immediate postoperative radiographs were reviewed by 2 investigators to measure critical shoulder angle, acromion-humeral interval, global lateralization, delta angle, preoperative glenoid height, and the level of inlay or onlay of the humeral stem. The morphology, width, and stigmata of osteoarthritis in the AC joint were assessed using computed tomography scans taken preoperatively. Of a total of 920 RSAs performed, 47 (5.1%) patients suffered a postoperative acromion fracture. These patients were compared with a control group of 141 patients, with a mean age of 76.4 years and similar distributions of gender and surgical indication. Patients in both groups had similar preoperative glenoid height (P =.953) and postoperative degree of inset or offset of humeral implant relative to the anatomic neck (P =.413). There were no differences in critical shoulder angle, acromion-humeral interval, global lateralization, and delta angle both preoperatively and postoperatively between the fracture and nonfracture groups. Computed tomography analysis also showed no differences in AC joint morphology (P =.760), joint space (P =.124), and stigma of osteoarthritis (P =.161). There was no relation between the features of the AC joint and the anatomic parameters of the humerus relative to the glenoid and acromion on postoperative acromion fractures after RSA. [ABSTRACT FROM AUTHOR]

Lesser tuberosity osteotomy (LTO) and subscapularis peel (Peel) are 2 common techniques used to mobilize the subscapularis tendon during anatomic total shoulder arthroplasty (TSA). The literature is inconclusive over which technique is optimal; thus, controversy exists over which technique should be performed. The purpose of this study was to compare specific functional internal rotation tasks and general outcome scores in TSA patients who received either an LTO or Peel. A retrospective review of 563 patients treated with primary TSA using either an LTO (n = 358) or Peel (n = 205) with a minimum 2-year follow-up was performed. Subjective internal rotation, active internal rotation, and specific questions related to functional internal rotation isolated from the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons functional questionnaires were reviewed. Other outcome scores including visual analog scale pain and function, Single Assessment Numerical Evaluation, SST, American Shoulder and Elbow Surgeons, and revision rates were compared between the 2 groups. The study found no difference in postoperative functional internal rotation and range of motion between LTO and Peel. Patients who received a Peel were shown to have a slightly greater improvement in the ability to perform toileting and a higher average change in SST score that did not reach clinical significance. There was no difference in the percentage of maximal improvement, revision rate, or need for revision between the 2 groups. No difference was found between the LTO and Peel techniques in regard to functional tasks of internal rotation at short-term follow-up. [ABSTRACT FROM AUTHOR]

Periprosthetic proximal humerus fractures (PPHFs) are a detrimental complication of shoulder arthroplasty, yet their characterization and management have been poorly studied. We aimed to determine the intra- and interobserver reliability of 4 previously described PPHF classification systems to evaluate which classifications are the most consistent. We retrospectively reviewed 32 patients (34 fractures) that were diagnosed with a PPHF between 1990 and 2017. Patient electronic medical records and research electronic data capture (REDCap) were used for data collection. Post-PPHF radiographs in multiple views for all 34 cases were organized into an encrypted, randomized Qualtrics survey. Four blinded fellowship-trained shoulder and elbow surgeons graded each fracture using previously reported classification systems by (1) Wright and Cofield (1995), (2) Campbell et al (1998), (3) Worland et al (1999), and (4) Groh et al (2008), along with selecting a preferred management strategy for each fracture. Grading was performed twice with at least 2 weeks between each randomized attempt. Intraobserver reliability was calculated as an unweighted Cohen kappa coefficient between attempt 1 and attempt 2 for each surgeon. Interobserver reliability and agreeability between surgeons' preferred management strategies were calculated for each classification system using Fleiss kappa coefficient. The kappa coefficients were interpreted using the Landis and Koch criteria. The average intraobserver kappa coefficient for each classification was as follows: Wright and Cofield = 0.703, Campbell = 0.527, Worland = 0.637, Groh = 0.699. The overall Fleiss kappa coefficient for interobserver reliability for each classification was as follows: Wright and Cofield = 0.583, Campbell = 0.488, Worland = 0.496, Groh = 0.483. Interobserver reliability was significantly greater with the Wright and Cofield classification. Using Landis and Koch criteria, all the classification systems assessed demonstrated only moderate interobserver agreement. Additionally, the mean interobserver agreeability kappa coefficient for preferred management strategy was 0.490, indicating only moderate interobserver agreement. There is only moderate interobserver reliability among the 4 PPHF classification systems and the preferred management strategy for the fractures assessed. Of the 4 PPHF classification systems, Wright and Cofield demonstrated the greatest mean intraobserver reliability and overall interobserver reliability. Our study highlights a need for the development of a PPHF classification system that can achieve high intra- and interobserver reliability and that can allow for a standardized treatment algorithm in the management of PPHFs. [ABSTRACT FROM AUTHOR]

Acromion/scapular spine fractures (ASFs) remain a challenging complication following reverse shoulder arthroplasty (RSA). Historically, nonoperative management has been the treatment of choice, with variable results. The purpose of this study is to report on both clinical and radiographic outcomes of nonoperative treatment. A new subclassification of Levy type II acromion fractures will be proposed, and outcomes will be evaluated in relation to the modified Levy classification. Forty-four patients diagnosed with ASF following RSA were matched 1:3 to a control group based on gender, age, and preoperative function. All ASF patients were treated nonoperatively. Patient-reported outcome measures, consisting of American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test, Single Assessment Numerical Evaluation, visual analog scale pain and function scores, satisfaction, and active range of motion were gathered preoperatively and at the most recent follow-up. Outcomes were stratified based on fracture type. Radiographic findings including fracture union, scapular rotation, progressive notching, and osteolysis were reviewed from latest follow-up and compared with initial postoperative films. ASFs were identified at a median of 2 months following RSA (8 type I; 22 type II; 14 type III), followed for a median of 37 months and compared to 108 matched controls. Patients with ASF had inferior clinical outcomes with a higher rate of dissatisfaction (27.8%) when compared to controls. Lateral fracture subtypes (I and IIA) were similar to controls and had little impact on outcomes. However, medial fracture subtypes (type IIB, IIC, and III) demonstrated inferior outcomes when compared to controls, with type III fracture patients demonstrating no improvement from baseline. The overall nonunion rate was 61.4%, with high rates of scapular rotation and osteolysis in medial fracture subtypes. Nonunion was associated with a higher incidence of secondary radiographic findings, including scapular rotation, progressive notching, and osteolysis. Results of nonoperative treatment of ASF following RSA differs based on fracture location. Fractures that occur at or medial to the glenoid face (IIB, IIC, III) demonstrate high rates of unsatisfactory results and worse clinical outcomes. Concerning radiographic findings of scapular tilt, progressive scapular notching and osteolysis were seen at a higher rate with medial fracture types and fracture nonunions. [ABSTRACT FROM AUTHOR]

Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial owing to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons to determine areas of consensus regarding treatment options for a variety of MIRCTs. A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the 6 included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either preferred treatment, acceptable treatment, not acceptable/contraindicated, or unsure/no opinion. Patient scenarios were declared to achieve consensus for the preferred and not acceptable/contraindicated categories when at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the acceptable treatment category, defined by an acceptable treatment or preferred treatment response. Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an acceptable treatment, with RSA selected for 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related to partial repair with graft augmentation. This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs. [ABSTRACT FROM AUTHOR]

Prosthetic joint infections (PJIs) following shoulder arthroplasty are a major source of morbidity and are most commonly caused by Cutibacterium acnes , a bacteria found concentrated in the dermis. Skin preparation using hydrogen peroxide has been shown to reduce positive cultures; however, direct application to the dermis has not been investigated. The purpose of this study is to determine whether the application of hydrogen peroxide to the dermis affects the incidence of positive C acnes cultures. A prospective, randomized controlled trial of patients undergoing primary shoulder arthroplasty by a single fellowship-trained surgeon was performed between February and November 2020. Enrolled patients were randomized to either receive standard skin preparation and antibiotic prophylaxis with or without an additional application of hydrogen peroxide to the dermis following incision. Culture samples were taken from the skin, dermis, glenohumeral joint, and air. Laboratory personnel and patients were blinded to randomization, and all cultures were held for 14 days. Culture positivity rate along with culture site, day of culture positivity, and bacterial abundance of positive cultures were analyzed. Stratified analysis by gender and age of ≤69 years was also performed. Sixty patients undergoing primary arthroplasty were randomized. The group receiving hydrogen peroxide (n = 30) and the control group (n = 30) were similar in age (71.1 ± 7.1 vs. 73.4 ± 9.8; P =.30), body mass index (29.4 ± 5.7 vs. 28.5 ± 6.0; P =.57), gender (P =.64), hand dominance (P =.65), and surgery type (P =.90). The overall rate of at least 1 positive culture was 18%. All positive cultures were C acnes. The positive culture rate in the hydrogen peroxide (20%) and control group were similar (16%; P >.99). There were no positive glenohumeral joint cultures and no wound complications. There was no significance difference in the culture site, day of culture positivity, and bacterial abundance. Stratification analysis by gender and age also demonstrated similar rates of C acnes between study groups. Standard skin preparation and antibiotic prophylaxis results in an overall low rate of skin and dermis culture positivity. The use of hydrogen peroxide after initial incision did not significantly alter the rate of positive C acnes cultures during shoulder arthroplasty and did not increase wound complications. [ABSTRACT FROM AUTHOR]

Early discharge has been a target of cost-control efforts given the growing demand for joint replacement surgery. The Outpatient Arthroplasty Risk Assessment (OARA) score, a medically based risk-assessment score, has shown high predictive ability in achieving safe early discharge following outpatient lower-extremity arthroplasty using a score threshold initially set at ≤59 points but more recently adapted to ≤79 points. However, no study has been performed using the OARA tool for shoulder replacement, which has been shown to have lower associated medical risks than lower-extremity arthroplasty. The purpose of this study was to determine the OARA score threshold for same-day discharge (SDD) following shoulder arthroplasty and evaluate its effectiveness in selecting patients for SDD. We hypothesized that the OARA score threshold for shoulder arthroplasty would be higher than that for lower-extremity arthroplasty. We performed a retrospective review of 422 patients who underwent primary anatomic or reverse shoulder arthroplasty between April 2018 and October 2019 performed by a single surgeon. As standard practice, all patients were counseled preoperatively regarding SDD and given the choice to stay overnight. Medical history, length of stay, and 90-day readmissions were obtained from medical records. Analysis of variance testing and screening test characteristics compared the performance of the OARA score vs. the American Society of Anesthesiologists Physical Status (ASA-PS) class and a previously published OARA score threshold used to define a low risk of outpatient lower-extremity arthroplasty. A preoperative OARA score cutoff of ≤110 points demonstrated a sensitivity of 98.0% for identifying patients with SDD after shoulder arthroplasty, compared with 66.7% using the hip and knee OARA score threshold of ≤59 points (P <.0001) and 80.4% using ASA-PS class ≤ 2 (P =.008). OARA scores ≤ 110 points also showed a negative predictive value of 98.9% and a false-negative rate of 2.0% but remained incomprehensive with a specificity of 24.0% (P <.0001). Analysis of variance demonstrated that mean OARA scores increased significantly with length of stay (P =.001) compared with ASA-PS classes (P =.82). Patients with OARA scores ≤ 110 points were also 2.5 times less likely to have 90-day emergency department visits (P =.04) than those with OARA scores > 110 points. There was no difference in 30- and 90-day readmission rates for patients with OARA scores ≤ 59 points, OARA scores ≤ 110 points, and ASA-PS classes ≤ 2. Our study suggests that a preoperative OARA score threshold of ≤110 points is effective and conservative in screening patients for SDD following shoulder arthroplasty, with low rates of 90-day emergency department visits and readmissions. This threshold is a useful screening tool to identify patients who are not good candidates for SDD. [ABSTRACT FROM AUTHOR]

Despite the growing recognition of acromial stress fractures (ASFs) after reverse total shoulder arthroplasty (RTSA), most of the current data are derived from single-center studies with limited generalizability. This multicenter study investigated the incidence of ASFs after RTSA and identified preoperative patient characteristics associated with their occurrence. Using 2 institutional registries from different regions of the United States, we identified 1479 patients undergoing either primary or revision RTSA between 2013 and 2018 with minimum 3-month follow-up. ASFs were defined as radiographic evidence of an acromial or scapular spine fracture with clinical symptoms (eg, tenderness over the acromion or scapular spine). Multivariable logistic regression was performed to identify preoperative patient factors associated with the development of ASFs. Overall, 54 (3.7%) patients were diagnosed with an ASF after RTSA. Patient-related factors independently associated with the development of an ASF included female sex (odds ratio [OR], 2.21 reference: male; 95% confidence interval [CI], 1.03-4.74; P <.05), rheumatoid arthritis (OR, 2.30; 95% CI, 1.02-5.16; P <.05), osteoporosis (OR, 2.55; 95% CI, 1.24-5.21; P <.05), a diagnosis of degenerative joint disease with rotator cuff tear (OR, 4.74 reference: degenerative joint disease without rotator cuff tear; 95% CI, 1.84-12.23; P <.05), and fracture malunion/nonunion (OR, 5.21; 95% CI, 1.20-22.76; P <.05). The non-negligible percentage of ASFs that occur after RTSA is associated with the diagnoses of rotator cuff dysfunction and chronic fracture sequelae in female patients with suboptimal bone health. This information can be used to counsel patients and set expectations about potential setbacks in recovery. [ABSTRACT FROM AUTHOR]

Profound improvements in function have been described in patients following reverse total shoulder arthroplasty (RSA). Previous studies have demonstrated young age, high preoperative function, and neurologic dysfunction to be predictors of poor functional improvement. However, no study to date has focused on patients electing to undergo RSA for function more than pain. The purpose of this study was to compare the outcomes of RSA in patients with minimal preoperative pain with those in patients who have higher baseline pain. We performed a retrospective matched-cohort study of RSA patients treated by a single surgeon with a minimum of 2 years' follow-up. Patients with at least moderate baseline pain (function-pain group), predefined by existing literature as a visual analog scale pain score > 3, were matched 3:1 based on sex, indication, and age to patients with minimal pain (function group), defined as a visual analog scale score ≤ 3. Patient-reported outcome measures, active range of motion, and overall satisfaction were compared. The percentage of maximal improvement in outcomes and the proportion of patients exceeding the established threshold that predicts excellent satisfaction were also compared. A total of 260 patients (195 in function-pain group and 65 in function group) were selected for matched analysis with a similar sex distribution; the mean age was 73.1 years, and the mean follow-up period was 50 months. No differences in most recent postoperative function, overall improvement in functional scores, and active motion were found between patients in the 2 groups (P >.05). However, pain scores improved only in patients with at least moderate baseline pain (P <.0001). Patient satisfaction was significantly different (P =.035), as 10.8% of patients who elected to undergo RSA for function were unsatisfied. The function cohort also had worse percentage of maximal Simple Shoulder Test score (P =.034) and American Shoulder and Elbow Surgeons score (P <.0001) improvement, and a lower proportion of these patients exceeded the threshold for the percentage of maximal improvement that predicts an "excellent" outcome (P <.0001). RSA patients with minimal preoperative pain achieve significant improvements in function and motion similar to those who choose to undergo RSA for both pain and function, but they are less satisfied and are less likely to achieve an excellent outcome. Patients electing to proceed with RSA with minimal pain should be counseled accordingly. [ABSTRACT FROM AUTHOR]

A critical step in reverse shoulder arthroplasty (RSA) is glenoid baseplate fixation. In cases of glenoid bone loss, use of the anatomic glenoid center line may not provide sufficient bone support for fixation. Anteversion along the alternative center line is a described method for achieving baseplate fixation in these cases. However, concern remains regarding negative consequences in functional outcomes and complications. The purpose of this study was to compare the outcomes of RSA using the anatomic or alternative center line. We performed a retrospective case-controlled study of patients who underwent RSA between November 2006 and August 2017, performed by a single surgeon, with a minimum of 2 years' follow-up. Patients treated with the anatomic center-line technique for baseplate fixation were matched 3:1 based on sex, indication for surgery, and age with patients treated with the alternative center-line technique. Patient-reported outcome measures (PROMs), active range of motion, and the ability to perform functional tasks of internal rotation were compared. Evaluations of the most recently obtained radiographs focused on acromial fractures, scapular notching, and glenoid loosening. A total of 88 patients (66 in anatomic center-line group and 22 in alternative group) participated in the matched analysis, with a mean age of 74.2 years (range, 58-89 years) and mean follow-up period of 53 months (range, 24-130 months). At the final follow-up, we found no significant differences in PROMs, including the Simple Shoulder Test score (P =.829), American Shoulder and Elbow Surgeons score (P =.601), visual analog scale pain score (P =.068), and Single Assessment Numeric Evaluation score (P =.674). Moreover, both the overall improvements in these PROMs and all active motions and functional tasks of internal rotation were not different. No radiographic evidence of glenoid loosening was found in either group, and 2 patients in each cohort (3% of the anatomic group and 9% of the alternative group) experienced an acromial fracture. Low-grade scapular notching developed in 15.2% of the anatomic group and 18.2% of the alternative center line group (P =.736). The alternative center line can be used for baseplate fixation in the setting of glenoid bone loss and leads to similar patient outcomes and functional tasks of internal rotation, as well as a low rate of complications, compared with the anatomic center line following RSA. [ABSTRACT FROM AUTHOR]

The incidence of medial calcar resorption has been shown to be common after uncemented total shoulder arthroplasty (TSA). With etiologies including stress shielding, debris-induced osteolysis, and infection, the clinical impact of medial calcar resorption has not been specifically examined. The purpose of this study was to determine whether resorption is associated with inferior outcomes or higher rates of radiographic loosening in TSA patients. We conducted a retrospective review of TSA patients with minimum 2-year clinical follow-up. Patient-reported and functional outcome measures were recorded preoperatively and postoperatively. Postoperative radiographs were evaluated for glenoid and humeral component loosening. A new calcar resorption grading system was introduced to quantify the degree of resorption and assess the progression. A total of 171 patients met the inclusion criteria, with average clinical and radiographic follow-up periods of 50 and 46 months, respectively. Calcar resorption was identified in 110 patients (64.3%). No significant overall differences were observed between the patients with and without calcar resorption. Subgroup analysis showed that patients with grade 3 resorption had a higher incidence of glenoid radiolucencies (50%, P =.001) and patients with a progression from grade 1 to grade 3 had higher incidences of glenoid (50%, P =.003) and humeral (9%, P =.039) radiolucencies. Medial calcar resorption following TSA with a standard-length press-fit humeral component is common. Overall, no differences in patient-reported outcome measures or radiographic loosening were found compared with patients without calcar resorption. However, grade 3 calcar resorption and more dramatic progression of resorption should raise the suspicion of prosthetic loosening. [ABSTRACT FROM AUTHOR]

Ideal management of severe glenoid retroversion during anatomic total shoulder arthroplasty (TSA) remains controversial, as previous reports have suggested that severe retroversion may negatively impact clinical outcomes. The purpose of this study was to evaluate the impact of severe glenoid retroversion on clinical and radiographic TSA outcomes using a standard glenoid component, as well as to compare outcomes among patients with less severe retroversion. A case-control study was performed comparing 40 patients treated with TSA with more than 20° of glenoid retroversion preoperatively (average follow-up, 53 months) vs. a matched cohort of 80 patients with less than 20° of retroversion (average follow-up, 49 months). In all patients, the surgical technique, implant design, and postoperative rehabilitation protocol were identical. Patients were matched based on sex, age, indication, and prosthetic size. Comparisons were made regarding patient-reported outcome measures (PROMs), motion, postoperative radiographic loosening, and the presence of medial calcar resorption. Preoperatively, both groups demonstrated similar PROMs and measured motion, except for preoperative Single Assessment Numeric Evaluation scores and American Shoulder and Elbow Surgeons total scores, which were higher for the severe retroversion group (44.4 vs. 31.3 [ P =.012] and 34.9 vs. 29.4 [ P =.048], respectively). Postoperative PROMs and motion were also similar between the 2 cohorts. No significant differences were observed for postoperative radiographic findings. Medial calcar resorption was identified in 74 patients (61.7%). Calcar resorption and individual resorption grades were not found to differ significantly. At midterm follow-up, preoperative severe glenoid retroversion does not appear to influence clinical or radiographic outcomes of TSA using a standard glenoid component. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine whether thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) score and American Shoulder and Elbow Surgeons (ASES) score exist that predict excellent patient satisfaction after reverse shoulder arthroplasty (RSA). Patients undergoing RSA with a single implant system were evaluated preoperatively and at a minimum 2-year follow-up. Receiver operating characteristic curve analysis determined thresholds to predict excellent patient satisfaction by evaluating the percentage of maximal improvement for SST and ASES scores. Preoperative factors were analyzed as independent predictors for achieving SST and ASES score thresholds. There were 198 (SST score) and 196 (ASES score) patients who met inclusion criteria. For SST and ASES scores, receiver operating characteristic curve analysis identified 61.3% (P <.001) and 68.2% (P <.001) maximal improvement as the threshold for maximal predictability of excellent satisfaction, respectively. Significant positive correlation between the percentage of maximum score achieved and excellent patient satisfaction for both groups was found (r = 0.440 [ P <.001] for SST score; r = 0.417 [ P <.001] for ASES score). Surgery on the dominant hand, greater baseline visual analog scale pain score, and cuff arthropathy were independent predictors for achieving the SST and ASES score threshold. Thresholds for the achievement of excellent satisfaction after RSA were 61.3% of maximal SST score improvement and 68.3% of maximal ASES score improvement. Independent predictors of achieving these thresholds were dominant-sided surgery and higher baseline visual analog scale pain scores for the SST score and rotator cuff arthropathy for the ASES score. [ABSTRACT FROM AUTHOR]

Background Anatomic total shoulder arthroplasty (TSA) provides reliable, reproducible, and durable results; however, outcomes of many modern TSA systems are lacking. The present study reports early to midterm results of a third-generation TSA system using a traditional-length press-fit humeral stem and cemented glenoid. Methods A retrospective review was conducted of TSA patients with minimum 2-year clinical follow-up. Patient-reported outcome measures, including Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, visual analog scale for pain, 12-Item Short Form Health Survey, and Single Assessment Numeric Evaluation, as well as measured active motion (forward elevation, external and internal rotation), were recorded at preoperative and postoperative intervals. Preoperative midglenoid axial computed tomography scans were used to evaluate eccentric glenoid wear, humeral head subluxation, and glenoid version. Most recent postoperative radiographs were used to evaluate glenoid loosening, humeral loosening, lesser tuberosity union, and medial calcar resorption. Patient satisfaction at final follow-up was reported as excellent, good, satisfied, or unsatisfied. Results There were 267 patients who met inclusion criteria, with a mean age of 70.9 years and mean clinical follow-up of 47 months. Average glenoid retroversion was 9.7°, and 27% had eccentric glenoid wear. At final follow-up, measured motion and nearly all patient-reported outcome measures showed significant improvements, with 75.6% of patients rating their satisfaction as excellent. No patient was considered "at risk" for humeral stem loosening. Glenoid radiolucencies were seen in 13.5% of shoulders (7 gross loosening). Five patients were revised to reverse TSA. Conclusion TSA using a third-generation traditional-length press-fit stem and cemented glenoid provides excellent early to midterm outcomes with low rates of loosening and high rates of excellent satisfaction. [ABSTRACT FROM AUTHOR]

Background Press-fit humeral fixation for reverse shoulder arthroplasty (RSA) has been shown to have loosening rates and outcomes similar to a cemented technique; however, increased value has not been reported. The purpose of this study was to determine whether the press-fit technique could improve the value of RSA using the procedure value index (PVI). Methods Primary RSA patients with complete hospitalization cost data, preoperative and minimum 2-year postoperative Simple Shoulder Test (SST) scores, and postoperative satisfaction were included. The PVI was calculated as improvement in the SST score (in units of minimal clinically important difference) divided by total cost and normalized. Itemized cost data were obtained from hospital financial records and categorized. Radiographic complications, infections, and revisions were noted. Comparisons were made between the press-fit and cemented RSA cohorts. Results A total of 176 primary RSA patients (83 cemented and 93 press fit) met the inclusion criteria (mean follow-up period, 44.6 months). Surgical indications (except failed rotator cuff repair), baseline SST scores, and demographic characteristics were similar. The calculated minimal clinically important difference for the SST score was 3.98. The average PVI was significantly greater in the press-fit cohort (1.51 vs 1.03, P <.001), representing a 47% difference. SST score improvement was not significantly different (P =.23). However, total hospitalization costs were significantly lower for the press-fit cohort ($10,048.89 vs $13,601.14; P <.001). Conclusion Use of a press-fit technique led to a 47% increase in value over a cemented technique. This appeared to be a function of decreased total costs rather than increased outcome scores. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to determine whether thresholds in the percentage of maximal improvement in the Simple Shoulder Test (SST) or American Shoulder and Elbow Surgeons (ASES) score exist for predicting "excellent" patient satisfaction after total shoulder arthroplasty (TSA). Methods A retrospective query identified patients who underwent TSA with a minimum of 2 years' follow-up. Preoperative and postoperative SST and ASES scores and postoperative patient satisfaction were recorded. Receiver operating characteristic curve analyses were performed to determine thresholds in the percentage of maximal improvement in the SST and ASES scores that predict excellent satisfaction. Univariate and multivariate analyses determined preoperative factors that predicted achievement of these thresholds. Results A total of 301 and 319 patients had at least 2 years' follow-up for the SST score and ASES score, respectively. We determined 72.1% of maximal improvement in the SST score to be the threshold for excellent satisfaction (area under the curve, 0.777; 95% confidence interval, 0.712-0.841; P <.001). We determined 75.6% of maximal improvement in the ASES score to be the threshold for excellent satisfaction (area under the curve, 0.799; 95% confidence interval, 0.743-0.856; P <.001). Both groups showed significant positive correlations between percentage of maximal score achieved and excellent satisfaction (r = 0.396 for SST score [ P <.001] and r = 0.325 for ASES score [ P <.001]). Younger age was the only independent predictor for achieving the SST score threshold. No independent predictors existed for the ASES score threshold. Conclusion Achievement of 72.1% of maximal SST score improvement and achievement of 75.6% of maximal ASES score improvement represent thresholds for achievement of excellent satisfaction after TSA. Most preoperative factors did not have an impact on the likelihood of achieving these thresholds. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to introduce the procedure value index (PVI) and apply this value instrument to shoulder arthroplasty. The PVI uses the value equation in units of minimal clinically important difference (MCID) to provide an objective system of quantifying value-driven care. Secondarily, we describe the PVI for both primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) to highlight value differences between these patient populations. Methods Patients undergoing primary shoulder arthroplasty with minimum 2-year follow-up were identified retrospectively. MCIDs were determined for the Simple Shoulder Test (SST) score, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, and Single Assessment Numeric Evaluation (SANE) score. Cost data were reported as total hospitalization costs, total charges, and total reimbursements. The PVI was calculated as the ratio of outcome improvement in units of MCID over the cost of care. Mean PVIs for TSA and RSA were compared. Results Five hundred thirty-four patients met the inclusion criteria. MCIDs for the SST, ASES, VAS pain, and SANE scores were 3.61, 29.49, 3.28, and 37.05, respectively. With the exception of the ASES score, improvements in units of MCID were not different between TSA and RSA. However, total hospitalization costs and charges were significantly higher for RSA (P <.001). PVIs based on total hospitalization costs and total charges for the SST, ASES, and VAS pain scores were significantly greater for TSA (P <.05). No other PVI was significantly different. Conclusions The PVI was greater for TSA when total hospitalization costs and total charges were considered. The PVI helps highlight value differences in shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to delineate the time taken to achieve maximum improvement (plateau of recovery) and the degree of recovery observed at various time points (speed of recovery) for pain and function after arthroscopic rotator cuff repair. Methods An institutional shoulder surgery registry query identified 627 patients who underwent arthroscopic rotator cuff repair between 2006 and 2015. Measured range of motion, patient satisfaction, and patient-reported outcome measures were analyzed for preoperative, 3-month, 6-month, 1-year, and 2-year intervals. Subgroup analysis was performed on the basis of tear size by retraction grade and number of anchors used. Results As an entire group, the plateau of maximum recovery for pain, function, and motion occurred at 1 year. Satisfaction with surgery was >96% at all time points. At 3 months, 74% of improvement in pain and 45% to 58% of functional improvement were realized. However, only 22% of elevation improvement was achieved ( P  < .001). At 6 months, 89% of improvement in pain, 81% to 88% of functional improvement, and 78% of elevation improvement were achieved ( P  < .001). Larger tears had a slower speed of recovery for Single Assessment Numeric Evaluation scores, forward elevation, and external rotation. Smaller tears had higher motion and functional scores across all time points. Tear size did not influence pain levels. Conclusion The plateau of maximum recovery after rotator cuff repair occurred at 1 year with high satisfaction rates at all time points. At 3 months, approximately 75% of pain relief and 50% of functional recovery can be expected. Larger tears have a slower speed of recovery. [ABSTRACT FROM AUTHOR]

Background Locked anterior shoulder (LAS) with static instability and anterior glenoid bone loss is challenging in the elderly population. Reverse shoulder arthroplasty (RSA) has been employed in treating these patients. No study has compared RSA for LAS with classically indicated RSA. Methods A retrospective case-control study of patients treated with RSA for LAS with glenoid bone loss and static instability was performed using matched controls treated with primary RSA for classic indications. Twenty-four cases and 48 controls were evaluated. Average follow-up was 25.5 months, and median age was 76 years. Motion, outcome assessments, and postoperative radiographs were compared. Results Preoperatively, LAS had significantly less rotation and lower baseline outcome scores. Glenoid bone grafting was more common ( P  = .05) in the control group (26%) than in the LAS group (6.3%). Larger glenospheres were used more often ( P  = .001) in the LAS group (75%) than in the control group (29%). Both groups demonstrated significant improvements in pain, function, and outcome scores. Postoperatively, the control group had significantly better elevation and functional outcome scores. With the exception of flexion and Simple Shoulder Test score, effectiveness of treatment was similar between groups. Postoperative acromion stress fractures were seen in 21% of LAS patients and 9% of controls ( P  = .023) with a predominance of type 3 fractures in LAS. Two LAS patients remained dislocated. Conclusion Patients with LAS treated with RSA can anticipate improvements in pain and function by use of larger glenospheres, often without the need for glenoid bone grafting. Worse postoperative motion and function and a higher incidence of acromion stress fracture may be expected. [ABSTRACT FROM AUTHOR]

Background Utilization of total elbow arthroplasty (TEA) has reportedly increased in recent years. Since the introduction of disease-modifying antirheumatic drugs, there has been a reported decline in its use among rheumatoid patients; yet, the shift in indications for TEA remains unclear. This study evaluated trends in TEA utilization from 2005 to 2012 by analyzing the most common indications within the population of Medicare patients. Methods We performed a retrospective review of a comprehensive Medicare patient population database using the PearlDiver supercomputer (Warsaw, IN, USA) for TEA utilization in rheumatoid arthritis (RA), osteoarthritis (OA), distal humerus fracture (DHF), post-traumatic arthritis (PTA), and distal humerus nonunion (DHNU). Total reported incidence of office visits and TEA utilization for each indication was reviewed. Results Utilization of TEA remained unchanged ( P  = .9530) despite a growing Medicare population ( P  = .0201). There was a significant decline in annual TEA utilization for RA ( P  = .002) and DHNU ( P  = .003). No significant change was found in TEA use for DHF, OA, and PTA. A significant increase was noted in total visits coded for OA, RA, and DHNU ( P  < .001). A significant, strong negative correlation was found for office visit coding and TEA use in RA ( r  = −0.850; P  = .008) and DHNU ( r  = −0.902; P  = .002). Conclusion From 2005 to 2012, utilization rates of TEA in the Medicare population remained constant. Despite increases in office visits, TEA use for RA and DHNU has declined, likely secondary to improved medical management with disease-modifying antirheumatic drugs and the surgeon's comfort with improved fracture fixation options. [ABSTRACT FROM AUTHOR]

Background Radial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomic monopolar press-fit radial head system commonly used for the treatment of radial head fractures. Methods A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with a press-fit anatomically designed RHA between November 2007 and April 2014. The most recent radiographs were evaluated for loosening, stress shielding, and instability. Postoperative motion and outcomes were reported at most recent follow-up. Results At an average follow-up of 30 months, 6 of the 15 patients (40%) demonstrated radiographic loosening. Six of the 9 patients (67%) without loosening demonstrated stress shielding (average, 6 mm). Functional outcome scores included a mean American Shoulder and Elbow Surgeons score of 70, Mayo Elbow Performance Score of 85, visual analog scale score for pain of 2, visual analog scale score for function of 7, and Single Assessment Numeric Evaluation score of 75. Average flexion-extension arc was 14° to 138°, and average pronation-supination was 75° to 74°. All 6 of the patients with radiographic loosening had undergone RHA with an associated ligamentous injury repair. Satisfaction among patients was high as no patient reported an unsatisfactory outcome. Conclusions The use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation because of a high rate of implant loosening observed. [ABSTRACT FROM AUTHOR]

Background Surgical management of proximal humeral fractures has reportedly increased in recent years. Much of this growth relates to a growing elderly population, together with the introduction of modern implants, such as locking plates and, recently, introduction of reverse shoulder arthroplasty (RSA). This study evaluated trends in surgical management of proximal humeral fractures from 2009 to 2012 by analyzing the use of hemiarthroplasty (HA), RSA, and osteosynthesis (open reduction with internal fixation [ORIF]) within the Medicare patient population. Methods We retrospectively reviewed a comprehensive Medicare patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for proximal humeral fractures treated with HA, RSA, or ORIF. Total use, annual utilization rates, age, and gender were investigated. Results Within the study period, 32,150 proximal humeral fractures were treated operatively, with no significant change in annual volume ( P = .119). The percentage of fractures treated surgically decreased significantly from 16.2% to 13.9% ( P < .001). The utilization rate decreased significantly for HA from 52% to 39% ( P < .001), increased significantly for RSA from 11% to 28% ( P < .001), and did not change significantly for ORIF ( P = .164). The utilization rate of RSA nearly tripled for patients older than 65 years (11% to 29%) and doubled for patients younger than 65 (6% to 12%). Conclusion From 2009 to 2012, utilization rates of ORIF remained fairly constant. HA remains the most commonly used surgical treatment for proximal humeral fractures in the Medicare population, but its use has declined significantly. This decline has been offset by a corresponding increase in RSA. [ABSTRACT FROM AUTHOR]

Background Total shoulder arthroplasty (TSA) has repeatedly been shown to be an effective and durable treatment option for end-stage arthritis with good long-term survivorship. Whereas pain relief is typically the primary goal, improvements in range of motion are typically expected as well. The factors that influence postoperative motion have not been well characterized. The purpose of the study was to examine the factors that influence ultimate postoperative motion after TSA. Methods A retrospective review was conducted of prospectively collected data of 230 patients with minimum 1-year follow-up after TSA for end-stage arthropathy with an intact rotator cuff. Analysis was focused on factors that may correlate with postoperative measured forward flexion, abduction, external rotation, and internal rotation. Included in this analysis was perception of motion, age, body mass index (BMI), comorbidities (smoking, diabetes, osteoporosis, hypercholesterolemia, inflammatory arthritis, and thyroid disease), and number of comorbidities. Results Preoperative motion in all directions was predictive of postoperative motion for forward flexion ( R = 0.235; P < .001), abduction ( R = 0.363; P < .001), external rotation ( R = 0.325; P < .001), and internal rotation ( R = 0.213; P = .002). BMI and diabetes both negatively correlated with internal rotation ( R = −0.134, P = .40 and R = −0.196, P = .003, respectively). Individual and total number of comorbidities were not predictive of postoperative motion. The patient's perception of preoperative motion also did not correlate with postoperative motion. Conclusions Preoperative range of motion before TSA is most predictive of final motion achieved. Individual and total number of comorbidities are not predictive of postoperative motion. Patients with high diabetes and increased BMI have limited postoperative internal rotation. [ABSTRACT FROM AUTHOR]

Background Recovery of functional internal rotation after primary shoulder arthroplasty is essential to perform many important activities of daily living. Functional internal rotation is typically reported as it relates to clinical examination findings of motion (posterior reach) and lift-off or belly-press tests. A more detailed evaluation of functional recovery of internal rotation after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) is needed. Methods A retrospective review of patients treated with primary TSA (n = 132) and RSA (n = 91) with a minimum 2-year follow-up was performed. Subanalysis of revision RSA (n = 24) and primary RSA was performed. Active range of motion, subjective internal rotation motion, manual internal rotation strength, and specific questions related to internal rotation function isolated from the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) functional questionnaires were reviewed. Results Compared with RSA, TSA patients could more likely reach the small of the back (SST) and wash the back/fasten bra (ASES). Active internal rotation motion, SST score, ASES score, and subjective internal rotation were greater after TSA. No significant difference was observed with respect to managing toileting between cohorts. Revision RSA patients were less likely to be able to wash the back/fasten bra (ASES) and easily manage toileting (ASES) compared with primary RSA patients. Conclusion Primary anatomic shoulder arthroplasty yields greater functional internal rotation than does primary RSA, with either procedure being effective at managing toileting. Patient education regarding activities of daily living related to internal rotation can be predicted. [ABSTRACT FROM AUTHOR]

Background Cerebral oximetry (rSO 2 ) has emerged as an important tool for monitoring of cerebral perfusion during surgery. High rates of cerebral desaturation events (CDEs) have been reported during surgery in the beach chair position. However, correlations have not been made with blood pressure measured at the cerebral level. The purpose of this study was to examine the correlations between brachial noninvasive blood pressure (NIBP) and estimated temporal mean arterial pressure (eTMAP) during CDEs in the beach chair position. Methods Fifty-seven patients underwent elective shoulder surgery in the beach chair position. Values for eTMAP, NIBP, and rSO 2 were recorded supine (0°) after induction and when a CDE occurred in the 70° beach chair position. Twenty-six patients experienced 45 CDEs, defined as a 20% drop in rSO 2 from baseline. Results Median reduction in NIBP, eTMAP, and rSO 2 from baseline to the CDE were 48.2%, 75.5%, and 33.3%, respectively. At baseline, there was a significant weak negative correlation between rSO 2 and NIBP ( r s = −0.300; P = .045) and no significant association between rSO 2 and eTMAP ( r s = −0.202; P = .183). During CDEs, there were no significant correlations between rSO 2 and NIBP ( r s = −0.240; P = .112) or between rSO 2 and eTMAP ( r s = −0.190; P = .212). No significant correlation between the decrease in rSO 2 and NIBP ( r s = 0.064; P = .675) or between rSO 2 and eTMAP ( r s = 0.121; P = .430) from baseline to CDE was found. Conclusion NIBP and eTMAP are unreliable methods for identifying a CDE in the beach chair position. Cerebral oximetry provides additional information to the values obtained from NIBP and eTMAP, and all should be considered independently and collectively. [ABSTRACT FROM AUTHOR]

Background Whereas patient expectations after anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) relate to sustained improvements in pain, function, and motion, the time necessary to reach these goals is unclear. Our purpose was to investigate the speed of recovery and to compare the effectiveness of primary TSA and RSA. Methods We analyzed (preoperative, 3 month, 6 month, 1-year, and 2-year scores) pain scores, functional scores, and motion for 122 patients treated with primary RSA and 166 patients treated with primary TSA with a minimum of 1 year of follow-up. Comparisons were made to determine the effectiveness of treatment, time required to reach a plateau in improvement, and percentage of overall improvement at 3 and 6 months. Results Significant improvements were observed for both TSA and RSA at all intervals ( P < .001), except with internal rotation for RSA. Pain relief was rapid after both TSA and RSA. TSA patients reached a consistent plateau for pain and function by 6 months and for shoulder elevation by 1 year. RSA patients demonstrated variability with multiple false plateau points. By 6 months, TSA patients had achieved 90% to 100% of functional improvement, whereas RSA patients reached 72% to 91%. The effectiveness of TSA was greater than that of RSA for all measures with the exception of elevation and abduction. Conclusion Whereas patients treated with primary TSA and RSA can expect rapid improvements in pain, those treated with TSA can anticipate a more consistent and effective recovery of pain, function, and shoulder rotation. Patients receiving RSA can expect a variable length of recovery with greater improvements in forward elevation and abduction. [ABSTRACT FROM AUTHOR]

Background The accuracy of reproducing a surgical plan during shoulder arthroplasty is improved by computer assistance. Intraoperative navigation, however, is challenged by increased surgical time and additional technically difficult steps. Patient-matched instrumentation has the potential to reproduce a similar degree of accuracy without the need for additional surgical steps. The purpose of this study was to examine the accuracy of patient-specific planning and a patient-specific drill guide for glenoid baseplate placement in reverse shoulder arthroplasty. Methods A patient-specific glenoid baseplate drill guide for reverse shoulder arthroplasty was produced for 14 cadaveric shoulders based on a plan developed by a virtual preoperative 3-dimensional planning system using thin-cut computed tomography images. Using this patient-specific guide, high-volume shoulder surgeons exposed the glenoid through a deltopectoral approach and drilled the bicortical pathway defined by the guide. The trajectory of the drill path was compared with the virtual preoperative planned position using similar thin-cut computed tomography images to define accuracy. Results The drill pathway defined by the patient-matched guide was found to be highly accurate when compared with the preoperative surgical plan. The translational accuracy was 1.2 ± 0.7 mm. The accuracy of inferior tilt was 1.2° ± 1.2°. The accuracy of glenoid version was 2.6° ± 1.7°. Conclusion The use of patient-specific glenoid baseplate guides is highly accurate in reproducing a virtual 3-dimensional preoperative plan. This technique delivers the accuracy observed using computerized navigation without any additional surgical steps or technical challenges. [ABSTRACT FROM AUTHOR]

Background: The aims were to determine the sensitivity of plain radiographs to detect scapular fractures after reverse shoulder arthroplasty (RSA), to test the reliability of a proposed classification, and to evaluate risk factors. Materials and methods: We matched 53 patients with scapular fractures after RSA to 212 control patients. Clinical risk factors were assessed by correlating comorbidities. Independent observers reviewed radiographs to assess fracture detection accuracy and test the reliability of a proposed classification. Radiographic risks were evaluated by measuring acromial thickness, acromial tilt, glenoid-to-tuberosity distance, and acromion-to-tuberosity (AT) distance. Results: Independent reviewers accurately diagnosed 78.8% of fractures and 97.4% of controls with good inter-rater reliability (? = 0.782) and excellent intrarater reliability (? = 0.862). Inter-rater reliability of the classification was moderate (? = 0.422). Osteoporosis significantly increased the risk of fracture (odds ratio, 1.97; 95% confidence interval, 1.00-3.91); however, no difference was found for other comorbidities or between preoperative and postoperative radiographic parameters. A significant difference occurred between groups from the postoperative radiographs to the most recent radiographs for AT distance (0.4 ± 5.5 mm for control group and 8.3 ± 7.6 mm for fracture group, P < .001) and acromial tilt (1.8° ± 6.3° for control group and 14° ± 15° for fracture group, P < .001). Of 16 scapular spine fractures, 14 occurred from a screw tip; however, screw orientation and length were not different between groups. Conclusion: Osteoporosis is a significant risk factor for scapular fractures after RSA. The current classification has only moderate reliability, suggesting that an alternative classification method is needed. Decreasing AT distance and increasing acromial tilt on consecutive radiographs may improve fracture detection. Advanced imaging may be needed to confirm the diagnosis. Whereas most scapular spine fractures occurred from a screw, the surgical technique did not increase the relative risk. [Copyright &y& Elsevier]

Hypothesis/background: Patients who are treated with reverse shoulder arthroplasty in the setting of proximal humeral bone loss present a technical challenge for humeral component fixation. The purpose of this study was to determine the effect of proximal humeral bone loss on fixation of reverse shoulder humeral implants. Materials and methods: Three reverse humeral designs (two modular and one monobloc) were cemented into twenty-four Sawbones humeri prepared to simulate intact and proximal humeral bone loss. Torque was applied to the humerus for 1,000 cycles in increments of 2.5 N-m to 25 N-m. Rotational micromotion of the implant was measured. Results: There was a significant decrease in rotational micromotion in the intact constructs when compared with the bone loss constructs (we found P < .01 when looking at torsion levels of 5 to 17.5 N-m). In the intact humerus, 10 of 12 implant constructs survived testing. The 2 that failed were modular implants. In the bone loss setting, 7 of 12 implant constructs survived testing. The 5 that failed were also modular implants. Conclusions: This is the first investigation on humeral component fixation in reverse shoulder arthroplasty. The proximal humerus adds stability to the fixation of a cemented humeral implant. Modular components in the presence of proximal humeral bone loss may be at increased risk of mechanical failure. Conversely, non-modular cemented humeral components can withstand greater loads before failure. [ABSTRACT FROM AUTHOR]

Background: Lesser tuberosity osteotomy has become a popular method of subscapularis management during total shoulder arthroplasty with high healing rates and reliable functional recovery. One major advantage of this technique is the ability to monitor healing using routing radiographs. Recognition of displacement of the lesser tuberosity may provide a unique opportunity for revision repair before the tuberosity becomes irreversibly retracted. Methods: A series of four patients were identified with a displaced lesser tuberosity osteotomy following total shoulder arthroplasty. Radiographs from these patients were reviewed to identify the optimal radiograph for detecting displacement. Results: In each of the four cases, the displaced lesser tuberosity osteotomy was not seen on the axillary radiograph. A true AP radiograph consistently provided the only clear view of the displaced osteotomy. CT or MRI was used to confirm displacement of the lesser tuberosity osteotomy. In each case, displacement of the lesser tuberosity resulted from either a traumatic event, or from patient non-compliance with post-operative restrictions. Discussion/Conclusion: This is the first report that characterizes the radiographic appearance of failure of the lesser tuberosity osteotomy technique. Displacement of lesser tuberosity osteotomy following shoulder arthroplasty is best observed using a true AP radiograph. [ABSTRACT FROM AUTHOR]

Background: A great challenge in reverse shoulder arthroplasty is the wide variation in glenoid morphology that adds uncertainties in glenoid component placement. The purpose of this study was to classify glenoid morphology and examining its effect on possible glenoid component fixation. Materials and methods: The morphology of 216 glenoids was classified into normal and abnormal with subgroups defined by erosion sites. Six anatomic and 2 surgical parameters were compared among the classified groups. Plain radiographs or 2-dimensional (2D) computed tomography (CT) scans showed 62.5% of glenoids were normal and 37.5% were abnormal, with further subclassification of abnormal in posterior (17.6%), superior (9.3%), global (6.5%), and anterior (4.2%) erosions using 3D CT models. Results: The standard centerline became significantly shorter in abnormal (19.6 ± 9.1 mm) than in normal (28.6 ± 4.1 mm, P < .0001) glenoids. Alternatively, the spine centerline provided longer bony distance in abnormal glenoids (34.9 ± 17.0 mm). Abnormal glenoid morphology also reduced peripheral screw placement area by 42% and limited it to the anterior and inferior quadrants. Discussion: Glenoid morphology of the rotator cuff deficient shoulder can be reliably classified using this classification system consisting of normal and abnormal, which included 4 subgroups of posterior, superior, global, and anterior erosions. Conclusions: Abnormal glenoid morphology was shown to have a significant effect on anatomical and surgical factors which can necessitate adjustments in surgical technique for reverse shoulder arthroplasty. Level of evidence: Basic Science Study. [Copyright &y& Elsevier]

Purpose: The purpose of this study is to specifically evaluate the implications of unlinked and linked designs on the survivorship of revision surgery. Methods: Between 1972 and 1990, 352 linked and 151 unlinked prostheses were inserted at our institution. One-hundred and twenty-two elbows (24%) underwent subsequent revision: 55 linked (16%) and 67 unlinked (44%). Survivorship of the initial and revision total elbow replacement was calculated using a Kaplan-Meier analysis. Comparisons were made between revisions done after a failed primary linked or unlinked designs. The unlinked revised to a linked device was more reliable than when revised to another unlinked device: 1 year survival 84% compared to 47%. Results: Initial survival was 56% at 367 months and 84% at 371 months for the unlinked and linked cohorts, respectively (P < .001). A second revision was required in 12 of the 35 elbows (30%) in the linked cohort and 14 of the 50 elbows (28%) in the unlinked. Conclusions: At our institution, primary linked implants display significantly better long-term survivorship (P < .001) than did the unlinked designs. Unlinked designs are most reliably converted to a linked implant. Level of evidence: Level 3; Treatment study, retrospective case-control study. [Copyright &y& Elsevier]

Background Revision of unstable reverse shoulder arthroplasty (RSA) remains a significant challenge. The purpose of this study was to determine the reliability of a new treatment-guiding classification for instability after RSA, to describe the clinical outcomes of patients stabilized operatively, and to identify those with higher risk of recurrence. Methods All patients undergoing revision for instability after RSA were identified at our institution. Demographic, clinical, radiographic, and intraoperative data were collected. A classification was developed using all identified causes of instability after RSA and allocating them to 1 of 3 defined treatment-guiding categories. Eight surgeons reviewed all data and applied the classification scheme to each case. Interobserver and intraobserver reliability was used to evaluate the classification scheme. Preoperative clinical outcomes were compared with final follow-up in stabilized shoulders. Results Forty-three revision cases in 34 patients met the inclusion for study. Five patients remained unstable after revision. Persistent instability most commonly occurred in persistent deltoid dysfunction and postoperative acromial fractures but also in 1 case of soft tissue impingement. Twenty-one patients remained stable at minimum 2 years of follow-up and had significant improvement of clinical outcome scores and range of motion. Reliability of the classification scheme showed substantial and almost perfect interobserver and intraobserver agreement among all the participants (κ = 0.699 and κ = 0.851, respectively). Discussion Instability after RSA can be successfully treated with revision surgery using the reliable treatment-guiding classification scheme presented herein. However, more understanding is needed for patients with greater risk of recurrent instability after revision surgery. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures. Methods We conducted a retrospective query of a single private payer insurance claims database using PearlDiver (Warsaw, IN, USA) from 2010 to 2014. Our search included the Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for total shoulder arthroplasty (TSA), hemiarthroplasty, and reverse shoulder arthroplasty (RSA). Medical comorbidities were also searched for through International Classification of Diseases codes. The comorbidities selected for analysis were obesity, morbid obesity, hypertension, smoking, diabetes mellitus, hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease, cirrhosis, depression, and chronic kidney disease (excluding end-stage renal disease). The reimbursement charges of the day of surgery, 90-day global period, and 90-day period excluding the initial surgical day of each comorbidity were analyzed and compared. Statistical analysis was conducted through analyses of variance or Kruskal-Wallis test. Results Comorbidities did not have a significant effect on same-day reimbursements but instead caused a significant effect on the subsequent 89-day (interval) and 90-day reimbursements in the TSA and RSA cohorts. For TSA and RSA, the highest reimbursement costs during the 90-day period after surgery were seen with the diagnosis of hepatitis C, followed by atrial fibrillation and later chronic obstructive pulmonary disease. For hemiarthroplasty, the same was true in the following order: hepatitis C, cirrhosis, and atrial fibrillation. Conclusion Shoulder arthroplasty reimbursements are significantly affected by comorbidities at time intervals following the initial surgical day. [ABSTRACT FROM AUTHOR]

Background Reverse shoulder arthroplasty has seen increased use for management of complex proximal humeral fractures in the elderly. Recent evidence has shown that tuberosity healing leads to improved active range of motion and functional outcomes. The purpose of this study was to report on the radiographic and clinical outcomes of a consecutive series of patients having undergone reverse shoulder arthroplasty for fracture utilizing the “black and tan” method—a hybrid cementation-impaction grafting technique that uses autogenous cancellous bone graft to create an interface between the proximal cement mantle and the area of tuberosity repair. Methods Twenty-five patients (average age, 77 years; range, 63-88 years) were included in the analysis with a mean follow-up of 17 months. All patients underwent reverse shoulder arthroplasty for a complex proximal humerus fracture using the black and tan technique. Results The tuberosity healing rate was 88%. At final follow-up, mean active elevation was 117° ± 23°, mean abduction was 86° ± 16°, and mean external rotation was 29° ± 18°. External rotation strength averaged 4.9 ± 0.2. The Simple Shoulder Test and Single Assessment Numeric Evaluation scores averaged 7 and 76, respectively. The mean American Shoulder and Elbow Surgeons total score was 71; visual analog scale score for pain, 2; and visual analog scale score for function, 7. Of the 25 patients, 21 (84%) rated their satisfaction with the surgery as excellent or good. Conclusions The black and tan technique together with standard suture repair and an implant with features that support tuberosity repair results in a high tuberosity healing rate with restoration of external rotation after reverse shoulder arthroplasty for fracture. [ABSTRACT FROM AUTHOR]

Background Glenoid bone loss is commonly observed during primary and revision reverse shoulder arthroplasty. Glenoid baseplates are often implanted with incomplete glenoid bone support. The purpose of this study was to evaluate the glenoid component fixation of the glenoid baseplate with variable amounts of incomplete coverage. Methods Twenty-eight polyurethane trabecular bone surrogates were instrumented with the same center screw–type glenoid baseplate with 4 peripheral 5.0-mm locking screws in a glenoid bone loss model consisting of 25%, 50%, 75%, and 100% coverage. Each construct was tested through a 55° arc of motion with both compressive and shear forces across the glenosphere. Baseplate micromotion was recorded throughout 10,000 cycles for each model. Results There was no significant difference in baseline micromotion between the 4 experimental groups ( P = .099). In the 25% baseplate coverage group, 3 of 7 exhibited micromotion above the 150-μm threshold (624.5, 469.1, and 712.1 μm) during cyclic loading. After 10,000 cycles of loading, the 25% coverage group exhibited significantly more micromotion than the 50% ( P = .049), 75% ( P = .026), and 100% ( P = .040) coverage groups. There was no significant difference between the 100%, 75%, and 50% coverage groups ( P = 1.00). Conclusions Glenoid baseplate fixation in the setting of glenoid bone loss is no different when 50%, 75%, or 100% of the baseplate is supported by glenoid bone. Bone loss resulting in only 25% coverage results in significantly greater micromotion, often above the 150-μm threshold. [ABSTRACT FROM AUTHOR]