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Background: The Latarjet procedure is considered the gold standard for treating patients with anterior shoulder instability in the presence of critical glenoid bone loss. Proponents of the Latarjet contend that its efficacy is in-part attributable to the "sling effect" of the conjoint tendon; however, recent studies have demonstrated similar restoration of anterior stability in patients undergoing free bone block (FBB) procedures. The purpose of this systematic review was to evaluate the biomechanical and clinical evidence for the sling effect., Methods: A systematic review was performed per PRISMA guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried separately for (1) controlled laboratory studies comparing the restoration of anterior stability with and without an intact, tensioned conjoint tendon and (2) comparative clinical studies comparing patient outcomes after Latarjet versus a FBB procedure. A descriptive synthesis of the controlled laboratory studies and a quantitative meta-analysis of comparative clinical studies was performed., Results: Six controlled laboratory studies and four comparative clinical studies were included. Four of the laboratory studies supported the presence of a sling effect, whereas two studies concluded there was no added effect; however, their data trended in favor of improved anterior stability with the sling effect. Meta-analysis of the four comparative clinical studies demonstrated no difference between Latarjet and FBB for any range of motion measure, outcome score, or the odds of recurrent instability (Odds ratio: 0.83, 95% confidence interval: 0.20-3.52), which is concordant with the findings of each individual study., Conclusion: While both Latarjet and FBB procedures are efficacious in restoring stability, our critical review of the literature suggests that the reduction in anterior translation attributed to the "sling effect" in biomechanical cadaveric studies is not clinically relevant when sufficient anterior glenoid bone has been restored., (Copyright © 2025. Published by Elsevier Inc.)

Background: Radiographs are frequently obtained after total shoulder arthroplasty (TSA) to confirm implant placement and follow the status of the bone and prostheses; however, standardization of their use is lacking. There are concerns regarding frequent use of radiographs due to their cost and patient radiation exposure. The aim of this study is to assess the postoperative radiograph frequency and efficacy in primary anatomic and reverse total shoulder arthroplasty. We hypothesize that multiple radiographs taken beyond the initial 2-week postoperative interval are of uncertain benefit for both primary anatomic and reverse total shoulder arthroplasties, regardless of the presence of symptoms., Methods: A retrospective chart and imaging review was conducted on all patients who underwent primary TSA between 2014 and 2021, with documentation of at least 2 years of follow-up. All available postoperative radiographs, radiologist interpretations, and clinic notes were followed up for 2 years after the date of surgery, or until another surgery was performed within the 2-year timeframe. Radiographs were assessed for component positioning, fractures, loosening, and dislocation. Clinic notes were also checked for changes in patient management. Patients were grouped by surgery type (anatomic/reverse)., Results: A total of 213 patients (234 surgeries) were identified (55 anatomic TSA, 179 reverse TSA). The mean number of radiographs within the first 2 years of surgery was 3.6 for anatomic TSA and 4.0 for reverse TSA. 166 patients were asymptomatic and had only 3 positive X-rays and zero revision rate in the first 2 years. No changes in management were implemented based on these routine radiographs. 68 surgeries were symptomatic, of which 21 had positive X-rays. Of this subgroup, 19 (90.5%) underwent revision., Conclusion: Routine radiographs are overused and typically do not lead to any changes in asymptomatic patients in the first 2 years after TSA. For patients experiencing pain or limited range of motion, ongoing assessment using additional X-rays, CT scans, or other diagnostic tests is recommended for effective monitoring., (Copyright © 2025. Published by Elsevier Inc.)

Background: Clinically important improvement after total shoulder arthroplasty is often assessed with shoulder-specific patient-reported outcome measures (PROMs) quantifying reduction in pain and restoration in function. It is unclear if commonly utilized threshold such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), or patient acceptable symptom state (PASS), represent optimal improvement from the patients' perspective. The objectives of this study were to utilize the Simple Shoulder Test to: 1) compare commonly utilized thresholds for change in score and final score to thresholds optimized to patient satisfaction using receiver operative characteristic (ROC) curve analysis, and 2) determine the impact of using different thresholds on reporting of independent predictors of successful outcome in terms of patient satisfaction., Methods: This study included 406 anatomic total shoulder arthroplasty (aTSA) patients from a longitudinally maintained database with two-year follow-up. Surveys included the Simple Shoulder Test (SST) and a satisfaction questionnaire. SST thresholds were calculated by commonly described techniques for MCID, SCB, %MPI (percentage of maximal possible improvement), and PASS. ROC curves were constructed to determine the optimal threshold of SST change in score (Change-ROC), final SST score (Final-ROC), and %MPI (%MPI-ROC) based on patient satisfaction. Youden's index (J) was calculated to determine each threshold's performance in maximizing sensitivity and specificity. Multivariable analysis was performed to determine predictors of surpassing selected threshold values., Results: The thresholds with the highest Youden's index correlating best with patient satisfaction were %MPI-ROC (aTSA 61%, J=0.49; RnR 63% J=0.64) and Final-ROC (aTSA 9.5, J=0.48; RnR 9.5 J=0.60). Commonly utilized thresholds including MCID of 2.0 (J=0.21) and SCB of 2.7 (2.7) had the lowest Youden's index of the thresholds studied. Characteristics predictive of success varied substantially based on selected threshold., Conclusions: Current thresholds commonly utilized to gauge success after aTSA have limited ability to predict success based on patient satisfaction using the Simple Shoulder Test. Given that focus in healthcare value is shifting towards patient satisfaction, optimal thresholds utilized to measure success after shoulder arthroplasty may require reconsideration., (Copyright © 2025. Published by Elsevier Inc.)

Background: There is conflicting evidence on the impact of mental health on postoperative outcomes following total joint arthroplasty. Specific to shoulder arthroplasty there is a lack of data investigating the correlation between mental health and surgical outcomes. Most studies have focused on patient-reported outcome measures, while few have explored objective clinical outcomes. Additionally, studies that do explore clinical outcomes often fail to control for comorbidities. The purpose of this study is to determine if the presence of a mental health condition is associated with poorer outcomes after shoulder arthroplasty when accounting for covariates., Methods: A retrospective chart review was performed on patients who underwent primary shoulder arthroplasty between 2007 and 2022 at a single institution. Mental health diagnoses assessed included disorders associated with depression, anxiety, trauma, alcohol-use disorder, bipolar disorder, and schizoid disorders. Multivariable regression modeling was used to control for confounding variables and assess the likelihood of adverse clinical outcomes for patients with mental health disorders. Patient-reported outcome measures were also collected and compared., Results: 1169 patients underwent shoulder arthroplasty between January 2007 and September 2023 at our institution. After controlling for covariates, all-cause readmission within 90 days was found to be significantly associated with alcohol-related disorders (OR = 3.22 [95% CI, 1.30-7.23], p = .007) and bipolar disorders (OR = 4.21 [95% CI, .88-15.58], p = .043)., Conclusion: After adjusting for covariates, alcohol-related and bipolar disorders may be associated with increased risk of 90-day readmission after shoulder arthroplasty, but further investigation is necessary in order to better assess these effects. No associations were found between any mental health disorders and 90-day reoperation of the same joint, 365-day mortality, or patient-reported outcomes., (Copyright © 2025. Published by Elsevier Inc.)

Background: Subscapularis tendon (SSC) tears have recently become an area of current research focus. However, the risk factors for atraumatic isolated SSC tears, particularly anatomical factors, remain poorly determined. Therefore, the purpose of this study was to identify the associated factors contributing to isolated SSC tears., Methods: This study involved single shoulders of 605 subjects drawn from a cohort of rural residents. The inclusion criteria required each subject to sign an informed consent document and to have a complete clinical evaluation. The exclusion criteria comprised the absence of a complete magnetic resonance imaging study, current medication use that might have affected serum lipid levels, a history of shoulder trauma or surgery, and the presence of osteoarthritis, calcific tendinitis, frozen shoulder, or superior or posterosuperior rotator cuff tear. Diagnoses of isolated SSC tear were based on magnetic resonance imaging findings. Logistic regression analysis was conducted using demographic, physical, social, anatomical, comorbidities, and serological parameters. Anatomical variables included the supraspinatus fossa glenoid angle on axial (SGAX), a method to measure glenoid version, coracohumeral distance on axial and sagittal plans, and coracoid index. When multicollinearity among studied variables was detected, separate multivariable analyses were performed to address this issue, with each analysis including only one of those multicollinear variables along with the other significant variables obtained from univariate analyses., Results: Among anatomical variables, coracohumeral distance on axial and sagittal planes, as well as the coracoid index, did not show significant associations. However, SGAX, an index of glenoid version, was found to be significantly associated with atraumatic isolated SSC tears. Greater glenoid retroversion is significantly associated with atraumatic isolated SSC tears, along with age, waist circumference, dominant side involvement, manual labor, diabetes, metabolic syndrome, and biceps tendon injury (P ≤ .013)., Conclusions: The SGAX, serving as an index for glenoid version, is an independently associated factor for atraumatic isolated subscapularis tendon tears, with greater glenoid retroversion being an anatomical risk factor for these tears, along with overuse-related factors such as dominant-side involvement and manual labor, as well as metabolic factors such as obesity, diabetes, metabolic syndrome, and biceps tendon injury., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Socioeconomic status has been shown to impact a patient's access to orthopedic care, but outcomes such as compliance with physical therapy and time to return to full activities has not been established. The aim of this study is to investigate the impact of socioeconomic status on physical therapy compliance and return to play time specifically in patients with shoulder instability. The area deprivation index (ADI) is a validated tool using factors from the US Census that measures socioeconomic deprivation in neighborhoods. Our hypothesis is that patients with higher socioeconomic deprivation are more likely to have more missed scheduled physical therapy appointments and a longer return to play after arthroscopic shoulder labrum repair for instability., Methods: This study included patients who underwent arthroscopic shoulder labrum repair between 2019 and 2023 at a single orthopedic hospital by a single surgeon. Demographic information (race, age, and sex), insurance type, ADI, physical therapy no-show visit rates, and return to play times were recorded., Results: The cohort included 73 patients, 14 of whom did not have return to play times. A total of 82.2% of the patients were male, 63.0% were White, and the mean age was 24 years. Patients with increasing ADI were significantly more likely not to attend a scheduled physical therapy session (P = .035). No association between ADI and return to play time was found (P = .165). No significant association between insurance type (private vs. Medicaid) and missed scheduled physical therapy appointments (P = .139) and return to play times was found (P = .741)., Conclusion: Increasing socioeconomic deprivation is associated with increased likelihood to miss scheduled physical therapy visits after shoulder instability surgery. These findings elucidate gaps in orthopedic care as postoperative physical therapy is a crucial part in the comprehensive care of shoulder instability., (Copyright © 2024. Published by Elsevier Inc.)

Background: It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation., Methods: Current Procedural Terminology codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services. Procedures were grouped into arthroscopic and open categories. Publicly available data from Centers for Medicare and Medicaid Services was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018 to 2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018 to 2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons., Results: A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (P < .01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (P = .838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (P = .064 and P = .005, respectively)., Conclusion: Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The last few years have been characterized by increasing numbers of reverse shoulder arthroplasties. In addition to the classic indication of cuff tear arthropathy, the use for complex proximal humeral fractures (PHFs) and rotator cuff tear (RCT) in very old patients have been established. The objective of this study is to clarify and substantiate the above statements specifically for Germany (based on official data from 2010 to 2022). Since substantial changes in the structure of the population are expected over time, all data must be adjusted for these changes. The hypotheses are (1) the German population is ageing with a shift to more elderly patients over time, and (2) the general use of shoulder arthroplasty (total anatomic - shoulder arthroplasty (aTSA) and reverse - rTSA) has increased during the time period, but the effect is beyond the shift of age stratification but attributable to a change of hospital admissions and surgical therapy for PHF and RCT., Methods: In this retrospective study, data were collected from the National Bureau of Statistics in Germany for the period of 2010 to 2022. Three different data sources were combined for the analysis: a database regarding the structure of the population in age groups for every year, a database reporting relevant operation codes, and the data on hospital admissions based on ICD-10 codes. The relevant data were extracted and combined using Excel spread sheets (Microsoft Corporation, version 2019). Absolute numbers are reported and adjusted for 100.000 inhabitants in each age group in order to calculate the incidence., Results: Only slight change in absolute numbers of the population (n = 81751602 to 84358845, +3%) was observed, but a substantial shift toward the group of elderly people: the peak age group has shifted from 40-50 to 55-65. The number of TSA has significantly increased (n = 15000 to n = 28117, +187%; incidence 18.35 to 28.53, +155%). The number of rTSA has largely increased (n = 5326 to n = 24067, +452%; incidence 6.51 to 28.53, +438%), whereas the number of aTSA steadily decreased (n = 9674 to n = 4050, -42%; incidence 11.83 to 4.80, -41%). The number of revision arthroplasties has increased 1.8-fold (n = 2179 to n = 3893; incidence 1.7-fold). The peak revision rate shifted from the age group 70-75 toward 90- 95; 76% of all revision cases were performed in patients 65 years and older in 2010 increasing to 87% in 2022. Hospital admissions for PHF have increased 7.8-fold (n = 110091 to n = 810907). The peak in the age groups has shifted by a decade from 70-74 to 80-84. The absolute number of surgical therapy for PHF has decreased (n = 12816 to n = 9562, 75%; incidence 72%). The number of hospital admissions for RCT increased by 2.6-fold (n = 47004 to n = 124096; incidence + 255%). The number of surgical interventions for RCT increased by 3.7% (n = 51350 to n = 53294; incidence 62.8 to 63.2). Combined numbers for the operative therapy of PHF, RCT, and rTSA show an increase of +124% (n = 69491 to n = 86715) with a peak shift on one decade toward the age group 60-94 with 79% of the patients in 2022. The increased use of rTSA, as expressed by incidence, is strongly correlated with the increasing proportion of people aged 65 and over., Conclusion: The data show a substantial increase in the use of shoulder arthroplasty procedures in Germany in the observed time period, with the main driving factor being the increase of rTSA, whereas aTSA numbers decreased. The combined analysis of the hospital admissions and operative procedures performed to treat PHF and RCT indicated a shift of treatment numbers from open reduction and internal fixation and rotator cuff repair in the elderly toward the alternative use of rTSA in this age group. The observed shift of the stratification of age groups gives a further explanation for the increase in rTSA use: the number of patients in the age groups with the typical and alternative indications for rTSA substantially increased with a shift of the peak age group towards the elderly of one decade. Healthcare officials should be aware of these fundamental changes in the population, which create further demands on the health care system. The expected continuation of rising numbers of rTSA needs to be addressed by providing adequate resources such as reimbursement, surgical and rehabilitation facilities, and staff., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Low socioeconomic status has been shown to contribute to poor outcomes in patients undergoing joint replacement surgery. However, there is a paucity of studies investigating shoulder arthroplasty. The purpose of this study was to evaluate the effect of socioeconomic status on baseline and postoperative outcome scores and implant survivorship after anatomic and reverse primary total shoulder arthroplasty (TSA)., Methods: A retrospective review of a prospectively collected single-institution database was performed to identify patients who underwent primary TSA. Zip codes were collected and converted to Area Deprivation Index (ADI) scores. We performed a correlation analysis between national ADI scores and preoperative, postoperative, and preoperative to postoperative improvement in range of motion (ROM), shoulder strength, and functional outcome scores in patients with minimum 2-year follow-up. Patients were additionally grouped into groups according to their national ADI. Achievement of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) and revision-free survivorship were compared between groups., Results: A total of 1148 procedures including 415 anatomic and 733 reverse total shoulder arthroplasties with a mean age of 64 ± 8.2 and 69.9 ± 8.0 years, respectively, were included. The mean follow-up was 6.3 ± 3.6 years for anatomic and 4.9 ± 2.7 years for reverse total shoulder arthroplasty. We identified a weak negative correlation between national ADI and most functional outcome scores and ROM preoperatively (R range 0.07-0.16), postoperatively (R range 0.09-0.14), and preoperative to postoperative improvement (R range 0.01-0.17). Thus, greater area deprivation was weakly associated with poorer function preoperatively, poorer final outcomes, and poorer improvement in outcomes. There was no difference in the proportion of each ADI group achieving MCID, SCB, and PASS in the anatomic total shoulder arthroplasty cohort. However, in the reverse total shoulder arthroplasty cohort, the proportion of patients achieving MCID, SCB, and PASS decreased with greater deprivation. There was no difference in survivorship between ADI groups., Conclusions: We found a negative effect of low socioeconomic status on baseline and postoperative patient outcomes and ROM; however, the correlations were relatively weak. Patients that reside in socioeconomically deprived areas have poorer functional outcomes before and after TSA and achieve less improvement from surgery. We should strive to identify modifiable factors to improve the success of TSA in socioeconomically deprived areas., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Historically, humeral shaft fractures have been managed nonoperatively in a functional brace. However, recent studies suggest an increase in rates of operative fixation. Disparities in surgical management based on insurance status have been demonstrated across many orthopedic conditions. This study aimed to identify if a correlation exists between insurance coverage and the probability of undergoing operative fixation for a humeral shaft fracture., Methods: A retrospective examination of the National Readmissions Database from 2016 to 2021 was conducted. Patients diagnosed with isolated closed humeral shaft fractures were identified via International Classification of Disease, 10th Revision codes, and surgical interventions were identified using International Classification of Disease, 10th Revision procedural codes. Utilizing weighted data, a total of 56,468 patients with isolated closed humeral shaft fractures were identified, 25,075 (44.4%) of whom underwent operative fixation. A univariate analysis was conducted using Pearson's chi-square test to isolate variables for inclusion in a multivariable analysis. A binary logistic regression analysis was then employed to explore demographic and other pertinent factors. Findings were reported as odds ratios., Results: After controlling for social and demographic variables, patients with Medicaid (OR, 0.54; 95% CI, 0.50-0.58; P < .001), Medicare (OR, 0.64; 95% CI, 0.60-0.68; P < .001), and self-pay patients (OR, 0.75; 95% CI, 0.67-0.84; P < .001) were less likely to undergo operative fixation of humeral shaft fracture than those with private insurance., Conclusions: Patients without private insurance or those with no insurance coverage are less likely to undergo operative fixation for humeral shaft fractures compared to those with private insurance, even after adjusting for social and demographic variables. The observed variability underscores the necessity for more refined treatment guidelines for humeral shaft fractures. Surgeons should be aware of these potential biases affecting management decisions., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Arthroscopic rotator cuff repair (ARCR) is one of the most common orthopedic procedures in the general population. Despite its prevalence, the price of ARCR varies significantly across regions, hospital models, and settings. The purpose of this study was to examine the effect of Geographic Region, Certificate of Need (CON) laws, and Medicaid expansion on ARCR pricing., Methods: This cross-sectional observational study used hospital payer-specific ARCR prices from the Turquoise Health Database using Current Procedural Terminology code 29827. These prices are negotiated rates or charges that hospitals establish with various payers, including insurance companies, Medicare, Medicaid, and self-pay patients, for medical services and treatments provided. Outliers below the 10th percentile and above the 90th percentile were excluded. State policies, including CON status and Medicaid expansion, were obtained from public sources, whereas additional socioeconomic and demographic data were sourced from the US Census. The state's region classification was determined based on 1 of 4 Geographic Regions defined by the US Census Bureau. A detailed analysis was also conducted for North Carolina, examining county-level data on urbanization and the Area Deprivation Index., Results: There were 57,270 ARCR prices from 2503 hospitals across the United States, with a median interquartile range listed price of $6428.17 (interquartile range: $2886.88). States with CON regulations had significantly lower ARCR prices than those without ($6500 vs. $8000, P < .0001). Multivariable analysis indicated that hospitals in the Northeast and West Regions listed significantly higher prices for ARCR than those in the Midwest Region (P < .0001). In contrast, hospitals in the South Region listed lower prices for ARCR than those in the Midwest Region (P < .0001). Medicaid expansion was associated with increased ARCR prices (P < .0001), whereas CON laws were linked to reduced prices (P < .0001). In North Carolina, Area Deprivation Index and urbanization status did not significantly affect ARCR prices., Conclusion: The prices listed for ARCR varied significantly depending on the Geographic Region where hospitals were located. In addition, CON laws were associated with reduced ARCR prices, whereas Medicaid expansion correlated with increased prices. These findings highlight the complex interplay between health care policy, regulatory frameworks, and socioeconomic factors in determining surgical prices., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Fixation of displaced radial head fractures using miniplates is technically challenging and has some drawbacks like hardware prominence and limitation of forearm rotation. Fixation by headless compression screws has emerged as a less invasive alternative to miniplates. This study compares the radiological and functional outcomes of both methods of fixation., Methods: This single-center, prospective, randomized controlled trial was conducted at an academic level 1 trauma center. Sixty patients with displaced isolated radial head fractures were randomized to treatment using either headless compression screws or miniplates in 2 parallel groups. At the final follow-up of 18 months, patients were evaluated radiologically for union and clinically using the Mayo Elbow Performance Score (MEPS), elbow range of motion, grip strength, the visual analogue scale (VAS) for pain, and the Disabilities of the Shoulder, Arm, and Hand (DASH) score., Results: Union was achieved after 8 ± 1.7 weeks in the screw group and after 8.5 ± 2.7 weeks in the plate group. The MEPS was significantly better in the screw group (87.7 ± 10.7) than in the plate group (80.5 ± 13.9). However, this difference is below the minimum clinically important difference (MCID) for the MEPS and as such may not be clinically meaningful. No significant differences were observed between both groups regarding flexion, extension ranges, VAS, grip strength, or the DASH score. However, supination and pronation were significantly better in the screw group. The rate of complications was higher in the plate group (26.7%) than in the screw group (3.3%)., Conclusion: Both techniques yielded comparable outcomes with better forearm rotation, a lower complication rate, and a lower hardware removal rate in the screw group., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Physician involvement in political advocacy has become increasingly important in recent years. This study aims to explore the types of involvement and barriers to involvement in political advocacy among American Shoulder and Elbow Surgeons (ASES) members, identify issues considered most important by ASES members, and assess demographic factors that might correlate with involvement in political advocacy efforts among ASES members., Methods: This survey was conducted by the ASES Political Advocacy Committee over a 2-week period in June 2021. The survey collected demographic information including sex, ethnicity, years in practice, practice type, political affiliation, and level of current involvement in political advocacy. Additional questions consisted of thoughts regarding current health care policy issues and the role of the American Academy of Orthopaedic Surgeons/ASES regarding such policy issues., Results: We received 297 responses for a total response rate of 27%. Of those who responded, 24.6% identified as Democrat, 33% identified as Republican, and 42.4% identified as Independent. There was no difference in political affiliation between membership groups. Physician Reimbursement (82%), Medical Liability Reform (50%), and Physician Ownership (50%) were the most important issues identified among respondents. Physician Ownership, Physician Reimbursement and Graduate Medical Education and Student Loan Reform were most important to those in early practice, while Quality and Research was most important to those with greater than 25 years of practice experience., Conclusion: There is strong agreement among surgeons regarding the most important political advocacy issues. The efforts of the American Academy of Orthopaedic Surgeons and ASES should focus on these areas. Additionally, the vast majority of respondents felt that advocacy efforts had a positive impact on patients and surgeons., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Patients who rely on their upper extremities for ambulation, or upper extremity ambulators (UEAs), place considerable stress on their shoulders through the use of assistive devices like walkers, crutches, canes, and wheelchairs. It has been postulated that UEAs may be at increased risk for complications following shoulder arthroplasty. This study aimed to systematically review the literature related to (1) patient-reported outcomes measures (PROMs), (2) functional outcomes, and (3) complications in UEAs who undergo shoulder arthroplasty., Methods: A systematic review of the PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify studies reporting clinical outcomes of shoulder arthroplasty in UEAs. Patient demographics, clinical characteristics, patient-reported outcomes measures, radiographic outcomes, and postoperative range of motion were collected and compared to control patients (ie bipedal ambulators) from the constituent studies., Results: A total of eight studies evaluating 248 UEA cases and 206 control cases were included for review. Ambulatory assistive devices utilized by UEAs included walkers (39%), wheelchairs (38%), canes (22%), and a crutch (<1%). Among UEA cases, 197 (79%) reverse total shoulder arthroplasty (TSA), 37 (15%) anatomic TSA, and 14 (6%) hemiarthroplasty were performed. Overall, patients exhibited significant improvements in mean American Shoulder and Elbow Surgeons scores, Constant-Murley scores, Simple Shoulder Test scores, and Visual Analog Scale scores postoperatively. Among 3 studies that included comparison with control groups of bipedal ambulators, no significant differences in outcomes were identified. The overall clinical complication rate was 17% for UEAs compared to 9.1% for controls. The rate of revision surgery was 7.7% for UEAs and 4.9% for bipedal ambulators., Conclusions: UEAs experience satisfactory pain relief, functional improvements, and good subjective outcomes following shoulder arthroplasty. However, complication and revision rates are higher compared to those for bipedal ambulators, and the majority of UEAs undergo reverse shoulder arthroplasty compared to anatomic TSA., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Recent mandates from the Center for Medicare and Medicaid Services require United States hospitals to disclose health care service pricing. Yet, there's a gap in understanding how state-level factors affect hospital service pricing, like total shoulder arthroplasty (TSA). Comprehending these influences can help policymakers and health care providers manage costs and improve care access for vulnerable populations. The purpose of this study was to examine the effect of state characteristics such as partisan lean, certificate of need (CON) status, and Medicaid expansion on TSA price., Methods: TSA price data was extracted from the Turquoise Health Database using Current Procedural Terminology code 23472. State partisan lean was determined by evaluating each state during the 2020 election year for its legislature (both senate and house), governor, presidential vote, and Insurance Commissioner Affiliation, categorizing states as either "Republican-leaning" or "Democratic-leaning." CON status, Medicaid expansion, Area Deprivation Index (ADI), and population density information was obtained from publicly available sources. Multivariable regression models were used to assess the relationship between these factors and TSA price., Results: The study included 2068 hospitals nationwide. The median (interquartile range) price of TSA across these hospitals was $12,607 ($9,185). In the multivariable analysis, hospitals in Republican-leaning states were associated with a significantly greater price of +$210 (P = .0151), while Medicaid expansion was also associated with greater price +$1,878 (P < .0001). CON status was associated with a significant reduction in TSA prices of -$2,880 (P < .0001). In North Carolina an ADI >85 was associated with a reduction in price (P = .0045), while urbanization designation did not significantly impact TSA price (P = .8457)., Conclusion: This cross-sectional observational study found that Republican-leaning states and Medicaid expansion were associated with increased TSA prices, while an ADI >85 and CON laws were associated with reduced TSA prices., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Medical malpractice represents a significant economic cost in health care. Increasingly large damage claims by professional athletes against physicians have raised concerns about the medicolegal challenges in caring for high-level athletes., Methods: An online proprietary legal research database was queried for lawsuits related to malpractice in the care of professional and amateur athletes from 1992 to 2023. Demographics of plaintiffs and defendants, details of lawsuit filings, and damages claimed were recorded for all cases, settlements, and jury verdicts. Descriptive statistics, linear regression, as well as univariate analysis of demographic factors and damage claims in inflation-adjusted 2023 dollars was performed., Results: Eighty-eight lawsuits were recorded from 1992 to 2023. The sum of indemnities exceeded 186 million in 2023 inflation-adjusted United States Dollars. Football players were the most commonly represented athletes (n = 26) and represented 49% of total financial awards. Fourteen cases (16%) involved treatment of the upper extremity. Professional and collegiate level of play was associated with higher damages in favor of plaintiffs when compared to other levels of play. No other demographic was associated with higher financial awards. Linear regression showed a significant positive trend with an increasing inflation-adjusted compensation for plaintiff verdicts in the last 30 years., Conclusions: There is an increasing medicolegal financial risk associated with the care of athletes. This is higher in collegiate and professional levels of play. As physicians, insurers and institutions adjust to these financial risks, care must be taken to avoid ramifications on the availability and quality of care provided to athletes. Shoulder and elbow surgeons may consider additional preoperative counseling, legal waiver forms regarding malpractice claims, and advocacy for medical malpractice reforms in the care of athletes with high earning potential to mitigate these increasing financial risks., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: When treating chronic prosthetic joint infection after shoulder arthroplasty, removal of the implants and cement is typically pursued because they represent a potential nidus for infection. However, complete removal can increase morbidity and compromise bone stock that is important for achieving stable revision implants. The purpose of this study is to compare the rates of repeat infection after 2-stage revision for prosthetic joint infection in patients who have retained cement or hardware compared to those who had complete removal., Materials and Methods: We retrospectively analyzed all two-stage revision total shoulder arthroplasties performed for infection at 2 institutions between 2011 and 2020 with minimum 2-year follow-up from completion of the two-stage revision. Patients were included if they met the International Consensus Meeting criteria for probable or definite infection. Postoperative radiographs after the first-stage of the revision consisting of prosthesis and cement removal and placement of an antibiotic spacer were reviewed to evaluate for retained cement or hardware. Repeat infection was defined as either ≥2 positive cultures at the time of second-stage revision with the same organism cultured during the first-stage revision or repeat surgery for infection after the two-stage revision in patients that again met the International Consensus Meeting criteria for probable or definite infection. The rate of repeat infection among patients with retained cement or hardware was compared to the rate of infection among patients without retained cement or hardware., Results: Thirty-seven patients met inclusion criteria and were included in the analysis. Six (16%) patients had retained cement and 1 patient (3%) had 2 retained broken glenoid baseplate screws after first-stage revision. Of the 10 cases of recurrent infection, 1 case (10%) involved retained cement/hardware. Age at revision (60.9 ± 10.6 vs. 65.0 ± 9.6, P = .264), body mass index (33.4 ± 7.2 vs. 29.7 ± 7.3, P = .184), Charlson Comorbidity Index (2 (0-8) vs. 3 (0-6), P = .289), male sex (7 vs. 16, P = .420), and presence of diabetes (1 vs. 3, P = .709) were not associated with repeat infection. Retained cement or hardware was also not associated with a repeat risk of infection (1 vs. 6, odds ratio = 0.389, P = .374)., Discussion: We did not find an increased risk of repeat infection in patients with retained cement or hardware compared to those without. Therefore, we believe that surgeons should consider leaving cement or hardware that is difficult to remove and may lead to increased morbidity and future complications., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Division chiefs (DCs) and department leadership play an integral role within the service, and in the department as a whole. The goal of this study was to assess the demographics and academic characteristics of the leadership in orthopedic shoulder and elbow services across academic centers in the United States and comment on the diversity within these leadership positions., Methods: Academic medical centers were identified using the FRIEDA database. DCs were identified using the hospitals' respective websites where data such as sex, race/ethnicity, academic rank, fellowship institution, and time since graduating fellowship. Scopus database was used to determine individual h-indices., Results: Of 198 academic programs identified, 49 were found to have a DC of the orthopedic shoulder and elbow division. An additional 26 programs' websites, in which data was found, were noted to have a shoulder and elbow division, but were not found to have a DC of the division. These DCs were mostly White (n = 43, 87.8%), with only 6 identified DCs with a different ethnicity. Forty-five of the DCs (91.8%) were male and 4 were female (8.2%). The average time out of fellowship was 20.7 years, and the average h-index was 18.9. More than 20% of the DCs trained at Columbia's Neer Shoulder and Elbow Fellowship. Six DCs were current or past president of ASES and 5 DCs completed the ASES traveling fellowship., Conclusions: There is a scarcity of available research on demographic and leadership characteristics in academic orthopedic shoulder and elbow. Shoulder and elbow DC had average h-index of 18.9 and 20% trained at one fellowship. There are also opportunities for increased gender, racial, and ethnic diversity among the leadership of shoulder and elbow divisions., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Glenoid bone loss in shoulder arthroplasty is a difficult problem that is prone to complications because of challenges with achieving glenoid component fixation and stability. The purpose of this study was to evaluate the outcomes of primary shoulder hemiarthroplasty for patients with severe glenoid medialization precluding placement of a glenoid component., Methods: This was a retrospective case series evaluating patients who underwent shoulder hemiarthroplasty for severe glenoid erosion and medialization between 2010 and 2020. Patients were evaluated via chart review and phone survey to determine if there were any reoperations at final follow-up and to obtain Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Simple Shoulder Test (SST) scores. Preoperative and postoperative radiographs were evaluated and compared to determine glenoid morphology, version, medialization, acromiohumeral distance, and humeral offset. Final postoperative films were also evaluated for anterosuperior migration and signs of mechanical failure, including loosening or periprosthetic fracture., Results: Overall, there were 28 patients during this period who underwent shoulder hemiarthroplasty for severe glenoid medialization. Eight patients were deceased at the time of the study, 2 were unable to complete surveys because of dementia, and 7 were lost to follow-up. The final cohort included 11 shoulders and 11 patients with a mean age of 71 ± 7.1 years and mean follow-up of 6.7 years (range 1.6-13.0 years). Mean postoperative SANE, ASES, and SST scores were 80.6 ± 17.6, 71.5 ± 29.3, and 7.6 ± 2.0, respectively. There were no reoperations or revision surgeries at final follow-up. Radiographic evaluation demonstrated severe glenoid medialization and decreased lateral humeral offset, which was unchanged postoperatively. There were 2 patients with signs of anterosuperior migration at final radiographic follow-up but no signs of implant failure., Conclusion: Shoulder hemiarthroplasty for severe medial glenoid bone loss provides modest clinical outcomes and low rates of reoperation at mid- to long-term follow-up and is an option worth considering in cases where placement of a glenoid component is challenging because of deficient bone stock and high risk for complications., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: All-suture buttons (ASBs) and interference screw (IS) are commonly utilized in the inlay subpectoral biceps tendon tenodesis. However, the biomechanical characteristics of these two methods have not been compared directly. The aim of present study was to compare the biomechanical properties of ASB vs. IS for inlay subpectoral biceps tendon tenodesis in a human cadaveric model., Methods: Sixteen fresh-frozen human cadaveric shoulders were randomly divided into two experimental inlay biceps tenodesis groups: ASB or IS. After tenodesis, every specimen was preloaded at 5 N for 2 minutes, followed with a cyclic loading test from 5 to 70 N for 500 load cycles. Then the load-to-failure test was performed. Afterward, the humerus was placed in a cylinder tube and secured with anchoring cement. Lastly, a two-point bending test was performed to determine the strength of the humerus. Destructive axial force was applied, and the failure strength and displacement were recorded., Results: No difference in stiffness was observed between the two groups (ASB = 27.4 ± 3.5 N/mm vs. IS = 29.7 ± 3.0 N/mm; P = .270). Cyclic displacement was significantly greater in the ASB group (6.8 ± 2.6 mm) than the IS group (3.8 ± 1.1 mm; P = .021). In terms of failure load, there were no statistical differences among the two groups (P = .234). The ASB group was able to withstand significantly greater displacement (11.9 ± 1.6 mm) before failure than the IS group (7.8 ± 1.5 mm; P = .001). During the humeral bending test, the ASB group exhibited significantly greater maximal load (2354.8 ± 285.1 N vs. 2086.4 ± 296.1 N; P = .046) and larger displacement (17.8 ± 2.8 mm vs. 14.1 ± 2.8 mm; P = .027) before fracture., Conclusions: In inlay subpectoral bicep tenodesis, ASB fixation appears to offer comparable stiffness and failure load to that of IS fixation. Additionally, the ASB group exhibited greater resistance to load and displacement before humeral fracture. However, the ASB group did demonstrate increased cyclic displacement compared to IS group., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Preoperative 3-dimensional (3D) computed tomography (CT)-based planning for anatomic total shoulder arthroplasty (TSA) has grown in popularity in the past decade with the primary focus on the glenoid. Little research has evaluated if humeral planning has any effect on the surgical execution of the humeral cut or the positioning of the prosthesis., Methods: Three surgeons performed a prospective study using 3D-printed humeri printed from CTs of existing patients, which were chosen to be -3, -1, 0, 1, and 3 standard deviations of all patients in a large database. A novel 3D printing process was used to 3D print not only the humerus but also all 4 rotator cuff tendons. For each surgical procedure, the printed humerus was mounted inside a silicone shoulder, with printed musculature and skin, and with tensions similar to human tissue requiring standard retraction and instruments to expose the humerus. Three phases of the study were designed. In phase 1, humeral neck cuts were performed on all specimens without any preoperative humeral planning; in phase 2, 3D planning was performed, and the cuts and implant selection were repeated; in phase 3, a neck-shaft angle (NSA) guide and digital calipers were used to measure humeral osteotomy thickness to aid in the desired humeral cut. All humeri were digitized. The difference between the prosthetic center of rotation (COR) and ideal COR was calculated. The percentage of patients with a varus NSA was calculated for each phase. The difference in planned and actual cut thickness was also compared., Results: For both 3D change in COR and medial to lateral change in COR, use of preoperative planning alone and with standard transfer instrumentation resulted in a significantly more anatomic restoration of ideal COR. The deviations from planned cut thickness decreased with each phase: phase 1: 2.6 ± 1.9 mm, phase 2: 2.0 ± 1.3 mm, phase 3: 1.4 ± 0.9 mm (P = .041 for phase 3 vs. phase 1). For NSA, in phase 1, 7 of 15 (47%) cases were in varus; in phase 2, 5 of 15 (33%) were in varus; and in phase 3, 1 of 15 (7%) cases was in varus (P = .013 for phase 3 vs. phase 1)., Conclusions: Use of preoperative 3D humeral planning for stemless anatomic TSA improved prosthetic humeral COR, whether performed with or without standard transfer instrumentation. The use of an NSA cut guide and calipers to measure cut thickness significantly reduced the percentage of varus humeral cuts and deviation from planned cut thickness., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: In patients with traumatic posterior shoulder instability, little is known about the precise location and size of the reverse Hill-Sachs lesion., Methods: Forty-nine shoulders of 47 patients with traumatic posterior instability were included in this study based on the following inclusion criteria: (1) a primary or recurrent traumatic posterior shoulder dislocation and (2) the initial event being caused by trauma. Patients were excluded if they had (1) no history of trauma, (2) prior shoulder surgery, (3) no computed tomographic (CT) examination, or (4) were seizure cases. Three-dimensional images of the humerus reconstructed from CT images were reviewed using an image analysis software. The location and size of the reverse Hill-Sachs lesion were measured and described on a clock face on the humeral head., Results: The reverse Hill-Sachs lesion was observed in 25 of 49 shoulders (51%). The reverse Hill-Sachs lesions were located between 1:37 and 2:48. The depth of the reverse Hill-Sachs lesion (mean ± standard deviation) was 5.8 ± 2.2 mm. The extent of the reverse Hill-Sachs lesion was 35° ± 12°. The average orientation of the reverse Hill-Sachs lesion, represented by an angle measured from the 12 o'clock position, was 64° ± 12° and pointing toward 2:09 on a clock face. The mean length and width of reverse Hill-Sachs lesions were 9.7 ± 4.7 mm and 11.1 ± 3.6 mm, respectively., Conclusion: The reverse Hill-Sachs lesion was a semicircular compression fracture located on the anteromedial aspect of the humeral head. Compared with shoulders with anterior shoulder instability, the humeral defect was smaller and located more inferiorly in shoulders with posterior instability., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Anatomic and reverse total shoulder arthroplasty (RSA) (total shoulder arthroplasty [TSA]) have surged in popularity in recent years. While RSA is Food and Drug Administration approved for cases of rotator cuff tear arthropathy, indications have expanded to include, among others, primary glenohumeral osteoarthritis (GHOA)., Methods: PubMed, Cochrane, and Google Scholar (pages 1-20) were queried through November 2023. Inclusion criteria consisted of studies that compared the utility of TSA to that of RSA for the treatment of GHOA with intact rotator cuff with respect to adverse events, patient-reported outcomes, and range of motion (ROM). The Risk Of Bias In Non-randomised Studies - of Interventions tool was used to assess the risk of bias in the included nonrandomized studies, and Review Manager 5.4 was used for statistical analysis. P values <.05 were deemed significant., Results: Fourteen studies met the above inclusion criteria. Twelve studies reported adverse outcomes, with the RSA group having a lower rate of complications (odds ratio = 0.54, P = .004) and reoperations (odds ratio = 0.31, P < .001) relative to TSA at an average follow-up of 3.4 years. Four studies reported Shoulder Pain and Disability Index and University of California Los Angeles scores, while 5 reported Simple Shoulder Test scores. These studies showed superior Shoulder Pain and Disability Index (P = .040), University of California Los Angeles (P = .006), and Simple Shoulder Test (P = .040) scores among the RSA group. No significant differences were seen with regards to other patient-reported outcomes. Ten studies reported on ROM, and the RSA group had a significantly lower external rotation relative to the TSA group (P < .001) while other ROM parameters did not show statistically significant differences., Conclusion: The present study provides support for RSA as a reasonable surgical option for patients with GHOA and an intact rotator cuff, with lower rates of adverse events and better outcomes relative to TSA, although at the expense of decreased external rotation. Patient education and counseling is key in order to decide optimal treatment as part of a shared decision-making process, as well as setting appropriate expectations., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Muscle atrophy after the rupture of a rotator cuff (RC) tendon is a major factor that increases the risk of secondary complications and re-rupture. Metformin, a type 2 diabetes treatment, can be used to modulate intracellular signaling pathways that promote muscle growth. This study aimed to verify whether systemic metformin administration could prevent supraspinatus (SS) atrophy after RC rupture in a rat model., Methods: This study is a comparative animal study aimed at investigating the effects of metformin. Twelve-week-old male Sprague-Dawley rats were used. The metformin group was administered intraperitoneal injection with 50 mg/kg metformin daily for 6 weeks after the RC tendon was cut, while the control group was given 0.9% saline solution. All rats were weighed and sacrificed 6 weeks after their surgery; then, SS were collected, and individual SS weights were measured. The expression of muscle atrophy genes was determined through quantitative reverse transcription polymerase chain reaction, and the amount of signal metabolism regulatory protein was measured by western blotting. Muscle atrophy and fatty infiltration (FI) were evaluated by histological staining., Results: Six weeks after RC tendon rupture, the SS weight in the metformin group was significantly higher than in the control group. Western blotting analysis revealed that the expression levels of phosphatidylinositol 3-kinase (P = .002), protein kinase B (P = .001), and mammalian targets of rapamycin (P = .009) protein were significantly higher in the metformin group than in the control group. The muscle atrophy-related marker genes Atrogin-1 (P = .036) and MuRF-1 (P < .000) in the metformin group were downregulated. The morphology of the SS, whose atrophy was prevented by metformin, had fewer wide pores and less reduced muscle fiber area than those of the control group. Muscle tissue staining analysis showed that FI was significantly suppressed by systemic metformin administration compared with that of the control group both qualitatively and quantitatively (P = .032). Metformin elicited an FI-suppressing effect by downregulating the adipogenic genes PPAR-γ (P = .001) and C/EBP-α (P< .001)., Conclusions: Metformin significantly prevented SS atrophy by activating the PI3K/AKT/mTOR pathway in an acute RC tear rat model. It also suppressed FI by downregulating adipogenic factors in the late stage of RC tear. These results strongly supported the usefulness of metformin for high-quality muscle preservation after RC rupture in clinical practice., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: Rheumatoid arthritis often leads to debilitating damage in the elbow joint, which may require total elbow arthroplasty (TEA). The Kudo TEA is one of the unlinked type prostheses with reportedly favorable outcomes. However, there is limited information available regarding its long-term performance. This retrospective study aimed to evaluate the long-term survivorship and identify risk factors associated with failure of the Kudo Type-5 TEA in patients with rheumatoid arthritis (RA), specifically exceeding 10 years., Methods: Patients with RA who underwent TEA with the Kudo Type-5 prosthesis from 1998 to 2009, with a minimum ten-year follow-up, were included. Failure, defined as revision surgery or radiographic loosening, was assessed using the Kaplan-Meier method. The patients' demographic data, radiographic measurements, range of motion, Mayo elbow performance score (MPES), and the material of the ulnar component were compared between the elbows with and without failure. Univariate analysis identified factors affecting long-term survivorship., Results: Among 49 elbows in 38 patients with a mean follow-up of 13.4 years, significant improvements in flexion range and MPES were observed. The failure rate was 39%, occurring in 19 elbows. Among these failures, 13 cases were attributed to issues with the ulnar component, making it the most common cause. The overall survivorship rate of the Kudo Type-5 prosthesis at ten years was 78%, as calculated using the Kaplan-Meier method. Factors associated with a higher failure risk included a shorter duration from RA onset to surgery (17.2 ± 5.8 years vs. 23.3 ± 8.7 years; p = 0.01), a lower preoperative stability score of MPES (6.6 ± 4.1 vs. 9.3 ± 1.7; p < 0.01), larger implant deviation assessed by the implant deviation index (9.3 ± 1.3% vs. 5.4 ± 1.1%; p = 0.03), and the use of the all-polyethylene ulnar component (79.0% vs. 46.7%; p = 0.04)., Conclusion: Although the Kudo Type-5 prosthesis demonstrated satisfactory results in patients with RA, failures occurred to some extent over a long-term follow-up period. Careful monitoring should be conducted, particularly in cases with a short duration from RA onset to surgery, preoperative instability, misalignment of the implant and the use of the all-polyethylene ulnar component., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Higher perioperative opioid use has been associated with an increase in periprosthetic joint infection, thromboembolic complications, respiratory events, gastrointestinal complications, cost, and length of stay following hip and knee arthroplasty. Limited data exists regarding the relationship between the postoperative opioid dose and complication rates following primary total shoulder arthroplasty (TSA). The purpose of this study is to investigate the relationship between perioperative opioid consumption and postoperative complications following TSA., Methods: The Premier Healthcare Database was queried to identify patients who underwent primary anatomic and reverse TSA from 2016-2020. Perioperative opioid consumption was totaled utilizing milligrams of morphine equivalents (MMEs) to stratify patients based on quintiles of consumption. Primary outcomes included total opioid consumption, 90-day postoperative complications, revision, and readmission., Results: 140,251 patients undergoing primary TSA were identified and stratified based on total opioid consumption into quintiles (<22.3, 22.3-25, 25.01-52.5, 52.6-83.3,> 83.3). Patients with increased MME exposure were significantly younger, more often female, and Black (p<0.0001 for all). On multivariate analysis, increased MME exposure was associated with increased risk of multiple surgical complications, including superficial wound infection, PJI, periprosthetic fractures, seroma, loosening, unspecified mechanical complications, and 90-day readmission. Regarding medical complications, rates of postoperative hemorrhage, pulmonary embolism (PE), pneumonia, acute respiratory failure, acute renal failure, and UTI significantly increased upon exposure to higher MMEs., Discussion and Conclusion: Our study noted that there was a dose dependent increase in the risk of surgical and medical complications with increasing totals of opioid perioperative opioid consumption following total shoulder arthroplasty. Despite controlling for numerous variables, patients with increased opioid requirements in the perioperative period had increased risk of PJI, periprosthetic fracture, loosening, readmission as well as several medical complications such as PE, respiratory failure, and renal failure., Level of Evidence: Level III; Retrospective Cohort Comparison using Large Database; Prognosis Study., (Copyright © 2024. Published by Elsevier Inc.)

Background: Isolated fractures of the greater tuberosity represent up to 20% of all proximal humeral fractures. Conservative and surgical treatment strategies are reported. Fracture displacement on radiographs is a key factor in treatment decisions, but the accuracy of measurement methods can limit this process. This study aimed to (Aim I) assess the inter- and intraobserver reliability of established radiographic measurements of fracture displacement and (Aims II/III) determine if these measurements can predict superior, posterior, or combined superior + posterior fracture displacement quantified on CT scans in a patient cohort., Methods: Forty-nine cases of isolated greater tuberosity fractures with complete radiographs and CT scans were analyzed. (Aim I) Displacement was measured on radiographs in millimeters as superior ('sup') and lateral ('lat') displacement, along with Mutch's superior ratio ('sGT'), anterior/posterior ratio ('apGT'), and Nyffeler's impingement index ('I-Ind'). Reliability was assessed by three independent observers. (Aim II) A humerus saw-bone model with predefined superior, posterior, and combined fracture displacements was used to validate a CT-based measurement technique. (Aim III) This CT-based method was applied to patient CT scans, and linear regression was used to test if radiographic measurements predicted the CT-measured displacements., Results: (Aim I) Inter- and intraobserver reliability was excellent for 'I-Ind' (inter 0.98/intra 0.94), good-excellent for 'lat' (0.82/0.76) and 'sGT' (0.75/0.94), and moderate for 'sup' (0.73/0.66) and 'apGT' (0.64/0.49). (Aim II) The CT-based technique accurately measured superior (R 2 =0.99), posterior (R 2 =0.99), and combined (R 2 =0.99) displacement. (Aim III) Patient CT scans showed mean displacement of 3.3±2.5 mm superior, 8.4±5.6 mm posterior, and 11.6±7 mm combined. Superior displacement correlated with 'sup' (p<0.001), posterior with 'lat' (p<0.001), 'apGT' (p=0.004), 'I-Ind' (p=0.048), and combined displacement with 'lat' (p<0.001) and 'apGT' (p=0.006). In fractures displaced ≥5mm, 'sup' (p=0.002) correlated with superior, 'lat' (p=0.003) and 'I-Ind' (p=0.049) with posterior, and 'lat' (p<0.001) with combined displacement., Conclusions: The CT-based technique accurately measured fragment displacement in the saw-bone model. For fractures with ≥5mm displacement, 'lat' was the best predictor of combined displacement (interobserver reliability: 0.82-0.94). However, in the reported cohort, 'lat' underestimated the "true" fragment displacement. Therefore, in 'lat' measurements ≥ 3mm, a CT scan for quantification of fragment displacement should be considered. However, these findings must be confirmed in bigger patient populations before clinical translation., (Copyright © 2024. Published by Elsevier Inc.)

Background: There is a relative paucity of studies examining how the superior capsule reconstruction (SCR) may alter the kinematics of the glenohumeral joint capsule itself, specifically with respect to rotation and translation in the anterior-posterior and superior-inferior planes. This then raises the possibility that the SCR may be having unintended consequences on glenohumeral kinematics. The purpose of this study was to quantify the glenohumeral joint kinematics following Fascia Lata SCR (FL-SCR). We hypothesized that the FL-SCR will not restore the glenohumeral joint kinematics to the intact condition., Methods: Eight fresh cadaver shoulders were studied using a custom shoulder testing system. Rotational range of motion was measured with 2.2Nm of torque. Glenohumeral kinematics throughout the range of motion were then measured at 0, 20 and 40 glenohumeral abduction. Anterior-posterior translation and superior-inferior translation from loading with 10, 15 and 20N in each direction was also measured. There were 3 testing conditions: (1) intact rotator cuff, (2) massive rotator cuff tear (MCT), and (3) MCT with fascia lata (FL) SCR. A repeated measures ANOVA with a Bonferroni correction was used for statistical analysis., Results: The total ROM was increased with MCT at 0, 20, and 40 degrees of abduction. FL-SCR restored total ROM to the intact state. FL-SCR shifted the humeral head inferiorly compared to the intact condition at 0 degrees of abduction. MCT resulted in increased anterior-posterior and superior-inferior translation; FL-SCR restored translation to intact levels., Conclusion: FL-SCR restores glenohumeral translations but alters glenohumeral kinematics in that it shifts the humeral head inferiorly compared to the intact rotator cuff state at low levels of abduction., (Copyright © 2024. Published by Elsevier Inc.)

Background: Operating room (OR) efficiency is of paramount importance for scheduling, cost efficiency and to allow for the high operating volume required to address the growing demand for arthroplasty. The purpose of this study was to develop a machine learning predictive model for Total Shoulder Arthroplasty (TSA) procedure duration and to identify factors which are predictive of a prolonged procedure., Methods: A retrospective review was undertaken of all TSA between 2013-2021 in a large academic institution. Patient, surgeon, anesthetic and shoulder specific factors were assessed. The duration of time in the OR was recorded and compared to the human scheduler and electronic health record (EHR) predicted procedure duration. Two gradient-boosted decision tree regression models were created with both training and validation datasets. The mean squared logarithmic error (MSLE) was chosen as the loss function. The first model (M1) considered patient, surgeon, and anesthetic factors, while the second model (M2) considered shoulder anatomy and pathology specific factors in addition., Results: Human schedulers' predicted 64.1% of cases accurately, with 26.7% under-predicted and 9.2% overpredicted. M1 successfully predicted 79.7% of cases, with 6.9% under-predicted and 13.4% over-predicted. M2 successfully predicted 82.5% of cases with 8.8% under-predicted and 8.8% overs-predicted. M2 was significantly more accurate in predicting anatomic TSA (aTSA) compared to reverse (rTSA) (90.6% vs 78.1%, p <0.001).The feature with the greatest impact on the shoulder specific model's prediction was the historical median procedure duration; followed by the EHR prediction, surgeon prediction, patient age and a traumatic indication. Factors which were associated with underpredicting procedure duration included younger age, traumatic indication, male sex, greater BMI and a B2 glenoid., Conclusion: Machine learning predictive models outperformed traditional scheduling, with a model incorporating general and shoulder specific data providing the most accurate prediction of TSA procedure duration. Integration of modelling has the potential to optimize theatre utilization and improve efficiency., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: Although open reduction and internal fixation (ORIF) is the gold standard treatment for displaced midshaft clavicle fractures, recent studies have advocated for nonoperative management, citing high rates of reoperation associated with operative intervention. However, no studies have compared nonoperative management to ORIF with dual-plate fixation, which may be associated with lower rates of reoperation compared to single-plate fixation. The purpose of this study was to compare the complications and patient-reported outcomes of dual mini-fragment plate fixation to nonoperative management for displaced midshaft clavicle fractures., Methods: This was a retrospective cohort study of patients who presented with a displaced midshaft clavicle fracture and underwent either nonoperative management or dual mini-fragment plate fixation from 2010-2021 with minimum 12-month follow-up. The primary outcomes were union complications including non-union, delayed union, and symptomatic malunion. Secondary outcomes were patient-reported outcomes including visual analog pain scale (VAS) and subjective shoulder value (SSV). A multivariate logistic regression model was utilized to determine the relationship between treatment and union complications., Results: One hundred and eleven patients were identified (mean age 41.6 ± 16.7 years) with average follow-up of 3.4 years. Of these, 62 underwent dual-plate fixation and 49 underwent nonoperative management with no differences in demographics or fracture characteristics. There were 0 non-unions, 1 delayed union, 0 symptomatic malunions, and 1 re-operation in the dual plating cohort compared to 4 non-unions (p=0.035), 1 delayed union (p=1.00), and 3 symptomatic malunions (p=0.083) in the nonoperative cohort. Patients who underwent nonoperative management were over 14 times more likely to develop a union complication (β=14.3; p=0.019). There were no differences between the dual plating and nonoperative cohort with regards to VAS (1.2 ± 2.2 vs 1.5 ± 2.4; p=0.559) and SSV (90 ± 16 vs 92 ± 15; p=0.671)., Conclusion: While both dual mini-fragment plate fixation and nonoperative management of displaced midshaft clavicle fractures demonstrate similarly excellent patient-reported pain and functional outcomes, dual-plate fixation has a 14-fold lower risk of union complications., (Copyright © 2024. Published by Elsevier Inc.)

Background: Subacromial pain is a common and disabling condition with multifactorial aetiology. Increasing evidence supports exercises as first-line treatment and need of surgery is debated. Long-term follow-ups after surgical- and non-surgical treatment are scarce. The primary aim of the present study was to investigate the 10-year outcomes after a study comparing specific and non-specific exercise treatment and the need for surgery. Secondarily we compared patients who had undergone exercise treatment, to those having surgery and explored the importance of rotator cuff status in relation to given treatment and outcomes., Methods: At enrolment 2009-2010, 97 patients with long-standing subacromial pain were on the waiting list for Arthroscopic Subacromial Decompression (ASD). They were randomized to specific exercises focusing on strengthening of the rotator cuff and scapula stabilizers (n=51) or control: unloaded range of motion exercises (n=46). ASD was optional during the entire observation time. Eligible patients from either group constitute the present 10-year cohort with non-operated (n=42) or operated (n=41) patients. The primary outcome was shoulder function and pain after 10 years assessed by the Constant-Murley score (CMS). Secondary outcomes were proportion of patients choosing surgery and rotator cuff status related to treatment and primary outcome., Results: At the 10-year follow-up, 83 of 97 patients (86%) participated. All patients significantly improved in CMS from baseline to 10-year follow-up, mean improvement of 37 (95% CI 33-41, p<0,0001). Non-operated patients had significantly better CMS compared to operated with mean difference 11 (95% CI 4-18) (p=0,003). Significantly more patients in the control exercise group 65% (26 of 40) had chosen surgery compared to 35% (15 of 43) in the specific exercise group up until 10 years (p=0,006). At 10 years, 55% of the patients had a partial or full thickness rotator cuff tear compared to 28% at baseline. There was no difference in tear progression between operated and non-operated patients (p=0,494). In the contralateral shoulder, 51% of the patients (39 of 76) had a cuff tear compared to 3% at baseline., Conclusions: Specific exercise treatment for patients with subacromial pain was effective and reduced the need for surgery with maintained results after 10 years. Responders to exercise treatment had the best long-term outcomes and ASD yielded satisfying outcome in non-responders. A rotator cuff tear was equally common in patients having undergone surgery as in those treated non-operatively and in the contralateral shoulder., (Copyright © 2024. Published by Elsevier Inc.)

Background: The restriction of active internal rotation (IR) after reverse shoulder arthroplasty (RSA) poses a challenging problem for reconstructive shoulder surgeons, particularly in patients suffering from massive rotator cuff tears (mRCT) with subscapularis (SSC) deficiency. This study aims to evaluate the biomechanical effectiveness of different tendon transfer techniques following medialized glenoid and lateralized humerus RSA in improving internal rotation (IR) strength., Methods: Eight cadaveric shoulder specimens were evaluated using a custom shoulder testing system designed to simulate loading conditions typical of mRCT with SSC insufficiency. The study examined four different conditions: 1) RSA alone, 2) RSA with pectoralis major (PM) tendon transfer, 3) RSA with latissimus dorsi (LD) transfer, and 4) RSA with combined LD and teres major (LDTM) transfer. Testing was conducted at abduction angles of 0º, 20º, and 40º under three distinct muscle loading conditions. IR torque was quantitatively assessed using a torque wrench at 60º IR. Additionally, the anterior dislocation force was measured at 20º abduction and 10° IR., Result: PM and LDTM transfers following RSA significantly increased IR strength at all abduction angles and loading conditions, (p < .001 for PM; p < .006 for LDTM) except at 0° under normal load. LD transfer only showed a significant increase in IR strength at 20° with triple load (p = .022). PM and LDTM transfers significantly increased IR strength across all positions and loading conditions compared to LD transfer, with PM transfers demonstrating notably higher strength improvements at 0° and 20° abduction under increased loads compared to LDTM transfer (p's < .026). Anterior dislocation forces were highest for PM, followed by LDTM and LD, with no significant differences compared to RSA alone or among the transfers (p > .864)., Conclusion: PM and LDTM transfers significantly improved IR strength in medialized glenoid and lateralized humerus RSA for mRCT with SSC deficiency, unlike isolated LD transfer. No difference in anterior dislocation force was noted among the transfers. However, further research is warranted to determine the effects of tendon transfers on IR strength across various RSA prosthesis designs., (Copyright © 2024. Published by Elsevier Inc.)

Background: Postoperative assessment following reverse total shoulder arthroplasty (rTSA) typically involves plain radiographs to evaluate implant positioning parameters, such as humeral distalization and lateralization along with medialization and distalization of the center of rotation (COR). However, the precision of these radiographic measurements remains unclear. This study aimed to validate the accuracy of radiographic two-dimensional (2D) measurements compared to three-dimensional (3D) surface model-based measurements derived from CT data for evaluating postoperative parameters in rTSA. Additionally, we examined how these parameters affect the distances between COR and the acromion (DA), and the COR and the greater tuberosity (DGT)., Methods: The study included 31 shoulders from 30 patients who underwent rTSA at a single institution. Radiographic images and computed tomography (CT) scans were obtained at an average of 16 ± 5 months postoperatively. Implant position parameters measured on both 2D radiographs and 3D surface models included medialization and distalization of the COR, humeral distalization, humeral lateralization offset, DA, and DGT. Measurements were conducted independently on two separate occasions by two certified orthopedic surgeons. Intraclass correlation coefficients (ICCs) were used to assess measurement reliability. Bland-Altman plots analyzed the agreement between 2D and 3D measurements. A linear mixed-effects model was used to analyze the relationship between implant positioning measurements and the DA and DGT., Results: The ICCs for radiographic and 3D measurements showed excellent reliability (>0.9 for all parameters). Bland-Altman analysis revealed minimal differences between 2D and 3D measurements for most parameters. However, significant fixed biases were noted for humeral distalization and distalization of the COR, indicating potential underestimations in radiographic assessments. The linear mixed-effect model revealed that DA was positively associated with distalization of the COR, humeral lateralization offset, and medialization of the COR (P=0.008, P=0.004, and P=0.005, respectively), but not humeral distalization (P = 0.798). DGT was positively associated with humeral distalization, humeral lateralization offset, and medialization of COR (P=0.002, P<0.001 and P<0.001, respectively), but not distalization of the COR (P=0.468)., Conclusions: Radiographic 2D measurements and 3D-surface model-based measurements are comparable for evaluating postoperative parameters of DA, DGT, humeral lateralization offset, and medialization of COR in shoulders with rTSA. However, fixed biases were present for humeral distalization and distalization of the COR. A larger DA can be achieved by medializing and distalizing the COR, while smaller DGT can be achieved by decreasing humeral lateralization and distalization and by lateralizing the glenoid., (Copyright © 2024. Published by Elsevier Inc.)

Background: Swimming is one of the most common sporting activities in the United States, and often popular among shoulder arthroplasty patients. While return to sport has become a popular topic recently, the literature focused on swimming is limited. The purpose of this study is to report the rate of return to swim after primary shoulder arthroplasty and evaluate changes in performance after surgery., Methods: A retrospective query of a single institution's shoulder and elbow surgery repository identified patients treated with primary total anatomic (aTSA) or reverse shoulder arthroplasty (rTSA) by a single fellowship trained shoulder and elbow surgeon between 1/2013 and 1/2022. Those patients who were self-identified as swimmers were surveyed to complete a swimming-specific questionnaire at a minimum two years follow-up. The questionnaire was used to evaluate the ability to return and swimming performance after surgery. Additionally, patient-reported outcome measures (PROMs), range of motion, strength, and satisfaction were evaluated., Results: A total of 102 (49 aTSA, 53 rTSA) patients responded at an average follow-up of 5.3 years. aTSA patients returned to swimming at a greater rate than rTSA patients (82% vs. 64%; p=.048), but no significant difference in the amount of time taken to return was observed of those who did return to swimming. Patients who returned to swim did so with longer swimming duration per session than they did preoperatively and maintained their primary swim stroke. Of those who returned to swim, overall swimming ability increased in 70% of aTSA and 74% of rTSA patients, and overall enjoyment increased in 70% of aTSA and 71% of rTSA patients., Conclusion: aTSA patients return to swimming at a higher rate than rTSA patients. However, of those patients who were able to return to swim, there were minimal differences in performance between aTSA and rTSA. Both cohorts demonstrated improved swimming ability and increased enjoyment postoperatively., (Copyright © 2024. Published by Elsevier Inc.)

Background: There is currently limited work that evaluates the effect of co-morbid hypothyroidism on complications and outcomes following total shoulder arthroplasty (TSA). This study aims to evaluate the impact of hypothyroidism on 90-day medical complications as well as 2-year implant related complications and revision rates following TSA., Methods: This retrospective database analysis evaluated patients who underwent TSA between October 1, 2015, and March 9, 2022. Patients with 2-year follow-up were categorized based on the presence of preoperative hypothyroidism within three months before TSA versus euthyroid status, resulting in 7,716 hypothyroid and 46,568 euthyroid patients. A 1:1 propensity score matching was performed, adjusting for age, gender, race, ethnicity, and comorbid conditions (diabetes, hypertension, chronic kidney disease, tobacco use, obesity, heart failure, and liver diseases). Postoperative complications were assessed at 90 days, and implant-related complications were evaluated at two years. A Bonferroni correction was applied to account for multiple comparisons., Results: After matching, 7,716 matched patients were included in each cohort. Hypothyroid patients had significantly higher risks of sepsis, infection, pulmonary embolism, stroke, and hospital readmission (all p < 0.0001), as well as higher rates of anemia, pneumonia, renal failure, and blood transfusion requirements (all p < 0.0001) within 90 days postoperatively. Myocardial infarction did not meet the significance threshold (p = 0.005). At two years, these patients had elevated rates of periprosthetic fractures, prosthetic joint infection, dislocation, revision surgeries, and mechanical loosening (all p < 0.0001)., Conclusion: Hypothyroidism is associated with an increased risk of 90-day medical complications and 2-year implant-related complications following shoulder arthroplasty. Further investigation into these findings and potential for perioperative medical optimization is indicated., (Copyright © 2024. Published by Elsevier Inc.)

Hypothesis and Background: Reverse shoulder arthroplasty (RSA) exhibits favorable outcomes in managing rotator cuff arthropathy, primary glenohumeral arthritis, and complex proximal humeral fractures. Despite its success and reliability, certain patients experience persistent pain and stiffness. The clinical utility of therapeutic arthroscopy in RSA patients remains an area for investigation. The purpose of this study was to report clinical outcomes, including patient-reported outcomes (PROs), range of motion (ROM), and satisfaction, in patients who underwent therapeutic arthroscopy for noninfectious stiffness and subcoracoid impingement following RSA. The hypothesis was that patients would experience clinical improvement and satisfaction, with earlier intervention being superior to later intervention., Methods: Multicenter retrospective review on patients who underwent therapeutic arthroscopy for noninfectious stiffness and anterior shoulder pain following RSA with minimum 1-year follow-up. PROs and ROM were collected pre- and postoperatively. Subjective improvement in ROM and pain, complications, satisfaction, and return to activities were recorded. Data was stratified into two cohorts based on timing of RSA to arthroscopy (1 year or less was considered early intervention and > 1 year late intervention) and variables were analyzed for each cohort., Results: A total of 19 patients met the study criteria (13 patients in early intervention cohort, 6 in late intervention cohort). The average time from the index surgery to arthroscopy was 7.7 ± 2.1 months in the early intervention cohort and 28.3 ± 10.3 months in the late intervention cohort (p=0.004). The overall cohort improved significantly regarding pain (VAS: Δ-1.1, p=0.003), ROM (FF: Δ21°, p=0.002; ER: Δ14°, p=0.010; IR: Δ1 spinal level, p=0.023) and PROs (ASES: Δ18.2, p=0.001; SSV: Δ16.3, p=0.009). The early intervention cohort demonstrated significant improvement in VAS (Δ-1.1, p=0.029), ASES (Δ16.2, p=0.013), SSV (Δ18.5, p=0.008), FF (Δ23º, p=0.016), and ER (Δ15°, p=0.028). The late intervention cohort had significant improvement in VAS (Δ-1.3, p=0.048) and FF (Δ17°, p=0.017). Seventy-four percent of patients in the overall cohort reported decreased pain, 79% improvement in ROM, 68% returned to activities, and 74% were satisfied. There were no complications., Conclusion: Therapeutic arthroscopy for noninfectious stiffness and anterior shoulder pain following RSA improves clinical outcomes in most patients with a low complication risk. Although postoperative outcomes were comparable between groups, functional improvement was more likely in patients who underwent intervention earlier., (Copyright © 2024. Published by Elsevier Inc.)

Background: Significant associations have been established among individual maximum joint and segment velocities with throwing arm kinetics and ball velocity in baseball., Purpose: Investigate how pitches with the fastest maximum joint and segment velocities, in both ideal and non-ideal sequence order, may impact ball velocity and throwing arm kinetics in professional baseball pitchers., Methods: Professional(n=338) pitchers threw 8-12 fastball pitches while evaluated with 3D-motion capture (480 Hz). Pitches (ideal and non-ideal sequence order) were classified as 'High Velocity' for each segment/joint velocity subcategory or 'Population' with any pitch eligible for inclusion in multiple subcategories. Kinematic and kinetic parameters were compared among subgroups with post-hoc regression analysis., Results: Population pitches in ideal sequence order (pitches: 71, pitchers:19) had significantly faster ball velocity than Population pitches in non-ideal order (pitches: 3685, pitchers: 338) (39.0±1.5 vs. 38.2±2.2m/s respectively, p<0.001). Irrespective of sequence, the Lead knee extension velocity subgroup had faster ball velocity (38.9±1.8ms), compared to Population (38.2±2.2m/s) (p<0.001, d=0.4). For non-ideal sequence pitches, for every 1091°/s increase in maximum shoulder internal rotation velocity, shoulder superior force increased by 3.67%Body Weight (BW). Pitches in ideal order, for every 1414°/s in maximum shoulder internal rotation velocity, there was an increase in shoulder superior force by 4.29%BW, elbow medial force by 5.33%BW, and elbow distractive force by 9.33%BW., Conclusion: Proper sequence order plays an important role in maximizing ball velocity with minimal implications for throwing arm kinetics. When throwing non-ideal sequence, increasing maximum lead knee extension velocity positively impacts ball velocity, while increasing other velocities has negative implications on throwing arm kinetics., (Copyright © 2024. Published by Elsevier Inc.)

Background: Failure rates in the management of recurrent posterior shoulder instability remain a concern. Cadaveric studies have established that posterior capsulolabral tears, glenoid retroversion, and posterior glenoid bone loss result in increased posterior humeral head translation in the setting of a posteriorly directed force. A high and flat acromion has recently been associated with posterior instability. Therefore, the purpose of this study was to evaluate a potential stabilizing effect of the acromion against posterior humeral head displacement., Methods: Eight fresh-frozen human cadaveric shoulders were biomechanically tested in a shoulder simulator in the load-and-shift and Jerk test positions. Prior to testing, CT scans were performed to measure native glenoid width, glenoid retroversion, posterior acromial coverage (PAC), sagittal acromial tilt (SAT) and posterior acromial height (PAH). Each specimen underwent four testing conditions using pre-planned and 3D printed cutting and reduction guides: (1) Intact joint, native acromion; (2) Intact joint, severe acromial malalignment (SAT 69°, PAC 47°, PAH 26mm); (3) Intact joint, moderate acromial malalignment (SAT 59°, PAC 57°, PAH 20mm); (4) Intact joint, corrected acromial alignment (SAT 48°, PAC 70°, PAH 11mm). The degree of acromial malalignment and acromial reorientation was chosen based on a previous study that defined acromial anatomy in patients with posterior instability. The humeral head was translated posteriorly until reaching either (1) a peak force of 150N or (2) a maximum posterior displacement of 50% of the glenoid width. Forces (N), displacement (mm) and acromiohumeral contact pressures (kPA) were simultaneously recorded., Results: The force needed to displace the humeral head by 50% of the glenoid width decreased between 23% and 60% in moderate to severe acromial malalignment (high and flat acromion) and increased up to 122% following surgical correction of acromial alignment (low and steep acromion) when compared to the native condition. Correction of acromial alignment significantly increased stability compared to all other scenarios after ≥5% of displacement (p<0.05 for all comparisons). Furthermore, it increased acromiohumeral contact pressures compared with severe malalignment in 30° flexion and with moderate and severe acromial malalignment in 60° flexion (p<0.05 for all comparisons)., Conclusion: The acromion acts as a mechanical buttress to posterior humeral head displacement. Surgical correction of acromial malalignment cannot only effectively restore but increase glenohumeral joint stability. Future studies are needed to define the quantitative relevance of the different factors contributing to posterior shoulder instability and assist in defining the optimal amount of correction needed in an individual situation., (Copyright © 2024. Published by Elsevier Inc.)

Background: Advancements in surgical planning, technique, and prosthesis design have improved adaptation to patient anatomy in reverse total shoulder arthroplasty (rTSA). Postoperative changes in deltoid and rotator cuff muscle length are important and may vary based on preoperative indications and prosthesis selection. The purpose of this study is to demonstrate the changes in deltoid and rotator cuff muscle length for planned rTSA using the spectrum of prosthesis configurations in both GHOA and RCA., Methods: Ten shoulder arthroplasty surgeons used preoperative planning software to plan rTSA cases for 20 subjects (10 GHOA, 10 RCA) following surgical guidelines. Each surgeon planned each case using three prosthesis configurations: (1) 8-mm lateralized glenosphere and 135° neck-shaft angle (135+8), (2) 4-mm lateralized glenosphere and 145° neck-shaft angle (145+4), and (3) 0-mm lateralized glenosphere and 155° neck-shaft angle (155+0). Pre- and postoperative deltoid and rotator cuff muscle lengths and percentage-change were calculated and compared between prosthesis configurations within each indication. Different muscle lines of action were included representing the deltoid, subscapularis, infraspinatus, and teres minor., Results: Preoperatively, the RCA cohort had significantly shorter muscle lines of action in the posterior, lateral, and anterior deltoid (P<0.001), a longer inferior subscapularis (P=0.022), and a longer teres minor (P=0.001) than the GHOA cohort. ANOVA and post-hoc analysis showed that post-planning lengths of each deltoid action line were greater in the 155+0 configuration compared to the 135+8 configuration in the RCA cohort (P<0.001, P=0.003, P=0.032, respectively), and post-planning lengths of the anterior and middle deltoid action lines were also greater for the same comparison in the GHOA cohort (P=0.004 and P=0.017, respectively). There were no significant differences in post-planning deltoid lengths between the 135+8 and 145+4 configurations in either diagnosis cohort (P>0.05). All post-planning rotator cuff muscle lengths (subscapularis, infraspinatus, and teres minor) differed significantly (P<0.001) between all prosthesis configurations in both diagnosis cohorts, with the 135+8 configuration resulting in the longest lengths and the 155+0 configuration resulting in the shortest lengths., Conclusion: Automated preoperative planning software calculates the lengths of muscle action lines, which vary between GHOA and RCA diagnoses. Varying rTSA implant geometries result in predictable differences in deltoid lengthening and rotator cuff shortening. Shoulder prostheses with a more lateralized center of rotation show greater rotator cuff muscle length and similar deltoid muscle length when compared to medialized designs with similar deltoid lengthening. Surgeons can use this software to understand the impact of implant geometry on muscle length., (Copyright © 2024. Published by Elsevier Inc.)

Background: There is significant heterogeneity of outcome measures used in the research of proximal humerus fractures (PHFs). Current evidence regarding the correlation and conversion between the various outcome measures is sparse. This study aims to study the correlation and conversion between the QuickDASH, Constant Score (CS) and Oxford Shoulder Score (OSS) in conservatively treated PHFs., Methods: A prospective cohort study of patients (n=136) with conservatively treated PHFs between August 2017 and April 2020 was conducted. Patients had a minimum follow-up period of 1 year. The three outcome measures (QuickDASH, CS and OSS) were collected at four time points - 6 weeks, 3 months, 6 months and 1 year after injury. Changes in scores across time and correlation between each pair of outcome measures was calculated. A linear regression model was used to derive conversion equations which were then internally validated., Results: A significant strong negative correlation was observed between the OSS and QuickDASH (coefficient: -0.746; p< 0.001), a significant moderate negative correlation was observed between the CS and QuickDASH (coefficient: -0.581; p< 0.001), and a significant moderate positive correlation was observed between the CS and OSS (coefficient: 0.697; p< 0.001). The six derived regression equations showed low mean differences between predicted and actual values (ranging from -1.21 to 2.51). The correlation between actual and predicted values was moderate to strong, ranging from a coefficient of 0.57 in the conversion from the CS to QuickDASH to 0.74 in the conversion from the CS to OSS and OSS to CS., Conclusion: In a cohort of patients with conservatively managed PHFs, moderate to strong correlations were seen in pairwise comparisons of the OSS, QuickDASH and CS. With linear regression analyses, six regression equations were derived to estimate one score from another. On internal validation, there was good agreement between the means of the predicted and actual scores but high within-individual variability. These formulae can help to compare studies with heterogeneous outcome measures and facilitate meta-analyses. However, these equations should not be used to predict one score from another in an individual due to variability when converting individual scores., (Copyright © 2024. Published by Elsevier Inc.)

Background: A failed prior Latarjet procedure can be a challenging situation for both patients and surgeons. The purpose of this study was to report on the techniques and outcomes of patients undergoing revision surgery for the treatment of recurrent anterior shoulder instability after a failed Latarjet procedure., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies which reported on surgical techniques for a failed Latarjet procedure with reporting of clinical outcomes. The search terms used were Latarjet failed. Patients were evaluated based on revision method, patient-reported outcome measures (PROMs), reoperation rates, recurrent instability, overall satisfaction, and return to sports and work., Results: Thirteen studies (all Level IV evidence) met inclusion criteria, including a total of 293 shoulders with a mean age of 28.3 years (range, 16-55 years) at the time of surgery. The mean follow-up time was 50.4 months (range, 14.0-208.0 months) and males accounted for 78.6% of all patients. Revision procedures included open and arthroscopic Eden-Hybinette, distal tibial allograft, iliac crest autograft, osteochondral glenoid allograft, and Bankart repair and/or capsular plication. These may all be viable techniques for revision surgery for a failed Latarjet procedure. All revision procedures showed improvements in PROMs including the Visual Analogue Scale, Constant score, subjective shoulder value, Walch-Duplay, and Rowe scores. Return to sports ranged from 46.1% to 94%. Recurrent instability rates ranged from 0% to 43.8%. Reoperation rates ranged from 0% to 31.3%. Overall satisfaction following a revision procedure ranged from 80% to 100%., Conclusion: A failed Latarjet procedure can be treated with various revision procedures such as open and arthroscopic Eden-Hybinette, distal tibial allograft, iliac crest autograft, osteochondral glenoid allograft, and Bankart repair and/or capsular plication. Overall, surgical management of the failed Latarjet results in improvements in PROMs, pain, return to sports, and decreased recurrent instability with a moderate complication rate., (Copyright © 2024. Published by Elsevier Inc.)

Background: Shoulder proprioception, in which the anterior glenohumeral capsule plays a major role, is critical to the functioning of the shoulder. Consequently, most surgeons either do not resect or reinsert the anterior capsule in shoulder stabilization surgery. In the original open Latarjet procedure (OLP), the anterior capsule is preserved. However, in the all-arthroscopic Latarjet procedure (ALP), complete anterior capsule resection is recommended for better view and access to the coracoid. This raises the question if there is a postoperative difference in proprioception between these 2 procedures. Therefore, the aims of this study are (1) to assess the difference in postoperative proprioception between the operated and healthy sides after the OLP and ALP and (2) to compare the difference in postoperative proprioception on the operated side between the OLP and ALP., Methods: We conducted a retrospective analysis including all patients who underwent a proprioception test after an OLP or ALP at our center. Collected baseline characteristics included sex, age at surgery, operated side, hand dominance, presence of a Hill-Sachs lesion, and time between surgery and the proprioception test. For the test, patients were positioned 1 meter from a wall. They were blindfolded and had to point at a target with a laser pointer taped to their index finger. The laser point was marked and the errors were measured horizontally and vertically and categorized as <4 cm, 4-8 cm, 8-16 cm, and >16 cm., Results: Between April 2022 and April 2024, a total of 91 cases were identified, of which 24 underwent an OLP and 67 underwent an ALP. No significant difference was found in error distribution between the healthy and operated side after both the OLP (P = .30 horizontally, P = .67 vertically) and ALP (P = .20 horizontally, P = .34 vertically). Moreover, there was no significant difference in error distribution between the operated sides after the OLP vs. ALP (P = .52 horizontally; P = .61 vertically)., Conclusion: Our data suggest that postoperative proprioception is not significantly different between the operated and healthy sides after both the OLP and ALP, nor between the operated sides after the OLP vs. after the ALP. This might imply that completely resecting the anterior glenohumeral capsule does not have a detrimental effect on shoulder proprioception. However, these results are multifactorial and prospective studies are needed to better understand the regeneration potential of glenohumeral capsule mechanoreceptors and the importance of the anterior capsule for shoulder proprioception., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)