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Prognostic factors for total shoulder arthroplasty (TSA) clinical outcomes are incompletely understood. This study investigates the associations of preoperative patient, disease-specific, and surgical factors with 1-year postoperative PENN Shoulder Score (PSS) in patients undergoing primary TSA. Cleveland Clinic patients undergoing primary anatomic TSA (aTSA) or reverse TSA (rTSA) for glenohumeral osteoarthritis (GHOA) or rotator cuff tear arthropathy (CTA) between February 2015 and August 2019, and having complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs), were included. Twenty preselected preoperative patient, disease-specific, and surgical factors were used to fit multivariable models for 1-year PSS and its subscores. Of 1427 eligible primary TSAs, 1174 had 1-year follow-up by PROMs (82%), with 1042 analyzed after additional exclusions, including 30% rTSAs for CTA (n = 308), 26% rTSAs for GHOA (n = 275), and 44% aTSAs for GHOA (n = 459). All PROMs showed statistically significant improvements postoperatively, with 89% of patients reaching an acceptable symptom state. Lower 1-year PSS was associated with younger age, female sex, current smoking, chronic pain diagnosis, history of prior surgery, worker's compensation claim, lower preoperative mental health, lower baseline PSS, absence of glenoid bone loss, and diagnosis-arthroplasty type (CTA-rTSA < GHOA-rTSA < GHOA-aTSA). The most important prognostic factors associated with 1-year PSS were diagnosis-arthroplasty type, baseline mental health status, and insurance status. Disease diagnosis, arthroplasty type, and several other baseline factors are strongly and individually associated with PROMs following primary TSA, with patients undergoing aTSA for GHOA demonstrating the highest PROM scores at 1-year follow-up. Patient, disease-specific, and surgical factors can be used to guide postoperative prognosis following primary TSA for improved preoperative patient counseling regarding expected outcomes of these procedures. [ABSTRACT FROM AUTHOR]

Background: Reestablishment of the native footprint during rotator cuff repair has been suggested as an important criterion for optimizing healing potential and fixation strength. Hypothesis: A double-row rotator cuff footprint [...]

Glenoid component loosening remains a common complication following anatomic total shoulder arthroplasty (TSA); however, plain radiographs are unable to accurately detect early implant migration. The purpose of this study was to validate the accuracy of a method of postoperative, three‐dimensional (3D) computed tomography (CT) imaging with metal artifact reduction (MAR) to detect glenoid component migration following anatomic TSA. Tantalum bead markers were inserted into polyethylene glenoid components for implant detection on 3D CT. In‐vitro validation was performed using a glenoid component placed into a scapula sawbone and incrementally translated and rotated, with MAR 3D CT acquired at each test position. Accuracy was evaluated by root mean square error (RMSE). In‐vivo validation was performed on six patients who underwent anatomic TSA, with two postoperative CT scans acquired in each patient and marker‐based radiostereometric analysis (RSA) performed on the same days. Glenoid component migration was calculated relative to a scapular coordinate system for both MAR 3D CT and RSA. Accuracy was evaluated by RMSE and paired Student's t‐tests. The largest RMSE on in‐vitro testing was 0.24 mm in translation and 0.11° in rotation, and on in‐vivo testing was 0.47 mm in translation and 1.04° in rotation. There were no significant differences between MAR 3D CT and RSA measurement methods. MAR 3D CT imaging is capable of quantifying glenoid component migration with a high level of accuracy. MAR 3D CT imaging is advantageous over RSA because it is readily available clinically and can also be used to evaluate the implant‐bone interface. [ABSTRACT FROM AUTHOR]

Background: Posterior glenoid bone loss is commonly associated with primary glenohumeral osteoarthritis. Surgical management of bone loss in anatomic total shoulder arthroplasty (aTSA) remains controversial. We studied the use of a stepped augmented glenoid component for management of Walch B2 and B3 glenoids and compared the radiographic and clinical outcomes at short-term follow-up with those achieved with a non-augmented component of the same design in Walch A1 glenoids.Methods: Ninety-two patients (42 A1, 29 B2, and 21 B3 glenoids) were prospectively followed after aTSA. Sequential 3-dimensional (3D) computed tomography (CT) imaging was performed preoperatively, within 3 months postoperatively with metal artifact reduction (MAR) to define implant position, and at a minimum of 2 years postoperatively with MAR. Scapular 3D registration with implant registration allowed 3D measurement of glenoid implant position, implant shift, and central peg osteolysis (CPO).Results: CPO with or without implant shift occurred in a higher percentage of B3 glenoids treated with the augmented glenoid component (29%) than A1 glenoids treated with a standard component (5%) (p = 0.028). There was no significant difference in the frequency of CPO between B2 glenoids with the augmented component (10%) and A1 glenoids with the standard component. There was no difference in postoperative glenoid component version and inclination between groups. B3 glenoids were associated with more component medialization relative to the premorbid joint line compared with A1 and B2 glenoids (p < 0.001).Conclusions: A stepped augmented glenoid component can restore premorbid glenoid anatomy in patients with asymmetric biconcave glenoid bone loss (Walch B2), with short-term clinical and radiographic results equivalent to those for patients without glenoid bone loss (Walch A1) treated with a non-augmented component. There is a greater risk of CPO in patients with moderate-to-severe B3 glenoid pathology with this stepped augmented glenoid component. Longer follow-up will help define the clinical implications of CPO over time.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate glenoid component position and radiolucency following anatomic total shoulder arthroplasty (TSA) using sequential 3-dimensional computed tomography (3D CT) analysis.Methods: In a series of 152 patients (42 Walch A1, 16 A2, 7 B1, 49 B2, 29 B3, 3 C1, 3 C2, and 3 D glenoids) undergoing anatomic TSA with a polyethylene glenoid component, sequential 3D CT analysis was performed preoperatively (CT1), early postoperatively (CT2), and at a minimum 2-year follow-up (CT3). Glenoid component shift was defined as a change in component version or inclination of ≥3° from CT2 to CT3. Glenoid component central anchor peg osteolysis (CPO) was assessed at CT3. Factors associated with glenoid component shift and CPO were evaluated.Results: Glenoid component shift occurred from CT2 to CT3 in 78 (51%) of the 152 patients. CPO was seen at CT3 in 19 (13%) of the 152 patients, including 15 (19%) of the 78 with component shift. Walch B2 glenoids with a standard component and glenoids with higher preoperative retroversion were associated with a higher rate of shift, but not of CPO. B3 glenoids with an augmented component and glenoids with greater preoperative joint-line medialization were associated with CPO, but not with shift. More glenoid component joint-line medialization from CT2 to CT3 was associated with higher rates of shift and CPO. A greater absolute change in glenoid component inclination from CT2 to CT3 and a combined absolute glenoid component version and inclination change from CT2 to CT3 were associated with CPO. Neither glenoid component shift nor CPO was associated with worse clinical outcomes.Conclusions: Postoperative 3D CT analysis demonstrated that glenoid component shift commonly occurs following anatomic TSA, with increased inclination the most common direction. Most (81%) of the patients with glenoid component shift did not develop CPO. Longer follow-up is needed to determine the relationships of glenoid component shift and CPO with loosening over time.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The purpose of the study was to describe the characteristics and demonstrate proof-of-concept and clinical use of a barium sulfate infused polypropylene radiopaque tissue marker for soft tissue localization and in vivo measurement of lengths and areas. Marker mechanical properties were evaluated by tensile tests. Biocompatibility was evaluated following 8–12 weeks' implantation in a pig model. Proof-of-concept of marker application was performed in a human cadaveric shoulder model, and methods for CT imaging and measurement of dimensions were established. Lastly, the method of clinical use of the markers was described in one patient undergoing arthroscopic rotator cuff repair (RCR). The radiopaque markers had a tensile strength of 28 ±4.7 N and were associated with minimal to mild inflammatory tissue reaction similar to polypropylene control. CT-based measurements showed relatively high precisions for lengths (0.66 mm), areas (6.97 mm2), and humeral orientation angles (2.1°) in the cadaveric model, and demonstrated 19 ±3 mm medio-lateral tendon retraction and 227 ±3 mm2 increase in tendon area in the patient during 26 weeks following RCR. No radiographic leaching, calcification or local adverse events were observed. The radiopaque tissue marker was biocompatible and had adequate strength for handling and affixation to soft tissues using standard suturing techniques. The marker could be used with low-dose, sequential CT imaging to quantitatively measure rotator cuff tendon retractions with clinically acceptable accuracy. We envision the radiopaque tissue marker to be useful for soft tissue localization and in vivo measurement of tissue and organ dimensions following surgery. [ABSTRACT FROM AUTHOR]

Background: Use of 3-dimensional (3D) computed tomography (CT) preoperative planning and patient-specific instrumentation has been demonstrated to improve the accuracy of glenoid implant placement in total shoulder arthroplasty (TSA). The purpose of this study was to compare the accuracy of glenoid implant placement in primary TSA among different types of instrumentation used with the 3D CT preoperative planning.Methods: One hundred and seventy-three patients with end-stage glenohumeral arthritis were enrolled in 3 prospective studies evaluating patient-specific instrumentation and 3D preoperative planning. All patients underwent preoperative 3D CT planning to determine optimal glenoid component and guide pin position based on surgeon preference. Patients were placed into 1 of 5 instrument groups used for intraoperative guide pin placement: (1) standard instrumentation, (2) standard instrumentation combined with use of a 3D glenoid bone model containing the guide pin, (3) use of the 3D glenoid bone model combined with single-use patient-specific instrumentation, (4) use of the 3D glenoid bone model combined with reusable patient-specific instrumentation, and (5) use of reusable patient-specific instrumentation with an adjustable, reusable base. Postoperatively, all patients underwent 3D CT to compare actual versus planned glenoid component position. Deviation from the plan (in terms of orientation and location) was compared across groups on the basis of absolute differences and outlier analysis. Univariable and multivariable comparisons were performed. As the initial analyses showed no significant differences in preoperative factors or in deviation from the plan between Groups 1 and 2 or between Groups 4 and 5 across studies, the final analysis was across 3 major treatment groups: standard instrumentation (Groups 1 and 2), single-use patient-specific instrumentation (Group 3), and reusable patient-specific instrumentation (Groups 4 and 5).Results: In nearly all comparisons, there were no significant differences in the deviation from the plan (absolute differences or outlier frequency) for glenoid implant orientation or location across the 3 major treatment groups.Conclusions: This study did not demonstrate that any type of patient-specific instrumentation resulted in consistent differences in accuracy of glenoid implant placement in primary TSA with 3D CT preoperative planning. Surgeons have multiple patient-specific instrumentation options available for improving accuracy of glenoid implant placement when compared with 2D imaging without patient-specific instrumentation.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Scapular notching is frequently observed following reverse total shoulder arthroplasty (rTSA), although the etiology is not well understood.Methods: Twenty-nine patients with preoperative computed tomography (CT) scans who underwent rTSA with a Grammont design were evaluated after a minimum of 2 years of follow-up with video motion analysis (VMA), postoperative three-dimensional (3D) CT, and standard radiographs. The glenohumeral range of motion demonstrated by the VMA and the postoperative implant location on the CT were used in custom simulation software to determine areas of osseous impingement between the humeral implant and the scapula and their relationship to scapular notching on postoperative CT. Patients with and without notching were compared with one another by univariable and multivariable analyses to determine factors associated with notching.Results: Seventeen patients (59%) had scapular notching, which was along the posteroinferior aspect of the scapular neck in all of them and along the anteroinferior aspect of the neck in 3 of them. Osseous impingement occurred in external rotation with the arm at the side in 16 of the 17 patients, in internal rotation with the arm at the side in 3, and in adduction in 12. The remaining 12 patients did not have notching or osseous impingement. Placing the glenosphere in a position that was more inferior (by a mean of 3.4 ± 2.3 mm) or lateral (by a mean of 6.2 ± 1.4 mm) would have avoided most impingement in the patients' given range of motion. Notching was associated with glenosphere placement that was insufficiently inferior (mean inferior translation, -0.3 ± 3.4 mm in the notching group versus 3.0 ± 2.9 mm in the no-notching group; p = 0.01) or posterior (mean, -0.3 ± 3.5 mm versus 4.2 ± 2.2 mm; p < 0.001). Two-variable models showed inferior and posterior (area under the curve [AUC], 0.887; p < 0.001), inferior and lateral (AUC, 0.892; p < 0.001), and posterior and lateral (AUC, 0.892; p < 0.001) glenosphere positions to be significant predictors of the ability to avoid scapular notching.Conclusions: Osseous impingement identified using patients' actual postoperative range of motion and implant position matched the location of scapular notching seen radiographically. Inferior, lateral, and posterior glenosphere positions are all important factors in the ability to avoid notching. Only small changes in implant position were needed to avoid impingement, suggesting that preoperative determination of the ideal implant position may be a helpful surgical planning tool to avoid notching when using this implant design.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: Estimation of anterior glenoid bone loss is important for surgical decision-making. The purpose of this study was to describe a method for estimating anterior glenoid bone loss.Methods: Thirty-nine cadaveric glenoids were digitized to obtain glenoid geometry. Glenoid bare spot centre, arthroscopic centre, and centre of the inferior glenoid circle relative to the geometric centre were measured. To simulate anterior glenoid bone loss, imaginary sequential osteotomies were created 0°, 22.5°, and 45° to the superior-inferior line in a 3D digitizing programme. Per cent of anterior glenoid bone loss area was calculated as the percentage of defect area relative to the entire area of the glenoid. The relationship between area loss and ratio of bone defect length to the distance from posterior glenoid to various centres was determined.Results: As the ratio of bone defect length to the distance from posterior glenoid to all three centres increased, the per cent area of bone loss increased exponentially. The ratio using the inferior circle centre and arthroscopic centre was highly correlated to the actual glenoid bone loss in all osteotomies (R 2 > 0.90). The ratio using the centre of bare area had the lowest correlation. The ratio of defect length to distance from posterior glenoid to arthroscopic centre greater than 2.4 for 0° and 2.0 for 45° osteotomies results in bone loss area greater than 25 %. The bare area centre had the largest variation. Average bone loss was overestimated when the centre of bare spot was used compared to other centre locations.Conclusion: Per cent of anterior glenoid bone loss can be estimated using the ratio of bone defect length to the distance from posterior glenoid rim to the centre of inferior glenoid circle or arthroscopic centre either preoperatively using 3D CT or arthroscopically which can be useful for determining surgical treatment. [ABSTRACT FROM AUTHOR]

Background: Walch defined the pathologic characteristics of glenohumeral osteoarthritis on the basis of patterns of glenoid morphology and humeral head subluxation. However, it is unclear how pathologic changes evolve over time. The purpose of this study was to determine whether there are common patterns of pathologic progression based on the Walch classification in primary glenohumeral osteoarthritis and if glenoid bone-loss patterns correlate with rotator cuff fatty infiltration.Methods: A retrospective chart review identified 65 shoulders with glenohumeral osteoarthritis for which at least 2 computed tomography (CT) scans had been performed at least 24 months apart. The CT scans were classified using a modification of the Walch classification. The amount and location of glenoid bone loss were measured using a vault model, and rotator cuff fatty infiltration was calculated as a percentage of cross-sectional muscle area.Results: The initial CT scans showed 42 A-type glenoids and 23 B-type glenoids. CT scans made at an average (and standard deviation) of 74 ± 32 months after the initial scans showed that only 8 of the 42 A1 glenoids had evidence of pathologic progression (5 to A2 type and 3 to B type) whereas 17 of 19 B1 glenoids had progressed (15 to B2 and 2 to B3); this difference was significant on univariate and multivariate analysis (p < 0.001). The odds of joint line medialization occurring were 8.1 times higher (95% confidence interval [CI]: 2.1 to 31.4) for B-type glenoids than for A-type glenoids. Among the glenoids that underwent medialization, those classified as B-type showed more medialization over time (estimated change, 0.70 mm/year; p = 0.036), whereas no significant relationship between medialization and time was observed for A-type glenoids (estimated change, 0.013 mm/year; p = 0.95). The median percent fatty infiltration in the infraspinatus muscle was higher in association with B-type glenoids than in association with A-type glenoids on both the initial (14% versus 7%; p < 0.001) and the final follow-up (16% versus 10%; p = 0.003) CT scans.Conclusions: Asymmetric bone loss rarely develops in A1 glenoids, whereas initial posterior translation of the humeral head (B1 glenoids) may be associated with subsequent development and progression of posterior glenoid bone loss over time. Differences in fatty infiltration of the posterior aspect of the rotator cuff were seen between A-type and B-type glenoids, but the clinical relevance of this finding is currently unknown.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Osteoarthritis of the glenohumeral joint has typical patterns of deformity as described by Walch et al. However, more severe glenoid pathology may be difficult to classify. The purpose of this study was to use 3-dimensional computed tomography (3-D CT) imaging analysis to define common pathologic subtypes that can be differentiated from the current Walch classification.Methods: We performed quantitative measurements of premorbid and pathologic anatomy using preoperative 3-D CT scans from 155 cases of advanced glenohumeral osteoarthritis that underwent anatomic or reverse total shoulder arthroplasty. We defined premorbid glenohumeral anatomy on the basis of previously validated methods using 3-D glenoid vault and humeral best-fit circle models including the premorbid glenoid version, joint-line medialization, and humeral-glenoid alignment (HGA). We determined the anatomic features that differentiate new glenoid morphologic subtypes from the existing Walch classification both qualitatively and quantitatively.Results: We defined 2 new glenoid subtypes (B3 and C2) for which the glenoid pathology and humeral alignment were not defined in the original Walch classification. The B3 glenoid has high pathologic retroversion, normal premorbid version, and acquired central and posterior bone loss that, on average, is greater than that of the B2 glenoid. The C2 glenoid is dysplastic with high pathologic retroversion, high premorbid version, and acquired posterior bone loss, giving it the appearance of a biconcave glenoid with posterior translation of the humeral head. This C2 glenoid can be confused with the B2 glenoid.Conclusions: The B3 and C2 patterns have qualitative and quantitative differences that may result in different clinical outcomes than classic B2 or C types; therefore, our findings suggest that these new subtypes should be included in a new or modified classification system. [ABSTRACT FROM AUTHOR]

Purpose: The optimum number of cross-stitches in modified Becker repair for extensor tendon injury is not known. The purpose of this study was to compare the biomechanical characteristics of 1, 2, and 3 cross-stitches in modified Becker extensor repairs. Methods: We used 8 fresh-frozen cadaveric hands (24 fingers). We exposed extensor tendons of the index, middle, and ring fingers over the proximal phalanx, cut them transversely at the mid-portion of zone IV (proximal phalanx), and repaired them in situ with a modified Becker technique with 1, 2, or 3 cross-stitches using 4-0 braided suture. We randomized the tendons within each hand for the number of cross-stitches. Stiffness, yield load, ultimate load, energy absorbed, and gap formation were measured. After a 5 N preload, each repair was cyclically loaded from 5 to 25 N for 30 cycles and from 5 to 35 N for 30 cycles at a rate of 20 mm/min to simulate loads during postoperative rehabilitation. After cyclic loading, the specimens were loaded to failure. Results: The repair with 1 cross-stitch showed superior gap resistance and stiffness during cyclic loading compared with 2 and 3 cross-stitches. One cross-stitch also resulted in higher stiffness and yield strength in load to failure testing. However, 3 cross-stitch configurations displayed higher ultimate strength. All repairs failed by knot slippage. Conclusions: A modified Becker extensor tendon repair with 1 cross-stitch provides superior mechanical properties for loads seen with postoperative rehabilitation compared with 2 and 3 cross-stitches for similar loads. Clinical relevance: These findings may lead to reduced operative time and decreased tendon damage with superior results. [ABSTRACT FROM AUTHOR]