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Background: Aseptic humeral stem loosening is an uncommon complication of shoulder arthroplasty, and its presence has been considered a highly specific predictor of prosthetic joint infection (PJI). Literature on aseptic humeral stem loosening is sparse. The primary purpose of this study was to determine the rate of aseptic humeral loosening in revision shoulder arthroplasty. Secondarily, we sought to identify predictors of septic and aseptic humeral loosening., Methods: Our institutional revision shoulder arthroplasty database was reviewed. Inclusion criteria were patients with humeral stem loosening as indicated in the operative report. Patient demographics, index surgery and indication, revision surgery and indication, and operative data were recorded. Charts were manually reviewed, and PJI scores were calculated using the International Consensus Meeting scoring criteria. International Consensus Meeting classifications of PJI "unlikely" and "possible" were considered aseptic, and PJI "probable" and "definite" were considered septic. Statistical analysis was performed to determine associations between the abovementioned variables and aseptic humeral loosening., Results: Forty-six patients with 48 shoulders were included in our analysis. Ten cases (21%) were classified as definite PJI, 13 cases (27%) were classified as probable PJI, 4 cases (8%) were classified as possible PJI, and 21 cases (44%) were classified as PJI unlikely. On analysis of stem design, there were no statistically significant associations with aseptic loosening; although, a lack of proximal porous ingrowth surface trended toward higher rates of aseptic loosening in all patients and in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) subgroup analyses. In the index RTSA subgroup, aseptic loosening was associated with female sex (P = .005). Seventeen of 39 shoulders (44%) that underwent either index ATSA or RTSA demonstrated concomitant glenoid loosening. The absence of glenoid loosening was associated with aseptic humeral loosening in index ATSA and RTSA (P < .001)., Conclusion: Fifty-two % of revision shoulder arthroplasty cases with humeral loosening performed at our institution were aseptic. There appear to be distinct demographic and radiographic factors that are more commonly associated with aseptic as opposed to septic humeral loosening. Our data demonstrate that demographic predictors of aseptic loosening of RTSA include female sex. The absence of glenoid component loosening is associated with aseptic humeral loosening and concomitant glenoid loosening is associated with septic humeral loosening. Understanding of these factors can guide the preoperative index of suspicion for PJI in the setting of humeral stem loosening., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Proximal humerus bone loss in shoulder arthroplasty is a difficult problem with limited treatment options. It most commonly occurs in the setting of a previously failed shoulder arthroplasty; however, it is occasionally encountered in cases of primary shoulder arthroplasty. Reconstruction of the proximal humerus is essential for soft tissue tension for implant stability and maximizing function. The purpose of this study was to analyze the clinical and functional outcomes of the allograft prosthetic composite (APC) technique for the management of proximal humeral bone loss in shoulder arthroplasty., Methods: A retrospective review was performed of all patients who underwent primary or revision shoulder arthroplasty using an APC technique with a reverse shoulder arthroplasty prosthesis for the management of proximal humerus bone loss. Data collected included demographic variables, previous shoulder surgeries, indication for APC, type of allograft utilized, fixation technique, and reoperation and revision rates. Patients were contacted by phone and/or email survey to obtain the latest patient-reported functional outcome scores., Results: We identified 14 patients who underwent shoulder arthroplasty using the APC technique with a reverse shoulder arthroplasty prosthesis. One (7.1%) was performed as a primary arthroplasty, and 13 (92.9%) were performed as revision arthroplasties. The indications for APC were instability (21.4%), periprosthetic fracture (21.4%), periprosthetic joint infection (14.3%), humeral component loosening (14.3%), rotator cuff failure (14.3%), fracture sequelae (7.1%), and failed hemiarthroplasty (7.1%). In terms of allograft type, 10 (71.4%) were performed with proximal femur allograft and 4 (28.6%) with proximal humerus allograft. There were 6 patients (42.9%) who sustained postoperative complications, 5 patients (35.7%) had instability, and 1 (7.1%) patient had postoperative wound drainage. All patients with a complication required a revision arthroplasty., Conclusion: The APC technique used to address proximal humerus bone loss in shoulder arthroplasty has a high complication rate with fair patient-reported functional outcome scores. Most of the postoperative complications and reoperations are related to implant instability., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The diagnosis of periprosthetic shoulder infection continues to be difficult to make with confidence. Serum D-dimer has proven to be effective as a screening tool for periprosthetic joint infection in other major joints; however, it has yet to be evaluated for use in periprosthetic shoulder infection., Questions/purposes: (1) Is D-dimer elevated in patients with probable or definite periprosthetic shoulder infections? (2) What is the diagnostic accuracy of D-dimer for periprosthetic shoulder infections? (3) What are the diagnostic accuracies of serum tests (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and D-dimer), singly and in combination?, Methods: Between March 2016 and March 2020, 94 patients undergoing revision total shoulder arthroplasty (anatomic or reverse) at a single institution had preoperative serum testing with CRP, ESR, and D-dimer. These 94 patients were a subset of 189 revision shoulder arthroplasties performed at this institution during the study period who met inclusion criteria and consented to participate. Included patients had a mean ± SD age of 69 ± 8 years, and 56% (53 of 94) were men. Patient records were reviewed to classify patients as definitely having infection, probably having infection, possibly having infection, or unlikely to have an infection, according to the International Consensus Meeting (ICM) definition of periprosthetic shoulder infection. Statistical analyses, including a receiver operating characteristic curve analysis, were performed to quantify the diagnostic value of D-dimer for periprosthetic shoulder infection. Based on the ICM definition, 4% (4 of 94), 15% (14 of 94), 14% (13 of 94), and 67% (63 of 94) of patients had definite, probable, possible, or unlikely periprosthetic shoulder infections., Results: D-dimer was elevated in patients with definite or probable infections (median [range] 661 ng/mL [150 to 8205]) compared with those with possible infections or those who were unlikely to have an infection (263 ng/mL [150 to 3060]; median difference 143 ng/mL [95% CI 40 to 503]; p = 0.01). In the receiver operating characteristic curve analysis, D-dimer had an area under the curve of 0.71 (0.50-0.92), demonstrating weak diagnostic value. A D-dimer level of 598 ng/mL provided a sensitivity and specificity of 61% (95% CI 36% to 82%) and 74% (95% CI 62% to 83%), respectively, for diagnosing a definite or probable infection according to the ICM definitions. The specificity of detecting periprosthetic joint infection (88% [95% CI 79% to 94%]) was high when three positive serum markers (ESR, CRP, and D-dimer) were required, at the expense of sensitivity (28% [95% CI 10% to 53%])., Conclusion: In periprosthetic shoulder infection, D-dimer is elevated. However, similar to other serum tests, it has limited diagnostic utility in identifying patients with periprosthetic shoulder infection. Further work is needed to understand the process by which D-dimer is associated with active infection., Level of Evidence: Level III, diagnostic study., Competing Interests: Each author certifies that neither he or she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Painful glenoid arthrosis following hemiarthroplasty is a common cause of reoperation, and conversion to anatomic total shoulder arthroplasty is one option., Methods: We identified patients who underwent revision of painful hemiarthroplasty to total shoulder arthroplasty over a 15-year period in a single tertiary-care health system. Presurgical and operative data were analyzed for 28 patients who met the inclusion and exclusion criteria. Patients were contacted at a minimum of 2 years' follow-up after revision surgery for functional outcome scores, reoperations, and implant survival., Results: The 2- and 5-year implant survival rates were 93% and 86%, respectively. Functional outcomes were obtained from 21 patients with surviving implants. The mean American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Single Assessment Numerical Evaluation score were 78 ± 20, 2.3 ± 2.6, and 71 ± 24, respectively. The mean Short Form 12 mental and physical scores were 49 ± 10 and 43 ± 9, respectively. Of the patients, 17 (81%) were either satisfied or very satisfied with their outcome. Complications were seen in 10 patients (36%), and 6 patients (21%) required reoperation., Conclusions: Anatomic total shoulder arthroplasty following hemiarthroplasty can achieve successful outcomes and implant survival rates. Given our poor understanding of reverse shoulder arthroplasty longevity, this procedure should remain an option for patients with glenoid arthrosis and an intact rotator cuff., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to report clinical outcomes in patients who underwent revision surgery for glenoid baseplate failure after index reverse shoulder arthroplasty (RSA). Methods: A retrospective review was performed to identify patients from 2010 to 2020 at a single institution who sustained glenoid baseplate failure after RSA and underwent revision surgery. Exclusion criteria included periprosthetic joint infection or lack of minimum 1 year clinical and radiographic follow-up. Included patients were contacted for clinical outcomes (American Shoulder Elbow Surgeons (ASES), Visual Analog Scale (VAS) pain, Single Assessment Numeric Evaluation (SANE) and Patient Satisfaction scores). Results: A total of 24 patients were identified, and 22 out of 24 (92%) patients were available for clinical follow-up at a mean period of 3.4 years after final revision surgery. The mean age was 70 years, and 15 out of 22 (68%) patients were female. A total of 17 patients were revised to RSA, and five patients were revised to hemiarthroplasty. For the 22 included patients, the mean follow-up ASES score was 64.6, VAS pain was 2.4 and SANE was 58%, which were all significantly improved versus pre-revision. In total, 64% of patients were satisfied or completely satisfied. Discussion: Revision surgery after glenoid baseplate failure in RSA yields unpredictable clinical outcomes. Revision to RSA or hemiarthroplasty both resulted in modest functional results with persistent mild pain. [ABSTRACT FROM AUTHOR]

Background: Primary rotator cuff repairs in complex cases (older patient age, larger tear sizes, chronic tears) and revision repairs are at high risk for failure of healing. Purpose: To examine clinical outcomes and healing rates in complex and revision rotator cuff repairs with dermal allograft augmentation. Study Design: Case series; Level of evidence, 4. Methods: A retrospective study was made of cases performed by 3 fellowship-trained surgeons via a uniform technique involving rotator cuff repairs with allograft augmentation. In all cases, a 1.5-mm, human, decellularized dermal graft was tied on top of the tendon at the medial row and compressed to the rotator cuff footprint using a double-row technique. Postoperative magnetic resonance imaging (MRI) was performed at a minimum of 6 months and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and 12-Item Short Form Health Survey scores were collected at a minimum of 2 years postoperatively. Results: A total of 35 patients (23 revision repairs, 12 primary complex repairs) were included. The mean patient age was 57.9 years (range, 41.0-70.5 years). All shoulders had 2-tendon tears (supraspinatus and infraspinatus), and 8 included the upper 50% of the subscapularis. At a minimum of 2 years after surgery (mean, 3.2 years), mean ASES and SANE scores improved from 42.4 and 35.3 to 77.6 and 73.5, respectively (P <.001). In the 23 patients (66%) with postoperative MRI evaluation, 11 (48%) had images showing the tendons were retorn. ASES (89.7 vs 66.4; P =.04) and SANE (84.1 vs 50.5; P =.02) scores were higher in healed patients than those with retears. The retear group had a higher degree of preoperative fatty atrophy of the infraspinatus (P =.024). Conclusion: Double-row arthroscopic repair with dermal allograft augmentation of complex and revision rotator cuff tears led to improved functional outcomes. Approximately half of patients experienced a failure of healing, which was associated with poorer functional results. [ABSTRACT FROM AUTHOR]

Recurrent multidirectional shoulder instability after failed capsular repair/plication, is a challenging treatment problem. The long head of the biceps has been identified as a structure that may be utilized as a checkrein to stop abnormal anterior and inferior translation of the humeral head. The purpose of this study is to analyse the outcomes of biceps suspensionplasty (BS) in the treatment of recurrent shoulder instability. A retrospective review identified patients with recurrent multidirectional instability that underwent BS as part of a revision shoulder stabilization procedure. Clinical records were reviewed for demographics, pain, complications, recurrent instability, reoperations, and range of motion. Patients were also administered ASES/SST/SANE/Rowe and Oxford instability questionnaire at minimum of 2-year clinical follow-up. Five patients (7 shoulders) were included with a mean follow-up of 3.2 years (2–7 years). Patients had an average of 1.6 prior procedures (1–3). Average patient age was 24.2 years (18.7–32.4 years) and all were female. Four shoulders were treated open while 3 were treated arthroscopically with a capsular shift and biceps suspension. Four shoulders also underwent capsular reconstruction with allograft. At final follow-up three shoulders had recurrent inferior subluxation, although all patients considered their shoulders to be much better (4) or somewhat better (3) and none have undergone repeat surgery. In our series of patients, we found BS may be useful as an adjunct to a revision capsular shift or reconstruction. While 42.8% of patients experienced recurrent subluxations, this high-risk population demonstrated encouraging subjective results and avoiding joint arthrodesis in the short-term. [ABSTRACT FROM AUTHOR]

Introduction: High rates of positive Cutibacterium acnes cultures from primary shoulder surgery make positive cultures in the revision surgery setting difficult to interpret. Our goal was to determine concordance between culture and next-generation sequencing techniques for identification of C. acnes from primary shoulder surgery. Methods: Patients undergoing shoulder arthroscopy for rotator cuff tear or primary anatomic shoulder arthroplasty for osteoarthritis were prospectively enrolled. Specimens were sent for culture (aerobic and anaerobic) and next-generation sequencing. For next-generation sequencing, the entire microbial DNA was sequenced in order to identify pathogens within the sample. Results: Our cohort consisted of 90 patients (45 patients in the osteoarthritis group and 45 patients in the rotator cuff tear group). At least one sample was positive for C. acnes in 18 (20%) cases by culture and in 14 (15.6%) cases by next-generation sequencing (p = 0.559). Four (22.2%) of the 18 cases with positive C. acnes cultures also had C. acnes identified by next-generation sequencing (kappa = 0.238). There was no difference in C. acnes identification rates between osteoarthritis and rotator cuff tear groups. Conclusions: There was limited concordance between culture and next-generation sequencing for C. acnes identification. Further studies are needed to determine the potential for next-generation sequencing as a diagnostic tool. [ABSTRACT FROM AUTHOR]

A well-functioning rotator cuff is necessary for successful anatomic total shoulder arthroplasty (TSA). This study evaluated patients who underwent concomitant TSA and rotator cuff repair (RCR) for functional outcomes, revision rates, and predictors of poor results. Retrospective chart review was conducted to identify patients who underwent TSA and RCR. Demographic data, rotator cuff tear and RCR characteristics, range of motion, and radiographs were recorded. Minimum 2-year functional outcomes were obtained. Predictors of reoperation and/or poor clinical results were determined. Fortyfive patients met inclusion criteria (22 high-grade partial-thickness and 23 full-thickness tears). Fourteen (31%) patients were labeled as having a poor result; 8 (18%) patients required reoperation. There was a significant difference between the acromiohumeral interval preoperatively and immediately postoperatively (P=.013). However, at maximum radiographic follow-up, the acromiohumeral interval was not significantly different from preoperative values (P=.86). Patients with a preoperative acromiohumeral interval of less than 8 mm had an increased rate of cuff-related reoperation (P=.003). Although concomitant TSA and RCR is a reasonable consideration, 31% of patients had a poor clinical result. An acromiohumeral interval of less than 8 mm was a predictor of cuff-related reoperation and may be an indication to consider reverse arthroplasty in the setting of joint arthrosis with a rotator cuff tear. [ABSTRACT FROM AUTHOR]

Background: The outcomes of shoulder arthroplasties in younger patients (55 years or younger) are not as reliable compared with those of the general population. Greater risk of revision and higher complication rates in younger patients present direct costs to the healthcare system and indirect costs to the patient in terms of quality of life. Previous studies have suggested an increased demand for shoulder arthroplasties overall, but to our knowledge, the demand in younger patients has not been explored. Questions/purposes: We asked: (1) What was the demand for shoulder arthroplasties between 2002 and 2011 in the United States for all patients and a specific subpopulation of patients who were 55 years old or younger? (2) How is the demand for shoulder arthroplasties in younger patients projected to change through 2030? (3) How is procedural demand projected to change in younger patients through 2030, and specifically, what can we anticipate in terms of hemiarthroplasty volume compared with that of total shoulder arthroplasty? Methods: We used the National Inpatient Sample database to identify primary shoulder arthroplasties performed between 2002 and 2011. A Poisson regression model was developed using the National Inpatient Sample data and United States Census Bureau projections on future population changes to predict estimated national demand for total shoulder arthroplasties and hemiarthroplasties in all patients and in the subpopulation 55 years old or younger. This model was projected until 2030, with associated 95% CIs. We then specifically analyzed the projected demand of hemiarthroplasties and compared this with demand for all arthroplasty procedures in the younger patient population. Results: Demand for shoulder arthroplasties in patients 55 years or younger is increasing at a rate of 8.2% per year (95% CI, 7.06%-9.35%), compared with a growth rate of 12.1% (95% CI, 8.35%-16.02%) per year for patients older than 55 years. In 2002, 15.9% (3587 of 22,617 captured in the National Inpatient Sample) of primary shoulder arthroplasties were performed in patients 55 years old or younger. In 2011, the relative size of the younger patient population had decreased to 11.0% (7001 of 63,784) of all recipients of shoulder arthroplasties. The demand for primary shoulder arthroplasties among younger patients is projected to increase by 333.3% (95% CI, 257.0%-432.5%) from 2011 to 2030. However, in patients older than 55 years demand is projected to increase by 755.4% (95% CI, 380.7%-1511.1%). Therefore, despite the increased predicted demand for shoulder arthroplasties in younger patients, they are predicted to account for only 4% of all recipients by 2030. The rate of hemiarthroplasties in patients 55 years or younger showed a 16.5% decline per year (95% CI, 16.1%-17.1%) from 2002 (53.6% of all arthroplasties) to 2011 (34.2% of all arthroplasties). By 2030, hemiarthroplasties are projected to account for only 23.5% of all shoulder arthroplasties in patients 55 years or younger. Conclusions: The demand for shoulder arthroplasties in younger patients continues to increase in the United States; however, rates of hemiarthroplasties are declining. The demand has substantial implications for future revision arthroplasties, which include the direct healthcare costs of revision arthroplasty, the indirect societal burden of missed productivity owing to time away from work, and the increased burden of the need for qualified surgeons to meet the demand. Despite the increasing rate of arthroplasties performed in younger patients, current and projected demands remain greater for older patients, indicating a disproportionately greater need for shoulder arthroplasties in older patients. This is in contrast to the trends observed in the literature regarding hip and knee arthroplasties that show projected demands to be greater in younger patients. Factors responsible for the difference in demand require further investigation but may be related to changing indications, reported poorer outcomes in younger patients, the increased popularity of reverse shoulder arthroplasties in the elderly, or the evolution of nonarthroplasty options. Level of Evidence: Level III, prognostic study. [ABSTRACT FROM AUTHOR]

The article mentions a study that measured the clinical outcomes of arthroscopic repair of combined tears of the anterior, posterior, and superior glenoid labrum, using validated scoring instruments, presence of complications, and need for revision surgery. It concludes that combined tears of the glenoid labrum constitute a small but significant portion of labral injuries and that arthroscopic repair of these injuries yields good postoperative outcomes and a low rate of recurrent labral injury.