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Aim: Anatomic total shoulder arthroplasty (TSA) is commonly used for glenohumeral osteoarthritis (OA) in patients with an intact rotator cuff. The aim of this study was to quantify advantages and disadvantages of the stemmed and stemless designs in terms of clinical outcome and complications. Methods: A review was developed based on the PRISMA statement and registered on PROSPERO. Inclusion criteria were comparative studies analyzing stemmed vs. stemless TSA in adults with OA. The literature search was performed in PubMed, Web of Science, and Wiley Cochrane Library up to January 2024. Constant and Murley Score (CMS), Range of Motion, and operative time were documented, as well as complications divided into minor and major complications. The Downs and Black’s “Checklist for Measuring Quality” was used to assess risk of bias and quality of evidence. Results: Out of 1876 articles retrieved; 14 were included in the meta-analysis for a total of 1496 patients (51.4% men, 48.6% women). The CMS was 74.8 points in the stemmed group and 76.9 points in the stemless group, with no differences in both overall score and subscales. No differences were found in elevation and abduction, while external rotation was 3.9° higher in the stemless group (p < 0.05) No differences were found in operating time and overall complications. However, deep infections were higher in the stemless group (2.2% vs. 0.8%, p < 0.05). The quality was assessed as poor, fair, good, and excellent in 0, 2, 7, and 5 studies, respectively. Conclusion: Stemless TSA may offer minor advantages in terms of external rotation, although the clinical relevance appears doubtful. On the other hand, a lower deep infection rate was documented for stemmed implants. Overall, stemmed and stemless TSA provided good clinical results, with similar benefits in terms of clinical outcomes and complications. [ABSTRACT FROM AUTHOR]

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. 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. 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). 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. [ABSTRACT FROM AUTHOR]

BACKGROUND: Anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) reliably alleviate pain and restore shoulder function for a variety of indications. However, these procedures are not well-studied in patients with neurocognitive impairment. Therefore, the purpose of this study was to investigate whether patients with dementia or mild cognitive impairment (MCI) have increased odds of surgical or medical complications following arthroplasty. METHODS: The PearlDiver database was queried from 2010 through October 2021 to identify a cohort of patients who underwent either ATSA or RTSA and had a minimum 2-year follow-up. Current Procedural Terminology and International Classification of Diseases codes were used to stratify this cohort into three groups: (1) patients with dementia, (2) patients with MCI, and (3) patients with neither condition. Surgical and medical complication rates were compared among these three groups. RESULTS: The overall prevalence of neurocognitive impairment among patients undergoing total shoulder arthroplasty was 3.0% in a cohort of 92,022 patients. Patients with dementia had increased odds of sustaining a periprosthetic humerus fracture (odds ratio [OR] = 1.46, P

The stemmed anatomic total shoulder arthroplasty is the gold standard in the treatment of glenohumeral osteoarthritis. However, the use of stemless total shoulder arthroplasties has increased in recent years. The number of revision procedures are relatively low, and therefore it has been recommended that national joint replacement registries should collaborate when comparing revision rates. Therefore, we aimed to compare the revision rates of stemmed and stemless TSA used for the diagnosis of glenohumeral osteoarthritis using data from both the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Danish Shoulder Arthroplasty Registry (DSR). We included all patients who were registered in the AOANJRR and the DSR from January 1, 2012, to December 2021 with an anatomic total shoulder arthroplasty used for osteoarthritis. Revision for any reason was used as the primary outcome. We used the Kaplan-Meier method to illustrate the cumulative revision rates and a multivariate cox regression model to calculate the hazard ratios. All analyses were performed separately for data from AOANJRR and DSR, and the results were then reported using a qualitative approach. A total of 13,066 arthroplasties from AOANJRR and 2882 arthroplasties from DSR were included. The hazard ratio for revision of stemmed TSA with stemless TSA as reference, adjusted for age and gender, was 1.67 (95% confidence interval [CI] 1.34-2.09, P <.001) in AOANJRR and 0.57 (95% CI 0.36-0.89, P =.014) in DSR. When including glenoid type and fixation, surface bearing (only in AOANJRR), and hospital volume in the cox regression model, the hazard ratio for revision of stemmed TSA compared to stemless TSA was 1.22 (95% CI 0.85-1.75, P =.286) in AOANJRR and 1.50 (95% CI 0.91-2.45, P =.109) in DSR. The adjusted hazard ratio for revision of total shoulder arthroplasties with metal-backed glenoid components compared to all-polyethylene glenoid components was 2.54 (95% CI 1.70-3.79, P <.001) in AOANJRR and 4.1 (95% CI 1.92-8.58, P <.001) in DSR. Based on data from 2 national shoulder arthroplasty registries, we found no significant difference in risk of revision between stemmed and stemless total shoulder arthroplasties after adjusting for the type of glenoid component. We advocate that metal-backed glenoid components should be used with caution and not on a routine basis. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to systematically review the available level I evidence regarding the impact of tranexamic acid (TXA) on early postoperative outcomes in patients undergoing anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). Methods: A systematic review of the literature through April 2023 was performed to identify level I RCTs examining the use of TXA at the time of primary TSA or RTSA. Results: Among 5 included studies, a total of 435 patients (219 TXA, 216 control) were identified. Superior hematologic outcomes were observed among the TXA cohort, including lower 24-hour drain output (MD −112.70 mL: p < 0.001), lower pre- to postoperative change in hemoglobin (MD: −0.68 g/dL, p < 0.001), and less total perioperative blood loss (MD: −249.56 mL, p < 0.001). Postoperative Visual Analog Scale for pain (VAS-pain) scores were lower in the TXA group, but not significantly (MD: −0.46, p = 0.17). Postoperative blood transfusion was required in 3/219 TXA patients (1.4%) and 7/216 control patients (3.2%) (RR: 0.40, p = 0.16). Conclusion: Perioperative TXA reduces drain output and total blood loss without increasing the risk of adverse events. TXA was not shown to decrease postoperative transfusion rates when compared to placebo controls. Level of Evidence: Level I, meta-analysis. [ABSTRACT FROM AUTHOR]

Background: Glenoid loosening is an issue in anatomic total shoulder arthroplasty (a-TSA). This has been attributed to abnormal glenoid anatomy, common among these patients. Different alternatives have been proposed to tackle glenoid bone loss and restore joint alignment with augmented glenoid implants being increasingly used to deal with this problem. This systematic review aims to evaluate the clinical and radiological outcomes of patients undergoing augmented glenoid a-TSAs. Our hypothesis was that augmented glenoid components will lead to good patient outcomes with a low incidence of complications and revision procedures. Methods: MEDLINE, EMBASE, CENTRAL and CINHAL were searched from inception to February 2022 for information pertaining to outcomes of patients undergoing a-TSA with augmented glenoid implants. Results: Eighteen studies reported on outcomes of 814 a-TSA (800 participants) with a mean follow-up of 3.7 years. Most studies (67%) were Type IV level of evidence. Almost 70% of participants underwent an a-TSA secondary to primary glenohumeral osteoarthritis. Most glenoids were type B2 (73%). Augmented glenoids material was mostly all-polyethylene (81%) with full wedge (45%) and stepped components (38%) designs being the most common. Most studies reported good clinical outcomes. 17 patients (4%) underwent a revision surgery. Conclusions: Our review found that patients undergoing a-TSA with augmented glenoid components report good outcomes at short-to-mid-term follow-up. Further research is warranted to determine if such outcomes remain similar in long term. Level of evidence: Level III, Systematic Review of Therapeutic Studies. [ABSTRACT FROM AUTHOR]

PURPOSE OF REVIEW: Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty. RECENT FINDINGS: The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.

A lesser tuberosity osteotomy (LTO) is commonly performed during total shoulder arthroplasty to access the glenohumeral joint. Healing of the LTO is critical to optimizing the outcome of the procedure and is enhanced by a repair that provides stability and compression across the osteotomy site. The purpose of this article is to describe a technique that uses a tensionable suture construct to repair the LTO during anatomic total shoulder arthroplasty using a stemless humeral component. The technique involves passing a row of high-tensile sutures through bone tunnels lateral to the osteotomy site (transosseous sutures) and another row of sutures through the humeral implant (implant sutures). One limb of each bone tunnel suture is then tied to its corresponding limb of implant suture and the remaining free strands of the tied sutures are manually tensioned and tied to each other. This technique is an efficient and reproducible method for creating compression and stability across the osteotomy site that facilitates bony healing.

Glenoid component loosening remains the most common reason for revision of anatomic total shoulder arthroplasty (aTSA). We assessed early clinical and radiographic outcomes following aTSA using a press-fit short stem and a peripherally enhanced fixation glenoid. 275 consecutive patients with end-stage glenohumeral arthritis and Walch A- or B-type glenoid morphology who underwent primary aTSA in 2017-2018 at two high-volume shoulder arthroplasty institutions were evaluated, and patient-reported outcomes (PROMs) and radiographic findings were studied in those with completed baseline and minimum 2-year follow-up, respectively. Patient demographics, glenoid morphology, body mass index (BMI), Charlson Comorbidity Index (CCI), range of motion, American Shoulder and Elbow Surgeons (ASES) score, and Simple Assessment Numeric Evaluation score were collected. Radiographic analysis of glenoid and humeral components was performed. Multivariable logistic, equal adjacent odds ordinal, and beta regression were respectively used to identify predictors of glenoid radiolucent lines, humeral calcar resorption, and total ASES score. Patients were 43% female, with a mean age of 66, a median BMI of 30, and median follow-up of 28.4 months. ASES and Simple Assessment Numeric Evaluation scores improved by respective medians of 54.4 and 55.0 points, forward elevation by median 35°, and external rotation by median 30° (all P <.001 for preoperative to postoperative change). Postoperative radiographs of 177 cases showed 10 (5.7%) glenoid osteolysis, 51 (28.8%) glenoid radiolucent lines, and 81 (45.8%) calcar resorptions. The follow-up duration (median 40.1 vs. 27.2 months; P <.001), BMI (median 27.5 vs. 30.7; P <.001), and Charlson Comorbidity Index (Q3 0 vs. 1; P =.02) were associated with glenoid osteolysis in bivariate analyses. In multiple logistic regression, surgeon (C vs. A/B) was the only statistically significant predictor of glenoid radiolucent lines [OR 0.27, 95% CI (0.1, 0.8)]. By descending importance, Surgeon C [OR 6.5 (2.0, 20.5)], humeral canal filling ratio [upper vs. lower quartile OR 2.3 (1.3, 4.0)], mediolateral humeral head deviation [upper vs. lower quartile OR 1.9 (1.0, 3.5)], and glenoid osteolysis [OR 13.5 (2.6, 71.6)] significantly predicted greater calcar resorption. Longer follow-up duration marginally statistically significantly predicted lower ASES score [upper vs. lower quartile OR 0.8 (0.6, 1.0)]. Following aTSA with a peripherally enhanced fixation glenoid, pain, range of motion, and patient-reported outcomes significantly improved at a minimum of 2 years with only 5.7% glenoid osteolysis despite heterogeneous preoperative glenoid pathologies. [ABSTRACT FROM AUTHOR]

Primary glenohumeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue because they may be responsible for a deterioration in long-term clinical and radiologic outcomes. The aim of this study was to perform a computed tomographic (CT) analysis of patients who underwent total shoulder arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3-, or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively. We performed a retrospective, single-center study including 62 TSA patients with a preoperative PHS of the glenohumeral joint (31 men, 31 women, 70 ± 9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases), or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up, the CT images were reconstructed in the scapular plane. A PHS index >65% defined persistence. The revision-free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ = 0.58) and strong at final follow-up (ρ = 0.73). Postoperative CT scans on average showed a surgical correction of PHS compared to preoperatively (79% vs. 65% respectively, P <.05) and retroversion (20° vs. 10° respectively, P <.05). At final follow-up, 25 of 62 patients had a persistence in the 2-dimensional (2D) model and 41 of 62 in the corrected 2D model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs. 59%, P <.05). Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow-up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance. [ABSTRACT FROM AUTHOR]

Clinically significant outcome (CSO) benchmarks have been previously established for shoulder arthroplasty by assimilating preoperative diagnoses and arthroplasty types. The purpose of this study was to establish unique CSO thresholds and compare the time-to-achievement of these for reverse shoulder arthroplasty (RSA) for osteoarthritis (GHOA), RSA for rotator cuff arthropathy (RCA), and total shoulder arthroplasty (TSA) for GHOA. Consecutive patients who underwent elective RSA for GHOA, TSA for GHOA, or RSA for RCA between February 2015 and May 2020, with 2-year minimum follow-up, were retrospectively identified from a prospectively maintained single surgeon registry. The American Shoulder and Elbow Surgeons (ASES) score was administered preoperatively and postoperatively at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year timepoints. Satisfaction and subjective overall improvement anchor questionnaires were administered at the time of final follow-up. Distribution-based methods were used to calculate the Minimal Clinically Important Difference (MCID), and anchor-based methods were used to calculate the Substantial Clinical Benefit (SCB) and the Patient Acceptable Symptom State (PASS) for each patient group. Median time to achievement, individual incidence of achievement at each time point, and cumulative incidence of achievement calculated using Kaplan–Meier survival curve analysis with interval censoring were compared between groups for each CSO. Cox-regression analyses were also performed to determine which patient factors were significantly associated with early or delayed achievement of CSOs. There were 471 patients eligible for study analysis: 276 RSA for GHOA, 107 TSA for GHOA, and 88 RSA for RCA. The calculated MCID, SCB, and PASS scores differed for each group. There were no significant differences in median time to achievement of any CSO between groups. Log-rank testing revealed that cumulative achievements significantly differed between groups for MCID (P =.014) but not for SCB (P =.053) or PASS (P =.620). On cox regression analysis, TSA patients had earlier achievement of SCB, whereas TSA and RSA for GHOA patients had earlier achievement of MCID. At 2-years, a significantly higher percentage of RSA for GHOA patients achieved MCID and SCB compared to RSA for RCA (MCID:100%, 95.5%, P =.003, SCB:94.6%, 86.4%, P =.036). Calculated CSO thresholds differ according to preoperative diagnosis and shoulder arthroplasty type. Patients undergoing TSA and RSA for GHOA achieve CSOs earlier than RSA for RCA patients, and a significantly higher percentage of RSA for GHOA patients achieve CSOs by 2 years compared to RSA for RCA patients. [ABSTRACT FROM AUTHOR]

Home health services provide patients with additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complication and reduce health care utilization. The aim of this investigation was to determine if patients assigned home health services following total shoulder arthroplasty (anatomic [TSA] and reverse [RSA]) exhibited lower rates of medical complications, lower health care utilization, and lower cost of care compared with patients not receiving these services. A national insurance database was retrospectively reviewed to identify all patients undergoing primary TSA and RSA from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home without services. We compared medical complication rates, emergency department (ED) visits, readmissions, and 90-day cost of care between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on all outcomes. A total of 1119 patients received home health services and were matched to 11,190 patients who were discharged home without services. There was no significant difference in patients who received home health services compared with those who did not receive home health services with respect to rates of ED visits within 30 days (OR 1.293; P =.0328) and 90 days (OR 1.215; P =.0378), whereas the home health group demonstrated increased readmissions within 90 days (OR 1.663; P <.001). For all medical complications, there was no difference between cohorts. Episode-of-care costs for home health patients were higher than those discharged without these services ($12,521.04 vs. $9303.48; P <.001). Patients assigned home health care services exhibited higher cost of care and readmission rates without a reduction in the rate of complication or early return to the ED. These findings suggest that home health care services should be strongly analyzed on a case-by-case basis to determine if a patient may benefit from its implementation. [ABSTRACT FROM AUTHOR]

Purpose: Stress shielding in short‐stem arthroplasty can cause critical metaphyseal bone loss. If the size and shape of the humeral shaft are important factors, it is unknown whether the shape of the polyethylene component in reverse shoulder arthroplasty (RSA) affects bone stress around or within the stem. We explored the impact of polyethylene shape on humeral and scapular stress distribution using a finite element model. Methods: We developed a shoulder‐specific finite element model. A defined set of muscle forces was applied to simulate movements. An intact rotator cuff state and a superior deficient rotator cuff state were modelled. We used the FX V135 short stem in three conditions: total shoulder arthroplasty (TSA), and RSA with symmetrical and asymmetrical polyethylene (145°/135°). We measured biomechanical markers related to bone stress for different implant sizes. Joint kinematics and the mechanical behaviour of the implant were compared. Results: Rupture of the supraspinatus muscle produced a functionally limited shoulder. The placement of an anatomic TSA with an intact rotator cuff restored function similar to that of a healthy shoulder. RSA in the rotator cuff‐deficient shoulder restored function regardless of stem size and polyethylene shape. While stem size had an impact on the stress distribution in the bone and implant, it did not show significant potential for increasing or decreasing overall stress. For the same stem, stress distribution at the humerus is different between TSA and RSA. Polyethylene shape did not alter the transmission of stress to the bone in RSA. Asymmetric polyethylene produced a greater abduction range of motion. Conclusions: In terms of bone stress distribution, smaller stems seemed more appropriate for TSA, while larger stems may be more appropriate for RSA. Polyethylene shape resulted in different ranges of motion but did not influence bone stress. Level of Evidence: Diagnostic Tests or Criteria; Level IV. [ABSTRACT FROM AUTHOR]

While there has been increased attention to the use of reverse total shoulder arthroplasty (RTSA) to treat rotator cuff intact glenohumeral osteoarthritis (RCIOA) for older age groups, there has not been as precise an assessment of the differences in utilization for female vs. male patients or in specific age groups. Our purpose was to determine if differences existed in the utilization of shoulder arthroplasty to treat RCIOA based on gender and age in North America. Anatomic total shoulder arthroplasty (ATSA) and RTSA cases were queried from the American Academy of Orthopaedic Surgeons Shoulder and Elbow Registry between January 2015 and December 2021. Cases were included if they had a diagnosis of RCIOA, defined by the International Classification of Diseases-10 codes M19.011, M19.012, and M19.019. Cases were stratified by procedure, age, gender, and year of surgery. Chi-square and Fisher's exact tests were calculated to assess the associations between procedure type and patient demographics. There were 2748 (48.06%) ATSA and 2970 (51.94%) RTSA procedures reported to the American Academy of Orthopaedic Surgeons Shoulder and Elbow Registry. There was a significant relationship between procedure type and age group (P <.001) in that ATSA was utilized more frequently than RTSA for patients ages <70 years old, and this relationship reversed for ages ≥ 70 years old. Female patients were more likely to receive RTSA (P <.001). When looking at the relationship between procedure type and gender by age group, both genders were more likely to receive ATSA compared to RTSA for age groups 50-59 and 60-69 (P =.0097 and P =.0005, respectively) but not for other age groups. For patients ≥ 70 years old, both females and males were more likely to receive RTSA, but this relationship did not reach statistical significance (P =.1094). For both genders and ages ≥ 70 years old, there was a significant relationship between year and procedure type (P <.0001) in that RTSA was more commonly utilized in 2017 and onward. When assessing patients with RCIOA, the use of ATSA and RTSA was similar, but for patients 50 to 69 years old, for both genders, the use of ATSA was greater. Although RTSA was more commonly used for both genders in the ≥ 70 years old population, this difference was not significant. Interestingly, for both genders, ages ≥ 70 years old, RTSA was significantly more utilized from 2017 onward. This analysis highlights the influence of age and gender in use of ATSA and RTSA. [ABSTRACT FROM AUTHOR]

The purpose of this study is to retrospectively analyze all primary anatomic total shoulder arthroplasty (aTSA) patients within a multicenter international database of a single prosthesis to identify risk factors for patients with rotator cuff tear (RCT) and aseptic glenoid loosening. To investigate the risk factors for RCT and aseptic glenoid loosening, we retrospectively analyzed all aTSA patients with 2-year minimum follow-up from a multicenter international database of a single platform shoulder system, only excluding patients with a history of revision arthroplasty, infections, and humeral fractures. A univariate/multivariate analysis was conducted to compare primary aTSA patients who had report of: 1) a RCT and/or subscapularis failure and 2) aseptic glenoid loosening/cage glenoid dissociations, to identify the differences in (i) intrinsic patient demographics and comorbidities and (ii) implant and operative parameters. Finally, to adapt our statistical analysis for prospective identification of patients most at-risk for RCT and aseptic glenoid loosening, we stratified the dataset by multiple risk factor combinations and calculated the odds ratio (OR) to determine the impact of accumulating risk factors on the incidence rate of each complication. 122 aTSA shoulders had a RCT for a rate of 3.2% and 123 aTSA shoulders had aseptic glenoid loosening for a rate of 3.3%. The multivariate analysis identified that aTSA patients with RCT were more likely to have previous shoulder surgery (P <.001) and small size glenoids (P =.002). Additionally, the multivariate analysis identified that aTSA patients with aseptic glenoid loosening were more likely to be younger (≤62 years at the time of surgery, P =.001), have small size glenoids (P =.033) and have a nonhybrid glenoids (P <.001). Stratifying patients with multiple risk factors identified multiple aTSA cohorts with ORs >2 for RCT or aseptic glenoid loosening. This analysis of 2699 primary aTSA identified risk factors for the two most common postoperative complications: RCTs and aseptic glenoid loosening. Using these risk factors, we calculated ORs for patient cohorts with multiple risk factors to identify the patients with the greatest risk for each complication. This information is useful to guide the surgeon in their preoperative counseling and potentially mitigate the occurrence of these complications, by indicating patients with these risk-factors for alternative treatment strategies, like rTSA, instead of aTSA. [ABSTRACT FROM AUTHOR]

Revision shoulder arthroplasty (RSA) is an increasingly common procedure that can involve cemented or uncemented humeral implants. Although cement fixation is often advocated, it is not clear if the outcome is comparable to that of press-fit fixation. This study evaluated the survivorship and outcomes of cemented and press-fit humeral components in patients undergoing RSA at our institution. Medical records from adult patients who underwent RSA were reviewed retrospectively. Demographics and surgical data as well as subjective and objective outcome measures were collected. Patients were stratified into 3 groups according to their humeral revision type: cemented, uncemented, and retained stems. A total of 70 RSA patients with an average follow-up of 51.8 ± 43.9 months were included in the analysis: stems were cemented in 18.6% of the patients, uncemented in 61.4%, and retained in 20.0%. There were no significant group differences in patient characteristics. Follow-up data were available for 54 (77.1%) patients 2 or more years after RSA. There were no differences in patient-reported outcome measures among the groups. Active abduction at 1 year was greater for uncemented revisions than for cemented and retained stem components (128.9° ± 49.7° vs. 98.1° ± 55.7° and 100.8° ± 49.9°, respectively; P <.05). Patients in the uncemented and retained stem cohorts had greater strength in forward flexion, abduction, and external rotation than those in the cemented cohort, whereas patients in the cemented stem group had lower internal rotation strength at 1 and 2+ years of follow-up (P <.05). Postoperative radiographs indicated that none of the stems were at risk for failure. However, humeral bone loss was more common among those with uncemented stems (P =.02); in most of the cases, the loss was attributable to stress shielding. Survivorship of the implants did not differ among the groups, ranging from 91.1% to 92.3%. Press-fit humeral components may be a viable option for RSA in patients with adequate humeral bone stock. [ABSTRACT FROM AUTHOR]

Inflammatory arthritis (IA) represents a less common indication for anatomic and reverse total shoulder arthroplasty (TSA) than osteoarthritis (OA). The safety and efficacy of anatomic and reverse TSA in this population has not been as well studied compared to OA. We analyzed the differences in outcomes between IA and OA patients undergoing TSA. Patients who underwent primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) from 2016-2020 were identified in the Premier Healthcare Database. Inflammatory arthritis (IA) patients were identified using International Classification of Diseases, Tenth Revision , diagnosis codes and compared to osteoarthritis controls. Patients were matched in a 1:8 fashion by age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, and patient comorbidities were compared. Multivariate regression was performed following matching to account for any residual confounding and 90-day complications were compared between the 2 cohorts. Descriptive statistics and regression analysis were employed with significance set at P <.05. Prior to matching, 5685 IA cases and 93,539 OA controls were identified. Patients with IA were more likely to be female, have prolonged length of stay and increased total costs (P <.0001). After matching and multivariate analysis, 4082 IA cases and 32,656 controls remained. IA patients were at increased risk of deep wound infection (OR 3.14, 95% CI 1.38-7.16, P =.006), implant loosening (OR 4.11, 95% CI 1.17-14.40, P =.027), and mechanical complications (OR 6.34, 95% CI 1.05-38.20, P =.044), as well as a decreased risk of postoperative stiffness (OR 0.36, 95% CI 0.16-0.83, P =.002). Medically, IA patients were at increased risk of PE (OR 2.97, 95% CI 1.52-5.77, P =.001) and acute blood loss anemia (OR 1.27, 95% CI 1.12-1.44, P <.0001). Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients with multiple increased surgical and postoperative medical complications in patients undergoing aTSA and rTSA. Surgeons should consider these potential complications and employ a multidisciplinary approach in preoperative risk stratification of IA undergoing shoulder replacement. [ABSTRACT FROM AUTHOR]

Machine learning (ML)–based clinical decision support tools (CDSTs) make personalized predictions for different treatments; by comparing predictions of multiple treatments, these tools can be used to optimize decision making for a particular patient. However, CDST prediction accuracy varies for different patients and also for different treatment options. If these differences are sufficiently large and consistent for a particular subcohort of patients, then that bias may result in those patients not receiving a particular treatment. Such level of bias would deem the CDST "unfair." The purpose of this study is to evaluate the "fairness" of ML CDST-based clinical outcomes predictions after anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) for patients of different demographic attributes. Clinical data from 8280 shoulder arthroplasty patients with 19,249 postoperative visits was used to evaluate the prediction fairness and accuracy associated with the following patient demographic attributes: ethnicity, sex, and age at the time of surgery. Performance of clinical outcome and range of motion regression predictions were quantified by the mean absolute error (MAE) and performance of minimal clinically important difference (MCID) and substantial clinical benefit classification predictions were quantified by accuracy, sensitivity, and the F1 score. Fairness of classification predictions leveraged the "four-fifths" legal guideline from the US Equal Employment Opportunity Commission and fairness of regression predictions leveraged established MCID thresholds associated with each outcome measure. For both aTSA and rTSA clinical outcome predictions, only minor differences in MAE were observed between patients of different ethnicity, sex, and age. Evaluation of prediction fairness demonstrated that 0 of 486 MCID (0%) and only 3 of 486 substantial clinical benefit (0.6%) classification predictions were outside the 20% fairness boundary and only 14 of 972 (1.4%) regression predictions were outside of the MCID fairness boundary. Hispanic and Black patients were more likely to have ML predictions out of fairness tolerance for aTSA and rTSA. Additionally, patients <60 years old were more likely to have ML predictions out of fairness tolerance for rTSA. No disparate predictions were identified for sex and no disparate regression predictions were observed for forward elevation, internal rotation score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, or global shoulder function. The ML algorithms analyzed in this study accurately predict clinical outcomes after aTSA and rTSA for patients of different ethnicity, sex, and age, where only 1.4% of regression predictions and only 0.3% of classification predictions were out of fairness tolerance using the proposed fairness evaluation method and acceptance criteria. Future work is required to externally validate these ML algorithms to ensure they are equally accurate for all legally protected patient groups. [ABSTRACT FROM AUTHOR]

Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA. We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA. Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P <.001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P <.001); this difference persisted when stratified by type of prosthesis for first and second TSA. Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type. [ABSTRACT FROM AUTHOR]

Abstract Purpose Stress shielding in short‐stem arthroplasty can cause critical metaphyseal bone loss. If the size and shape of the humeral shaft are important factors, it is unknown whether the shape of the polyethylene component in reverse shoulder arthroplasty (RSA) affects bone stress around or within the stem. We explored the impact of polyethylene shape on humeral and scapular stress distribution using a finite element model. Methods We developed a shoulder‐specific finite element model. A defined set of muscle forces was applied to simulate movements. An intact rotator cuff state and a superior deficient rotator cuff state were modelled. We used the FX V135 short stem in three conditions: total shoulder arthroplasty (TSA), and RSA with symmetrical and asymmetrical polyethylene (145°/135°). We measured biomechanical markers related to bone stress for different implant sizes. Joint kinematics and the mechanical behaviour of the implant were compared. Results Rupture of the supraspinatus muscle produced a functionally limited shoulder. The placement of an anatomic TSA with an intact rotator cuff restored function similar to that of a healthy shoulder. RSA in the rotator cuff‐deficient shoulder restored function regardless of stem size and polyethylene shape. While stem size had an impact on the stress distribution in the bone and implant, it did not show significant potential for increasing or decreasing overall stress. For the same stem, stress distribution at the humerus is different between TSA and RSA. Polyethylene shape did not alter the transmission of stress to the bone in RSA. Asymmetric polyethylene produced a greater abduction range of motion. Conclusions In terms of bone stress distribution, smaller stems seemed more appropriate for TSA, while larger stems may be more appropriate for RSA. Polyethylene shape resulted in different ranges of motion but did not influence bone stress. Level of Evidence Diagnostic Tests or Criteria; Level IV.

Background: Anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) reliably alleviate pain and restore shoulder function for a variety of indications. However, these procedures are not well-studied in patients with neurocognitive impairment. Therefore, the purpose of this study was to investigate whether patients with dementia or mild cognitive impairment (MCI) have increased odds of surgical or medical complications following arthroplasty. Methods: The PearlDiver database was queried from 2010 through October 2021 to identify a cohort of patients who underwent either ATSA or RTSA and had a minimum 2-year follow-up. Current Procedural Terminology and International Classification of Diseases codes were used to stratify this cohort into three groups: (1) patients with dementia, (2) patients with MCI, and (3) patients with neither condition. Surgical and medical complication rates were compared among these three groups. Results: The overall prevalence of neurocognitive impairment among patients undergoing total shoulder arthroplasty was 3.0% in a cohort of 92,022 patients. Patients with dementia had increased odds of sustaining a periprosthetic humerus fracture (odds ratio [OR] = 1.46, P

Background: This study examined trends in inpatient charges for primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), hemiarthroplasty (HA), and revision total shoulder arthroplasty (revTSA) over the past decade. Methods: The New York Statewide Planning and Research Cooperative System was queried for patients undergoing primary aTSA, rTSA, HA, and revTSA from 2010 to 2020 using International Classification of Diseases procedure codes. The primary outcome measured was total charges per encounter. Secondary outcomes included accommodation and ancillary charges, charges covered by insurance, and facility volume. Ancillary charges were defined as fees for diagnostic and therapeutic services and accommodation charges were defined as fees associated with room and board. Subgroup analysis was performed to assess differences between high- and low-volume centers. Results: During the study period, 46,044 shoulder arthroplasty cases were performed: 18,653 aTSA, 4002 HA, 19,253 rTSA, and 4136 revTSA. An exponential increase in rTSA (2428%) and considerable decrease in HA (83.9%) volumes were observed during this period. Total charges were the highest for rTSA and revTSA and the lowest for aTSA. Subgroup analysis of revTSA by indication revealed that total charges were the highest for periprosthetic fractures. For aTSA, rTSA, and HA, high-volume centers achieved significantly lower total charges compared to low-volume centers. Over the study period, total inpatient charges increased by 57.2%, 38.4%, 102.4%, and 68.4% for aTSA, rTSA, HA, and revTSA, outpacing the inflation rate of 18.7%. Conclusion: Total inpatient charges for all arthroplasty types increased dramatically from 2010 to 2020, outpacing inflation rates, but high-volume centers demonstrated greater success at mitigating charge increases compared to low-volume centers.

Background: Despite the importance of the deltoid to shoulder biomechanics, very few studies have quantified the three-dimensional shape, size, or quality of the deltoid muscle, and no studies have correlated these measurements to clinical outcomes after anatomic (aTSA) and/or reverse (rTSA) total shoulder arthroplasty in any statistically/scientifically relevant manner. Methods: Preoperative computer tomography (CT) images from 1057 patients (585 female, 469 male; 799 primary rTSA and 258 primary aTSA) of a single platform shoulder arthroplasty prosthesis (Equinoxe; Exactech, Inc., Gainesville, FL) were analyzed in this study. A machine learning (ML) framework was used to segment the deltoid muscle for 1057 patients and quantify 15 different muscle characteristics, including volumetric (size, shape, etc.) and intensity-based Hounsfield (HU) measurements. These deltoid measurements were correlated to postoperative clinical outcomes and utilized as inputs to train/test ML algorithms used to predict postoperative outcomes at multiple postoperative timepoints (1 year, 2–3 years, and 3–5 years) for aTSA and rTSA. Results: Numerous deltoid muscle measurements were demonstrated to significantly vary with age, gender, prosthesis type, and CT image kernel; notably, normalized deltoid volume and deltoid fatty infiltration were demonstrated to be relevant to preoperative and postoperative clinical outcomes after aTSA and rTSA. Incorporating deltoid image data into the ML models improved clinical outcome prediction accuracy relative to ML algorithms without image data, particularly for the prediction of abduction and forward elevation after aTSA and rTSA. Analyzing ML feature importance facilitated rank-ordering of the deltoid image measurements relevant to aTSA and rTSA clinical outcomes. Specifically, we identified that deltoid shape flatness, normalized deltoid volume, deltoid voxel skewness, and deltoid shape sphericity were the most predictive image-based features used to predict clinical outcomes after aTSA and rTSA. Many of these deltoid measurements were found to be more predictive of aTSA and rTSA postoperative outcomes than patient demographic data, comorbidity data, and diagnosis data. Conclusions: While future work is required to further refine the ML models, which include additional shoulder muscles, like the rotator cuff, our results show promise that the developed ML framework can be used to evolve traditional CT-based preoperative planning software into an evidence-based ML clinical decision support tool. [ABSTRACT FROM AUTHOR]

Severe glenoid deformity has been associated with inferior outcomes and higher complication rates in shoulder arthroplasty. In patients with intact rotator cuffs, there is no clear consensus as to whether anatomic total shoulder arthroplasty (aTSA) or reverse (rTSA) shoulder arthroplasty is the optimal implant in patients with glenoid deformities. The purpose of this study was to compare outcomes of aTSA vs. rTSA in glenoid deformities with greater than 15° retroversion. A retrospective review of a large multicenter database was conducted. All patients who underwent either aTSA or rTSA with an intact rotator cuff and glenoid retroversion 15° or greater with minimum 2-year follow-up were included. Range of motion (ROM), revisions, and patient reported outcomes (PROs) including Constant score, Simple Shoulder test, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, Shoulder Pain and Disability Index), Shoulder Arthroplasty Smart score were collected for all patients pre and postsurgery. Overall, 336 patients were included with 187 receiving an aTSA and 149 rTSA. Reverse patients overall had more comorbidities (75.0% vs. 65.1%; P =.05) and were older (70.9 ± 7.0 vs. 66.3 ± 7.7 years; P <.001). Average follow-up for the aTSA group was 62.0 ± 37.8 months vs. 40.6 ± 22.9 months for rTSA (P <.001). Preoperative retroversion in the anatomic group averaged 20.7 ± 5.5 degrees vs. 24.2 ± 7.7 in reverse patients (P <.001). Both groups demonstrated significant improvements in all PROs and ROM from pre to postsurgery. At latest follow-up aTSA patients had significantly better internal rotation scores (4.9 ± 1.6 vs. 4 ± 1.8; P <.001), external rotation (50 ± 19 vs. 38 ± 18; P <.001) and Shoulder Arthroplasty Smart scores (80.2 ± 13.5 vs. 76.6 ± 11.3; P =.017) but worse pain VAS (1.5 ± 2.3 vs. 0.9 ± 1.9; P =.016). There was no significant difference in abduction or forward elevation or PRO's (Shoulder function, Simple Shoulder test, Constant, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, or Shoulder Pain and Disability Index). Overall revision rate (7% vs. 1%; P =.002) was higher in aTSA. ATSA and rTSA results in significant improvements in patients with glenoid retroversion equal or greater than 15°. Anatomic TSA patients have better postoperative internal rotation score, external rotation, and SAS score but demonstrated no other significant improvement in ROM or PRO. However, there was significantly higher rate of complications and revisions with short-term follow-up following aTSA. [ABSTRACT FROM AUTHOR]

Anatomic total shoulder arthroplasty (aTSA) has historically been considered the gold-standard surgical strategy for patients with end-stage glenohumeral osteoarthritis (GHOA). However, reverse shoulder arthroplasty (RSA) is increasingly used for shoulders with GHOA with an intact rotator cuff due to concerns regarding late cuff failure, anatomic glenoid component loosening, and the impact of bone loss and severe soft-tissue balance in aTSA. With substantial differences in cost between aTSA and RSA, it remains unclear whether the increased risk of late rotator cuff dysfunction in older adults justifies the increased cost of RSA. Therefore, the objective of this study was to utilize a decision-analytic Markov model to 1) quantify the cost-effectiveness of aTSA vs. RSA in patients with GHOA and intact rotator cuff and 2) determine whether an age exists at which RSA is more cost-effective than aTSA. A Markov model was developed to determine accumulated costs and quality-adjusted life years (QALYs) over a lifetime horizon for patients with end-stage GHOA and an intact rotator cuff who undergo either aTSA or RSA. Costs, health utility values, and transition probabilities were derived from the published literature. Sensitivity analyses were performed to identify age cutoffs at which one treatment option is more cost-effective than the other. For the baseline case of a 72-year-old patient, aTSA resulted in 9.43 QALYs and $29,077 in accumulated costs, while RSA produced 9.44 QALYs at a total cost of $31,199 (incremental cost-utility ratio (ICER) comparing rTSA to aTSA: $188,222.94/QALY). Because the ICER for rTSA fell above the $50,000 willingness-to-pay (WTP) threshold, aTSA was determined to be the most cost-effective strategy for patients of this age. Within the age-based sensitivity analysis, RSA was the most cost-effective option for those 67 years of age or younger, while aTSA was the dominant strategy at 77 years and older, resulting in both equal QALYs and lower costs for patients in this age group. Based on this analysis, aTSA is a cost-effective treatment strategy for GHOA with an intact rotator cuff in adults over 67 years of age. For patients between the ages of 67 and 77, RSA resulted in marginally higher QALYs, but this increase was not enough to offset the increased costs to be considered cost-effective. In this model, RSA was cost-effective for individuals 67 years of age or younger. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the impact of a nonopioid multimodal pain protocol on the amount of opioids prescribed, pain level, and complications in patients undergoing total shoulder arthroplasty (TSA) compared to a standard opioid regimen. We retrospectively reviewed 2 consecutive cohorts who underwent either primary anatomic or reverse TSA by a single surgeon. The opioid cohort included patients from 2016 to 2020 who received an intraoperative periarticular injection (Ropivacaine, Epinephrine, and Ketorolac cocktail) and were prescribed Oxycodone/Acetaminophen 5/325 mg on discharge. The nonopioid cohort included patients from 2020 to 2022, consisting of preoperative oral analgesics (Celecoxib, Pregabalin, and Tramadol); intraoperative intravenous Dexamethasone and Acetaminophen and periarticular injection; and postoperative oral Dexamethasone and oral analgesics (Pregabalin, Tizanidine, Magnesium, Ibuprofen, and Acetaminophen). The nonopioid cohort had the option to ask for an opioid prescription postoperatively if needed. Patient-reported outcomes collected included visual analog scale scores for pain and Patient-Reported Outcome Measurement Information System up to 1 year after surgery. Opioid consumption using Morphine Milligram Equivalents were compared up to 3 months postoperatively. There were 232 patients in the opioid and 112 in the nonopioid cohorts, respectively. The nonopioid protocol had lower mean visual analog scale scores at preoperative (6.4 vs. 7.4, P <.05), 10-day (3.5 vs. 4.2, P <.05), and 6-week postoperative time points (2.1 vs. 2.8, P <.05), but no differences between the groups were noted 3 months postoperatively. No differences in Patient-Reported Outcome Measurement Information System–upper extremity, pain interference, or depression were found preoperatively and up to 1 year after surgery. Opioid consumption was lower in the nonopioid cohort at all time periods (P <.01). Patients in the nonopioid cohort had significantly lower Morphine Milligram Equivalents at discharge, 10-day, 6-week, and 90-day time periods (P <.01) when compared to the opioid cohort. When analyzing risk factors for continued opioid prescriptions for the whole cohort, preoperative opioid use within 90 days before surgery (relative risk 4.69 [95% confidence interval 3.18-6.91; P <.01) and current tobacco use (relative risk 2.61 [95% confidence interval 1.50-4.54]; P =.01) were associated with continued refills >30 days. Complications in the perioperative period and 90-day hospital readmissions were not significantly different between the groups. A nonopioid postoperative regimen for patients undergoing TSA significantly reduces opioid prescriptions with similar patient-reported outcomes, subjective pain scores, and without increased complication rates compared to an opioid-only regimen. [ABSTRACT FROM AUTHOR]

Anatomic total shoulder arthroplasty (TSA) using a stemless prosthesis continues to increase in popularity as literature supporting their use grows. Intraoperative findings, however, may require switching from a planned stemless prosthesis to using a stemmed implant, yet literature attempting to understand the incidence and risk factors leading to this outcome is limited. The purpose of this study was to document the incidence of intraoperative change from a planned stemless implant to a stemmed prosthesis and to determine the correlation between the deltoid tuberosity index and this decision. All patients scheduled to undergo TSA with a stemless humeral prosthesis between 2018 and 2023 at a single academic institution were retrospectively reviewed. Sociodemographic data, comorbidities, and preoperative deltoid tuberosity indices (DTI) were collected for review. DTI was used as an approximation for a patient's bone mineral density. Surgeon plan for stemless TSA was verified via saved three-dimensional preoperative plans. Ninety-two patients were scheduled to undergo stemless TSA, 8 (8.70%) of which received a stemmed implant based on intraoperative findings. In all cases, the operative surgeon deemed the metaphyseal bone inadequate to facilitate use of a stemless implant. DTI was significantly higher in the stemless group relative to the stemmed group (1.55 vs. 1.37, P =.0023). Approximately 9% of planned stemless TSA were converted to stemmed TSA due to proximal humerus bone insufficiency based on surgeon assessment at time of surgery. Diminished DTI was noted to be a risk factor. Preoperative planning may be improved by including imaging parameters to assess bone sufficiency (eg, DTI). [ABSTRACT FROM AUTHOR]

Total shoulder arthroplasty (TSA) is a common orthopedic procedure for which there are anatomic TSA (aTSA) and reverse TSA (rTSA) options. The current study aimed to characterize the 2011-2020 utilization trends of aTSA and rTSA as well as assess and compare perioperative outcomes using a large, national, multi-insurance administrative data set. Data were utilized from the 2011 through 2020 M151 PearlDiver database. Trends in usage of aTSA relative to rTSA were characterized. For the more recent years (2015 through 2020), after 1:1 matching of patients based on age, sex, and Elixhauser Comorbidity Index, perioperative outcomes and surgeon volume were compared for the two procedures with univariable and multivariable analyses. From 2011 through 2020, a total of 148,231 TSAs were identified (aTSA 57,680 [38.9%]; rTSA 90,551 [61.1%]). Over this period, the yearly overall incidence of TSAs being performed increased from 5890 to 23,215 (an increase of 394.1%) and the percent of TSA being performed with rTSA increased from 31.4% to 74.9%. The increased percentage of rTSA was accounted for by increased numbers of rTSA, as opposed to decreased aTHA. When assessing patients from the more recent years (2015-2020), those undergoing rTSA were older, more female, and had a higher Elixhauser Comorbidity Index (P <.0001 for each). After matching for these criteria, 33,582 were available from each of the subcohorts for comparing perioperative outcomes. Of these matched patients, those undergoing rTSA (compared to aTSA) were of independently greater odds for: transfusion (odds ratio [OR] 1.92), wound dehiscence (OR 1.54), any adverse event (OR 1.29), sepsis (OR 1.46), acute kidney infection (OR 1.35), pneumonia (OR 1.30), urinary tract infection (OR 1.28), and severe adverse events (OR 1.16). For surgeon volume, there was a long right-tail where the average ± standard deviation was more than twice the median for both rTSA (average: 40.7 ± 78.9; median: 16 [39]) and aTSA (average: 39.2 ± 56.3; median: 18 [39]). From 2011 to 2020, the number of TSAs performed yearly increased by 394.1%, of which rTSA increased from 31.4% to 74.9%. This shows that rTSA has been a disruptive technology in TSA because it has expanded the TSA patient population. There were increased perioperative adverse events associated with rTSA vs. aTSA, which is not explained by patient demographics or comorbidities. Given the rapid adoption of rTSA and the low average annual volume of this procedure performed per surgeon (<7), the effect of surgeon volume on perioperative outcome following rTSA merits further investigation. [ABSTRACT FROM AUTHOR]

Achieving a durable result with anatomic total shoulder arthroplasty (aTSA) in shoulders with glenoid retroversion deformities, specifically Walch B3 glenoid deformities, can be a challenge. In this retrospective series, we report the mid-term clinical and radiographic follow-up of aTSA in patients with B3 glenoids with nonaugmented polyethylene implants. Patients who had undergone aTSA at a single institution by fellowship-trained surgeons between January 2013 and August 2017 with a preoperative computed tomography scan demonstrating a B3 glenoid were identified. All patients underwent aTSA with a lesser tuberosity osteotomy and a nonaugmented all-polyethylene glenoid. Eccentric reaming was performed to achieve near complete seating of the glenoid component with less emphasis on retroversion. Patients were contacted to complete patient-reported outcome scores and radiographic review. Immediate postoperative radiographs were assessed for posterior humeral subluxation measured relative to the axis of the glenoid component and implant seating. Final radiographs were reviewed for glenoid loosening using Lazarus rating and change in posterior humeral subluxation. Twenty-five subjects met inclusion criteria and were available for follow-up. The cohort had a mean age of 65.1 (range: 55-81) years and consisted of 6 females (24%; 6/25). These patients had a mean follow-up of 6.2 years (range: 3.9-8.4). American Shoulder and Elbow Surgeons improved from 38.2 ± 13.2 to 90.0 ± 16.9 (P <.001). Eighty percent (20/25) of these patients were available for radiographic review and had an average Lazarus grade of 1.9 (range: 0-5). There was no change in mean posterior glenohumeral subluxation (4.6% vs. 2.3%; P =.15) relative to their immediate postoperative films. The 12 patients with a Lazarus grade less than 2 had a greater Western Ontario Osteoarthritis of the Shoulder Index (96.9 ± 1.3 vs. 67.4 ± 12.8; P <.001), American Shoulder and Elbow Surgeons (94.0 ± 5 vs. 76.3 ± 16; P =.03), Single Assessment Numeric Evaluation (88.2 ± 8.7% vs. 66.7 ± 15%; P =.02), and satisfaction (98.5 ± 0.7% vs. 79.9 ± 13.2%; P =.002) compared to the 8 patients with a Lazarus grade more than or equal to 2. These 8 patients were more likely to have had severe preoperative biplanar deformity (retroversion >25° and inclination >10°) than the 12 without early glenoid radiolucency (63% [5/8] vs. 17%; P =.04). At mid-term follow-up, aTSA with standard implants for B3 glenoid deformity provides a reliable treatment option for restoration of function and improvement in pain. Mid-term radiographic review demonstrated development of early glenoid component lucencies in shoulders with severe biplanar deformities with associated deterioration in their clinical function. Long-term follow-up is needed to understand the clinical and radiographic outcome durability after aTSA in the setting of a B3 glenoid. [ABSTRACT FROM AUTHOR]

Subscapularis function is critical after anatomic total shoulder arthroplasty (aTSA). Recently, however, a technique has been described that features a chevron or V-shaped subscapularis tendon cut (VT). This biomechanical study compared repair of the standard tenotomy (ST), made perpendicular to the subscapularis fibers, to repair of the novel VT using cyclic displacement, creep, construct stiffness, and load to failure. This biomechanical study used 6 pairs of fresh frozen paired cadaveric shoulder specimens. One specimen per each pair underwent VT, the other ST. Subscapularis tenotomy was performed 1 cm from the insertion onto the lesser tuberosity. For VT, the apex of the V was 3 cm from the lesser tuberosity. After tenotomy, each humerus underwent humeral head arthroplasty. Eight figure-of-8 sutures were used to repair the tenotomy (Ethibond Excel; Ethicon, US LLC). Specimens were cyclically loaded from 2 to 100 N at 45 degrees abduction at a rate of 1 Hz for 3000 cycles. Cyclic displacement, creep, and stiffness and load to failure were measured. Cyclic displacement did not differ significantly between the ST and VT from 1 to 3000 cycles. The difference in displacement between the V-shaped and standard tenotomy at 3000 cycles was 1.57 mm (3.66 ± 1.55 mm vs. 5.1 ± 2.8 mm, P =.31, respectively). At no point was the V-shape tenotomy (VT) >3 mm of average displacement, whereas the standard tenotomy (ST) averaged 3 mm of displacement after 3 cycles. Creep was significantly lower for VT in cycles 1 through 3. For all cycles, stiffness was not significantly different in the VT group compared with the ST group. Load to failure was not statistically significant in the VT compared to the standard tenotomy throughout all cycles (253.2 ± 27.7 N vs. 213.3 ± 76.04 N; P =.25, respectively). The range of load to failure varied from 100 to 301 N for standard tenotomy compared with 216 to 308 N for VT. This study showed that VT and ST demonstrated equivalent stiffness, displacement, and load to failure. VT had the benefit of less creep throughout the first 3 cycles, although there was no difference from cycle 4 to 3000. The VT had equivalent biomechanical properties to the ST at time zero, an important first step in our understanding of the technique. The VT technique warrants further clinical study to determine if the technique has clinical benefits over ST following aTSA. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infections occur in 1%-4% of primary total shoulder arthroplasties (TSAs). Cutibacterium acnes is the most commonly implicated organism and has been shown to persist in the dermis despite use of preoperative antibiotics and standard skin preparations. Studies have shown decreased rates of cultures positive for C acnes with use of preoperative benzoyl peroxide or hydrogen peroxide (H 2 O 2), but even with this positive deep cultures remain common. We sought to determine whether an additional application of H 2 O 2 directly to the dermis following skin incision would further decrease deep culture positivity rates. We performed a randomized controlled trial comparing tissue culture results in primary TSA in patients who received a standard skin preparation with H 2 O 2 , ethanol, and ChloraPrep (CareFusion, Leawood, KS, USA) vs. an additional application of H 2 O 2 to the dermis immediately after skin incision. Given the sexual dimorphism seen in the shoulder microbiome regarding C acnes colonization rates, only male patients were included. Bivariable and multivariable analyses were performed to compare rates of positive cultures based on demographic and surgical factors. Dermal cultures were found to be positive for C acnes at similar rates between the experimental and control cohorts for the initial (22% vs. 28%, P =.600) and final (61% vs. 50%, P >.999) dermal swabs. On bivariable analysis, the rate of positive deep cultures for C acnes was lower in the experimental group, but this difference was not statistically significant (28% vs. 44%, P =.130). However, patients who underwent anatomic TSA were found to have a significantly greater rate of deep cultures positive for C acnes (57% vs. 28%, P =.048); when controlling for this on multivariable analysis, the experimental cohort was found to be associated with significantly lower odds of having positive deep cultures (odds ratio, 0.37 [95% confidence interval, 0.16-0.90], P =.023). There were no wound complications in either cohort. An additional H 2 O 2 application directly to the dermis following skin incision resulted in a small but statistically significant decrease in the odds of having deep cultures positive for C acnes without any obvious adverse effects on wound healing. Given its cost-effectiveness, use of a post-incisional dermal decontamination protocol may be considered as an adjuvant to preoperative use of benzoyl peroxide or H 2 O 2 to decrease C acnes contamination. [ABSTRACT FROM AUTHOR]

Traditional, commercially sourced patient-specific instrumentation (PSI) systems for shoulder arthroplasty improve glenoid component placement but can involve considerable cost and outsourcing delays. The purpose of this randomized controlled trial was to compare the accuracy of glenoid component positioning in anatomic total shoulder arthroplasty (aTSA) using an in-house, point-of-care, 3-dimensionally (3D) printed patient-specific glenoid drill guide vs. standard nonspecific instrumentation. This single-center randomized controlled trial included 36 adult patients undergoing primary aTSA. Patients were blinded and randomized 1:1 to either the PSI or the standard aTSA guide groups. The primary endpoint was the accuracy of glenoid component placement (version and inclination), which was determined using a metal-suppression computed tomography scan taken between 6 weeks and 1 year postoperatively. Deviation from the preoperative 3D templating plan was calculated for each patient. Blinded postoperative computed tomography measurements were performed by a fellowship-trained shoulder surgeon and a musculoskeletal radiologist. Nineteen patients were randomized to the patient-specific glenoid drill guide group, and 17 patients were allocated to the standard instrumentation control group. There were no significant differences between the 2 groups for native version (P =.527) or inclination (P =.415). The version correction was similar between the 2 groups (P =.551), and the PSI group was significantly more accurate when correcting version than the control group (P =.042). The PSI group required a significantly greater inclination correction than the control group (P =.002); however, the 2 groups still had similar accuracy when correcting inclination (P =.851). For the PSI group, there was no correlation between the accuracy of component placement and native version, native inclination, or the Walch classification of glenoid wear (P >.05). For the control group, accuracy when correcting version was inversely correlated with native version (P =.033), but accuracy was not correlated with native inclination or the Walch classification of glenoid wear (P >.05). The intraclass correlation coefficient was 0.703 and 0.848 when measuring version and inclination accuracy, respectively. When compared with standard instrumentation, the use of in-house, 3D printed, patient-specific glenoid drill guides during aTSA led to more accurate glenoid component version correction and similarly accurate inclination correction. Additional research should examine the influence of proper component position and use of PSI on clinical outcomes. [ABSTRACT FROM AUTHOR]

Elderly patients and their surgeons may eschew shoulder arthroplasty due to concerns over patient safety and longevity. The purpose of this study was to review the current literature evaluating the clinical and radiographic outcomes of shoulder arthroplasty performed in patients 80 years and older. A literature search of the Embase, PubMed, Medline, and Cochrane databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating the outcomes of primary and revision anatomic (aTSA) and reverse (RSA) total shoulder arthroplasty in patients 80 years and older were included for analysis. A total of 15 studies evaluating 1685 primary aTSAs, 1170 primary RSAs, 69 RSAs performed for fracture, and 45 revision RSAs were included for review. The postoperative active forward flexion and external rotation ranged from 138° to 150° and 45° to 48° after aTSA and from 83° to 139° and 16° to 47° after RSA, respectively. Postoperative visual analog scale pain scores ranged from 0 to 1.8 after aTSA and from 0 to 1.4 after RSA. Ninety-day mortality ranged from 0% to 3%, and perioperative complications ranged from 0% to 32%. Late complications ranged from 5.6% to 24% for aTSA patients and 3.5% to 29% for patients undergoing RSA for all indications. Common complications included glenoid loosening (0%-18%) and rotator cuff tear (5.6%-10%) after aTSA and scapular notching (0%-40%) and scapular fracture (4%-9.4%) after RSA. Reoperation rates ranged from 0% to 6% after aTSA and from 0% to 13% after RSA. aTSA and RSA in this population are safe and effective, demonstrating low rates of perioperative mortality and reoperation, durability that exceeds patient longevity, satisfactory postoperative range of motion, and excellent pain relief. Late complication rates appear to be similar for aTSA and RSA. [ABSTRACT FROM AUTHOR]

Background: With advancements in the technology, techniques, and biomechanical understanding of shoulder arthroplasty, higher rates of postoperative return to various sports have been seen in the past decade. Purpose: To observe the return-to-golf rate after various types of shoulder arthroplasty (anatomic total shoulder arthroplasty [TSA], hemiarthroplasty [HA], and reverse total shoulder arthroplasty [RSA]) and also to review the protocols for return to golf. Study Design: Scoping review; Level of evidence, 4. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in a search of PubMed, JSTOR, Google Scholar, ScienceDirect, and CORE using the keywords "return to sport,""shoulder arthroplasty,""golf,""TSA,""shoulder arthroplasty,""hemiarthroplasty,""reverse shoulder arthroplasty,""RSA,""sports," and "athlete." Of 145 preliminary results, 10 retrospective studies (n = 178 patients) published between 1998 and 2021 were included in the final analysis. Results: The mean patient age was 65 years. Of the 172 patients with reported return-to-sport rates, the mean return-to-golf rate was 75.8% for all types of shoulder arthroplasty. Of these 172 patients, 107 patients were categorized by type of procedure: Anatomic TSA had the highest return-to-golf rate at 77.6% (49/107), followed by HA at 64.3% (14/107) and RSA at 59.1% (44/107). Four studies commented on return to the full 18 holes of golf, with a return-to-sport timeline ranging from 5 to 6 months postoperatively. One study specified the return-to-golf timeline based on the type of shot and reported the mean number of weeks before putting, chipping, and returning to the course as 20, 22, and 27 weeks, respectively. Two studies that reported on golf playing frequency noted an increase from before to 1 year after TSA, from a mean of 1.6 and 0.7 times per week to 2.0 and 1.7 times per week, respectively. Only 1 study, published in 1998, provided a comprehensive return-to-golf protocol. Conclusion: The return-to-golf rate after shoulder arthroplasty was highest after anatomic TSA (78%) compared with HA (64%) and RSA (59%). The most commonly reported duration before returning to a full 18 holes was 5 to 6 months, but patients returned to putting and chipping earlier. [ABSTRACT FROM AUTHOR]

Background: Patient-reported outcome measures (PROMs) are increasingly used to evaluate outcomes in patients undergoing shoulder arthroplasty. The Patient-Reported Outcome Measures Information System (PROMIS) is popular due to low cost and question burden. Females have been reported to have lower postoperative PROMIS scores after shoulder surgery, but studies have not focused on a dedicated cohort of shoulder arthroplasty patients or examined upstream differences in preoperative scores. This study aimed to characterize sex differences in baseline PROMIS scores among anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) patients. Methods: Data were collected over a 9-month period. Demographics, Charlson Comorbidity Index (CCI), smoking status, BMI, American Shoulder and Elbow Surgeons (ASES) scores, PROMIS Pain, Physical Function (PF), Upper Extremity, Depression, and Anxiety scores, as well as Single Assessment Numeric Evaluation (SANE) scores were collected. Student t-tests were performed to determine correlation with baseline PROMs. A minimal clinically important difference (MCID) of 4 was used to determine if a PROMIS score difference between groups was clinically important. Significance was set as P

Purpose: Accurate glenoid component placement in total shoulder arthroplasty (TSA) remains challenging even with preoperative planning, especially for variable glenoid erosion patterns in the coronal plane. Methods: We retrospectively reviewed 170 primary TSAs in which preoperative planning software was used. After registration of intraoperative bony landmarks, surgeons were blinded to the navigation screen and attempted to implement their plan by simulating placement of a central-axis guide pin: 230 screenshots of simulated guide pin placement were included (aTSA = 66, rTSA = 164). Displacement, error in version and inclination, and overall malposition from the preoperatively-planned target point were stratified by the Favard classification describing superior-inferior glenoid wear: E0 (n = 89); E1 (n = 81); E2 (n = 29); E3(n = 29); E4(n = 2). Malposition was considered > 10° for version/inclination errors or > 4 mm displacement from the starting point. Results: Mean displacement error was 3.5 ± 2.7 mm (aTSA = 2.7 ± 2.3 mm, rTSA = 3.8 ± 2.9 mm), version error was 5.7 ± 4.7° (aTSA = 5.8 ± 4.4°, rTSA = 5.7 ± 4.8°), inclination error was 7.1 ± 5.6 (aTSA = 4.8 ± 4.8°, rTSA = 8.1 ± 5.7°), and malposition rate was 53% (aTSA = 38%, rTSA = 59%). When compared by Favard classification, there were no differences in any measure; when stratified by TSA type, version error differed for rTSAs (P =.038), with E1 having the greatest version error (6.9 ± 5.2°) and E3 the least (4.2 ± 3.4°). When comparing glenoids without wear (E0) and glenoids with superior wear (E2 and E3), the only difference was greater version error in glenoids without wear (6.0 ± 4.9° vs. 4.6 ± 3.7°, P =.041). Conclusions: Glenoid malposition did not differ based on coronal glenoid morphology. Although, malposition was relatively high, suggesting surgeons should consider alternate techniques beyond preoperative planning and standard instrumentation in TSA. Level of evidence III: Retrospective Cohort Study. [ABSTRACT FROM AUTHOR]