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Background: Available surveys that evaluate shoulder strength and pain often combine rotator cuff muscles making the test unable to differentiate subscapularis tears from other pathology including concomitant supraspinatus, infraspinatus tears. The purpose of this study was to validate a subscapularis-specific shoulder survey (Baltimore Orthopedic Subscapularis Score) as a viable clinical outcome assessment through analysis of psychometric properties. Methods: A 5-question survey was given to a study population of 390 patients, 136 of whom had full thickness rotator cuff tears with a minimum score of 5 (better) and a maximum score of 25 (worse). Surveys were given during the initial consultation, preoperative visit, and postoperative visit. Content validity, construct validity, test-retest reliability, responsiveness to change, internal consistency, and minimal clinically important difference using distribution and anchor-based methods were determined for our subscapularis function survey. Results: A high correlation was reported on test-retest reliability (intraclass correlation coefficient = 0.89). An acceptable internal consistency was reported for all patients surveyed (Cronbach alpha = 0.91). Floor and ceiling effects for patients with rotator cuff pathology were minimized (1% for both). Patients with an isolated subscapularis tear scored worse than supraspinatus/infraspinatus tears and exhibited similar dysfunction as patients with a supraspinatus/infraspinatus/subscapularis tear. An acceptable construct validity was reported with subscapularis-involved tears demonstrating higher scores with significance (P 0.8). The minimal clinically important difference using a distribution and anchor-based method was 4.1 and 4.6, respectively. Among patients with rotator cuff tears in this population, a score of 22 or higher predicts a subscapularis tear 75% of the time, in spite of its low overall prevalence. Conclusion: The subscapularis shoulder score demonstrated acceptable psychometric performance for outcomes assessment in patients with rotator cuff disease. This survey can be used as an effective clinical tool to assess subscapularis function.

Background: The Neer classification is among the most widely used systems to describe proximal humerus fractures (PHF) despite the poor interobserver agreement. The purpose of this study was to verify whether or not blinded shoulder surgeons and trainees agree with the authors of articles published in the highest impact-factor orthopedic journals. Methods: All articles regarding PHF published between 2017 and 2019 in the top 10 orthopedic journals as rated by impact factor were searched. Articles were included if the authors used the Neer classification to describe at least 1 PHF in the figures. Figures were extracted without the legend, and X-rays ± computed tomography scan images were included when available. An international survey was conducted among 138 shoulder surgeons who were asked to record the Neer classification for each de-identified radiograph in the publications. The type of fracture mentioned in the legend of the published figure was considered as the gold standard. Results: Survey participants agreed with the published article authors in 55% of cases overall (range 6%-96%, n = 35). The most common response disagreed with the article authors in 13 cases (37%), underestimating the number of parts in 11 of 13 cases. The interobserver agreement between the 138 responders was fair (k = 0.296). There was an association between the percentage of concordant answers and greater experience (number of years of shoulder surgery practice) of the responders (P = .0023). The number of parts, the number or type of available imaging modalities, and the geographic origin of participants did not influence the agreement between responders and authors. Discussion: In more than one-third of cases, specialized shoulder surgeons disagree with article authors when interpreting the Neer classification of de-identified images of PHF in published manuscripts. Morphologic classification of PHF as the sole basis for treatment algorithms and surgical success should be scrutinized.

Introduction: Preoperative axillary nerve palsy is a contraindication to reverse total shoulder arthroplasty (rTSA) due to the theoretical risk of higher dislocation rates and poor functional outcomes. Treatment of fracture-dislocations of the proximal humerus with rTSA is particularly challenging, as these injuries commonly present with concomitant neurologic and soft tissue injury. The aim of the current study was to determine the efficacy of rTSA for this fracture pattern in geriatric patients presenting with occult or profound neurologic injury. Methods: A retrospective case series of all shoulder arthroplasty procedures for proximal humerus fractures from February 2006 to February 2018 was performed. Inclusion criteria were patients aged greater than 65 years at the time of surgery, fracture-dislocations of the proximal humerus, and treatment with rTSA. Patients with preoperative nerve injuries were compared to patients without overt neurologic dysfunction. Forward elevation, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Visual Analog Scale (VAS), and Subjective Shoulder Value (SSV) were obtained at final follow-up. Results: Forty-six rTSA for acute fracture were performed during the study period, 16 patients met the inclusion criteria and 5 (31%) presented with overt preoperative nerve injuries. At mean 3.1 years follow up, there were no postoperative complications including dislocations and final forward elevation was similar between study groups. Patients with overt nerve palsy had higher QuickDASH and VAS scores with lower SSV and self-rated satisfaction. Discussion: In the majority of patients with or without overt nerve injury, rTSA reliably restored overhead function and led to good or excellent patient-rated treatment outcomes. Overt nerve palsy did not lead to higher complication rates, including dislocation. Despite greater disability and less satisfaction, complete or partial nerve recovery can be expected in the majority of patients. Conclusion: Nerve injury following proximal humeral fracture dislocation may not be an absolute contraindication to rTSA.