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Background: Biomechanical research demonstrates increased subscapularis abduction range of motion (ROM) when the tendon’s upper two-thirds is repaired over-the-top of the center of rotation during reverse shoulder arthroplasty (RSA). This study compares the clinical outcomes of patients undergoing RSA with over-the-top subscapularis repair (OTTR) to patients without repair. Methods: We retrospectively reviewed 97 consecutive RSAs with either OTTR of the subscapularis (N = 75) or no repair (N = 22). Repair was attempted in all patients but not performed if the subscapularis could not be brought to the over-the-top position in 20° of external rotation (ER) and 30° of abduction. Improvements in ROM were compared to the minimal clinically important difference for RSA. Results: The mean follow-up was 3.8 ± 1.6 years. Demographics were similar between groups. Preoperatively, patients undergoing repair had greater ER when compared to those without repair (15 ± 16° vs. 5 ± 12°, P = .003). Postoperatively, patients undergoing repair had greater forward elevation (132 ± 21° vs. 126 ± 22°, P = .268) and abduction (114 ± 26° vs. 106 ± 23°, P = .193) with both exceeding the minimal clinically important difference (−2.9° and −1.9°, respectively); however, not statistically significant. Patients with repair were more frequently able to reach the small of their back postoperatively (65% vs. 21%, P = .006) but had less improvement in ER (13 ± 20° vs. 24 ± 20°, P = .028). Postoperative outcome scores, complications, and reoperations were similar between groups. Discussion: OTTR of the subscapularis in RSA had similar ROM and outcome scores compared to no repair, but a significantly larger proportion of patients with repair achieved functional internal rotation to the small of the back. ER limitations seen after conventional repair may also apply to this novel technique, but without a corresponding detrimental effect on forward elevation or abduction.

Background: Although substantial motion at the acromioclavicular joint (ACJ) occurs during overhead shoulder motion, the influence of ACJ arthritis on postoperative outcomes of patients undergoing reverse total shoulder arthroplasty (rTSA) is unclear. We assessed the influence of ACJ arthritis, defined by degenerative radiographic changes, and its severity on clinical outcomes after primary rTSA. Methods: We conducted a retrospective review of a prospectively collected shoulder arthroplasty database of patients that underwent primary rTSA with a minimum 2-year clinical follow-up. Imaging studies of included patients were evaluated to assess ACJ arthritis classified by radiographic degenerative changes of the ACJ; severity was based upon size and location of osteophytes. Both the Petersson classification and the King classification (a modified Petersson classification addressing superior osteophytes and size of the largest osteophyte) were used to evaluate the severity of degenerative ACJ radiographic changes. Severe ACJ arthritis was characterized by large osteophytes (≥2 mm). Active range of motion (ROM) in abduction, forward elevation, and external and internal rotation as well as clinical outcome scores (American Shoulder and Elbow Surgeons Shoulder, Constant, Shoulder Pain and Disability Index, simple shoulder test, University of California, Los Angeles scores) were assessed both preoperatively and at the latest follow-up; outcomes were compared based on severity of ACJ arthritis. Multivariable linear regression models were used to determine whether increasing severity of ACJ arthritis was associated with poorer outcomes. Results: A total of 341 patients were included with a mean age of 71 ± 8 years and 55% were female. The mean follow-up was 5.1 ± 2.4 years. Preoperatively, there were no differences in outcomes based on the severity of ACJ pathology. Postoperatively, there were no differences in outcomes based upon the severity of ACJ arthritis except for greater preoperative to postoperative improvement in active internal rotation in patients with normal or grade 1 ACJ arthritis vs. grade 2 and 3 (3 ± 2 vs. 1 ± 2 and 1 ± 3, P = .029). Patients with ACJ arthritis and osteophytes ≥2 mm had less favorable Shoulder Pain and Disability Index scores, corresponding to greater pain (−49.3 ± 21.5 vs. −41.3 ± 26.8, P = .015). On multivariable linear regression, increased severity of ACJ arthritis was not independently associated with poorer postoperative ROM or outcome scores. Conclusion: Overall, our results demonstrate that greater ACJ arthritis severity score is not associated with poorer outcome scores and has minimal effect on ROM. However, patients with the largest osteophytes (≥2 mm) did have slightly worse pain postoperatively. Radiographic presence of high-stage ACJ arthritis should not alter the decision to undergo rTSA.

Background: Both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (RTSA) are being increasingly performed. In the event of a complication necessitating revision, RTSA is more commonly performed in both scenarios. The purpose of this study was to compare clinical outcomes between patients undergoing revision RTSA for failed primary anatomic versus reverse total shoulder arthroplasty. Methods: We performed a retrospective review of a prospective single-institution shoulder arthroplasty database. All revision RTSAs performed between 2007 and 2019 with a minimum 2-year clinical follow-up were initially included. After excluding patients with a preoperative diagnosis of infection, an oncologic indication, or incomplete outcomes assessment, we included 45 revision RTSAs performed for failed primary aTSA and 15 for failed primary RTSA. Demographics, surgical characteristics, active range of motion (external rotation [ER], internal rotation, forward elevation [FE], abduction), outcome scores (American Shoulder and Elbow Surgeons score, Constant Score, Shoulder Pain and Disability Index, Simple Shoulder Test, and University of California, Los Angeles score), and the incidence of postoperative complications was compared between groups. Results: Primary aTSA was most often indicated for degenerative joint disease (82%), whereas primary RTSA was more often indicated for rotator cuff arthropathy (60%). On bivariate analysis, no statistically significant differences in any range of motion or clinical outcome measure were found between revision RTSA performed for failed aTSA vs. RTSA. On multivariate linear regression analysis, revision RTSA performed for failed aTSA vs. RTSA was not found to significantly influence any outcome measure. Humeral loosening as an indication for revision surgery was associated with more favorable outcomes for all four range of motion measures and all five outcome scores assessed. In contrast, an indication for revision of peri-prosthetic fracture was associated with poorer outcomes for three of four range of motion measures (ER, FE, abduction) and four of five outcome scores (Constant, Shoulder Pain and Disability Index, Simple Shoulder Test, University of California, Los Angeles). A preoperative diagnosis of fracture was associated with a poorer postoperative range of motion in ER, FE, and abduction, but was not found to significantly influence any outcome score. However, only two patients in our cohort had this indication. Complication and re-revision rates after revision RTSA for failed primary aTSA and RTSA were 27% and 9% vs. 20% and 14% (P = .487 and P = .515), respectively. Conclusion: Clinical outcomes of patients undergoing revision RTSA for failed primary shoulder arthroplasty did not significantly differ based on whether aTSA or RTSA was initially performed. However, larger studies are needed to definitively ascertain the influence of the primary construct on the outcomes of revision RTSA.

Background: The rate at which patients regain shoulder strength after anatomic and reverse total shoulder arthroplasty (TSA) is unknown. In this study, we aimed to quantify differences in the timeline during which patients gained shoulder strength after primary anatomic and reverse TSA. Methods: We retrospectively reviewed prospectively collected data from 374 shoulders after primary anatomic TSA (aTSA) and 601 shoulders after primary reverse TSA (rTSA). Postoperative improvement in external rotation (ER) strength and forward elevation (FE) strength from baseline was assessed at 3 months, 6 months, 1 year, and 2 years. Percent change in mean shoulder strength between each time point was determined for anatomic and reverse groups separately. A handheld dynamometer was used to assess ER strength with the involved shoulder in 0° ER, 0° abduction, and the elbow in 90° flexion and FE strength with the involved shoulder in the scapular plane at 30° of flexion and 30° of abduction. Results: Both aTSA and rTSA groups ceased to have statistically significant gains in FE strength after 1 year postoperatively. In contrast, patients continued to have statistically significant gains in ER strength between 1 year and 2 years postoperatively after rTSA (P = .001), but not after aTSA (P = .476). Both aTSA and rTSA groups saw improvement in strength in both ER (+32.1% and +51.4%, respectively) and FE (+38.3% and +90.3%, respectively) at 2-year follow-up. The aTSA group’s ER and FE strength increased the most between 3 and 6 months (+16.2% and +35.7%, respectively). In contrast, the rTSA group gained the most ER strength between 6 months and 1 year (+14.8%) and the greatest FE strength between baseline and 3 months (+40.3%). Conclusion: Patients gain ER strength earlier and FE strength later after aTSA compared with rTSA. Most gains in strength occurred in the first year. However, statistically significant gains in shoulder ER strength in the rTSA group continued between 1 year and 2 years postoperatively, suggesting that 2-year follow-up may be inadequate to capture the full benefits of rTSA on shoulder strength. The results of this study provide insight into the timeline of strength recovery after aTSA and rTSA that will help inform patient counseling and future study design.

Background: Rotator cuff tears and glenoid loosening remain the two most common causes for revision after anatomic total shoulder arthroplasty. Oversizing of the humeral head leads to increased contact force across the glenohumeral joint and is hypothesized to contribute to clinical and radiographic failure. The purpose of this study is to compare the rate of radiographic overstuffing between standard short humeral heads and newer extra-short heads with decreased lateral offset. Methods: Fifty-five consecutive anatomic total shoulder arthroplasties performed using extra-short humeral heads were retrospectively reviewed and compared with age- and sex-matched controls receiving standard short heads. A total of 110 postoperative radiographs were analyzed using the Iannotti's perfect circle method to compare the prosthesis' center of rotation (COR) with the native humeral head COR. A difference in the COR of >3.0 mm was considered malpositioned. Malpositioning medially was considered overstuffed, and malpositioning laterally was considered understuffed. The direction of displacement of malpositioned prostheses was categorized using a quadrant system. Furthermore, we used a novel method to evaluate medial and superior overstuffing by measuring the displacement between the anatomic and prosthetic head positions along perpendicular axes. Results: Using the Iannotti's perfect circle method, 56% of heads were malpositioned. Overstuffing occurred more frequently with short heads compared with extra-short heads (47% vs. 4%, P

Background: Little is known about the role of disorders of the acromioclavicular joint (ACJ) and how they relate to complications after reverse shoulder arthroplasty (RSA). The purpose of this study is to compare the severity of ACJ osteoarthritis in patients undergoing RSA with and without postoperative acromial and scapular spine fractures. Methods: A retrospective review was performed to identify all patients who underwent primary RSA between 1/1/2007 and 10/31/2019 with a postoperative acromial or scapular spine stress fracture from a single institution. Patients who underwent RSA with a fracture were compared with an age-, sex-, and preoperative diagnosis-matched control group (1:4 controls) with a minimum 2-year follow-up. We compared demographics, medical comorbidities, and ACJ osteoarthritis between the 2 groups. Preoperative radiographs and 3-dimensional computed tomography scans were evaluated for ACJ osteoarthritis in all patients. The Petersson classification, a modified Petersson classification, location of the osteophytes, subchondral cysts, ACJ space, and size of the largest osteophyte were recorded and compared between the 2 groups. Results: The study included 11 patients who underwent primary RSA (8 women and 3 men) with acromial (6) and scapular spine (5) fractures confirmed radiographically and 44 matched controls (average follow-up 3.1 vs. 4.3 years, P = .17). Average age at surgery was similar between study and control groups (69.6 vs. 70.0 years, P = .86). ACJ osteoarthritis with osteophytes larger than 2 mm was common and similar between the 2 groups (91% of patients with acromial fracture and 66% of controls, P = .15). There was no significant difference in the size or location of the ACJ osteophytes. The Petersson classification was similar between groups. However, the percentage of patients with subchondral ACJ cysts was higher in the fracture group (91% vs. 50%, P = .02), and the percentage of patients with large spanning or fused osteophytes was significantly higher in the fracture group (55% vs. 14%, P = .008). Conclusion: Radiographic ACJ osteoarthritis is common in patients undergoing RSA. Severe ACJ osteoarthritis with completely spanning or fused osteophytes may predispose patients to acromial or scapular spine fractures after RSA.

Background: Accurate glenoid component placement in shoulder arthroplasty is often difficult even with the use of preoperative planning. Computer navigation and patient-specific guides increase component placement accuracy, but which patients benefit most is unknown. Our purpose was to assess surgeons' accuracy in placing a glenoid component in vivo using 3-dimensional preoperative planning and standard instruments among various glenoid wear patterns. Methods: We conducted a retrospective review of 170 primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) performed at a single institution. Commercially available preoperative planning software was used in all arthroplasties with multiplanar 2-dimensional computed tomography and a 3-dimensional implant overlay. After registration of intraoperative bony landmarks to the navigation system, participating surgeons with knowledge of the preoperative plan were blinded to the computer screen and attempted to implement their preoperative plan by simulating placement of a central-axis glenoid guide pin. Two hundred thirty-three screenshots of surgeon's simulated guide pin placement were included. Glenoid displacement, error in version and inclination, and overall malposition from the preoperatively planned target point were stratified by posterior wear status (with [Walch B2 or B3] or without [A1, A2, or B1]) and Walch classification (A1, A2, B1, B2, or B3). The glenoid component was considered malpositioned when version or inclination errors exceeded 10° or the starting point displacement exceeded 4 mm. Results: For rTSA, errors in version were greater for glenoids with posterior wear compared with those without (8.1° ± 5.6° vs. 4.7° ± 4.0°; P 10° compared with those without (31% vs. 8%; P

Background: Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous. Methods: Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests. Results: The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%. Conclusions: Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.

Background: Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this 2-part study was to systematically review each of the most common complications of RSA, limiting each search to publications in 2010 or later. In this part (part I), we examined (1) scapular notching (SN), (2) periprosthetic infection (PJI), (3) mechanical failure (glenoid or humeral component), and (4) neurologic injury (NI). Methods: Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Overall, 113 studies on SN, 62 on PJI, 34 on mechanical failure, and 48 on NI were included in our reviews. Univariate analysis was performed with the χ2 or Fisher exact test. Results: The Grammont design had a higher SN rate vs. all other designs combined (42.5% vs. 12.3%, P < .001). The onlay humeral design had a lower rate than the lateralized glenoid design (10.5% vs. 14.8%, P < .001). The PJI rate was 2.4% for primary RSA and 2.6% for revision RSA. The incidence of glenoid and humeral component loosening was 2.3% and 1.4%, respectively. The Grammont design had an increased NI rate vs. all other designs combined (0.9% vs. 0.1%, P = .04). Conclusions: Focused systematic reviews of the recent literature with a large volume of RSAs demonstrate that with the use of non-Grammont modern prosthesis designs, complications including SN, PJI, glenoid component loosening, and NI are significantly reduced compared with previous studies. As the indications for RSA continue to expand, it is imperative to accurately track the rates and types of complications to justify its cost and increased indications.

Background: Humeral stem lucencies are uncommon after uncemented anatomic total shoulder arthroplasty (aTSA), and their clinical significance is unknown. This study compares clinical outcomes of aTSA with and without humeral stem lucencies. Methods: Two-hundred eighty aTSAs using an uncemented grit-blasted metaphyseal-fit humeral stem between 2005 and 2013 were retrospectively evaluated for radiographic humeral stem lucencies. All shoulders were evaluated at a minimum 5-year follow-up from a multicenter database. Clinical outcomes included range of motion (ROM) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Constant score, University of California–Los Angeles Shoulder Score (UCLA), Simple Shoulder Test (SST), and Shoulder Pain and Disability Index (SPADI) scores. Postoperative radiographs were evaluated and complications were recorded. Results: Two-hundred forty-three humeral stems showed no radiolucent lines. Among the 37 humeral stems with lucent lines, lines were most common in zones 8, 4, 7, and 3. Preoperative ROM and functional outcomes were similar between groups. Postoperative change in outcomes exceeded the minimal clinically important difference (MCID) for all ROM and outcomes in both groups. Postoperative change between groups showed no significant difference in ROM or outcome scores, but improved mean abduction exceeded the MCID in the patients without humeral lines. The complication rate after omitting patients with humeral loosening was higher in patients with humeral lucencies, as was the revision rate. There was also a higher glenoid-loosening rate in patients with humeral lucencies. Conclusion: Humeral lucent lines after uncemented stemmed aTSA have a small negative effect on ROM and functional outcomes compared with patients without lucent humeral lines, which may not be clinically significant. The complication and revision rates were significantly higher in patients with humeral lucencies.

Purpose: This study aimed to evaluate the outcome measures that the current isolated capitellar and trochlear fracture literature has used. Methods: A systematic literature review identified capitellar and/or trochlear fracture treatment articles published between January 1, 2006 and December 31, 2016. Exclusion criteria included review articles, meta-analyses, technique articles, and biomechanical/anatomic studies. Included studies were reviewed for patient demographics and reports of range of motion, outcome measures, satisfaction rate, return to previous level of activity, complication rate, and reoperation rate. The use of different outcome measures was compared among smaller and larger case series and in journals with higher and lower impact factors. Results: Of 285 articles, 45 met inclusion criteria. Mean number of capitellum and/or trochlea fractures per study was 11.3 (mean patient age, 34.6 years). Average follow-up was 29.4 months. Eight outcome measures were used, the most common of which were the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand/Quick–Disabilities of the Arm, Shoulder, and Hand, and American Shoulder and Elbow Surgeons scores. An average of 1.09 outcome measures were reported per study; 15% of studies reported a satisfaction rate. Larger studies were associated with more outcome measures and used the MEPS more often. Studies in journals with an impact factor of 1 or greater had more patients, more reported outcome scores, and higher use of the MEPS compared with studies with an impact factor of less than 1. Conclusions: Capitellum and trochlea fracture studies have major outcome-measure reporting inconsistencies. The MEPS is the most frequently reported measure. Higher-level journals and studies with 5 or more fractures reported more outcome scores. Future studies should include commonly reported outcome measures to allow for cross-study comparison. Type of study/level of evidence: Therapeutic IV. Key words: capitellum fracture, cross-study comparison, MEPS, outcome measures, trochlea fracture

Background Few studies in the literature analyze clinical factors associated with superoptimal and suboptimal forward elevation in primary reverse total shoulder arthroplasty (RTSA). We investigate the functional outcome stratified by shoulder elevation 12 months after primary RTSA and its correlation with selected clinical patient factors. Methods We analyzed prospectively collected data within a comprehensive surgical database on patients who had undergone primary RTSA between June 2004 and June 2013. Two hundred eighty-six shoulders were stratified into 2 groups: group I for shoulders that had achieved at least 145° of active forward elevation 12 months postoperatively (90th percentile of active forward elevation, 29 shoulders) and group II for shoulders that never achieved at least 90° of active forward elevation 12 months postoperatively (10th percentile of active forward elevation, 28 shoulders). Statistical analysis associated independent clinical variables with postoperative motion using univariate analysis followed by logistic regression. Results Active shoulder elevation of at least 90° was achieved 12 months postoperatively in 259 subjects (90%). Upon comparison with group II (