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The editorial "What's New in Musculoskeletal Tumor Surgery" highlights recent advancements in musculoskeletal tumor surgery, focusing on soft-tissue sarcomas, tenosynovial giant cell tumors, prevention of thromboembolic complications, and international collaboration in orthopaedic oncology. The document discusses innovative approaches such as molecular diagnostics, machine learning, immunotherapy, and predictive models for prognosis and treatment planning. It also addresses wound management strategies, surgical techniques for bone sarcomas, and the challenges of managing metastatic bone disease. The editorial emphasizes the importance of personalized treatment planning, subtype-specific approaches, and ongoing research to optimize patient care and outcomes in the field of musculoskeletal tumor surgery. [Extracted from the article]

Staphylococcus aureus is a common cause of bacterial infections of the skin, soft tissues, bones, bloodstream, and respiratory system. When the infection spreads to the joints, it is known as septic arthritis. The shoulder is the third most common location for septic arthritis in adults. Treatment is arthroscopic or open irrigation and debridement, but even after eradicating the bacteria, cartilage and bone destruction can occur. This article describes a patient who developed bilateral septic arthritis of the shoulders shortly after a urinary tract infection, and was treated with a relatively rare reverse shoulder hemiarthroplasty procedure. [ABSTRACT FROM AUTHOR]

The treatment of proximal humeral fractures is controversial, and operative treatment is increasing despite sparse evidence to support any surgical method over another. We present the 5-year results of the DelPhi (Delta-PHILOS) trial, in which the hypothesis was that reverse total shoulder arthroplasty (RTSA) yields better clinical results compared with open reduction and internal fixation (ORIF). The DelPhi trial was a multicenter single-blinded randomized controlled trial comparing RTSA versus ORIF for the treatment of displaced AO/OTA type-B2 and C2 proximal humeral fractures in patients 65 to 85 years of age. One hundred and twenty-four patients were allocated to RTSA (64 patients) or ORIF (60 patients). The primary outcome was the Constant score, and secondary outcomes included the Oxford Shoulder Score, radiographic measurements, and quality of life. The results were reported as the mean difference between the groups, with the 95% confidence interval (CI). The mean age was 75 years, and 90% of the patients were female. Overall, 65 of the 124 patients were available at a minimum of 5 years. The mean Constant score was 71.7 (95% CI, 67.1 to 76.3) for the RTSA group, compared with 58.3 (95% CI, 50.6 to 65.9) for the ORIF group, representing a significant difference of 13.4 (95% CI, 5.2 to 21.7) in favor of RTSA (p = 0.002). Among patients with type-C2 fractures, the mean Constant score was 73.3 (95% CI, 67.5 to 79.2) for the RTSA group and 56.0 (95% CI, 47.4 to 64.7) for the ORIF group, representing a significant difference of 17.3 (95% CI, 7.5 to 27.0) in favor of RTSA (p = 0.001). Patients with type-B2 fractures demonstrated a nonsignificant difference of 8.1 (95% CI, −7.3 to 23.3) in favor of RTSA (p = 0.29). Patients 65 to 74 years of age showed a significant mean difference of 15.7 (95% CI, 4.9 to 26.7) in favor of RTSA (p = 0.006), whereas patients 75 to 85 years of age showed a nonsignificant difference of 10.8 (95% CI, −3.0 to 24.6) in favor of RTSA. In the present study, RTSA was superior to plate fixation for displaced AO/OTA type-B2 and C2 fractures in elderly patients at 5 years. Patients 65 to 74 years of age and patients with type-C2 fractures benefited the most. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background Acquired acromial compromise, including thinning (less than 30% of the normal acromion) or fragmentation resulting from acromiohumeral impingement or previous acromioplasty, is a concern in reverse shoulder arthroplasty (RSA). This condition may lead to shoulder pain and difficulties in arm elevation because of acromial insufficiency fracture. Questions/purposes (1) Do patients with acromial compromise (thinning less than 30% of normal acromion or fragmentation) have worse functional outcome scores, ROM, and strength after RSA compared with patients without acromial compromise? (2) Are patients with acromial compromise at a higher risk of complications such as acromial insufficiency fracture after RSA? (3) Do patients who develop acromial insufficiency fracture have predisposing associated factors and worse clinical outcomes? Methods Between January 1, 2016, and December 31, 2020, we treated 398 patients with RSA, and all patients were considered potentially eligible for this study. Our clinic is part of the orthopaedic department within a tertiary general hospital, serving patients from across the country. Among them, 49% (197 of 398) of patients were excluded for the following reasons: 8% (31 of 398) because of proximal humerus fracture, 5% (19 of 398) because of osteonecrosis, 9% (35 of 398) because of previous infective arthritis, 5% (18 of 398) because of a deformed shoulder, 4% (14 of 398) because of poor general condition after surgery, 3% (12 of 398) because of death, and another 17% (68 of 398) were lost before the minimum study follow-up, leaving 51% (201 of 398) for analysis. A preoperative acromial compromise was defined as follows: (1) thinning of the acromion (< 3 mm), which means a thickness of less than 30% of the normal acromion thickness (8 to 9 mm), and (2) acromial fragmentation. Acromial thickness was measured using a CT scan. The middle portion of the anterolateral acromion, situated lateral to the distal end of the clavicle, was crosschecked using the axial view. Measurements were subsequently performed from both coronal and sagittal views. In all, 29 patients with acromion compromise and 172 without acromion compromise met the inclusion and exclusion criteria. There was no differential loss to follow-up before 2 years between patients with and without acromial compromise in this study (36% [16 of 45] versus 23% [52 of 224]; p = 0.12). We matched patients using propensity score, pairing them in a 1:3 ratio based on gender, age, bone mineral density, diagnosis, previous rotator cuff repair surgery, subscapularis repair or latissimus dorsi transfer performed during surgery, the type of prosthesis used, and follow-up duration. Twenty-three patients with acromial compromise (acromion compromised group) and 69 patients without acromial compromise (normal control group) were matched; the mean 6 SD duration of follow-up was 40 6 22 months in those with acromial compromise and 43 6 19 months the in normal control group. Pre- and postoperative functional outcome scores, ROM, and shoulder strength were compared. Shoulder scaption refers to lifting the arm in the scapular plane, and scaption strength was measured by applying upward force with the arm at 90° while seated, pushing it as far as possible and measured using a handheld myometer. Complications, including acromial insufficiency fracture, scapular notching, dislocation, periprosthetic infection, and overall risk of complication, were analyzed. Acromial insufficiency fracture was diagnosed based on clinical and radiological findings. Clinically, sudden pain and tenderness at the acromion along with reduced shoulder elevation raised acromial insufficiency fracture suspicion. Radiologically, acromion tilt on plain radiograph or fracture line on coronal CT view confirmed diagnosis of acromial insufficiency fracture. Results Comparing both groups, patients with a compromised acromion had no difference in American Shoulder and ElbowSurgeons scores (60612 versus 64612; mean difference -4 [95% CI -11 to 2]; p = 0.16), Constant scores (48 6 10 versus 54 6 12; mean difference -6 [95% CI -13 to 0]; p = 0.06), forward flexion degree (125 6 24 versus 130 6 21; mean difference -5 [95% CI -16 to 6]; p = 0.36), and scaption strength (563 versus 663; mean difference -1 [95% CI -3 to 0]; p = 0.13). Having acromial compromise was not associated with increased risk of overall complications (30% [7 of 23] versus 19% [13 of 69], relative risk 2 [95% CI 1 to 4]; p = 0.26). However, the only complication that was higher in the acromial compromised group was infection (13% [3 of 23] versus 0% [0 of 69], relative risk not available; p = 0.01). Only the lateralized glenoid prosthesis demonstrated negative association with the acromial insufficiency fracture occurrence; no other factors showed an association. The use of lateralized glenoid prostheses was not observed in patients with acromial insufficiency fracture (0% [0 of 7] acromial insufficiency fracture versus 39% [33 of 85] no acromial insufficiency fracture, relative risk 0 [95% CI 0]; p = 0.047). Conclusion In patients with acquired acromial compromise--such as thinning or fragmented acromion because of advanced cuff tear arthropathy or previous acromioplasty--primary RSA resulted in no different functional outcome score, ROM, shoulder strength, and overall complications compared with patients without acromial compromise. Our findings suggest that a thin or fragmented acromion may not necessarily be exclusion criteria for RSA, potentially aiding surgeons in their decision-making process when treating these patients. However, one of the major complications, postoperative infection, is more frequently observed in patients with acquired acromial compromise. Pre- and postoperative caution would be necessary to prevent and detect infection even when short-term outcomes are favorable in this study. Further studies with large cohorts and long-term follow-up durations are needed. Level of Evidence Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Optimizing the function of muscles that cross the glenohumeral articulation in reverse total shoulder arthroplasty (RTSA) is controversial. The current study used a geometric model of the shoulder to systematically examine surgical placement and implant-design parameters to determine which RTSA configuration most closely reproduces native muscle-tendon lengths of the deltoid and rotator cuff. Methods: A geometric model of the glenohumeral joint was developed and adjusted to represent small, medium, and large shoulders. Muscle-tendon lengths were assessed for the anterior deltoid, middle deltoid, posterior deltoid, and supraspinatus from 0 to 90° of scaption; for the subscapularis from 0° to 60° of internal rotation (IR) and 0° to 60° of scaption; for the infraspinatus from 0° to 60° of external rotation (ER) and 0° to 60° of scaption; and for the teres minor from 0° to 60° of ER at 90° of scaption. RTSA designs were virtually implanted using the following parameters: (1) surgical placement with a centered or inferior glenosphere position and a humeral offset of 0, 5, or 10mmrelative to the anatomic neck plane, (2) implant design involving a glenosphere size of 30, 36, or 42 mm, glenosphere lateralization of 0, 5, or 10 mm, and humeral neck-shaft angle of 135°, 145°, or 155°. Thus, 486 RTSA-shoulder size combinations were analyzed. Linear regression assessed the strength of association between parameters and the change in each muscletendon length from the native length. Results: The configuration that most closely restored anatomic muscle-tendon lengths in a small shoulder was a 30-mm glenosphere with a centered position, 5 mm of glenoid lateralization, 0 mm of humeral offset, and a 135° neck-shaft angle. For a medium shoulder, the corresponding combination was 36mm, centered, 5mm, 0mm, and 135°. For a large shoulder, it was 30mm, centered, 10mm, 0mm, and 135°. The most important implant-design parameter associated with restoration of native muscle-tendon lengths was the neck-shaft angle, with a 135° neck-shaft angle being favored (b = 0.568 to 0.657, p < 0.001). Themost important surgical parameter associated with restoration of nativemuscle-tendon lengths was humeral offset, with a humeral socket placed at the anatomic neck plane being favored (b = 0.441 to 0.535, p < 0.001). Conclusions: A combination of a smaller, lateralized glenosphere, a humeral socket placed at the anatomic neck plane, and an anatomic 135° neck-shaft angle best restored native deltoid and rotator cuff muscle-tendon lengths in RTSA. Clinical Relevance: This study of surgical and implant factors in RTSA highlighted optimal configurations for restoration of native muscle-tendon lengths of the deltoid and rotator cuff, which has direct implications for surgical technique and implant selection. Additionally, it demonstrated the most influential surgical and implant factors with respect to muscletendon lengths, which can be used to aid intraoperative decision-making. [ABSTRACT FROM AUTHOR]

Background: This study aimed to identify implant positioning parameters and patient factors contributing to acromial stress fractures (ASFs) and scapular spine stress fractures (SSFs) following reverse shoulder arthroplasty (RSA). Methods: In a multicenter retrospective study, the cases of patients who underwent RSA from June 2013 to May 2019 and had aminimum3-month follow-up were reviewed. The study involved 24 surgeons, from 15 U.S. institutions, who were members of the American Shoulder and Elbow Surgeons (ASES). Study parameters were defined through the Delphi method, requiring 75% agreement among surgeons for consensus. Multivariable logistic regression identified factors linked to ASFs and SSFs. Radiographic data, including the lateralization shoulder angle (LSA), distalization shoulder angle (DSA), and lateral humeral offset (LHO), were collected in a 2:1 control-to-fracture ratio and analyzed to evaluate their association with ASFs/SSFs. Results: Among 6,320 patients, the overall stress fracture rate was 3.8% (180 ASFs [2.8%] and 59 SSFs [0.9%]). ASF risk factors included inflammatory arthritis (odds ratio [OR] = 2.29, p < 0.001), a massive rotator cuff tear (OR = 2.05, p = 0.010), osteoporosis (OR = 2.00, p < 0.001), prior shoulder surgery (OR = 1.82, p < 0.001), cuff tear arthropathy (OR = 1.76, p = 0.002), female sex (OR = 1.74, p = 0.003), older age (OR = 1.02, p = 0.018), and greater total glenoid lateral offset (OR = 1.06, p = 0.025). Revision surgery (versus primary surgery) was associated with a reduced ASF risk (OR = 0.38, p = 0.019). SSF risk factors included female sex (OR = 2.45, p = 0.009), rotator cuff disease (OR = 2.36, p = 0.003), osteoporosis (OR = 2.18, p = 0.009), and inflammatory arthritis (OR = 2.04, p = 0.024). Radiographic analysis of propensity score-matched patients showed that a greater increase in the LSA (DLSA) from preoperatively to postoperatively (OR = 1.42, p = 0.005) and a greater postoperative LSA (OR = 1.76, p = 0.009) increased stress fracture risk, while increased LHO (OR = 0.74, p = 0.031) reduced it. Distalization (DDSA and postoperative DSA) showed no significant association with stress fracture prevalence. Conclusions: Patient factors associated with poor bone density and rotator cuff deficiency appear to be the strongest predictors of ASFs and SSFs after RSA. Final implant positioning, to a lesser degree, may also affect ASF and SSF prevalence in at-risk patients, as increased humeral lateralization was found to be associated with lower fracture rates whereas excessive glenoid-sided and global lateralization were associated with higher fracture rates. [ABSTRACT FROM AUTHOR]

Background: Metallic lateralized-offset glenoid reverse shoulder arthroplasty (RSA) for cuff tear arthropathy combines the use of a metallic augmented baseplate with a metaphyseally oriented short stem design that can be applied at a 135° or 145° neck-shaft angle, leading to additional lateralization on the humeral side. Lateralization of the center of rotation decreases the risk of inferior scapular notching and improves external rotation, deltoid wrapping, residual rotator cuff tensioning, and prosthetic stability1-4. Metallic increased-offset RSA (MIO-RSA) achieves lateralization and corrects inclination and retroversion while avoiding graft resorption and other complications of bony increased-offset RSA (BIO-RSA)5-8. Reducing the neck-shaft angle from the classical Grammont design, in combination with glenoid lateralization, improves range of motion9,10 by reducing inferior impingement during adduction at the expense of earlier superior impingement during abduction2,11. Lädermann et al.12 investigated how different combinations of humeral stem and glenosphere designs influence range of motion and muscle elongation. They assessed 30 combinations of humeral components, as compared with the native shoulder, and found that the combination that allows for restoration of >50% of the native range of motion in all directions was a 145° onlay stem with a concentric or lateralized tray in conjunction with a lateralized or inferior eccentric glenosphere. In addition, the use of a flush-lay or a slight-onlay stem design (like the one utilized in the presently described technique) may decrease the risk of secondary scapular spine fracture13,14. The goal of this prosthetic design is to achieve an excellent combination of motion and stability while reducing complications. Description: This procedure is performed via a deltopectoral approach with the patient in the beach-chair position under general anesthesia combined with a regional interscalene nerve block. Subscapularis tenotomy and capsular release are performed, the humeral head is dislocated, and any osteophytes are removed. An intramedullary cutting guide is placed for correct humeral resection. The osteotomy of the humeral head is performed in the anatomical neck with an inclination of 135° and a retroversion of 20° to 40°, depending on the anatomical retroversion. The glenoid is prepared as usual. The lateralized, augmented baseplate is assembled with the central screw and the baseplate-wedge-screw complex is placed by inserting the screw into the central screw hole. Four peripheral screws are utilized for definitive fixation. An eccentric glenosphere with inferior overhang is implanted. The humerus is dislocated, and the metaphysis is prepared. Long compactors are utilized for proper stem alignment, and an asymmetric trial insert is positioned before the humerus is reduced. Stability and range of motion are assessed. The definitive short stem is inserted and the asymmetric polyethylene is impacted, resulting in a neck-shaft angle of 145°. Following reduction, subscapularis repair and wound closure are performed. Alternatives: BIO-RSA is the main alternative to MIO-RSA. Boileau et al.15 demonstrated satisfactory early and long-term outcomes of BIO-RSA for shoulder osteoarthritis. A larger lateral offset may also be achieved with a thicker glenosphere2,16. Mark A. Frankle developed an implant that addressed the drawbacks of the Grammont design: a lateralized glenosphere combined with a 135° humeral neck-shaft angle. The 135° neck-shaft angle provides lateral humeral offset, preserving the normal length-tension relationship of the residual rotator cuff musculature, which optimizes its strength and function. The lateralized glenosphere displaces the humeral shaft laterally, minimizing the potential for impingement during adduction2,9,17,18. The advantage of BIO-RSA and MIO-RSA over lateralized glenospheres is that the former options provide correction of angular deformities without excessive reaming, which can lead to impingement19. Rationale: BIO-RSA has been proven to achieve excellent functional outcomes15,20,21; however, the bone graft can undergo resorption, which may result in early baseplate loosening. Bipolar metallic lateralized RSA is an effective strategy for achieving lateralization and correction of multiplanar defects while avoiding the potential complications of BIO-RSA6,7,22-24. MIO-RSA also overcomes another limitation of BIO-RSA, namely that BIO-RSA is not applicable when the humeral head is not available for use (e.g., humeral head osteonecrosis, revision surgery, fracture sequelae). Expected Outcomes: A recent study evaluated the clinical and radiographic outcomes of metallic humeral and glenoid lateralized implants. A total of 42 patients underwent primary RSA. Patients were documented prospectively and underwent follow-up visits at 1 and 2 years postoperatively. That study demonstrated that bipolar metallic lateralized RSA achieves excellent clinical results in terms of shoulder function, pain relief, muscle strength, and patient-reported subjective assessment, without instability or radiographic signs of scapular notching23. Kirsch et al.25 reported the results of primary RSA with an augmented baseplate in 44 patients with a minimum of 1 year of clinical and radiographic follow-up. The use of an augmented baseplate resulted in excellent short-term clinical outcomes and substantial deformity correction in patients with advanced glenoid deformity. No short-term complications and no failure or loosening of the augmented baseplate were observed. Merolla et al.7 compared the results of 44 patients who underwent BIO-RSA and 39 patients who underwent MIO-RSA, with a minimum follow-up of 2 years. Both techniques provided good clinical outcomes; however, BIO-RSA yielded union between the cancellous bone graft and the surface of the native glenoid in <70% of patients. On the other hand, complete baseplate seating was observed in 90% of MIO-RSA patients. Important Tips: When performing subscapularis tenotomy, leave an adequate stump to allow end-to-end repair. Tenotomize the superior part of the subscapularis tendon in an L-shape, sparing the portion below the circumflex vessels. As glenoid exposure is critical, perform a 270° capsulotomy. Continuously check the orientation of the baseplate relative to the prepared hole and reamed surface to ensure accurate implantation of the full wedge baseplate to achieve a proper fit. Aim for 70% to 80% seating of the baseplate onto the prepared glenoid surface. Avoid overtightening or excessive advancement of the baseplate into the subchondral bone. Gaps between the baseplate and glenoid surface should also be avoided. In order to avoid varus or valgus malpositioning of the final implant, obtain proper diaphyseal alignment by following "the three big Ls": large, lateral, and long. Use a large metaphyseal component to fill the metaphysis. Place the guide pin for the reaming of the metaphysis slightly laterally into the resected surface of the humerus. Use long compactors for diaphyseal alignment to avoid varus or valgus malpositioning of the final implant. Use an intramedullary cutting guide for correct humeral resection. Utilize the correct liner in order to obtain proper tensioning and avoid instability. Acronyms and Abbreviations: K wire = Kirschner wire ROM = range of motion [ABSTRACT FROM AUTHOR]

Case: (1) A 69-year-old man sustained a proximal humeral fracture-dislocation. During emergency surgery, copious bleeding occurred. A pseudoaneurysm was identified 30 days postoperatively. (2) A 69-year-old man sustained a proximal humeral fracture and axillary artery injury. Physical examination demonstrated a cold but pink hand. Hemiarthroplasty and bypass vein grafting were performed. (3) An 86-year-old woman sustained a proximal humeral fracture and axillary artery injury. Her hand had turned cold and pale. Reverse shoulder arthroplasty and bypass vein grafting were performed. Conclusion: In cases of proximal humeral fractures with significant displacement, concomitant axillary artery injury must be assessed and if there is a high index of suspicion, prompt advanced imaging is necessary. [ABSTRACT FROM AUTHOR]

Case: A 71-year-old female patient presented with severe glenoid bone loss and deformity after 2 subsequent failed arthroplasty procedures because of baseplate failures. The patients then underwent a conversion from reverse shoulder arthroplasty to hemiarthroplasty, while using a distal radius allograft to augment the deformed glenoid. At the 2-year follow-up, the patient reported minimal pain and satisfactory outcomes. Conclusion: This case presents the distal radius as a potentially useful allograft option for augmenting severe glenoid bone loss in the setting of revision shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Background: Controversy exists regarding the ideal humeral component version to optimize humeral rotation and patient outcomes in reverse total shoulder arthroplasty (rTSA). Methods: Patients undergoing primary rTSA for rotator cuff tear arthropathy, a massive rotator cuff tear, or primary osteoarthritis with a rotator cuff tear were randomized to placement of the humeral component in neutral version or 30° of retroversion. Shoulder active range of motion and strength and visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES), and Patient-Reported Outcomes Measurement Information System Global 10 (PROMIS-10) scores were collected up to 2 years postoperatively. The goal of the study was to determine whether humeral external rotation and internal rotation are affected by humeral component version following rTSA at 2 years postoperatively. Results: Sixty-six patients were included in the analysis. The median follow-up was 26 months for the neutral and 27 months for the 30° retroversion group. No differences between the groups were observed with respect to the primary diagnosis, sex, age, body mass index, or American Society of Anesthesiologists (ASA) class. The 2 groups did not differ significantly in terms of improvement at 2 years in active shoulder abduction (p = 0.969), forward elevation (p = 1.000), internal rotation measured as the highest spinal level reached (p = 1.000), internal rotation with the arm abducted 90° (p = 0.451), external rotation (p = 0.362), or muscle strength in forward elevation (p = 1.000), abduction (p = 1.000), external rotation (p = 0.617), or internal rotation (p = 1.000). The 2 groups did not differ significantly in terms of improvement in postoperative ASES (p = 1.000), PROMIS-10 physical (p = 1.000), or VAS pain scores (p = 0.718) at the time of final follow-up. In the neutral version group, 1 patient underwent revision for instability and 1 for stiffness. One acromial stress fracture occurred in the 30° humeral retroversion group. Scapular notching was observed in 7 (21.2%) of the patients in neutral version group and 5 (15.2%) of the patients in the 30° retroversion group (p = 0.750). Conclusions: Securing the humeral component at neutral version or 30° of retroversion in rTSA resulted in similar active shoulder external rotation, internal rotation, forward elevation, abduction, and strength measurements, complication rates, and VAS pain, PROMIS-10 physical, and ASES scores at 2 years postoperatively. [ABSTRACT FROM AUTHOR]

Background Reconstruction of the proximal humerus in children who undergo bone tumor resection is challenging because of patients’ small bone size and possible limb length discrepancy at the end of skeletal growth due to loss of the physis. There are several options for proximal humerus reconstruction in children, such as clavicula pro humero, free vascularized fibula grafting, massive bone osteoarticular allografting, endoprostheses, and allograft-prosthesis composites, but no consensus exists on the best method for reconstruction. Resurfaced allograft-prosthesis composites could be an alternative surgical option, but little is known about the results of this surgical technique. Questions/purposes (1) What are the complications and what is the survivorship free from reconstruction failure associated with resurfaced allograft-prosthesis composites in a small, single-center case series? (2) What Musculoskeletal Tumor Society scores do patients achieve after reconstructions with resurfaced allograft-prosthesis composites? Methods This study was a retrospective, single-arm case analysis in a single institution. We generally considered resurfaced allograft-prosthesis composites in children with malignant bone tumors involving the metaepiphysis of the proximal humerus in whom there was no evidence of joint contamination and in whom axillary nerve preservation was possible. Between 2003 and 2021, we treated 100 children (younger than 15 years) with bone tumors of the humerus. Thirty children (30%) with diaphyseal tumors (21 children) or distal tumors (9 children) were excluded. Among the potentially eligible children, 52 were not analyzed because they were treated with other procedures such as amputation, modular prostheses, cement spacers, free vascularized fibula grafting, and massive bone osteoarticular allografts. We included 18 children (26% of the potentially eligible children) who were treated with resurfaced allograft-prosthesis composites. There were 9 boys and 9 girls, with a median age of 10 years (range 4 to 15 years) at the time of diagnosis. A long stem (≥ 6 cm) in the resurfaced allograft-prosthesis composite was used in 9 children and a short stem (< 6 cm) was used in the remaining 9. One of the 18 children had a follow-up of less than 2 years. The median follow-up of the remaining 17 children was 4.7 years (range 2 to 19 years). The children’s medical records were reviewed for clinical and functional outcomes. We performed a competing risk analysis to calculate the reconstruction failure-free survival of resurfaced allograft-prosthesis composites. Reconstruction failure was defined as removal of the implant or allograft because of implant loosening or breakage and allograft fracture or resorption. We analyzed the children’s postoperative complications and functional outcomes at the end of the follow-up period using the Musculoskeletal Tumor Society functional scoring system. Results The competing risk analysis revealed that reconstruction failure was 25% (95% confidence interval 7% to 40%) at 3 years, reaching a plateau. Four of 18 children underwent surgical revision with a new reconstruction. The reasons for reconstruction revision were resorption of the allograft at the proximal part (2 children) and fracture of the allograft (2 children). Reconstruction revision was performed in 3 of 9 children who underwent reconstruction with a short stem and in 1 of 9 children who underwent reconstruction with a long stem. Several children had other complications that did not result in removal of the allograft. Allograft resorption was observed in 4 of 18 children, but no additional surgical treatment was performed. Shoulder instability or subluxation was observed in 4 of 18 children, but only 1 child underwent surgery with a reverse shoulder arthroplasty without removal of the resurfaced allograft-prosthesis composite. Limited elbow motion because of plate impingement was observed in 1 child who underwent surgical cutting of the protruding distal part of the plate. Incomplete radial nerve palsy after surgery occurred in 1 child, with spontaneous resolution after 2 months. Screw loosening occurred in 2 children who underwent surgery with removal of loose screws. Two children had a nonunion at the graft-host bone junction; 1 child underwent surgery with bone grafting and refixation of the graft-host bone junction, and the other child with both nonunion and plate breakage was treated with bone grafting and refixation of the graft-host bone junction with a new plate. Among 17 children who had a follow-up longer than 2 years, the median Musculoskeletal Tumor Society functional score at the last follow-up interval was 23 of 30 (range 20 to 26); 1 child was considered to have an excellent result (functional score ≥ 26), 15 children were considered to have a good result (functional score 21 to 25), and 1 child was considered to have a fair result (functional score ≤ 20). The Musculoskeletal Tumor Society functional score did not change after excluding 4 children who underwent replacement of resurfaced allograft-prosthesis composites (24 of 30 [range 20 to 26]). The median angle of flexion of the shoulder was 40° (range 20º to 90°), and the median angle of abduction was 30° (range 20º to 90°). Conclusion Resurfaced allograft-prosthesis composites showed a high risk of complications, but not all complications resulted in removal of the reconstructed allograft. We used this technique mainly for very young children with small bones and for older children who underwent axillary nerve preservation. Although its success may be limited owing to a high risk of complications, a resurfaced allograft-prosthesis composite could be an alternative surgical option in order to preserve the bone stock and achieve good functional outcomes in very young children. We recommend using a long-stem resurfaced allograft-prosthesis composite, which may reduce the risk of complications. [ABSTRACT FROM AUTHOR]

The article discusses the impact of acquired acromion compromise, such as thinning and fragmentation, on outcomes after reverse shoulder arthroplasty (RSA). While acromial stress fractures are a known complication of RSA, the study found that patients with preoperative acromial compromise did not have worse outcomes in terms of functional scores or risk of stress fractures. Surgeons are advised not to hesitate in performing acromioplasty due to fear of increased fracture risk, and further research is needed to identify biomechanical risk factors for stress fractures after RSA. [Extracted from the article]

Background: Cementless reverse shoulder arthroplasty has become increasingly popular because of the improved implant design, porous ingrowth surface, and surgical techniques. When avoiding the risks of cement use, a press-fit arthroplasty stem that has been implanted may not feel immediately stable, especially if the medullary canal size is in between standard stem diameters. To help surgeons improve fixation and avoid overstuffing the medullary canal, we present the matchstick autograft augmentation technique. The use of humeral autograft, analogous to impaction grafting in hip arthroplasty, has been reported to have promising short-term outcomes2,3. This technique of using humeral autograft material, dubbed matchstick autografts because of their shape and size, allows for optimization of humeral stem stability with the option of smaller cementless humeral implants. By avoiding overstuffing of the medullary canal, this technique aims to reduce the incidences of intraoperative fracture, postoperative stress shielding, and potential implant loosening4-6. Description: Cementless reverse total shoulder arthroplasty is routinely performed via the anterosuperior approach7; however, a deltopectoral approach can be utilized if desired. The canal is sequentially broached with implant trials until the tactile feedback demonstrates axial and rotational stability. In cases in which tactile feedback during implantation demonstrates slight movement, the smaller implant size can be selected and augmented with matchstick autograft. An oscillating saw is utilized to cut the edges of the previously resected humeral head in order to expose the subchondral bone surface. Graft sticks about 20 mm in length and 1 to 3 mm in width are then fashioned. Humeral trials are then implanted with the matchstick grafts placed lengthwise alongside the humeral stem. Axial and rotational press-fit is again assessed. If adequate, the formal humeral implant is selected and implanted in position. As in conventional impaction grafting, the grafts are compressed to the side of the humeral canal, but they offer more corticocancellous structure than bone chips. This technique is applicable even in some fracture scenarios. Alternatives: When a specific press-fit humeral stem size does not achieve adequate stability, there are typically 3 surgical alternatives. First, a larger stem size can be selected. Second, the implant can be inserted deeper to achieve press-fit stability. Third, cement can be added to fill the medullary canal and create immediate stability. Rationale: When implanting the humeral prosthesis, the operating surgeon's primary goal is stem stability. When faced with lack of stability, the surgeon can select a larger humeral stem, risking stress shielding; implant the stem deeper, compromising length and risking humeral fracture; or consider a cemented implant. In order to minimize the risk of intraoperative cardiopulmonary events and complicated subsequent revision surgeries8, the use of cement should be avoided if at all possible. Shoulder surgeons have reported grafting techniques, analogous to hip impaction grafting, that have yielded good success3. The technique that we describe utilizes a matchstick structural autograft that helps improve cementless fixation in primary humeral implantation cases and allows for the use of a smaller stem. The structural shape of the graft allows this technique to be utilized even in selected proximal humeral fractures. Expected Outcomes: Other studies have reported on the use of softer cancellous autografts to stabilize humeral implants in shoulder arthroplasty. In a study of 286 arthroplasties with a minimum follow-up of 2 years, Lucas et al. reported that 267 humeral stems (93.3%) had not subsided3. Humphrey and Bravman used cancellous autograft to achieve metaphyseal centering of the humeral component in 53 patients, with no cases of humeral implant loosening at 12 months2. Lo et al. reported 91% tuberosity healing in their series of cementless reverse total shoulder arthroplasties augmented with matchstick autografts1, with no cases of aseptic humeral stem loosening. Montemaggi et al. used matchstick autografts to augment 46 primary cementless reverse total shoulder arthroplasties and found zero instances of humeral loosening at 1-year follow-up9. Important Tips: The strongest humeral matchstick grafts come from the subchondral surface. After creating the graft, it is palpated for structural integrity. A stiffer or softer graft can be chosen, depending on surgeon preference. Surgeons can try impacting the graft with humeral trials to assess the stem stability prior to final implantation. Acronyms and Abbreviations: RTSA = reverse total shoulder arthroplasty FX = fracture 3D CT = 3-dimensional computed tomography XR = x-ray FU = follow-up [ABSTRACT FROM AUTHOR]

Background Proximal humeral fractures (PHFs) often occur in elderly individuals who experience low-energy falls. Open reduction and internal fixation (ORIF) of the proximal humerus is typically performed in young, active patients because of their good bone quality and high functional demands. Although good short-term results have been reported after ORIF in young patients, few studies have specifically evaluated long-term outcomes. Questions/purposes (1) What are the long-term clinical outcomes scores and (2) radiologic outcomes of non-osteoporotic three-part and four-part PHFs treated with locking plates? (3) What complications occurred after treatment, and what factors are associated with poor postoperative functional outcomes scores and avascular necrosis (AVN) of the humeral head after ORIF? Methods Between June 2005 and December 2012, we surgically treated 774 patients for displaced two-, three-, and four-part PHFs. Approximately 75% (581 of 774) underwent ORIF, 10% (77 of 774) underwent hemiarthroplasty, 7% (54 of 774) underwent intramedullary nailing, 5% (39 of 774) underwent reverse shoulder arthroplasty, and the remaining 3% (23 of 774) underwent other surgical treatments. We considered those who had ORIF as potentially eligible. Based on that criterion, 75% (581) were eligible. However, only patients with nonosteoporotic three- and four-part PHFs (cortical thickness of the proximal humeral diaphysis greater than 6 mm on a preoperative AP radiograph of the affected shoulder) and a minimum of 10 years of follow-up were included. Sixtyfour percent (498 of 774) of the patients were excluded because of simple or osteoporotic fractures, 1% (7 of 774) were excluded because of ipsilateral limb multiple fractures, 0.3% (2 of 774) were excluded because of pathologic PHFs, and another 2% (13 of 774) were lost before the minimum study follow-up of 10 years, leaving 8% (61 of 774) for analysis here. The mean age at surgery was 45 ± 12 years, with a mean follow-up of 13 years. Fifty-seven percent (35 of 61) of the patients were men. Patientreported outcomes were evaluated using the University of California Loas Angeles (UCLA) score (range 0 to 35; higher scores represent better shoulder function) and Constant score (range 0 to 100; higher scores represent better shoulder function) at least 10 years postoperatively. Postoperative radiographs were reviewed to assess the cortical bone thickness of the proximal humerus, neckshaft angle, head-to-tuberosity distance, and radiologically confirmable complications. Logistic regression analysis was performed to evaluate factors associated with poor postoperative functional scores (UCLA score ≤ 27 or Constant score ≤ 70) and AVN of the humeral head; the association between AVN and postoperative functional outcomes was also assessed. Results At the most-recent follow-up, these patients had a mean UCLA score of 31 ± 3 and a Constant score of 88 ± 10. The mean neck-shaft angle was 133° ± 10°, and 23% (14 of 61) of patients experienced AVN of the humeral head during follow-up. Twenty-nine complications in 30% (18 of 61) of patients were reported. After controlling for potentially confounding variables such as age and gender, we found that the presence of greater tuberosity malposition (odds ratio 18 [95% confidence interval 2 to 167]; p = 0.01) and immediate postoperative neck-shaft angle less than 130° (OR 19 [95% CI 3 to 127]; p = 0.002) were associated with poor postoperative functional scores. Fourpart PHFs (OR 13 [95% CI 2 to 82]; p = 0.008) and metaphyseal extension less than 8 mm (OR 7 [95% CI 1 to 35]; p = 0.03) were associated with AVN of the humeral head. For patients who met the criteria for anatomic reduction (achievement of all of the following three criteria: neckshaft angle ≥ 130°, head-shaft displacement < 5 mm, and head-to-tuberosity distance greater than or equal to 3 mm and less than or equal to 20 mm), there were no differences in postoperative functional scores between patients with AVN and those without. Conclusion ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. When encountering complex PHFs in patients with good bone quality, every effort must be made to achieve an anatomic reduction of the fracture as far as possible, which may not reduce the risk of AVN (this occurred in nearly one-fourth of patients). However, good outcomes can usually be expected, even in patients with AVN. Because this was a retrospective study with a high risk of bias owing to sparse data, the factors associated with poor post-operative functional outcomes must be further investigated in large prospective studies. Level of Evidence Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Rotator cuff tears are the most frequent shoulder injury in patients over 50 years old. Treatment of rotator cuff tears is individualized based on the age, demands, and symptoms of the patient. Nonoperative treatment may often be effective, especially in lower-demand or elderly patients. Surgical repair is indicated after failure of nonoperative treatment or in patients whose high-demand lifestyle requires full strength and function of the shoulder. In older patients, larger tears are less likely to heal and rotator cuff repair may not reliable. In cases of failed previous rotator cuff repair, there may not be enough viable tissue for complete repair. If there is underlying arthritis, a rotator cuff repair is unlikely to resolve all symptoms, and treatment to care for the arthritis and rotator cuff tear is indicated. Reverse shoulder arthroplasty provides the surgical answer for these scenarios and is now being used for numerous indications of shoulder pathology. [ABSTRACT FROM AUTHOR]

Background: There is variability in the trajectories of pain intensity and magnitude of incapability after shoulder arthroplasty. A better understanding of the degree to which variation in recovery trajectories relates to aspects of mental health can inform the development of comprehensive biopsychosocial care strategies. Questions/purposes: (1) Do pain intensities at baseline and the trajectories during recovery differ between groups when stratified by mental health composite summary score, arthroplasty type, and revision surgery? (2) Do magnitudes of capability at baseline and the trajectories during recovery differ between these groups? Methods: We used a registry of 755 patients who underwent shoulder arthroplasty by a single surgeon at a specialized urban orthopaedic hospital that recorded the mental component summary (MCS) score of the Veterans RAND 12, a measure of shoulder-specific comfort and capability (American Shoulder and Elbow Surgeons [ASES] score, which ranges from 0 to 100 points, with a score of 0 indicating worse capability and pain and 100 indicating better capability and pain and a minimum clinically important difference of 6.4), and the VAS for pain intensity (range 0 [representing no pain] to 10 [representing the worst pain possible], with a minimum clinically important difference of 1.4) preoperatively, 2 weeks postoperatively, and 6 weeks, 3 months, 6 months, and 1 year after surgery. Forty-nine percent (368 of 755) of the patients were men, with a mean age of 68 ± 8 years, and 77% (585) were treated with reverse total shoulder arthroplasty (rTSA). Unconditional linear and quadratic growth models were generated to identify the general shape of recovery for both outcomes (linear versus quadratic). We then constructed conditional growth models and curves for pain intensity and the magnitude of capability showing mean baseline scores and the rates of recovery that determine the trajectory, accounting for mental health (MCS) quartiles, primary or revision arthroplasty, and TSA or reverse TSA in separate models. Because pain intensity and capability showed quadratic trends, we created trajectories using the square of time. Results: Patients in the worst two MCS quartiles had greater pain intensity at baseline than patients in the best quartile (difference in baseline for bottom quartile: 0.93 [95% CI 0.72 to 1.1]; p < 0.01; difference in baseline for next-worst quartile: 0.36 [95% CI 0.16 to 0.57]; p < 0.01). The rates of change in recovery from pain intensity were not different among groups (p > 0.10). Patients with revision surgery had greater baseline pain (difference: 1.1 [95% CI 0.7 to 1.5]; p < 0.01) but no difference in rates of recovery (difference: 0.031 [95% CI 0.035 to 0.097]; p = 0.36). There were no differences in baseline pain intensity and rates of recovery between patients with reverse TSA and those with TSA (baseline pain difference: -0.20 [95% CI -0.38 to -0.03]; p = 0.18; difference in rate of recovery: -0.005 [95% CI -0.035 to 0.025]; p = 0.74). Patients in the worst two MCS quartiles had worse baseline capability than patients in the best quartile (difference in baseline for bottom quartile: -8.9 [95% CI -10 to -7.4]; p < 0.001; difference in baseline for the next-worst quartile: -4.9 [95% CI -6.4 to -3.4]; p < 0.01), with no differences in rates of recovery (p > 0.10). Patients with revision surgery had lower baseline capability (difference in baseline: -13 [95% CI -15 to -9.7]; p < 0.01), with a slower rate of recovery (difference in rate of recovery: -0.56 [95% CI -1.0 to -0.079]; p = 0.021). There were no differences in baseline capability or rates of recovery between TSA and reverse TSA. Conclusion: The observation that preoperative and 1-year comfort and capability are associated with mental health factors and with similar recovery trajectories reminds us that assessment and treatment of mental health is best considered an integral aspect of musculoskeletal care. Future studies can address how prioritization of mental health in musculoskeletal care strategies might reduce variation in the 1-year outcomes of discretionary surgeries such as shoulder arthroplasty. Level of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

This document is a commentary on a research article titled "What Is the Revision-free Survival of Resurfaced Allograft-prosthesis Composites for Proximal Humerus Reconstruction in Children With Bone Tumors?" The article discusses the challenges and surgical options for reconstructing the shoulder in children after tumor resection. It highlights the use of resurfaced allograft-prosthesis composites as a viable surgical option, combining lessons learned from allograft and prosthetic reconstructive procedures. The document emphasizes the need for further research and collaboration to improve outcomes and tailor surgical procedures to individual patients. [Extracted from the article]

Case: A 60-year-old man sustained a massive irreparable rotator cuff tear and axillary nerve palsy with deltoid dysfunction after an anterior shoulder dislocation. He underwent staged reverse end-to-side radial-to-axillary nerve transfer with return of deltoid function allowing for subsequent reverse shoulder arthroplasty. At 1 year postoperatively, he returned to full activity. Conclusion: Irreparable rotator cuff tears complicated by axillary nerve palsy can be effectively treated with a staged approach of nerve transfer followed by reverse shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Failed rotator cuff repairs pose several challenges due to the high incidence rate, complexity, and range of symptoms. We propose an overview for assessing and treating failed rotator cuff repairs. For active young patients, attempt revision repair with patch augmentation if possible. When anatomic revision is not viable, but muscle is retained, consider partial repair with interposition bridging. Isolated, irreparable supraspinatus tears may benefit from superior capsule reconstruction. Tendon transfer is suitable for patients with significant atrophy and multiple irreparable cuff tears. Low-demand elderly patients or those with substantial glenohumeral arthritis may consider reverse total shoulder arthroplasty if conservative management fails. There are a variety of reported outcomes in the literature but long-term studies with larger cohorts are needed to improve the management of failed rotator cuff repair. [ABSTRACT FROM AUTHOR]

An editorial is presented on surgical procedure not improving the outcomes in low-energy, geriatric, proximal humeral fractures compared with closed management. Topics include meta-analysis compared the results of hook plate fixation only with those of hook plate fixation plus coracoclavicular augmentation; and surgeons should counsel patients with regard to the high likelihood of secondary intervention following ORIF.

Background: Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear.Questions/purposes: (1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA?Methods: Between January 1, 2013, and June 30, 2018, we treated 235 patients for a proximal humeral fracture. We considered only patients without previous ipsilateral fracture or surgery, other fractures, or radial nerve injuries; age older than 70 years; and patients without neurologic disease or cognitive dysfunction as potentially eligible. Sixty-nine percent (162 patients) of the patients were eligible; a further 31% (73 patients) were excluded because 18% (13 of 73 patients) did not meet the inclusion criteria, 62% (45 patients) underwent nonoperative treatment, and 21% (15 patients) declined to participate. Patients were nonrandomly allocated to receive RTSA if they had supraspinatus Goutallier/Fuchs Grade 3 or 4 atrophy or ORIF if they had supraspinatus Goutallier/Fuchs Grade 1 or 2 atrophy. This left 81 patients who were treated with RTSA and another 81 patients who were treated with ORIF. Among the 81 patients treated with RTSA, 11% (nine patients) were lost to the minimum study follow-up of 2 years or had incomplete datasets, leaving 89% (72 patients) for analysis. Among the 81 patients treated with ORIF, 19% (15 patients) were lost before the minimal study follow-up of 2 years or had incomplete datasets, leaving 82% (66 patients) for analysis. The median follow-up for both groups was 53 months (range 24 to 72 months). The mean age was 76 ± 2.9 years in the RTSA group and 73 ± 2.9 years in the ORIF group. In the RTSA group, 27 patients had a three-part fracture and 45 patients had a four-part fracture. In the ORIF group, 24 patients had three-part fractures and 42 patients had four-part fractures (p = 0.48). Shoulder function was assessed using functional outcome questionnaires (ASES, DASH, and Constant) and active ROM measurements. A surgical complication was defined as any instance of dislocations, fractures, adhesive capsulitis, nerve injuries, or surgical site infections. Radiographic outcomes after ORIF (malunion, tuberosity resorption, or avascular necrosis) and RTSA (notching and osteolysis) were assessed. In calculating the revision rate, we considered unplanned revision procedures only.Results: Compared with patients treated with ORIF, patients treated with RTSA had superior improvements in Constant (85.0 ± 7.0 versus 53.0 ± 5.0; mean difference 32 [95% CI 30 to 34]; p < 0.01), ASES (46.3 ± 3.7 versus 30.0 ± 3.5; mean difference 16 [95% CI 15 to 18]; p < 0.01), and DASH scores (40.5 ± 4.2 versus 30.5 ± 2.6; mean difference 10 [95% CI 9 to 11]; p < 0.01). The mean elevation was 135° ± 7° for patients with RTSA and 100° ± 6° for patients with ORIF (mean difference 35o [95% CI 33 to 37]; p < 0.01). The mean abduction was 131° ± 7° for patients with RTSA and 104° ± 6° for those with ORIF (mean difference 27o [95% CI 25° to 29°]; p < 0.01). The mean external rotation was 85° ± 5° for patients with RTSA and 64° ± 5° for those with ORIF (mean difference 21° [95% CI 19° to 23°]; p < 0.01). The mean internal rotation was 45° ± 6° for patients with RTSA and 40° ± 6° for those with ORIF (mean difference 5° [95% CI 3° to 7°]; p < 0.01). The risk of complications was not different between patients with ORIF and those with RTSA (5% [three of 66] versus 1% [one of 72]; relative risk 3.3 [95% CI 0.3 to 30.7]; p = 0.30). Among patients with ORIF, 8% had varus malunions (five of 66), 6% had resorption of the greater tuberosity (four of 66), and 2% had avascular necrosis of the humeral head (one of 66). In the RTSA group, 24% (17 of 72 patients) demonstrated reabsorption of periprosthetic bone and 79% of patients (57 of 72) exhibited no notching. The risk of revision was not different between the RTSA and ORIF groups (0% [0 of 72] versus 9% [six of 66]; relative risk 0.07 [95% CI 0.0 to 1.2]; p = 0.07).Conclusion: In patients older than 70 years with three-part and four-part proximal humerus fractures, primary RTSA resulted in better patient-reported outcome scores and better ROM than ORIF with an angular stable locking plate. Our findings might help surgeons decide between internal fixation and arthroplasty to surgically treat these injuries in older patients. Although RTSA seems to be a preferable treatment modality in view of these findings, longer follow-up is required to evaluate its longevity compared with ORIF with an angular locking plate. Dissimilar to ORIF, which is generally stable once healed, arthroplasties are at a continued risk for loosening and infection even after healing is complete.Level Of Evidence: Level II, therapeutic study. [ABSTRACT FROM AUTHOR]

The author reflects on updates on the treatment of musculoskeletal system tumors based on retrospective study research that could help guide clinical practice. Other topics include the reconstruction of the pelvis remedies like structural allograft, double-barreled free vascularized fibular grafting, and ice-cream cone prosthesis, and the lower extremity remedies like compliant compressive osseointegration.

An editorial is presented which explores the authors experience of being orthopaedic surgery and rehabilitation medicine remaining synergistic fields of medicine. Topics include physical therapy with exergames using the principles of gamification with physical therapy supporting in patients following arthroscopic shoulder surgery; and muscular endurance in the shoulder and arm comparing with low-intensity exercise alone.

Background: Proximal humerus fractures are the second-most common fragility fracture in older adults. Although reverse total shoulder arthroplasty (RTSA) is a promising treatment strategy for proximal humerus fractures with favorable clinical and quality of life outcomes, it is associated with much higher, and possibly prohibitive, upfront costs relative to nonoperative treatment and other surgical alternatives.Questions/purposes: (1) What is the cost-effectiveness of open reduction internal fixation (ORIF), hemiarthroplasty, and RTSA compared with the nonoperative treatment of complex proximal humerus fractures in adults older than 65 years from the perspective of a single-payer Canadian healthcare system? (2) Which factors, if any, affect the cost-effectiveness of ORIF, hemiarthroplasty, and RTSA compared with nonoperative treatment of proximal humerus fractures including quality of life outcomes, cost, and complication rates after each treatment?Methods: This cost-utility analysis compared RTSA, hemiarthroplasty, and ORIF with the nonoperative management of complex proximal humerus fractures in adults older than 65 years over a lifetime time horizon from the perspective of a single-payer healthcare system. Short-term and intermediate-term complications in the 2-year postoperative period were modeled using a decision tree, with long-term outcomes estimated through a Markov model. The model was initiated with a cohort of 75-year-old patients who had a diagnosis of a comminuted (three- or four-part) proximal humerus fractures; 90% of the patients were women. The mean age and gender composition of the model's cohort was based on a systematic review conducted as part of this analysis. Patients were managed nonoperatively or surgically with either ORIF, hemiarthroplasty, or RTSA. The three initial surgical treatment options of ORIF, hemiarthroplasty, and RTSA resulted in uncomplicated healing or the development of a complication that would result in a subsequent surgical intervention. The model reflects the complications that result in repeat surgery and that are assumed to have the greatest impact on clinical outcomes and costs. Transition probabilities and health utilities were derived from published sources, with costs (2020 CAD) sourced from regional costing databases. The primary outcome was the incremental cost-utility ratio, which was calculated using expected quality-adjusted life years (QALYs) gained and costs. Sensitivity analyses were conducted to explore the impact of changing key model parameters.Results: Based on both pairwise and sequential analysis, RTSA was found to be the most cost-effective strategy for managing complex proximal humerus fractures in adults older than 65 years. Compared with nonoperative management, the pairwise incremental cost-utility ratios of hemiarthroplasty and RTSA were CAD 25,759/QALY and CAD 7476/QALY, respectively. ORIF was dominated by nonoperative management, meaning that it was both more costly and less effective. Sequential analysis, wherein interventions are compared from least to most expensive in a pairwise manner, demonstrated ORIF to be dominated by hemiarthroplasty, and hemiarthroplasty to be extendedly dominated by RTSA. Further, at a willingness-to-pay threshold of CAD 50,000/QALY, RTSA had 66% probability of being the most cost-effective treatment option. The results were sensitive to changes in the parameters for the probability of revision RTSA after RTSA, the treatment cost of RTSA, and the health utilities associated with the well state for all treatment options except ORIF, although none of these changes were found to be clinically realistic based on the existing evidence.Conclusion: Based on this economic analysis, RTSA is the preferred treatment strategy for complex proximal humerus fractures in adults older than 65 years, despite high upfront costs. Based on the evidence to date, it is unlikely that the parameters this model was sensitive to would change to the degree necessary to alter the model's outcome. A major strength of this model is that it reflects the most recent randomized controlled trials evaluating the management of this condition. Therefore, clinicians should feel confident recommending RTSA for the management of proximal humerus fractures in adults older than 65 years, and they are encouraged to advocate for this intervention as being a cost-effective practice, especially in publicly funded healthcare systems wherein resource stewardship is a core principle. Future high-quality trials should continue to collect both clinical and quality of life outcomes using validated tools such as the EuroQOL-5D to reduce parameter uncertainty and support decision makers in understanding relevant interventions' value for money.Level Of Evidence: Level III, economic and decision analysis. [ABSTRACT FROM AUTHOR]

Background: Three-part and four-part fracture-dislocations of the proximal humerus are characterized by severe soft tissue disruptions that can compromise the viability of the humeral head. As a result, nonunion and avascular necrosis are more common in these injuries. In such injuries, surgical treatment (internal fixation or arthroplasty) is performed in most patients who are determined to be fit for surgery to potentially restore shoulder function. Although the decision to preserve or replace the humeral head is simple in young patients or those > 65 years, in most other patients, the decision can be complicated, and little is known about which patient-related and injury-related factors may be independently associated with poor shoulder function or complications like avascular necrosis.Questions/purposes: (1) What proportion of fractures united after internal fixation of a three-part or four-part fracture-dislocation of the proximal humerus, what is the mean Constant score at a minimum of 2 years after this injury, and what proportion had serious complications (such as loss of fixation, nonunion, reoperation, or avascular necrosis)? (2) After controlling for potential confounding variables, what factors are independently associated with poor shoulder function (defined as a Constant score < 55 out of 100) and occurrence of serious complications such as loss of fixation or reduction resulting in revision surgery, nonunion, or radiographic evidence of avascular necrosis of the humeral head?Methods: Between 2011 and 2017, the senior author of this study (ASG) treated 69 patients with three-part or four-part proximal humerus fracture dislocations. During this time, indications for internal fixation in these patients were adequate humeral bone quality as determined by the surgeon on radiographs, adequate bone stock and volume available for fixation in the humeral head as determined on CT images, and the absence of a head split component as assessed on preoperative radiographs and CT images. On this basis, 87% (60 patients) underwent internal fixation with a locked plate and suture fixation of the tuberosities through a deltopectoral approach. Thirteen percent (nine patients) underwent either a hemiarthroplasty or a reverse total shoulder arthroplasty. Of the 60 patients who underwent internal fixation, four declined to participate in the study and two with brachial plexus palsy were not considered for inclusion. This study focused on the remaining 54 patients who were considered potentially eligible. To be included, a minimum follow-up of 2 years was required; 11% (6 of 54) were lost before that time, and the remaining 48 patients were analyzed at a mean of 48 months ± 17 months in this retrospective study, which drew data from longitudinally maintained institutional databases. Fracture union was assessed by obliteration of fracture lines and the presence of bridging trabecular bone on plain radiographs. Shoulder function was assessed using the Constant score, which is scored from 0 to 100 points, with 0 indicating the most disability and 100 the least disability. The anchor-based minimal clinically important difference for the Constant score is 9.8 points. Twelve patient-related and injury-related factors were analyzed using a multivariate regression model to identify factors that are independently associated with poor results after internal fixation as measured by shoulder function and the occurrence of serious complications. We categorized results as poor if patients had one or more of the following: Constant score < 55 out of 100 at the last follow-up examination (for patients who underwent revision surgery, the Constant score immediately before revision was considered) and loss of fixation or reduction resulting in revision surgery, nonunion, or avascular necrosis of the humeral head. Patients were screened for avascular necrosis at 6 and 12 months after surgery, then annually for another 2 years. Further assessments were made only based on symptoms.Results: Seventy-nine percent of the fractures united within 18 weeks of surgery (38 of 48), and an additional 13% united by 24 weeks (6 of 48), while 8% did not unite (4 of 48). The mean Constant score at the last follow-up was 68 ± 12. Twenty-one percent (10 of 48) had a Constant score < 55, indicating poor shoulder function. Twenty-one percent (10 of 48) experienced avascular necrosis, and 15% (7 of 48) with either nonunion or avascular necrosis underwent revision shoulder arthroplasty. Two patients who underwent arthroplasty had both nonunion and avascular necrosis. After controlling for potentially confounding variables, we found that being a woman (odds ratio 1.7 [95% confidence interval 1.4 to 2.1]; p = 0.01), four-part fracture dislocations (OR 2.1 [95% CI 1.5 to 2.7]; p < 0.001), absence of a metaphyseal head extension (OR 2.4 [95% CI 1.8 to 3.3]; p < 0.001), absence of active back-bleeding from the humeral head (OR 3.4 [95% CI 2.3 to 5.1]; p < 0.001), height of the head segment < 2 cm (OR 2.3 [95% CI 1.8 to 2.8]; p < 0.001), and absence of capsular attachments to the head fragment (OR 2.2 [95% CI 1.6 to 2.9]; p < 0.001) were independently associated with poor shoulder function and the occurrence of complications such as nonunion and avascular necrosis.Conclusion: Internal fixation of three-part and four-part proximal humerus fracture dislocations resulted in poor shoulder function and complications in a high number of patients, although fracture union was achieved in most patients. A nonunion proportion of 8%, 21% proportion of avascular necrosis, and 15% proportion of patients who underwent revision surgery suggests this is a fairly terrible injury. Being a woman and injury factors such as four-part fracture dislocation, absent metaphyseal head extension and back-bleeding from the head, height of the fractured head segment < 2 cm, and absence of capsular attachments to the head were independently associated with poor function and complications. Our findings can help surgeons decide between internal fixation and arthroplasty for the surgical treatment of these injuries in patients across different age groups and functional demands.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

CORR Insights®: Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years My residents usually dread going with me to see patients with proximal humerus fractures. Proximal humerus fractures require us to understand the injury characteristics and patients' baseline function - key information that is missing from many studies about proximal humerus fractures. [Extracted from the article]

Case: A 70-year-old male patient presented with anterior deltoid weakness from Parsonage-Turner neuropathy status post failed nerve transfer and a failed total shoulder arthroplasty with pseudoparalysis. The patient underwent revision to a reverse total shoulder arthroplasty with concomitant pectoralis major transfer to substitute for the anterior deltoid. An excellent functional result was attained as early as 6 weeks after surgery. Conclusion: Pectoralis major transfer can be an effective treatment option for isolated anterior deltoid insufficiency, even in the setting of a reverse total shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Background: Component selection and placement in reverse total shoulder arthroplasty (RTSA) is still being debated. Recently, scapulothoracic orientation and posture have emerged as relevant factors when planning an RTSA. However, the degree to which those parameters may influence ROM and whether modifiable elements of implant configuration may be helpful in improving ROM among patients with different postures have not been thoroughly studied, and modeling them may be instructive.Questions/purposes: Using a dedicated expansion of a conventional preoperative planning software, we asked: (1) How is patient posture likely to influence simulated ROM after virtual RTSA implantation? (2) Do changes in implant configuration, such as humeral component inclination and retrotorsion, or glenoid component size and centricity improve the simulated ROM after virtual RTSA implantation in patients with different posture types?Methods: In a computer laboratory study, available whole-torso CT scans of 30 patients (20 males and 10 females with a mean age of 65 ± 17 years) were analyzed to determine the posture type (Type A, upright posture, retracted scapulae; Type B, intermediate; Type C, kyphotic posture with protracted scapulae) based on the measured scapula internal rotation as previously described. The measurement of scapular internal rotation, which defines these posture types, was found to have a high intraclass correlation coefficient (0.87) in a previous study, suggesting reliability of the employed classification. Three shoulder surgeons each independently virtually implanted a short, curved, metaphyseal impaction stem RTSA in each patient using three-dimensional (3D) preoperative surgical planning software. Modifications based on the original component positioning were automatically generated, including different humeral component retrotorsion (0°, 20°, and 40° of anatomic and scapular internal rotation) and neck-shaft angle (135°, 145°, and 155°) as well as glenoid component configuration (36-mm concentric, 36-mm eccentric, and 42-mm concentric), resulting in 3720 different RTSA configurations. For each configuration, the maximum potential ROM in different planes was determined by the software, and the effect of different posture types was analyzed by comparing subgroups.Results: Irrespective of the RTSA implant configuration, the posture types had a strong effect on the calculated ROM in all planes of motion, except for flexion. In particular, simulated ROM in patients with Type C compared with Type A posture demonstrated inferior adduction (median 5° [interquartile range -7° to 20°] versus 15° [IQR 7° to 22°]; p < 0.01), abduction (63° [IQR 48° to 78°] versus 72° [IQR 63° to 82°]; p < 0.01), extension (4° [IQR -8° to 12°] versus 19° [IQR 8° to 27°]; p < 0.01), and external rotation (7° [IQR -5° to 22°] versus 28° [IQR 13° to 39°]; p < 0.01). Lower retrotorsion and a higher neck-shaft angle of the humeral component as well as a small concentric glenosphere resulted in worse overall ROM in patients with Type C posture, with severe restriction of motion in adduction, extension, and external rotation to below 0°.Conclusion: Different posture types affect the ROM after simulated RTSA implantation, regardless of implant configuration. An individualized choice of component configuration based on scapulothoracic orientation seems to attenuate the negative effects of posture Type B and C. Future studies on ROM after RTSA should consider patient posture and scapulothoracic orientation.Clinical Relevance: In patients with Type C posture, higher retrotorsion, a lower neck-shaft angle, and a larger or inferior eccentric glenosphere seem to be advantageous. [ABSTRACT FROM AUTHOR]

This article discusses the long-term outcomes of locking plates for nonosteoporotic three-part and four-part proximal humeral fractures. Proximal humeral fractures are becoming more common and account for 5% of all fractures in adults. There is controversy surrounding the best way to classify and manage these fractures, with some suggesting that surgery offers no benefit compared to nonoperative treatment. However, about 15% to 30% of patients undergo surgery, most commonly open reduction and internal fixation (ORIF). The use of locking plates has improved the stability of proximal humeral fractures, but they are associated with a high rate of complications. The article highlights the importance of anatomic fracture reduction for good long-term results and provides insights into the ideal patient for ORIF. The study recommends further research to standardize classification systems, explore other surgical techniques, and improve education and training for the evaluation and treatment of these fractures. [Extracted from the article]

The terms used in the search were proximal humerus, proximal humerus fracture, proximal humeral fracture, fractures of the proximal humerus, reverse total shoulder arthroplasty, clinical, trial, and clinical trials. CORR ® Synthesis: What Is the Role of Reverse Shoulder Arthroplasty for the Treatment of Proximal Humerus Fractures in Patients Older Than 65 Years? Proximal humerus fractures are the third most common fracture in people older than 65 years and are the second most common fracture in the upper extremity [[10], [12], [15], [27]]. RTSA seems to have more compelling advantages in patients with proximal humerus fractures who have the most severe fracture patterns, such as displaced head-splitting fractures and fracture dislocations; this is especially true in patients whose preinjury activity levels were higher [[12]]. [Extracted from the article]

Background: Previous studies have identified risk factors for different types of treatment of proximal humeral fracture (PHF) and allowed the development of a patient-specific, evidence-based treatment algorithm with the potential of improving overall outcomes and reducing complications. The purpose of this study was to evaluate the results and complications of treating PHF using this algorithmic approach.Methods: All patients with isolated PHF between 2014 and 2017 were included and prospectively followed. The initial treatment algorithm (Version 1 [V1]) based on patients' functional needs, bone quality, and type of fracture was refined after 2 years (Version 2 [V2]). Adherence to protocol, clinical outcomes, and complications were analyzed at a 1-year follow-up.Results: The study included 334 patients (mean age, 66 years; 68% female): 226 were treated nonoperatively; 65, with open reduction and internal fixation (ORIF); 39, with reverse total shoulder arthroplasty (RTSA); and 4, with hemiarthroplasty. At 1 year, the preinjury EuroQol 5-Dimension (EQ-5D) values were regained (0.88 and 0.89, respectively) and the mean relative Constant Score (CS) and Subjective Shoulder Value (SSV) (and standard deviation [SD]) were 96% ± 21% and 85% ± 16%. Overall complications and revision rates were 19% and 13%. Treatment conforming to the algorithm outperformed non-conforming treatment with respect to relative CS (97% versus 88%, p = 0.016), complication rates (16.3% versus 30.8%, p = 0.014), and revision rates (10.6% versus 26.9%, p < 0.001).Conclusions: Treating PHF using a patient-specific, evidence-based algorithm restored preinjury quality of life as measured with the EQ-5D and approximately 90% normal shoulders as measured with the relative CS and the SSV. Adherence to the treatment algorithm was associated with significantly better clinical outcomes and substantially reduced complication and revision rates.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Currently, there seems to be a paradigm change in the surgical treatment of proximal humeral fractures in patients aged 65 years and older, with a considerable increase in the use of reverse total shoulder arthroplasty (RTSA) compared with angular stable internal fixation (locking plate fixation). However, even among shoulder specialists there is controversy regarding the best treatment strategy.Questions/purposes: To evaluate for (1) a greater risk of in-hospital major adverse events, (2) a greater risk for in-hospital surgical complications, and (3) a greater risk of 30-day mortality, locking plate fixation and RTSA were compared for the treatment of proximal humerus fractures of patients aged 65 years and older after controlling for potentially confounding variables in a large-database analysis.Methods: Health claims data of the largest German insurance company including approximately one-third of the population (26.5 million policyholders) between 2010 and 2018 were analyzed. This database was chosen because of its size, nationwide distribution, and high quality/completeness. In total, 55,070 patients (≥ 65 years of age) treated with locking plate fixation (75% [41,216]) or RTSA (25% [13,854]) for proximal humeral fracture were compared. As primary endpoints, major adverse events (including acute myocardial infarction, stroke, organ failure, resuscitation, and death) and surgical complications (infection, hematoma, loss of reduction, dislocation, and revision surgery) were analyzed. The risk of all endpoints was analyzed with multivariable logistic regression models in the context of comorbidities to address existing group differences.Results: After controlling for potentially confounding variables such as age, sex, and risk profile, RTSA was associated with a higher risk for major adverse events (OR 1.40 [95% CI 1.29 to 1.53]; p < 0.001) and surgical complications (OR 1.13 [95% CI 1.05 to 1.21]; p < 0.01) compared with locking plate fixation. There was no evidence for an increase in mortality (OR 0.98 [95% CI 0.86 to 1.12]; p = 0.81).Conclusion: The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with RTSA for proximal humeral fractures in patients 65 years and older. Treatment decisions should be based on individual risk estimation to avoid potential harmful events. Future studies must include long-term outcomes and quality of life to enlighten these findings in a broader context.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

➤: Despite an increasing rate of civilian low-velocity gunshot injuries, there remains a lack of evidence-based treatment standards.➤: Most low-velocity gunshot-induced fractures of the extremity can be managed similarly to non-gunshot-induced fractures, with the goals of restoring function and minimizing complications.➤: There are a limited number of high-quality studies to support the use of prophylactic antibiotics for nonoperatively treated gunshot wounds.➤: Intra-articular retained bullets should be removed, while prophylactic irrigation and debridement for a transarticular bullet is not routinely warranted for infection prevention.➤: Much of the literature on low-velocity gunshot wounds is Level-III or IV evidence, warranting the need for higher-powered, randomized, prospective investigations. [ABSTRACT FROM AUTHOR]

That paper from the United Kingdom (UK) was a randomized, adaptive trial on the InSpace (Stryker) biodegradable subacromial balloon spacer for treatment of symptomatic irreparable rotator cuff tears [[4]]. Translational research refers to the move from basic science to human trials - literally taking products, drugs, or devices from bench to bedside (and, not too coincidentally, the namesake of this column). The InSpace received FDA approval in 2021 [[4]], despite, seemingly, insufficient evidence of efficacy, and - with numbers like that - not nearly enough patients to make claims about safety. 3 Matsen FA III., The InSpace balloon (Stryker, USA): is this innovation of value to patients with irreparable rotator cuff tears?. [Extracted from the article]

Comparison of clinical outcomes after anatomic total shoulder arthroplasty and reverse shoulder arthroplasty in patients 70 years and older with glenohumeral osteoarthritis and an intact rotator cuff. For example, Levin et al. [[6]] defined the use of reverse total shoulder arthroplasty in a patient with an intact rotator cuff as an inappropriate outcome in their model. CORR Insights®: Is Advanced Imaging to Assess Rotator Cuff Integrity Before Shoulder Arthroplasty Cost-effective? For example, to understand whether only radiographs are sufficient in a subset of patients undergoing shoulder arthroplasty, we could compare the outcomes radiographically and clinically (patient-reported outcomes) of surgeons who practice in these two different ways. [Extracted from the article]

➤: Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation.➤: In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF).➤: In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty.➤: Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time. [ABSTRACT FROM AUTHOR]

Case: We present a case of a physical therapy-induced fracture of the proximal humerus, presumably caused by forceful shoulder flexion and external rotation, after reverse total shoulder arthroplasty (RTSA) in a 70-year-old woman with underlying osteopenia, systemic lupus erythematosus, long-term glucocorticoid use, and common variable immunodeficiency. Conclusion: This case of a physical therapy-induced greater tuberosity fracture after RTSA presents an example of an early postoperative complication with no impact on eventual successful surgical outcomes. Special consideration should be given to tailor the postoperative rehabilitation after RTSA in patients with increased risk of fractures. [ABSTRACT FROM AUTHOR]

Biomechanical studies from that era set out to determine how well shoulder arthroplasty replicated normal shoulder anatomy, and the goal of the procedure was to replicate normal shoulder biomechanics as much as possible. Interestingly, when the goal of the biomechanical models is to modify the implant position to improve shoulder motion, the model must include not only prosthesis positioning but also prosthesis design variables thought to influence shoulder motion. Received November 17, 2021 Accepted December 22, 2021 Online date: January 13, 2022 When total shoulder arthroplasty was first developed, orthopaedic surgeons used it to treat nearly every shoulder condition, although our understanding of the biomechanics of this procedure at that time was rudimentary at best. Indeed, rTSA opened the door for the successful treatment of many shoulder conditions that were not amenable to treatment with anatomic total shoulder arthroplasty. [Extracted from the article]

Background: Acromial and scapular fractures after reverse total shoulder arthroplasty (rTSA) are rare and challenging complications, and little information is available in the literature to identify patients who are at risk. This study analyzes risk factors for, and compares the outcomes of patients with and without, acromial and scapular fractures after rTSA with a medialized glenoid/lateralized humeral implant.Methods: Four thousand one hundred and twenty-five shoulders in 3,995 patients were treated with primary rTSA with 1 design of reverse shoulder prosthesis by 23 orthopaedic surgeons. Sixty-one of the 4,125 shoulders had radiographically identified acromial and scapular fractures. Demographic characteristics, comorbidities, implant-related data, and clinical outcomes were compared between patients with and without fractures to identify risk factors. A multivariate logistic regression, 2-tailed unpaired t test, and chi-square test or Fisher exact test identified significant differences (p < 0.05).Results: After a minimum duration of follow-up of 2 years, the rate of acromial and scapular fractures was 1.77%, with the fractures occurring at a mean (and standard deviation) of 17.7 ± 21.1 months after surgery. Ten patients had a Levy Type-1 fracture, 32 had a Type-2 fracture, 18 had a Type-3 fracture, and 1 fracture could not be classified. Patients with acromial and scapular fractures were more likely to be female (84.0% versus 64.5% [p = 0.004]; odds ratio [OR] = 2.75 [95% confidence interval (CI) = 1.45 to 5.78]), to have rheumatoid arthritis (9.8% versus 3.3% [p = 0.010]; OR = 3.14 [95% CI = 1.18 to 6.95]), to have rotator cuff tear arthropathy (54.1% versus 37.8% [p = 0.005]; OR = 2.07 [95% CI = 1.24 to 3.47]), and to have more baseplate screws (4.1 versus 3.8 screws [p = 0.017]; OR = 1.53 [95% CI = 1.08 to 2.17]) than those without fractures. No other implant-related differences were observed in the multivariate analysis. Patients with fractures had significantly worse outcomes than patients without fractures, and the difference in mean improvement between these 2 cohorts exceeded the minimum clinically important difference for the majority of measures.Conclusions: Acromial and scapular fractures after rTSA are uncommon, and patients with these fractures have significantly worse clinical outcomes. Risk factors, including female sex, rheumatoid arthritis, cuff tear arthropathy, and usage of more baseplate screws were identified on multivariate logistic regression analysis. Consideration of these findings and patient-specific risk factors may help the orthopaedic surgeon (1) to better inform patients about this rare complication preoperatively and (2) to be more vigilant for this complication when evaluating patients postoperatively.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Reverse shoulder arthroplasty has been proven to improve function in shoulders with cuff-tear arthropathy, but existing studies are primarily single-center studies with a small number of patients, which limits their ability to identify patients who have an increased risk of revision or a worse functional outcome.Questions/purposes: (1) What is the estimated 10-year cumulative revision rate after reverse shoulder arthroplasty for cuff-tear arthropathy, and what factors are associated with the risk of revision? (2) What is the patient-reported outcome 1 year after surgery, and what factors are associated with a worse patient-reported outcome?Methods: We included all patients treated with reverse shoulder arthroplasty for cuff-tear arthropathy reported in the Danish Shoulder Arthroplasty Registry from 2006 to 2015. During the study period, the completeness of reporting was 93% for both primary and revision arthroplasties. Estimated revision rates were illustrated using the Kaplan-Meier method, and hazard ratios were calculated using a Cox regression model. Patient-reported outcome was measured with a postal survey at 12 months (range 10-14 months) postoperatively using the Western Ontario Osteoarthritis of the Shoulder (WOOS) index. The WOOS is a patient-administered questionnaire that measures the quality of life of patients with glenohumeral osteoarthritis. A visual analog scale that ranges from 0 to 100 is used for each question. There are 19 questions, giving a total score ranging from 0 to 1900, with 1900 being the worst. For simplicity of presentation, raw scores were converted to a percentage of the maximum score, with 100 being the best. There is no defined minimal clinically important difference of the WOOS, but the Danish Shoulder arthroplasty registry has for many years regarded an arbitrary difference of 10 or above as being clinically relevant. The rate of response to the WOOS was 71%.Results: The estimated 10-year cumulative revision rate was 8.5% (95% confidence interval, 5.7%-11.3%) with differences between the arthroplasty model (21.0%; 95% CI, 11.8% to 30.8% for the Delta Mark III and 5.5%; 95% CI, 3.7% to 7.3% for the Delta Xtend) and gender (6.0%; 95% CI, 3.0% to 9.0% for women and 13.1%; 95% CI, 7.1% to 19.1% for men). After controlling for potential confounding variables including gender, previous surgery, arthroplasty model, and period of surgery, the risk of revision was higher with the Delta Mark III than with the Delta Xtend (hazard ratio 2.7; 95% CI, 1.3 to 5.4; p < 0.01) and higher in men than in women (hazard ratio 2.7; 95% CI, 1.6 to 4.7; p < 0.01). Thirty-three percent (19 of 57) of the revision arthroplasties were performed for dislocation and 32% (18 of 57) were to treat periprosthetic joint infection. After controlling for confounding variables, only previous surgery was associated with a worse WOOS score (mean difference -10.6; 95% CI, -15.2 to -5.9; p < 0.01); there were no associations between a worse score and gender, arthroplasty model, age group, or period of surgery.Conclusions: The results from the present study can be used to inform patients about their individual risk of revision or a disappointing functional outcome. The study also demonstrates the need for proper patient selection and attention to technical details to reduce the risk of revision, especially for men. Our follow-up time was, however, short, with only an estimate of the 10-year revision rate. Future studies with a long-term follow-up duration are needed to confirm our results.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

The article discusses a clinical trial which compared lateralized glenospheres and nonlateral and distalized glenospheres for external rotation at 2 years in patients who underwent reverse total shoulder arthroplasty (RTSA). Topics discussed include the mean change in external rotation of the shoulder at 0° and 90°, secondary outcomes measured including internal rotation, abduction and radiographic findings, and the lack of difference in outcome between the treatment groups.

Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial. CORR Insights®: Reverse Total Shoulder Arthroplasty Is the Most Cost-effective Treatment Strategy for Proximal Humerus Fractures in Older Adults: A Cost-utility Analysis Footnotes 1 I This i CORR Insights® I is a commentary on the article i "Reverse Total Shoulder Arthroplasty Is the Most Cost-effective Treatment Strategy for Proximal Humerus Fractures in Older Adults: A Cost-utility Analysis" I by Khalik and colleagues available at: i DOI: 10.1097/CORR.0000000000002244. [Extracted from the article]

CORR Insights®: Reduced Revision Rates in Total Shoulder Arthroplasty With Crosslinked Polyethylene: Results From the Australian Orthopaedic Association National Joint Replacement Registry Previous simulation and wear studies of polyethylene and shoulder arthroplasty were in the setting of reverse total shoulder arthroplasty [[1], [3], [5]]. Although it is important to study aseptic loosening caused by microparticle debris, which is a leading cause of revision in reverse total shoulder arthroplasty [[3]], there are several other important variables to consider when examining the survivorship of anatomic total shoulder arthroplasty. [Extracted from the article]

Background: Instability after shoulder arthroplasty remains a complication with limited salvage options. Reoperation for instability with anatomic designs has led to high rates of persistent instability, therefore we aimed to evaluate the use of RSA for treatment of prosthetic instability.Questions/purposes: (1) After revision shoulder arthroplasty to a reverse prosthesis (RSA), what is the survivorship free from dislocations at 2 and 5 years? (2) What factors are associated with dislocations? (3) What is the survivorship free from revision after revision to RSA? (4) From preoperation to postrevision to RSA, what are the clinical outcomes-the proportion of patients with moderate to severe pain, shoulder elevation and external rotation ROM, American Shoulder and Elbow Surgeons scores, and Simple Shoulder Test scores?Methods: All shoulder arthroplasties revised for prosthetic instability using RSA components between January 2004 and July 2014 were retrospectively studied. During the period in question, we performed 82 revisions for instability of an anatomic total shoulder arthroplasty (TSA) (n = 62), hemiarthroplasty (n = 13), or reverse TSA (n = 7). We typically used a reverse TSA to treat this problem, but we identified 12 treated in other ways, including revision of a TSA to hemiarthroplasty (n = 3), revision of a reverse TSA to hemiarthroplasty (n = 2), revision of hemiarthroplasty to a hemiarthroplasty (n = 1), and revision of an anatomic TSA to another anatomic TSA (n = 6). This left 70 patients for evaluation; of those, 65 (93%) were available for analysis at a mean of 3 years (range, 2-10 years). A total of seven patients died. Eight of the 65 shoulders were not evaluated during the last 5 years, including three in patients who died earlier. The mean age of the patients at the time of revision RSA was 65 years (range, 40-89 years). Data were obtained from a longitudinally maintained institutional joint registry. Instability was defined as severe subluxation confirmed on clinical and radiographic examinations. We evaluated pain and ROM, and Kaplan-Meier curves were used to estimate survivorship.Results: The survivorship free from dislocation at 2 and 5 years was 87% (95% CI, 80%-94%) and 79% (95% CI, 67%-91%) respectively, with 10 of 65 (15%) patients having an episode of dislocation after revision surgery. Persistent instability was more common in those with a BMI greater than 35 kg/m2 (hazard ratio [HR], 5; 95% CI, 2-16; p = 0.008) and prior hemiarthroplasty (HR, 5; 95% CI, 2-16; p = 0.005), whereas patients who had undergone a previous TSA were less likely to have persistent instability (HR, 0.08; 95% CI, 0.0-0.30; p < 0.001) The survival free from rerevision for any indication at 2 and 5 years was 85% (95% CI, 76%-94%) and 78% (95% CI, 66%-90%) respectively; with the numbers available, we were not able to find associated factors. Fewer patients had moderate or severe pain after revision to RSA (preoperative: 48 of 65 [74%]; postoperative: nine of 65 [14%]; p < 0.001). After surgery, patients showed improvement in shoulder elevation (preoperative: 42° [± 30°], postoperative: 112° [42°]; mean difference, 70° [95% CI, - 83o to 57°]; p < 0.001) and external rotation (preoperative: 20° [± 22°], postoperative: 42° [± 23°]; mean difference, 22° [95% CI, - 30° to - 14°]; p < 0.001). American Shoulder and Elbow Surgeons scores improved (preoperative: 21 [± 10], postoperative: 68 [± 14], mean difference, 46 [95% CI, - 58 to - 35]; p < 0.001); where a higher score is better. Simple Shoulder Test scores also improved (preoperative: 2/12 [± 2], postoperative: 7/12 [± 3]; mean difference, 5 [95% CI, - 7 to - 2.17]; p < 0.001); where a higher score is better.Conclusions: Revision RSA for prosthetic instability after shoulder arthroplasty is associated with reasonable implant survival and few complications. Approximately one in seven patients will have a recurrent dislocation. In patients with persistent instability or with risk factors for instability, consideration should be given for use of larger glenospheres and increasing the lateral offset at the time of RSA.Level Of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

On my first day in the operating room, I scrub a complete scapular and proximal humeral resection with a scapular allograft and reverse shoulder arthroplasty. Halfway through my fourth year, I begin a tumor rotation at Memorial Sloan Kettering Cancer Center. In my second week on the rotation, I am with my attending in clinic when we see a college senior returning for her 5-year follow-up appointment after a distal humeral resection and allograft for chondrosarcoma. [Extracted from the article]

The article presents the discussion on patients having primary reverse shoulder arthroplasty (RSA). Topics include deltopectoral (DP) approach differ from an anterosuperior (AS) approach for metaglene positioning; and revision or tumoral surgery, or acute proximal humeral fracture . with humeral head dislocation.

The article discusses the instabilities of shoulder arthroplasty. Topics include are the causes which are responsible for instabilities after shoulder arthroplasty, morbid obesity being one of the causes of shoulder instability, and determining instabilities in the joints through different techniques after the postoperative surgeries.