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Background The Patient-Reported Outcomes Measurement Information System minimal clinically important difference (PROMIS MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) of patient-reported outcome measures provide clinical significance to patient-reported outcome measures scores. The goal of this study is to measure the MCID, SCB, and PASS of PROMIS Upper Extremity v2.0 (PROMIS UE) in patients undergoing total shoulder arthroplasty (TSA). Methods All patients who underwent TSA since October 2017 were identified from our institutional database. Patients who had completed the PROMIS UE outcome measure before surgery were asked to complete a PROMIS UE and anchor survey that contained two transition questions to assess patient satisfaction and change in symptoms since treatment. The anchor-based MCID, SCB, and PASS were calculated as the change in PROMIS UE score that represented the optimal cutoff for a receiver operating characteristic curve. The distribution-based MCID was calculated as a range between the average standard error of measurement multiplied by 2 different constants: 1 and 2.77. Results This study enrolled 165 patients. The anchor-based MCID for PROMIS UE was calculated to be 8.05 with an AUC of 0.814. The anchor-based SCB was calculated to be 10.0 with an AUC of 0.727. The distribution-based MCID was calculated to be between 3.12 and 8.65. The PASS was calculated to be 37.2 with an AUC of 0.90. Conclusions The establishment of MCID, SCB, and PASS for PROMIS UE scores after shoulder arthroplasty provides meaningful and objective clinical interpretation of the improvements in outcome scores after TSA.

Background The purpose of this study was to determine if addition of CT to axillary radiographs (AXR) alters preoperative decision making for shoulder arthroplasty. Methods Preoperative deidentified images (XR alone and XR with CT) of 50 patients with glenohumeral arthritis were reviewed independently by 3 reviewers in a blinded fashion. Each reviewer graded images for glenoid wear pattern as simple (Walch A1 or B1) or advanced [A2, B2, C]), adequacy of AXR and need for advanced imaging. The reviewers determined a preoperative plan for all patients based on XR alone vs. XR and CT including the arthroplasty type (anatomic or reverse total shoulder) and their plan for treating glenoid wear (eccentric or standard reaming vs. bone graft or augment). Kappa values (κ) were calculated to determine inter-rater agreement and consistency among multiple reviewers. Fisher's exact test was used to assess any difference in preoperative plan once the shoulders were separated into simple and advanced glenoid wear patterns. Results The 3 reviewers agreed that quality of AXRs was significantly inadequate (P Conclusion Axillary radiographs are often inadequate for preoperative planning in shoulder arthritis with advanced glenoid wear patterns (Walch A2, B2, C types). Addition of CT imaging to radiographs in shoulder arthritis with advanced glenoid wear can affect the preoperative decision with respect to type of shoulder arthroplasty and/or plan for addressing glenoid wear (reaming, bone graft or augmented glenoids). Level of evidence Level IV

Purpose To describe the clinical features, treatment, and outcomes in patients with complex region pain syndrome (CRPS) following shoulder surgeries. Methods Three patients were diagnosed with CRPS according to the Budapest criteria. Patients were followed up prospectively at regular intervals for a minimum of 2 years. Demographic data, clinical symptoms, physical examination findings, treatment received, and outcomes were collected and reported. Results The minimum time interval between surgery and diagnosis was 3 weeks (average, 8 weeks). The index procedures included 2 arthroscopic rotator cuff repairs and 1 open Latarjet. Neurologic pain, muscle spasms, hand and wrist swelling, and joint stiffness were seen in the shoulder, wrist, and hand, but the elbow was spared in all patients. Despite the use of multimodal treatment modalities, the symptoms were refractory to treatment for prolonged periods (range, 6-12 months). Hand and wrist symptoms took an average of 4 months longer than shoulder symptoms to improve. At the latest follow-up (range, 24-26 months), varying degrees of residual hand dysfunction, pain, and inability to make a fist or fully extend the fingers were noted in all 3 patients. Conclusions CPRS type 1 following shoulder surgery is a disabling condition with a long-protracted clinical course. CRPS can present as early as few weeks after shoulder surgery, with symptoms of neuropathic pain, spasm, and stiffness affecting the entire upper-extremity joints except the elbow. CRPS symptoms resolve earlier in the shoulder compared with the wrist and hand, with pain improving first, followed by recovery of motion and function. Residual stiffness affecting grip function is last to recover and can present up to 2 years after onset of symptoms. Although prompt recognition and multimodal approach are considered the mainstay of treatment, there is no gold standard treatment modality that can reproducibly alter the natural history of CRPS. Level of Evidence IV, therapeutic case series.

With an ongoing opioid epidemic in the United States, it is important to examine if decreased opioid prescribing can affect patient experience, namely satisfaction with pain control.The purpose of this study was to investigate what effect, if any, decreased opioid prescribing after total shoulder arthroplasty had on Press Ganey satisfaction surveys.A retrospective review was conducted on patients who underwent primary anatomic or reverse total shoulder arthroplasty between October 2014 and October 2019. Patients with complete Press Ganey survey information and no history of trauma, fracture, connective tissue disease, or prior shoulder arthroplasty surgery were included in the analysis. Patients were segregated into 2 groups, pre-protocol and post-protocol, based on the date of surgery relative to implementation of an institutional opioid reduction protocol, which occurred in October 2018. Prescriptions were converted to morphine milligram equivalents (MME) for direct comparison between different opioid medications.A total of 201 patients met inclusion criteria, and there were 110 reverse total shoulder arthroplasties and 91 anatomic total shoulder arthroplasties. Average opioids prescribed on discharge for the pre-protocol group were 426.3 ± 295 MME (equivalent to 56.8 tablets of oxycodone 5 mg), whereas after the initiation of the protocol, they were 193.8 ± 199 MME (equivalent to 25.8 tablets of oxycodone 5 mg); P.0001. Average satisfaction with pain control did not change significantly between pre-protocol and post-protocol (4.71 ± 0.65 pre-protocol and 4.74 ± 0.44 post-protocol, P = .82).A reduction in opioids prescribed after a total shoulder replacement is not associated with any negative effects on patient satisfaction, as measured by the Press Ganey survey.

Purpose To compare biomechanical and clinical outcomes between knotless and knotted anchors in arthroscopic labral repair, specifically in (1) Bankart repair, (2) SLAP repair, (3) posterior labral repair, and (4) remplissage augmentation of Bankart repair. Methods MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to find biomechanical and clinical studies comparing knotted and knotless anchors using the search term “knotless anchor.” Results Overall, 17 studies met inclusion criteria. There were 7 studies evaluating the biomechanical outcomes, of which 5 found mixed results between knotted and knotless anchors for arthroscopic Bankart repair, 1 demonstrated a difference for SLAP repair favoring knotless anchors, and 2 showed no significant difference for Remplissage in terms of ultimate load-to-failure. Four studies evaluated knotless labral anchors compared with knotted anchors in patients undergoing arthroscopic Bankart repair with no significant differences in outcomes reported between the 2 anchor types, except in one study that found an improved visual analog scale score and a lower recurrence and revision rate with knotted anchors. Five studies evaluated knotless anchors compared with knotted anchors in patients undergoing SLAP repair, and none of the included studies found any significant differences in the patient reported outcome measures or revision rates. Of the 5 studies comparing operative time, 4 found a reduced time with knotless anchors. Conclusions The clinical results show no significant differences in outcomes between knotless and knotted anchors for labral repair in the shoulder, including Bankart repair, SLAP repair, and posterior labral repair. However, there was conflicting evidence supporting knotless or knotted anchors in the biomechanical studies. However, operative times may be reduced with the use of knotless anchors. Level of Evidence III, A Systematic Review of Level II and III studies.

Preoperative 3D planning and intraoperative navigation for shoulder arthroplasty has recently gained interest because of the potential to enhance the surgeon's understanding of glenoid anatomy and improve the accuracy of glenoid component positioning. The purpose of our study was to assess the impact of preoperative 3D planning on the surgeon's selection of the glenoid component (standard vs. augmented) and compare duration of surgery with and without intraoperative navigation.We retrospectively analyzed 200 consecutive patients who underwent shoulder arthroplasty. The first group of 100 patients underwent shoulder arthroplasty using standard 2D preoperative planning based on standard radiographs and computed tomographic scans. The second group of 100 patients underwent shoulder arthroplasty using 3D preoperative planning and intraoperative navigation. Type of glenoid component and operative time were recorded in each case.For the group of patients with standard preoperative planning, only 15 augmented glenoid components were used, whereas in the group of patients with 3D preoperative planning and navigation, 54 augments were used (P.001). The operative time was 11 minutes longer for the procedures that used intraoperative navigation, compared with those that did not (P.001). This difference diminished as the surgeon became more proficient with the navigation technique.Use of preoperative 3D planning changes the surgeon's understanding of the patient's glenoid anatomy. In our study, using 3D planning increased the likelihood that the surgeon selected an augmented glenoid component compared with 2D planning. Intraoperative navigation slightly lengthened the duration of surgery, but this became insignificant as part of a learning curve within 6 months.

Introduction There is no current standard by which culture specimens from revision shoulder arthroplasty should be handled, processed, cultured, and reported. Due to the relatively low numbers of cases multicenter study may provide information to form consensus recommendations. However, assimilation of multicenter data requires comparable methodologies. The objective of this study was to document and evaluate the extent of variability between surgeons and institutions. Methods An 11-question survey was sent to 20 shoulder surgeons as part of the American Shoulder and Elbow Society (ASES) Periprosthetic Joint Infection (PJI) Multicenter Workgroup. Questions addressed how samples are handled in the operating room by surgeons, processing of tissue samples and explants by laboratories, number of media, culture incubation durations, and culture reporting. Results Common practices regarding specimen handling and processing were identified including prolonged culture incubation times >13 days (94% of participants). However, substantial variation in handling of tissue and explant specimens, number and type of media used, and reporting of results were identified. The majority of surgeons reported using a sterile instrument to harvest each individual tissue specimen (10/17, 59%), more so than using any available instrument (4/17, 24%) or washing and re-using the same instrument (3/17, 18%). Half of the institutions require a time limit by which samples must be processed in the laboratory (8/16, 50%). Nine institutions (9/16, 56%) report cultures in a semi-quantitative manner, while 7 (44%) report cultures in a binary fashion. Five institutions reported having performed a negative control study, and the rate of positive cultures ranged between 0% and 17%. The majority of positive cultures from the negative controls contained Cutibacterium (92%). Discussion Specimen handling, processing, culturing, and reporting varies widely between institutions. Due to the risk of false positives as demonstrated by negative control studies, surgeons should be cognizant of potential sources of contamination at the specimen handling level in the operating room and specimen processing level in the laboratory. Given the challenges in interpretation of positive cultures in revision shoulder arthroplasty, further studies are needed to determine whether assimilation of data across institutions is acceptable or whether a standard culturing methodology across institutions is necessary. Level of Evidence: V

The aims of this study were to examine variances in inpatient opioid consumption after total shoulder arthroplasty (TSA) and to determine factors influencing inpatient opioid utilization.The sample included patients undergoing elective TSA at a tertiary-level institution between January 2016 and April 2018. Opioid consumption during the inpatient stay was converted into morphine milligram equivalents (MMEs), accounting for dosage and route of administration. The MMEs were calculated per patient encounter and used to calculate mean opioid consumption. Bivariate linear regression analysis was performed to assess the impact of patient-related factors and surgery-related factors on inpatient opioid consumption.Altogether 20 surgeons performed 622 TSAs. The average opioid dose per encounter was 47.4 ± 65.7 MME/d. MMEs prescribed varied significantly among surgeon providers (P .01). Pre-existing psychiatric disorders (P = .00012), preoperative opioid use (P = .0013), highest quartile of median household income (P = .048), current-smoker status (P.001), age60 years (P.01), and general anesthesia (vs. regional anesthesia, P = .005) were associated with significant inpatient opioid consumption after TSA. Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences.There is considerable variation in inpatient opioid consumption after TSA at the same institution. Knowledge of modifiable and nonmodifiable risk factors that increase inpatient opioid consumption will help to optimize multimodal analgesia protocols for TSA.

» For shoulder arthroplasty, regional anesthesia is safer when compared with general anesthesia. There is insufficient evidence to demonstrate the superiority of regional anesthesia with respect to pulmonary complications and hospital length of stay. » Infiltration of the shoulder with local anesthetics offers no additional benefits compared with single-shot or continuous brachial plexus blocks for shoulder arthroplasty. » There is high-quality evidence (Level I) demonstrating lower pain scores and lower perioperative opioid requirements after a continuous peripheral nerve block compared with a single-shot nerve block. However, catheter dislodgment and logistical issues with catheter insertion are impediments to the widespread usage of a continuous nerve block with an indwelling catheter. » Liposomal bupivacaine is comparable with non-liposomal local anesthetic agents with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after total shoulder arthroplasty. » Perioperative dexamethasone administration improves postoperative pain control, decreases perioperative opioid requirements, and reduces postoperative nausea.

» Pectoralis major (PM) tendon tears are predominantly seen in young men, and the majority of tears occur as tendon avulsions involving the sternal head. Weightlifting, specifically bench-pressing, and sporting activities with eccentric overloading of the PM tendon are the 2 most common activities that result in PM injury. » Early surgical repair or reconstruction should be offered to younger, active patients with a complete PM tear; the majority of the patients undergoing surgical repair achieve good-to-excellent outcomes. » Nonsurgical treatment of a complete PM tear is an option but will result in cosmetic deformity and a deficit in adduction strength of the arm. Outcomes after nonsurgical treatment of complete PM tears are less satisfactory than those obtained after surgical treatment. » Currently, there is no consensus on the chronological definition of PM tears (acute versus chronic), the critical time limit for performing surgical repair, the ideal fixation device (cortical button, bone tunnel, or suture anchors), the indications for allograft use, and the ideal rehabilitation protocol after treatment of PM tears.

Introduction Management of the subscapularis during shoulder arthroplasty is controversial. The purpose of this study was to compare the biomechanical performance of subscapularis peel (SP) and lesser tuberosity osteotomy (LTO) in a cadaveric model. Methods The subscapularis and proximal humerus were dissected from all soft tissues in 21 fresh-frozen human cadaveric shoulders and randomized to undergo SP, LTO, or standard subscapularis tenotomy (ST, control). For SP and LTO, six #5 sutures were passed through eyelets in the implant (on lateral border and through drill holes in bicipital groove [2] and under trunion [4]). Double-row repair was performed using two lateral row transosseous sutures and four medial row sutures through the tendon (SP) or osseotendinous junction (LTO). Biomechanical properties and mode of failure were tested. Results There were no significant differences in elongation amplitude, cyclic elongation, or maximum load to failure between the three groups (P > 0.05). Mean stiffness was significantly higher in LTO (P = 0.009 vs. SP and ST). In the ST group, 7/7 specimens failed at the tendon-suture interface. For SP, 4/7 failed at the tendon-suture interface, one at the suture-bone interface, one fractured around the implant stem, and one at the knots. For LTO, 3/7 failed at the tendon-suture interface, two at the suture-bone interface and two fractured around the implant stem. Conclusions In this cadaveric model, subscapularis repair via ST, SP, and LTO techniques was biomechanically equivalent. Additional studies are needed to confirm these findings and determine the influence of biologic healing on healing rates and clinical outcomes. Level of evidence N/a, biomechanical laboratory study

Background Reducing intraoperative wound contamination is a critical preventive strategy for reducing the risk of prosthetic joint infection in shoulder arthroplasty. The aim of this study was to investigate the potential microbial colonization of subscapularis tagging sutures during shoulder arthroplasty. Methods In this prospective study, 50 consecutive patients undergoing primary shoulder arthroplasty (anatomic or reverse) were enrolled. Patients with revision shoulder arthroplasty and proximal humeral fractures were excluded. Nonabsorbable, braided tagging sutures were placed through the subscapularis tendon prior to tenotomy. A similar nonabsorbable, braided suture (control) was placed in a sterile container on the back table, open to the operating room environment. Subscapularis tagging sutures (experimental specimens) and control sutures were collected prior to subscapularis tenotomy repair and submitted for aerobic and anaerobic cultures. Cultures were held for 21 days to account for extended growth of slow-growing bacteria. Results A total of 12 of 50 experimental and 16 of 50 control sutures had positive cultures. Staphylococcus epidermidis and Cutibacterium acnes were the 2 most commonly isolated organisms. Active tobacco use (P = .038) and procedure length (P = .03) were significantly associated with positive cultures. No significant association between positive subscapularis tagging suture cultures and positive control cultures was found (P = .551). Patient age, sex, body mass index, and significant medical comorbidities were not significantly associated with positive cultures. Discussion Subscapularis tagging sutures are a potential source of microbial contaminant in shoulder arthroplasty, and we recommend exchanging the tagging suture with a suture opened immediately prior to subscapularis repair.

Hypothesis The aim of this meta-analysis was to compare the safety, efficacy, and opioid-sparing effect of liposomal bupivacaine (LB) vs. nonliposomal local anesthetic agents (NLAs) for postoperative analgesia after shoulder surgery. Methods A systematic literature review of randomized controlled clinical studies comparing the efficacy of LB with NLAs in shoulder surgery was conducted. Seven level I and II studies were included in the meta-analysis, and shoulder surgical procedures included arthroscopic rotator cuff repair and shoulder arthroplasty. Bias was assessed using The Cochrane Collaboration's tool. The primary outcome measures were visual analog scale pain scores and opioid consumption 24 and 48 hours after shoulder surgery. Subgroup analysis was performed for the method of LB administration (interscalene nerve block vs. local infiltration). Results A total of 7 studies (535 patients) were included in the final meta-analysis comparing LB (n = 260) with NLAs (n = 275). No significant difference was found between the LB and NLA groups in terms of visual analog scale pain scores at 24 hours (95% confidence interval, –1.02 to 0.84; P = .86) and 48 hours (95% confidence interval, –0.53 to 0.71; P = .78). Both groups had comparable opioid consumption at both 24 hours (P = .43) and 48 hours (P = .78) postoperatively and with respect to length of stay (P = .87) and adverse events (P = .97). Subgroup analysis demonstrated comparable efficacy irrespective of the method of administration of LB. Conclusion LB is comparable to NLAs with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after arthroscopic rotator cuff repair and total shoulder arthroplasty.

Aims The aim of this study was to investigate the effects of preoperative bisphosphonate treatment on the intra- and postoperative outcomes of arthroplasty of the shoulder. The hypothesis was that previous bisphosphonate treatment would adversely affect both intra- and postoperative outcomes. Patients and Methods A retrospective cohort study was conducted involving patients undergoing arthroplasty of the shoulder, at a single institution. Two patients with no previous bisphosphonate treatment were matched to each patient who had received this treatment preoperatively by gender, age, race, ethnicity, body mass index (BMI), and type of arthroplasty. Previous bisphosphonate treatment was defined as treatment occurring during the three-year period before the arthroplasty. The primary outcome measure was the incidence of intraoperative complications and those occurring at one and two years postoperatively. A total of 87 patients were included: 29 in the bisphosphonates-exposed (BP+) group and 58 in the non-exposed (BP-) group. In the BP+ group, there were 26 female and three male patients, with a mean age of 71.4 years (51 to 87). In the BP- group, there were 52 female and six male patients, with a mean age of 72.1 years (53 to 88). Results Previous treatment with bisphosphonates was positively associated with intraoperative complications (fracture; odds ratio (OR) 39.40, 95% confidence interval (CI) 2.42 to 6305.70) and one-year postoperative complications (OR 7.83, 95% CI 1.11 to 128.82), but did not achieve statistical significance for complications two years postoperatively (OR 3.45, 95% CI 0.65 to 25.28). The power was 63% for complications at one year. Conclusion Patients who are treated with bisphosphonates during the three-year period before shoulder arthroplasty have a greater risk of intraoperative and one-year postoperative complications compared with those without this previous treatment.

CASE We report a rare variant of sternoclavicular joint (SCJ) dislocation, namely locked anterior-inferior dislocation, with unique clinical, radiographic, and intraoperative findings. In this variant, the medial clavicle was displaced anteriorly and inferiorly and locked in the manubrial-intercostal space, with corresponding mechanical dysfunction of the ipsilateral shoulder girdle joints. Symptoms unique to this variant included painful neck spasms and limited glenohumeral elevation. Nonsurgical treatment was not successful, and open reduction and ligament reconstruction resulted in correction of the fixed deformity with resolution of the clinical symptoms. CONCLUSION Locked anterior-inferior SCJ dislocation is indicated for early open reduction and ligament reconstruction.

Background Uncorrected superior glenoid wear in patients managed with reverse total shoulder arthroplasty (rTSA) can result in increased complications, including baseplate failure. The present study quantifies the clinical and radiographic outcomes of patients with Favard type-E1, E2, and E3 glenoid deformity who were managed with rTSA with use of a superior or superior/posterior augmented glenoid baseplate. Methods We retrospectively reviewed the records for 68 patients with shoulder arthritis and Favard type-E1, E2, or E3 glenoid deformity who were managed with primary rTSA and a 10° superior augmented or 10° superior/8° posterior augmented baseplate. The mean duration of follow-up was 40 months (range, 24 to 85 months). Outcomes were assessed preoperatively and at the latest follow-up with shoulder range of motion and use of outcome scores including the Simple Shoulder Test (SST), University of California Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and Shoulder Pain and Disability Index (SPADI) score. Radiographs were evaluated preoperatively and at the time of the latest follow-up. Differences in preoperative and postoperative range of motion and outcome metrics were assessed with use of a 2-tailed Student t test. Results The majority of patients experienced clinically meaningful improvements in terms of pain and function following rTSA with a superior or superior/posterior augment, with 94% of patients rating themselves as "much better" (73.5%) or "better" (20.5%) at the time of the latest follow-up. At least 88% of the patients exceeded the minimum clinically important difference (MCID) threshold, and 75% of patients exceeded the substantial clinical benefit (SCB) threshold, for each of the clinical outcome metrics and range of motion. Five complications were reported (prevalence, 7.4%), including acromial stress fracture (2 patients), posttraumatic scapular neck fracture (1 patient), chronic shoulder pain (1 patient), and aseptic glenoid loosening (1 patient). Conclusions The present short-term clinical and radiographic study demonstrated that shoulder arthropathy with superior glenoid wear patterns (Favard types E1, E2, and E3) can be successfully treated with rTSA with a superior or superior/posterior augmented baseplate. Longer-term clinical and radiographic follow-up is necessary to confirm that these promising short-term results are durable. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose To ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after arthroscopic posterior shoulder stabilization. Methods Medline, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies on arthroscopic posterior shoulder stabilization. Studies were included if they reported RTP data or rehabilitation protocols and excluded if concomitant procedures influenced the rehabilitation protocol. Rate and timing of RTP, along with rehabilitation protocols, were assessed. Results This review found 25 studies, including 895 cases, meeting the study’s inclusion criteria. The majority of patients were male (82.7%), with an age range of 14 to 66 years and a follow-up range of 4 to 148.8 months. The overall RTP rate ranged from 62.7% to 100.0%, and 50.0% to 100.0% returned to the same level of play. Among collision athletes, the overall rate of RTP was 80.0% to 100.0%, with 69.2%-100.0% returning to the same level of play. In overhead athletes, the overall rate of RTP was 85.2% to 100.0%, with 55.6% to 100.0% returning to the same level of play. Four studies (128 patients) specifically addressed the timing of RTP, and the range to RTP was 4.3 to 8.6 months. Specific RTP criteria were reported in a majority of studies (60%), with the most reported item being restoration of strength (44%). Conclusion There is a high rate of return to sport after arthroscopic posterior shoulder stabilization, ranging from 4.3 to 8.6 months after surgery. Return to preinjury level is higher for collision athletes compared with overhead athletes. However, there is inadequate reporting of RTP criteria in the current literature, with no clear timeline for when it is safe to return to sport. Level of Evidence IV, systematic review of level II to IV studies

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. Methods A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. Conclusion Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. Level of Evidence Level V, expert opinion.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. Methods A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. Conclusion Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. Level of Evidence Level V: expert opinion.

Background The study evaluates patient-reported outcomes in revision shoulder arthroplasty (RevSA) according to etiology. Methods Twenty-three consecutive RevSA (minimum 2-year follow-up) were retrospectively reviewed. Patient-reported outcome (PRO) scores and range of motion were compared by the type of revision procedure and indication. Results EQ5D-QOL, VAS-pain, ASES, and forward elevation improved after RevSA. The infection group had least improvements. Revision to a reverse total shoulder arthroplasty (RTSA) demonstrated the most improvement in VAS-pain, forward elevation, and ASES. Conclusions Revision to RTSA significantly improved PRO scores compared to hemi- or total shoulder arthroplasty. RevSA for infection demonstrated the least improvement in outcomes.

A major factor that impacts the long-term outcome and complication rates of total shoulder arthroplasty is the preoperative posterior glenoid bone loss quantified by glenoid retroversion. The purpose of this study was to assess if glenoid retroversion varies significantly at different glenoid heights in Walch B2 and B3 glenoids. Patients with B2 and B3 glenoid types were included following retrospective review of 386 consecutive CT shoulder studies performed for arthroplasty preoperative planning. True axial CT reconstructions were created using a validated technique. Two readers independently measured the glenoid retroversion angles according to the Friedman method using the “intermediate” glenoid at three glenoid heights: 75% (upper), 50% (equator), and 25% (lower). The variances between the three levels for a given patient were calculated. Twenty-nine B2 and 8 B3 glenoid types were included. There was no significant difference in variance of glenoid version among the three levels in B2 or B3 groups. The mean variance in retroversion degree between equator-lower, upper-equator, and upper-lower glenoid was − 0.4, 0.3, and − 0.2 for B2; and − 0.2, 1.9, and 1.9 for B3 glenoid, respectively. The level of inter-reader agreement was fair to good for variance at equator-lower, and good to excellent for upper-equator and upper-lower glenoid. Glenoid version can be accurately measured at any level between 25 and 75% of glenoid height for Walch B2 and B3. We recommend that the glenoid equator be used as the reference to assure consistent and reliable version measurements in this group of patients.

Glenohumeral arthritis has become increasingly prevalent. For patients with glenohumeral arthritis and an intact rotator cuff, an anatomic total shoulder arthroplasty (TSA) has been shown to provide substantial pain relief with consistent, reproducible results. The primary indication is intractable pain that has not responded to nonoperative treatment, resulting in a substantial negative impact on the quality of life of the patient. Other indications for anatomic TSA include posttraumatic glenohumeral arthritis, inflammatory arthritis, and humeral head osteonecrosis. Contraindications include active infection, deltoid insufficiency, severe glenoid bone deficiency, and excessive glenohumeral posterior subluxation or laxity that cannot be surgically corrected. In order to provide the stability necessary to withstand the forces that impact the glenoid, the implant used in TSA should replicate the native anatomy of the individual patient by using a combination of implant modularity with different humeral neck angles and glenoid version augments, as well as dual eccentricity of the neck and head implant. The major steps in TSA include (1) preoperative planning, (2) patient positioning and setup, (3) surgical exposure, (4) accessing the glenohumeral joint, (5) preparation of the humerus, (6) exposure and preparation of the glenoid with component insertion, (7) humeral component insertion and trial reduction, (8) subscapularis reattachment and closure, and (9) postoperative immobilization and rehabilitation. The expected outcomes of TSA include improved quality of life (as indicated by improved outcome and patient satisfaction scores), shoulder active range of motion, and strength. In a large study examining outcomes of TSA in patients >55 years old, Patel et al.(1) reported improved American Shoulder and Elbow Surgeons (48.3 ± 23.0), Constant (33.1 ± 16.7), and University of California Los Angeles (16.7 ± 6.3) shoulder scores, as well as improved active range of motion in active abduction (42° ± 41°), forward flexion (46° ± 40°), external rotation (33° ± 23°), and internal rotation (2.2° ± 1.8°) and decreased visual analog scale scores (−5.1 ± 2.9). Another study(2) showed increased maximal weight improvement of 7.7 ± 4.0 lbs (3.5 ± 1.8 kg).

Introduction:Posttraumatic arthritis (PTA) is a common sequela of proximal humerus fractures that is commonly managed with anatomic or reverse total shoulder arthroplasty (TSA). TSA for PTA is more challenging than that performed for primary osteoarthritis and frequently leads to worse patient outcomes. CPT uniformly classifies all cases of primary TSA, irrespective of procedural complexity and resource utilization. This study analyzes intraoperative differences and 30-day outcomes for anatomic and reverse TSA performed in the posttraumatic shoulder.Methods:Patients undergoing TSA from 2008 to 2015 were selected from the National Surgical Quality Improvement Program database and stratified according to concurrent procedures and administrative codes indicating posttraumatic diagnoses. Perioperative parameters and 30-day complications were recorded; multivariate analyses were performed to determine whether PTA was a risk factor for poor outcomes.Results:A total of 8508 primary and 243 posttraumatic TSAs were identified. Posttraumatic TSA patients were slightly younger ( P = .003), more likely to be female ( P Conclusions:Compared with primary osteoarthritis, a preoperative diagnosis of PTA is an independent risk factor for prolonged operative times and postoperative transfusion in anatomic or reverse TSA patients; such patients may be less than optimal candidates for same-day discharges or outpatient shoulder arthroplasty.

Objective The purpose of this study is to quantify the clinical and radiographic outcomes of patients with severe posterior glenoid wear who were treated with reverse total shoulder arthroplasty (rTSA) and a posterior augmented baseplate. Methods A total of 67 primary rTSA patients with osteoarthritis and posterior glenoid wear were treated with an 8° posterior augmented glenoid baseplate. All patients had a Walch B2, B3, or C glenoid, 2-year minimum follow-up, and mean follow-up of 40 months. All patients were scored preoperatively and at the latest follow-up using 5 clinical outcome metrics; active range of motion was also measured. A Student's 2-tailed, unpaired t-test quantified differences in outcomes, where P Results All patients experienced significant improvements in pain and function after primary rTSA with a posterior augmented glenoid baseplate. Three complications were reported for a rate of 4.5%; no cases of aseptic glenoid loosening occurred. A total of 90% of patients exceeded the minimal clinically important difference threshold, and 80% of patients exceeded the substantial clinical benefit threshold for each clinical outcome metric and range of motion measure. No differences in outcomes or complications were observed between Walch B2 and B3 patients, demonstrating that this full-wedge posterior augmented baseplate was equally good in each type of glenoid deformity. Discussion Primary rTSA patients with Walch B2, B3, and C glenoids who received an 8° posterior augmented glenoid baseplate experienced excellent clinical and radiographic outcomes with a low complication rate and no reports of aseptic glenoid loosening at a mean follow-up of 40 months.

Background: Irreparable rotator cuff (RC) tears without arthritis is a challenging clinical problem in young adults. Reverse total shoulder arthroplasty (RTSA) has been proposed as one of the surgical treatment options for this condition. Methods: In this review, we discuss the current understanding of the role of RTSA for the management of irreparable RC tears without arthritis based on authors personal experience and available scientific literature. Results: Reverse total shoulder arthroplasty (RTSA) is a constrained arthroplasty system that can allow the deltoid and remaining rotator cuff to substitute for the lost function of irreparable RC. Furthermore, the pain relief is consistent with often a dramatic improvement in patient comfort, shoulder function and stability. In patients with pseudoparalysis of the shoulder without advanced arthritis, RTSA effectively restores forward elevation above the shoulder but may not dramatically improve external (ER) or internal rotation (IR). However, due to concerns over implant longevity, caution has to be exercised when using RTSA for symptomatic irreparable RC tears with preserved active forward elevation (AFE) and in patients less than 65 years of age. Conclusion: RTSA is a reasonable surgical option for irreparable rotator cuff repair without arthritis. However, caution should be exercised when offering RTSA to young patients and patient without pseudoparalysis because they can have a higher complication and dissatisfaction rate. In addition, longevity of RTSA and subsequent need for revision surgery remains a significant concern in this population.

The purpose of this study was to evaluate the short-term clinical and radiographic outcomes of humeral hemiarthroplasty and concentric glenoid reaming (“ream and run” procedure) and to compare the outcomes with those of total shoulder arthroplasty (TSA) for glenohumeral arthritis. Patients with glenohumeral arthritis who underwent the ream and run procedure with a minimum follow-up of 2 years were retrospectively reviewed. The primary outcome was revision to TSA. Secondary outcome measures included functional outcome scores, range of motion, and radiographic assessment. The outcome measures were compared with those of age- and sex-matched control patients who underwent anatomic TSA during the study period. One patient in the ream and run group required revision to TSA 14 months after the surgery because of excessive shoulder pain. There were significant improvements in the postoperative outcome scores and range of motion and external rotation in the ream and run group. Postoperative radiographs showed concentric glenoids without posterior subluxation in all except 1 shoulder. The outcome measures in the ream and run group were similar to those in the TSA control group except for active forward elevation and external rotation. The ream and run procedure provides improved pain relief and shoulder function at short-term follow-up for patients with shoulder arthritis. [ Orthopedics . 2018; 41(6):e854–e860.]

The long head of biceps tendon (LHBT) is frequently involved in rotator cuff tears and can cause anterior shoulder pain. Tendon hypertrophy, hourglass contracture, delamination, tears, and tendon instability in the bicipital groove are common macroscopic pathologic findings affecting the LHBT in the presence of rotator cuff tears. Failure to address LHBT disorders in the setting of rotator cuff tear can result in persistent shoulder pain and poor satisfaction after rotator cuff repair. Tenotomy or tenodesis of the LHBT are effective options for relieving pain arising from the LHBT in the setting of reparable and selected irreparable rotator cuff tears.

The long head of biceps tendon (LHBT) is a well-recognized cause of anterior shoulder pain. Tenotomy or tenodesis of the LHBT is an effective surgical solution for relieving pain arising from the LHBT. Cosmetic deformity of the arm, cramping or soreness in the biceps muscle, and strength deficits in elbow flexion and supination are the three most common adverse events associated with tenotomy of the LHBT. Complications associated with tenodesis of the LHBT include loss of fixation resulting in cosmetic deformity, residual groove pain, pain or soreness in the biceps muscle, infection, stiffness, hematoma, neurologic injury, vascular injury, proximal humerus fracture, and reflex sympathetic dystrophy.

The functional role of the long head of biceps in shoulder is controversial but it is well accepted as a pain generating structure. The long head of biceps can result in anterior shoulder pain after shoulder arthroplasty. Tenodesis of the long head of the biceps during shoulder arthroplasty is a safe and easy procedure, which minimizes the risk of postoperative "Popeye" deformity and anterior shoulder pain.

A Hill-Sachs lesion (HSL) is an impression fracture that is typically located in the posterior superolateral location on the humeral head and is a tell tale sign of anterior shoulder dislocation. Hill-Sach lesions are a common associated pathoanatomic finding in anterior shoulder instability but a large, clinically significant HSL is uncommon. The management of a large HSL is a challenging clinical situation in a young patient. The first priority is repair of anterioinferior capsulolabral soft tissues and restoration of glenoid arc to increase the glenoid track and this option alone is effective in most of the patients. A large HSL in presence of bipolar bone loss may require surgical management to prevent engagement. Anatomic restoration of the humeral head defect with a fresh humeral head osteochondral allograft provides anatomic stability and biology (live cartilage cells) and is a viable option for treatment of large HSL. We reserve prosthetic option (arthroplasty) for elderly patients with large HSLs or as a salvage option for failed allograft reconstruction of HSL in young patient with arthritis.

Background: The results of open and arthroscopic instability repairs have been shown to be equivalent in recent literature. Purpose: To compare the time to recurrence (TTR) of instability and disease-specific outcome measures in patients undergoing open and arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with recurrent traumatic anterior shoulder instability and a Bankart lesion on diagnostic arthroscopy underwent either open Bankart repair (OB) or arthroscopic Bankart and suture capsulorrhaphy (ABSC) using suture anchors. There was a minimum follow-up of 24 months. The primary outcome measures included Western Ontario Shoulder Instability Index (WOSI) score and time to recurrence of instability (dislocation or subluxation). Rowe score, Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons (ASES) score, and Short Form–12 (SF-12) score were also compared. Results: A total of 82 shoulders in 80 patients (ABSC, n = 58; OB, n = 24) were evaluated at a mean of 39 months postoperatively. There were 4 clinical failures in the OB group (4 dislocations) and 7 clinical failures in the ABSC group (2 dislocations and 5 subluxations; P = .72 vs OB). The mean time to recurrence of postoperative instability was significantly shorter in the ABSC group (12.6 ± 2.7 months) compared with the OB group (34.2 ± 12 months; P = .04). The WOSI score in the OB group (265 ± 48.1) was better but not statistically significantly compared with the ABSC group (449.8 ± 63.8; P = .06). Conclusion: The time to recurrence of instability after open Bankart repair is significantly longer compared with arthroscopic Bankart repair. Clinical Relevance: Delayed time to recurrence after open Bankart repair suggests that the open technique may be more suited to withstand the high stress and demands of a heavy-duty profession (contact athletes and heavy manual labor).

Study Design. Rat spinal fusion model. Objective. This study aimed to compare the efficacy of lentiviral gene therapy, and adenoviral gene therapy in inducing spinal fusion in an immune competent rat spinal fusion model. Summary of Background Data. Recombinant bone morphogenetic proteins (BMPs) have also been used for spinal fusion successfully in clinical trials. However, large doses of BMPs are required to induce adequate bone repair. Hence, regional gene therapy may be a more efficient method to deliver proteins to a specific anatomic site. Recently, lentiviral vectors based on human immunodeficiency virus have been developed for gene therapy. However, lentiviral gene therapy for spinal fusion has not been compared with adenoviral gene therapy. Methods. Lewis rats were divided into 7 groups. group I, II, III, and IV rats were implanted with a collagen sponge containing rat bone marrow cells (RBMCs) transfected with Lenti-BMP-2, Adeno-BMP-2, Lenti-GFP, Adeno-LacZ, respectively. Group V, VI, and VII rats were implanted with a collagen sponge containing recombinant BMP-2, a collagen sponge containing untransfected RBMCs, and a collagen sponge alone, respectively. The rats were assessed at 4, 6, and 8 weeks after implantation. After sacrificing the rats, their spines were explanted and assessed by manual palpation, high-resolution microcomputed tomography, and histologic analysis. Results. Spinal fusion was observed in all animals in group I, II, and V rats at 8 weeks. None of the rats in groups III, IV, VI, and VII showed spinal fusion. The volumes of the new bone in the area between the L4 and L5 transverse processes were greater in group I rats than in group II, and V rats with a significant difference. Conclusion. BMP-2-producing RBMCs developed using lentiviral gene transfer induced more abundant bone within the fusion mass than the RBMCs transduced via adenoviral gene transfer and recombinant protein therapy.

Introduction Recombinant bone morphogenic proteins (BMPs) have shown promise in enhancing in vivo bone formation but have been limited by suboptimal delivery methods. Gene therapy utilizing viral vectors has been proposed as a vehicle for BMP delivery. Previous work has demonstrated the capacity of a BMP-containing lentiviral vector (LV-BMP) to stimulate bone formation in the muscle pouch of a SCID mouse. This study compares the efficacy of BMP-containing adenovirus (Ad-BMP) and LV-BMP vectors in healing a critically sized rat femoral defect. Methods A critically sized femoral defect was created in the hind limb of 20 Lewis rats. Rat bone marrow cells (RBMCs) co-transfected with Ad-BMP and Ad-luciferase (Ad-luc) were seeded onto a collagen sponge and implanted in the femoral defect of 10 animals (group AV). RBMCs co-transfected with LV-BMP and LV-luc were implanted in the hind limb of 10 animals (group LV). Luciferase expression was assessed using cooled charge coupled device (CCCD) imaging at 3 days and weekly thereafter for 8 weeks. Radiographs were taken at 4 weeks and 8 weeks. Animals were sacrificed at 8 weeks and their femurs were harvested for histological, histomorphometrical, micro CT, and biomechanical analysis. Results Preliminary data demonstrate that luciferase expression and bone healing were present in both groups. Luciferase expression in group LV was detected at 8 weeks postoperatively while expression in group AV routinely ceased by 3 weeks. Both vectors induced bone union by 8 weeks; however, this healing was more frequent in group LV (10/10 animals) as compared to group AV (7/10 animals). Femurs harvested from group LV demonstrated improved structural properties including energy to failure (LV: 2.018, Ad: 1.343 NΣmΣdeg), stiffness (LV: 0.076, Ad: 0.056 NΣm/deg; p Conclusion RBMCs transfected with LV-BMP are more effective at healing a critical size rat femoral defect than Ad-BMP. Luciferase expression was noted at a later time point for those animals in group LV compared to group AV. Gene therapy using a LV vector is a novel and efficient technique for the delivery of osteoinductive growth factor BMP to a site of significant bone loss associated with trauma, revision joint arthroplasty, pseudoarthrosis of the spine, and tumor resection.