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COVID-19 triggered disruption in the conventional care pathways for many orthopedic procedures. The current study aims to quantify the impact of the COVID-19 pandemic on shoulder arthroplasty hospital surgical volume, trends in surgical case distribution, length of hospitalization, posthospital disposition, and 30-day readmission rates.This study queried all Medicare (100% sample) fee-for-service beneficiaries who underwent a shoulder arthroplasty procedure (Diagnosis-Related Group code 483, Current Procedural Terminology code 23472) from January 1, 2019, to December 18, 2020. Fracture cases were separated from nonfracture cases, which were further subdivided into anatomic or reverse arthroplasty. Volume per 1000 Medicare beneficiaries was calculated from April to December 2020 and compared to the same months in 2019. Length of stay (LOS), discharged-home rate, and 30-day readmission for the same period were obtained. The yearly difference adjusted for age, sex, race (white vs. nonwhite), Centers for MedicareMedicaid Services Hierarchical Condition Category risk score, month fixed effects, and Core-Based Statistical Area fixed effects, with standard errors clustered at the provider level, was calculated using a multivariate analysis (P .05).A total of 49,412 and 41,554 total shoulder arthroplasty (TSA) cases were observed April through December for 2019 and 2020, respectively. There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% (19% reduction in anatomic TSA, 13% reduction in reverse shoulder arthroplasty, and 3% reduction in fracture cases). LOS for all shoulder arthroplasty cases decreased by 16% (-0.27 days, P .001) when adjusted for confounders. There was a 5% increase in the discharged-home rate (88.0% to 92.7%, P .001), which was most prominent in fracture cases, with a 20% increase in discharged-home cases (65.0% to 73.4%, P .001). There was no significant change in 30-day hospital readmission rates overall (P = .20) or when broken down by individual procedures.There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% during the COVID-19 pandemic. A decrease in LOS and increase in the discharged-home rates was also observed with no significant change in 30-day hospital readmission, indicating that a shift toward an outpatient surgical model can be performed safely and efficiently and has the potential to provide value.

There is concern that excessive glenoid component retroversion leads to altered biomechanics and baseplate failure in reverse shoulder arthroplasty (RSA). However, much of this has been rooted in the total shoulder arthroplasty experience. In the current literature, it is not well defined whether glenoid baseplate positioning in reverse arthroplasty affects functional outcomes. Our practice has been to preserve glenoid bone stock without aiming for a certain degree of retroversion. We aimed to evaluate the correlation between pre- and postoperative retroversion in a cohort of RSAs and determine the effect of glenoid retroversion on functional outcomes, range of motion, and postoperative complications.A retrospective review of patients who had an RSA between 2017 and 2019 was performed. Preoperative computed tomography scans were used to assess preoperative retroversion, and axillary radiographs were used for postoperative retroversion. Outcome measures included American Shoulder and Elbow Surgeons score, visual analog scale for pain score, Single Assessment Numeric Evaluation score, range of motion, radiographic lucency, and complications.A total of 271 patients were eligible for the study. There was a 76.9% 2-year follow-up rate. In total 161 patients had postoperative retroversion ≤15° (group A), and 110 patients had retroversion15° (group B). There were no significant differences in American Shoulder and Elbow Surgeons, visual analog scale, or Single Assessment Numeric Evaluation scores. There were also no significant differences in postoperative range of motion. There was 1 baseplate failure in each group, and there was 1 patient in group B with asymptomatic radiographic loosening (baseplate at risk). The mean change in pre- to postoperative retroversion was 1° and 4° in groups A and B, respectively.There was no significant difference in postoperative functional outcomes, range of motion, or complications between patients who had baseplate retroversion ≤15° vs. those who had retroversion15°.

Indications for reverse total shoulder arthroplasty (RTSA) have expanded to include primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Limited evidence exists on RTSA in patients with primary GHOA and no posterior glenoid wear (Walch A1, A2, and B1 morphologies). The purpose of this retrospective cohort study was to determine if glenoid morphology is associated with clinical outcomes in patients undergoing RTSA for primary GHOA.A retrospective review of prospectively collected data was performed in patients undergoing primary RTSA for GHOA with a minimum of 2-year clinical follow-up. Preoperative computed tomography and magnetic resonance imaging were used to categorize glenoid morphology as described by the modified Walch classification. Pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) pain scores, and range of motion (ROM) measurements were compared across Walch glenoid subtypes. The percentage of patients that reached previously established clinically significant thresholds for minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also comparatively assessed. Multivariable analysis was used to evaluate the association between glenoid morphology and postoperative ASES score while controlling for potentially confounding variables.Of the 247 consecutive patients, 197 were available at a minimum 2-year follow-up (80%). Significant improvements were seen in ASES, VAS pain, SANE, and ROM from baseline to final postoperative follow-up in the combined patient cohort (all P.001). Most (98.0%) patients reached MCID, and 90.9% of patients reached SCB for ASES threshold. No significant differences were found among Walch subtypes in terms of preoperative to postoperative improvement in ASES (P = .39), SANE (P = .4), VAS pain (P = .49), forward elevation (P = .77), external rotation (P = .45), or internal rotation (P= 0.1). The only significant difference in postoperative outcomes between Walch glenoid subtypes was higher postoperative ASES scores among type B3 glenoids compared with type A1 glenoids (P = .03) on univariate analysis. However, no individual Walch glenoid subtype was associated with lower postoperative ASES scores on multivariable analysis (P.05).Primary RTSA provides excellent short-term outcomes in patients with glenohumeral arthritis with intact rotator cuff, regardless of the degree of preoperative glenoid deformity. Surgeons can use these data to support the use of RTSA for glenohumeral arthritis in a more standardized way.

The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs.We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores.Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤ .001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (-9.75 points) and SANE (-7.63 points) scores and greater residual pain (+1.13 points) (all P ≤ .001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P.001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P.001).Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives.

Acromial (ASF) and scapular spine (SSF) stress fractures are well-recognized complications of reverse shoulder arthroplasty (RSA), but much of the current data are derived from single-center or single-implant studies with limited generalizability. This study from the American Shoulder and Elbow Surgeons (ASES) Complications of Reverse Shoulder Arthroplasty Multicenter Research Group determined the incidence of ASF/SSF after RSA and identified preoperative patient characteristics associated with their occurrence.Fifteen institutions including 21 ASES members across the United States participated in this study. Patients undergoing either primary or revision RSA between January 2013 and June 2019 with a minimum 3-month follow-up were included. All definitions and inclusion criteria were determined using the Delphi method, an iterative survey process involving all primary investigators. Consensus was achieved when at least 75% of investigators agreed on each aspect of the study protocol. Only symptomatic ASF/SSF diagnosed by radiograph or computed tomography were considered. Multivariable logistic regression was performed to identify factors associated with ASF/SSF development.We identified 6755 RSAs with an average follow-up of 19.8 months (range, 3-94). The total stress fracture incidence rate was 3.9% (n = 264), of which 3.0% (n = 200) were ASF and 0.9% (n = 64) were SSF. Fractures occurred at an average 8.2 months (0-64) following RSA with 21.2% (n = 56) following a trauma. Patient-related factors independently predictive of ASF were chronic dislocation (odds ratio [OR] 3.67, P = .04), massive rotator cuff tear without arthritis (OR 2.51, P.01), rotator cuff arthropathy (OR 2.14, P.01), self-reported osteoporosis (OR 2.21, P.01), inflammatory arthritis (OR 2.18, P.01), female sex (OR 1.51, P = .02), and older age (OR 1.02 per 1-year increase, P = .02). Factors independently associated with the development of SSF included osteoporosis (OR 2.63, P.01), female sex (OR 2.34, P = .01), rotator cuff arthropathy (OR 2.12, P = .03), and inflammatory arthritis (OR 2.05, P = .03).About 1 in 26 patients undergoing RSA will develop a symptomatic ASF or SSF, more frequently within the first year of surgery. Our results indicate that severe rotator cuff disease may play an important role in the occurrence of stress fractures following RSA. This information can be used to counsel patients about potential setbacks in recovery, especially among older women with suboptimal bone health. Strategies for prevention of ASF and SSF in these at-risk patients warrant further study. A follow-up study evaluating the impact of prosthetic factors on the incidence rates of ASF and SSF may prove highly valuable in the decision-making process.

Background The impact of stem alignment on hip arthroplasty outcomes has been thoroughly evaluated, but there is limited data assessing this relationship in reverse shoulder arthroplasty (RSA). In this study, we investigated the association of humeral stem alignment with patient outcomes following RSA. Methods Using our prospectively maintained institutional registry, we identified patients who underwent reverse shoulder arthroplasty between July 2015 and September 2017 with minimum 2-year follow-up. Two raters independently assessed stem alignment using full-length humeral view radiographs. Stem alignment was correlated to American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, range of motion, complications, and scapular notching at 2-year follow-up. Results Of the 117 patients that fit our inclusion criteria, 68 (58%) had neutral or valgus alignment and 49 (42%) had varus alignment. ASES score, VAS pain score, range of motion, complications, and scapular notching showed no differences between the 2 cohorts at 2-years postoperatively. Change (mean, SD) in ASES scores (52.5 ± 17.7 vs. 41.3 ± 21.2, P = .01) and VAS pain scores (−5.7 ± 2.5 vs. −4.6 ± 2.6, P = .02) were greater in the neutral/valgus cohort compared to the varus cohort. Demographics analysis revealed that the neutral or valgus cohort had a larger female population (74% vs. 59%, P Conclusion Humeral stem alignment does not appear to affect clinical outcomes at 2-years postoperatively. Improvement in ASES score and VAS pain score were slightly inferior in varus patients, however this difference was not clinically relevant. There may be a correlation between male gender and varus alignment, likely due to better bone quality and larger musculature. Further investigation into the association between stem angulation and clinical outcomes is warranted. Levels of Evidence Level III; Retrospective Cohort Study.

Concerted efforts to optimize outcomes and data transparency in shoulder arthroplasty have led to the creation of the American Academy of Orthopaedic Surgeons (AAOS) Shoulder and Elbow Registry, the first nationwide registry of its kind. We used online crowdsourcing to explore the general public's perceptions and beliefs toward the disclosure of quality and price data in shoulder arthroplasty.A total of 498 participants recruited using Amazon Mechanical Turk (MTurk) completed a survey regarding beliefs about public disclosure of quality and price data in shoulder arthroplasty. The MTurk is an online marketplace for crowdsourcing tasks (e.g., answering surveys) to a pool of over 500,000 registered workers in exchange for financial compensation. Requesters post human-intelligence tasks, and workers can respond to those that they are interested in completing. This web-based platform is an efficient survey tool for medical research, with comparable national representativeness to traditional convenience samples.The majority (95%) of respondents believed surgeons and hospitals should share their data with national registries such as the AAOS Shoulder and Elbow Registry. Most believed that patients considering shoulder arthroplasty should have public access to surgeons' outcomes and complication rates (96%), years of experience (95%), and case volume (92%). Most respondents desired price transparency in implant costs (95%), surgeon reimbursement (80%), and hospital reimbursement (84%). In decreasing order of importance, the top three factors guiding surgeon choice were: (1) surgeon included in the insurer's network, (2) annual case volume, and (3) publicly available outcomes.Increased quality and price transparency in shoulder arthroplasty may empower patients to make better-informed decisions about their care and ultimately enhance value. Given the strong public desire for data transparency and the notion that public disclosure of data is intrinsically associated with performance improvement, surgeons and hospitals should strongly consider submitting their data to national registries such as the AAOS Shoulder and Elbow Registry.

Background We used online crowdsourcing to explore public perceptions and attitudes towards virtual orthopaedic care, and to identify factors associated with perceived difficulty navigating telehealth services during the COVID-19 pandemic. Methods A modified version of the validated Telemedicine Satisfaction and Usefulness Questionnaire was completed by 816 individuals using crowd-sourcing methods. Multivariable logistic regression modelling was used to determine population characteristics associated with perceived difficulty using telehealth technology. Results Most respondents (85%) believed that telehealth visits would be a convenient form of healthcare delivery, and 64% would prefer them over in-person office visits. The majority (92%) agreed that telehealth would save them time, but 81% had concerns regarding the lack of physical contact during a musculoskeletal examination. More respondents would feel comfortable using telehealth for routine follow-up care (81%) compared to initial assessment visits (59%) and first postoperative appointments (60%). Roughly 1 in 15 (7%) expressed difficulty with using telehealth; these respondents were more often unmarried, lower-income, and more medically infirm, and reported greater symptoms of depression. After multivariable adjustment, lower income and poor health were retained as predictors of difficulty with navigating telehealth technology (p = 0.027,p = 0.036, respectively). Conclusion The majority of the public appears receptive to telehealth for orthopaedic care for both new patient visits and follow-up appointments. The finding that people with multiple chronic conditions and psychosocial needs struggle to engage with telehealth suggests that those who arguably stand to benefit the most from continued care are the ones being unintentionally left out of this digitization boom.

Background As demand for primary total joint arthroplasty (TJA) continues to grow, a proportionate increase in revision TJA (rTJA) is expected. It is essential to understand costs and reimbursement of rTJA as our country moves to bundled payment models. We aimed (1) to characterize implant and total hospital costs, (2) assess reimbursement, and (3) determine revenue for rTJA in comparison with primary TJA. Methods The average implant and total hospital cost of all primary and rTJA procedures by diagnosis-related group (DRG) was calculated using time-driven activity-based costing at an orthopedic hospital from 2018 to 2020. Average reimbursement and payer type were assessed by DRG. Revenue was calculated by deducting average time-driven activity-based costing total costs from reimbursement. Results 13,946 arthroplasties were included in the study. Implant cost comprised 55.8% of total hospital costs for rTJA DRG 468, compared with 43.6% of total hospital costs for primary TJA DRG 470. Total hospital costs for DRG 468 were 61.1% more than DRG 470. Reimbursement for rTJA was 1.23x more than primary TJA. Private payers paid 23.2% more than Medicare for rTJA. Margin for DRG 468 was 1.5% less than primary DRG 470. Conclusion rTJA requires more hospital resources and costs than primaries, yet hospital reimbursement may be inadequate with the additional expenditures necessary to provide optimal care. If hospitals cannot perform revision services under the current reimbursement model, patient access may be limited. Implant costs are a major contributor to overall rTJA cost. Strategies are needed to reduce revision implant costs to improve value of care. Level of Evidence Level III, economic and decision analysis.

Despite the growing recognition of acromial stress fractures (ASFs) after reverse total shoulder arthroplasty (RTSA), most of the current data are derived from single-center studies with limited generalizability. This multicenter study investigated the incidence of ASFs after RTSA and identified preoperative patient characteristics associated with their occurrence.Using 2 institutional registries from different regions of the United States, we identified 1479 patients undergoing either primary or revision RTSA between 2013 and 2018 with minimum 3-month follow-up. ASFs were defined as radiographic evidence of an acromial or scapular spine fracture with clinical symptoms (eg, tenderness over the acromion or scapular spine). Multivariable logistic regression was performed to identify preoperative patient factors associated with the development of ASFs.Overall, 54 (3.7%) patients were diagnosed with an ASF after RTSA. Patient-related factors independently associated with the development of an ASF included female sex (odds ratio [OR], 2.21 reference: male; 95% confidence interval [CI], 1.03-4.74; P.05), rheumatoid arthritis (OR, 2.30; 95% CI, 1.02-5.16; P.05), osteoporosis (OR, 2.55; 95% CI, 1.24-5.21; P.05), a diagnosis of degenerative joint disease with rotator cuff tear (OR, 4.74 reference: degenerative joint disease without rotator cuff tear; 95% CI, 1.84-12.23; P .05), and fracture malunion/nonunion (OR, 5.21; 95% CI, 1.20-22.76; P.05).The non-negligible percentage of ASFs that occur after RTSA is associated with the diagnoses of rotator cuff dysfunction and chronic fracture sequelae in female patients with suboptimal bone health. This information can be used to counsel patients and set expectations about potential setbacks in recovery.

Reverse total shoulder arthroplasty (RSA) continues to see tremendous growth as the indications have expanded. A variety of complications have been described, including fractures of the acromion or scapular spine. These fractures are painful and can compromise shoulder stability and functional outcomes following RSA. Multiple studies have recently investigated the incidence, risk factors, and treatment strategies for these injuries. In this article, the authors review current literature and discuss the incidence, cause, associated risk factors, treatment options, and outcomes following fractures of the acromion or scapular spine after RSA.

Reverse shoulder arthroplasty (RSA) is increasingly being utilized for the treatment of primary osteoarthritis. However, limited data are available regarding the outcomes of RSA as compared with anatomic total shoulder arthroplasty (TSA) in the setting of osteoarthritis.We performed a retrospective matched-cohort study of patients who had undergone TSA and RSA for the treatment of primary osteoarthritis and who had a minimum of 2 years of follow-up. Patients were propensity score-matched by age, sex, body mass index (BMI), preoperative American Shoulder and Elbow Surgeons (ASES) score, preoperative active forward elevation, and Walch glenoid morphology. Baseline patient demographics and clinical outcomes, including active range of motion, ASES score, Single Assessment Numerical Evaluation (SANE), and visual analog scale (VAS) for pain, were collected. Clinical and radiographic complications were evaluated.One hundred and thirty-four patients (67 patients per group) were included; the mean duration of follow-up (and standard deviation) was 30 ± 10.7 months. No significant differences were found between the TSA and RSA groups in terms of the baseline or final VAS pain score (p = 0.99 and p = 0.99, respectively), ASES scores (p = 0.99 and p = 0.49, respectively), or SANE scores (p = 0.22 and p = 0.73, respectively). TSA was associated with significantly better postoperative active forward elevation (149° ± 13° versus 142° ± 15°; p = 0.003), external rotation (63° ± 14° versus 57° ± 18°; p = 0.02), and internal rotation (≥L3) (68.7% versus 37.3%; p0.001); however, there were only significant baseline-to-postoperative improvements in internal rotation (gain of ≥4 levels in 53.7% versus 31.3%; p = 0.009). The overall complication rate was 4.5% (6 of 134), with no significant difference between TSA and RSA (p = 0.99). Radiolucent lines were observed in association with 14.9% of TSAs, with no gross glenoid loosening. One TSA (1.5%) was revised to RSA for the treatment of a rotator cuff tear. No loosening or revision was encountered in the RSA group.When performed for the treatment of osteoarthritis, TSA and RSA resulted in similar short-term patient-reported outcomes, with better postoperative range of motion after TSA. Longer follow-up is needed to determine the ultimate value of RSA in the setting of osteoarthritis.Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

In anatomic total shoulder arthroplasty (TSA), subscapularis repair is essential for shoulder stability and function postoperatively; however, the role of subscapularis repair in reverse TSA remains unclear. Some evidence suggests that subscapularis repair is associated with improved postoperative stability and range of motion, whereas other evidence indicates that repair is unnecessary and has no effect on clinical outcomes. In this review, we will analyze the existing literature addressing subscapularis repair during reverse TSA and discuss the effect of medialized and lateralized prosthesis designs on the utility of tendon repair.

Background The purpose of this study was to evaluate the relative contribution of the reverse shoulder arthroplasty (RSA) humeral stem length on initial implant fixation, which may contribute to the long-term success of uncemented shoulder implants. Methods Three RSA humeral components were randomly divided into the following testing groups: (1) 100% Stem length (n = 7); (2) 50% Stem length (n = 7); (3) 0% Stem length (n = 7). Each humeral stem was press-fit into twenty-one 4th Generation Osteoporotic Sawbones humeri. Torque and compressive axial load were applied to the humerus for 10,000 cycles at ±2.5 Nm and −392 N, respectively. Rotational micromotion of the implant was measured. Results Micromotion for all 3 testing groups was below the 150 µm micromotion threshold throughout testing. The overall micromotion in Group 2 was significantly larger than Group 1 (P Conclusion All stem lengths studied maintained micromotion below the 150 µm threshold, suggesting that any of these treatment groups would provide adequate initial fixation to allow bony on-growth. Clinically, stemless or short-stemmed prosthesis design offer theoretical benefits such as the degree of freedom for humeral stem placement independent of diaphysis. This study concluded that the zero-length stem will allow for this and provide adequate fixation comparable to the full-length stem. Level of Evidence Basic Science Study.

Background Elective total shoulder arthroplasty is highly successful, but there is a subset of patients who continue to experience pain after this procedure. The purposes of this study were to elucidate the prevalence and patient characteristics predictive of persistent pain after shoulder arthroplasty. Methods We identified patients who had received an elective primary shoulder arthroplasty (anatomic or reverse) between 2016 and 2017 from our prospectively maintained, single-surgeon registry. Patients were stratified by the presence or absence of persistent pain at 2 years postoperatively, as defined by a Visual Analog Pain score of ≥2. This value was chosen in accordance with previously reported values for minimal clinically important differences. Multivariable logistic regression was used to identify factors associated with persistent pain. Results Of the 244 patients included for analysis, 46(18.9%) had persistent pain at 2 years postoperatively. The average pain score in this group was found to be significantly greater than the patients without pain (3.6 ± 1.6 vs 0.14 ± 0.35, P Conclusion About 1 in 5 patients report persistent pain after elective primary shoulder arthroplasty. Prompt identification of at-risk patients (eg, those with severe postoperative inpatient pain and a history of prior shoulder surgery) may prove effective in optimizing the pain experience after shoulder arthroplasty. Level of evidence Level III; Cohort Study with Prospective Data and Retrospective Study Design.

Background Patients undergoing elective shoulder arthroplasty have highly variable pain experiences. We sought to characterize preoperative patient characteristics associated with fast and slow pain relief after elective total shoulder arthroplasty and evaluated whether differences in early pain recovery predicted longer term pain relief. Methods We identified 324 patients undergoing elective primary shoulder arthroplasty, reverse and anatomic, between 2015 and 2018 from our prospective registry. Postoperative pain relief was defined as the difference in preoperative and 2-week postoperative pain intensity. Three groups were then created: fast responders (top decile), slow responders (bottom decile), and normal responders. Multinomial regression was used to identify preoperative patient factors associated with either slow or fast pain responses. Results Factors associated with a fast pain response included older age and being married. A slow pain response was associated with being unmarried. Pain intensity was lower in the fast responders at 6 weeks (0.60 ± 0.80 vs. 3.4 ± 2.50, P Conclusion The postoperative pain experience after shoulder arthroplasty seems to be influenced by patient age and marital status. Patients with marginal improvement in pain relief should be counseled that their recovery may be more prolonged, but by the 1-year mark they are likely to achieve comparably low pain levels to other patients. Level of evidence Level III; Retrospective Design; Prognosis Study

Background Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group. Methods Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories. Results Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87). Discussion Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.

Our understanding of the pathology of and treatment for glenohumeral arthritis (GHA) has grown dramatically in the past few decades. Original observations regarding patterns of glenoid erosion, glenoid retroversion, and posterior humeral head subluxation in patients with primary GHA were documented in the 1980s and early 1990s. In the late 1990s, Walch et al proposed what is now the most widely used classification system to describe the characteristic pathology of GHA. Improved understanding of both premorbid and pathologic anatomies, along with advancements in imaging, have steered modifications in this classification system. These changes have improved its reliability and helped to further guide management decisions. The purpose of this article is to review the evolution of the Walch classification, understand the rationale behind the modifications, and discuss potential future developments.

Aims Existing literature indicates that inferiorly inclined glenoid baseplates following reverse total shoulder arthroplasty (RSA) produce better outcomes compared to superiorly inclined baseplates. We aim to compare clinical outcomes for RSAs with superiorly and neutrally/inferiorly inclined lateralized glenospheres. Methods We retrospectively reviewed 154 consecutive patients undergoing RSA between July 2015 and July 2017 by one single-fellowship trained surgeon (AJ). Two raters (KAM and MVS) independently measured glenoid inclination in preoperative and minimum two year follow-up radiographs (anteroposterior/Grashey) using the RSA angle. Inclination was then compared to patient-reported outcomes, range of motion (ROM), and independently assessed degree of scapular notching and staging of heterotopic ossification at two year follow-up. Results Median postoperative inclination for each group was found to be -3.6° (interquartile range (IQR) -2.1 to -6.9) and 6.0° (3.2° to 10.1°) for the neutrally/inferiorly and superiorly inclined cohorts, respectively. Preoperative inclination was highly associated with postoperative inclination (p = 0.004). When comparing superiorly and neutrally/inferiorly inclined glenospheres, there were no differences in heterotopic ossification (p = 0.606), scapular notching (p = 0.367), American Shoulder and Elbow Surgeons score (p = 0.419), Single Assessment Numeric Evaluation (p = 0.417), Visual Analogue Scale (VAS) pain score (p = 0.290), forward elevation (p = 0.161), external rotation (p = 0.537), or internal rotation (p = 0.656). Conclusion Compared to neutral and inferior inclination, up to 6° ± 3° of superior glenoid baseplate inclination on a lateralized RSA design produces no differences in postoperative ROM or patient-reported outcomes, and produces similar levels of scapular notching and heterotopic ossification. Additionally, the degree of preoperative inclination represents an important factor in surgical decision-making as it is strongly associated with postoperative inclination. It is important to note that the findings of this study are only reflective of lateralized RSA prostheses. Cite this article: Bone Joint J 2021;103-B(2):360–365.

Background Despite rapid increases in the demand for total shoulder arthroplasty, data describing cost trends are scarce. We aim to (1) describe variation in the cost of shoulder arthroplasty performed by different surgeons at multiple hospitals and (2) determine the driving factors of such variation. Methods A standardized, highly accurate cost accounting method, time-driven activity-based costing, was used to determine the cost of 1571 shoulder arthroplasties performed by 12 surgeons at 4 high-volume institutions between 2016 and 2018. Costs were broken down into supply costs (including implant price and consumables) and personnel costs, including physician fees. Cost parameters were compared with total cost for surgical episodes and case volume. Results Across 4 institutions and 12 surgeons, surgeon volume and hospital volume did not correlate with episode-of-care cost. Average cost per case of each institution varied by factors of 1.6 (P = .47) and 1.7 (P = .06) for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA), respectively. Implant (56% and 62%, respectively) and personnel costs from check-in through the operating room (21% and 17%, respectively) represented the highest percentages of cost and highly correlated with the cost of the episode of care for TSA and RSA. Conclusions Variation in episode-of-care total costs for both TSA and RSA had no association with hospital or surgeon case volume at 4 high-volume institutions but was driven primarily by variation in implant and personnel costs through the operating room. This analysis does not address medium- or long-term costs.

Background The distalization shoulder angles (DSA) and lateralization shoulder angles (LSA) were developed to reproducibly measure DSA and LSA after reverse total shoulder arthroplasty (RSA). In this study, we sought to validate these measurements and their associations with clinical outcomes following RSA. Methods We retrospectively reviewed 238 patients undergoing RSA between May 2016 and December 2017 by 1 single-fellowship trained surgeon (A.J.). Two raters (K.A.M and E.C.) independently measured DSA and LSA in preoperative and postoperative radiographs (AP/Grashey and humeral-length views) using DSA, LSA, and humeral lengthening methodologies. DSA and LSA were then compared to patient-reported outcomes and range of motion (ROM) collected at 2-year follow-up. Results Interobserver reliability analysis showed near perfect agreement for DSA, LSA, and humeral lengthening. Lateralized prostheses were associated with higher LSAs (88.26 ± 7.44 vs. 81.95 ± 6.49; P Conclusion The DSA and LSA shoulder angles are simple and highly reproducible measures, but seem to have marginal correlation with postoperative clinical outcomes. Further investigations into the prognostic utility of minimally cumbersome RSA measurement methodologies are warranted. Level of Evidence Level Ⅲ; Retrospective Cohort Study

Background US Food and Drug Administration Investigation Device Exemption studies and academic journals emphasize the importance of two-year follow-up data in reporting outcomes of total shoulder arthroplasty, but there is limited data evaluating appropriate follow-up length. We aim to evaluate change in postoperative outcomes and complications between one and two years following anatomic and reverse total shoulder arthroplasties. Methods We retrospectively identified 250 patients who underwent anatomic and reverse total shoulder arthroplasties between 2013 and 2016 from a single surgeon arthroplasty registry. Patients without both one- and two-year follow-up data were excluded. We compared American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale for pain, and goniometer-measured range of motion. Results Patient-reported outcome measurements ( p > 0.05) did not change between one and two years postoperatively following both reverse ( n = 146) and anatomic ( n = 104) total shoulder arthroplasties. Range of motion increased slightly ( p Discussion Minimum two-year clinical follow-up may not be necessary for future shoulder arthroplasty Investigation Device Exemption and other peer-reviewed investigations. Patient-reported outcomes (ASES and pain score) and range of motion plateau at one year postoperatively without additional complications. One-year follow-up is an acceptable minimum follow-up length. Level of evidence Level III—retrospective analysis.

Background Lateralization of the glenosphere in reverse shoulder arthroplasty likely mitigates scapular notching; however, there is a paucity of data evaluating the effect of heterotopic ossification (HO) at the inferior aspect of the glenoid neck. Methods We retrospectively reviewed 107 consecutive reverse shoulder arthroplasty patients between April 2013 and April 2016. During the study period, the surgeon switched from a 2.5-mm lateral center of rotation and a 155° neck-shaft angle (NSA) to a 6- or 10-mm lateralized design with a 135° NSA. Preoperative and minimum 2-year postoperative patient-reported outcomes and range of motion were collected. Two-year postoperative radiographs were evaluated for scapular notching and HO. Results The lateralized center of rotation implant was 72% less likely to develop HO and 85% less likely to produce scapular notching than the medialized prosthesis. Conclusion Implants with laterally offset glenospheres and 135° NSA may decrease postoperative HO and scapular notching. Level of evidence Level III, retrospective cohort study.

Background: Vascularized fibula graft (VFG) transfer is an established method of repairing large skeletal defects resulting from trauma, tumor resection, or infection. It obviates the process of creeping substitution that conventional bone grafts undergo and therefore exhibits better healing and improved strength. The aim of this study is to evaluate hypertrophy in VFG. Methods: We retrospectively reviewed patients undergoing VFG and studied immediate and late postoperative radiographs. Orthogonal views were measured for width of graft cortex and intramedullary canal, as well as adjacent recipient bone. Changes were measured for total cross sectional area, cortical area, intramedullary area, and graft width. Results: Thirty patients were included in the analysis, with recipient sites including 3 forearm, 4 humerus, 12 tibia, and 11 femur. Mean follow-up was 7.6 years (0.5-24.9 years). Patients’ mean age was 31 (16-59 years). Average hypertrophy was 254% in early postoperative period and 340% in the late postoperative period. There was rapid graft hypertrophy in early postoperative period that plateaued with time. The width of the graft increased over time but didn’t exceed the width of the adjacent recipient bone. In the later postoperative period, the size of graft intramedullary canal increased. Upper and lower extremity grafts showed similar hypertrophy. Conclusions: Using VFG to treat large skeletal defects is an attractive option in part due to the graft’s ability to hypertrophy. We describe an early period of periosteal hypertrophy, followed by endosteal hypertrophy. These processes have relevance to function, mechanical strength, and surgical decision-making.

Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption.We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables.Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P = .035).LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.

There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty.We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores.Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P = .51), SANE (P = .50), and ASES (P = .72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [P = .56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [P = .42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [P = .88]. No differences in hospitalization costs were noted between groups (P = .77).Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum.

Background As health care shifts to a value-based model with bundled-payment methods, it is important to understand the costs and reimbursements of arthroplasty procedures that represent the largest expenditure of Medicare. The aim of the present study was to characterize the variation in (1) total hospital costs, (2) reimbursement, and (3) profit margin for different arthroplasty procedures. Methods The total hospital costs of total knee arthroplasty (TKA), total hip arthroplasty (THA), anatomic total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and total ankle arthroplasty (TAA) were calculated with use of time-driven activity-based costing at an orthopaedic institution from 2018 to 2020. The average reimbursement for each type of procedure was determined. Profit margin, defined as the reimbursement profit after direct costs, was calculated by deducting the average time-drive activity-based total hospital costs from the reimbursement value. Multivariate analyses were performed to evaluate the associations between costs, reimbursement, and profit margins. Results There were 13,545 arthroplasty procedures analyzed for this study, including 6,636 TKAs, 5,902 THAs, 346 TSAs, 577 RSAs, and 84 TAAs. Costs and reimbursement were highest for TAA. THA and TKA resulted in the highest profit margins, whereas RSA resulted in the lowest. The strongest associations with profit margin were private insurance (0.46547), age (-0.22732), and implant cost (-0.19240). Conclusions THA and TKA had greater profit margins overall than TAA and upper-extremity arthroplasty in general. Profit margins for RSA, TSA, and TAA were all at least 28% lower than those for TKA or THA. Lower-volume arthroplasty procedures were associated with decreased profit margins. Study findings suggest that optimizing implant costs and length of stay are important for sustaining institutional fiscal health when performing shoulder and ankle arthroplasty surgery.

Currently, appropriateness criteria evaluating when to perform total shoulder arthroplasty (TSA) is lacking. In the absence of society guidelines and limited quality evidence, the RAND/University California in Los Angeles (UCLA) method provides a suitable alternative to evaluate appropriateness and assist in clinical decision making. Given the rise in utilization, appropriateness criteria for TSA have the potential to be an extremely powerful tool for improving quality of care and controlling costs. Thus, the goal of this study was to test explicit criteria to assess the appropriateness of TSA decision making using the RAND/UCLA appropriateness method.A review of recent scientific literature to gather available evidence about the use, effectiveness, efficiency, and the risks involved in surgical intervention was performed by a shoulder/elbow fellowship trained physician. Based on pertinent variables including age, rotator cuff status, previous surgical management, mobility, symptomatology, and imaging classifications, 186 clinical scenarios were created. Appropriateness criteria for TSA were developed using a modified Delphi method with a panel consisting of American Shoulder and Elbow Surgeons (ASES) members. A second panel of ASES members rated the same scenarios, with reliability testing performed to compare groups.Panel members reached agreement in 40 (64%) indications. TSA was appropriate in 15 (24%) of indications. For patients with severe symptomatology, TSA was often appropriate for patients aged75 years and inconclusive or inappropriate for patients aged75 years. Among patients aged65 years, TSA varied between appropriate and inconclusive, often dependent on Walch classification. For patients with moderate symptomatology, TSA was inappropriate or inconclusive for patients aged65 or75 years. When compared to the second panel's results, moderate agreement was obtained with a weighted kappa statistic of 0.56.Using the RAND/UCLA method, ASES members created an appropriateness decision tree for pertinent patient variables. This presents the data in a manner that streamlines the clinical decision-making process and allows for rapid and more reliable determination of appropriateness for practitioners. The decision tree is based on a combination of clinical experience from high-volume ASES-member surgeons and a comprehensive review of current evidence. This tool can be used as part of a broader set of factors, including individual patient characteristics, prior studies, and expert opinion, to inform clinical decision making, improve quality of care, and control costs.

Anterior shoulder joint capsule thickening is typically present in osteoarthritic shoulders, but its association with specific patterns of glenoid wear is incompletely understood. We sought to determine the relationship between anterior capsular thickening and glenoid deformity in primary glenohumeral osteoarthritis.We retrospectively identified 134 consecutive osteoarthritic shoulders with magnetic resonance imaging and computed tomography scans performed. Axial fat-suppressed magnetic resonance imaging slices were used to quantify the anterior capsular thickness in millimeters, measured at its thickest point below the subscapularis muscle. Computed tomography scans were used to classify glenoid deformity according to the Walch classification, and an automated 3-dimensional software program provided values for glenoid retroversion and humeral head subluxation. Multinomial and linear regression models were used to characterize the association of anterior capsular thickening with Walch glenoid type, glenoid retroversion, and posterior humeral head subluxation while controlling for patient age and sex.The anterior capsule was thickest in glenoid types B2 (5.5 mm, 95% confidence interval [CI]: 5.0-6.0) and B3 (6.1 mm, 95% CI: 5.6-6.6) and thinnest in A1 (3.7 mm, 95% CI: 3.3-4.2; P .001). Adjusted for age and sex, glenoid types B2 (odds ratio: 4.4, 95% CI: 2.3-8.4, P .001) and B3 (odds ratio: 5.4, 95% CI: 2.8-10.4, P .001) showed the strongest association with increased anterior capsule thickness, compared to glenoid type A1. Increased capsular thickness correlated with greater glenoid retroversion (r = 0.57; P .001) and posterior humeral head subluxation (r = 0.50; P .001). In multivariable analysis, for every 1-mm increase in anterior capsular thickening, there was an adjusted mean increase of 3.2° (95% CI: 2.4-4.1) in glenoid retroversion and a 3.8% (95% CI: 2.7-5.0) increase in posterior humeral head subluxation.Increased thickening of the anterior shoulder capsule is associated with greater posterior glenoid wear and humeral head subluxation. Additional research should determine whether anterior capsular disease plays a causative role in the etiology or progression of eccentric glenohumeral osteoarthritis.

The primary purpose of this study was to evaluate the clinical outcomes of patients who underwent reverse total shoulder arthroplasty performed for primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff compared with rotator cuff tear arthropathy (CTA).This was a retrospective review of prospectively collected data including consecutive patients who underwent primary reverse total shoulder arthroplasty for GHOA or CTA with a minimum of 2-year follow-up. Baseline patient demographics and clinical outcomes including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation, and visual analog scale for pain were collected. Univariate and multivariate regression analyses were performed to evaluate the effect of preoperative diagnosis on clinical outcomes.Patients with a preoperative diagnosis of GHOA demonstrated significantly better postoperative active forward elevation (138.6° versus 127.3°; P0.01), external rotation (54.2° versus 43.8°; P0.01), and change in internal rotation (Δ 2.1 points versus Δ 1.2 points; P0.01). Patients with GHOA demonstrated significantly better postoperative ASES (86.8 versus 76.6; P0.01), Single Assessment Numerical Evaluation (89.7 versus 78.5; P0.01), and visual analog scale scores (0.63 versus 1.2; P0.01). Minimal clinically important difference for ASES score was achieved by 97.5% of patients with GHOA compared with 86.7% of patients with CTA (P0.01), whereas substantial clinical benefit was achieved by 90.4% of patients with GHOA and 71.7% of patients with CTA (P0.01). After a multivariate linear regression analysis, postoperative ASES scores were independently associated with previous ipsilateral shoulder surgery (P = 0.042), preoperative ASES score (P = 0.01), and primary diagnosis of GHOA (P0.01).RTSA performed in patients with GHOA and an intact rotator cuff is associated with improved functional and clinical outcomes compared with those patients treated for CTA.Level III Therapeutic Study.

Background There is growing policy interest in reducing the length of stay (LOS) after discretionary orthopedic surgery but few data to guide improvement efforts. We characterized the primary reasons and predisposing factors associated with extended LOS after elective total shoulder arthroplasty. Methods We retrospectively identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017. Extended LOS was defined as a stay greater than the 75th percentile. Medical records were manually reviewed to ascertain the primary reason for extended LOS. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with prolonged hospitalization. Results The most common reason for extended LOS was pain (41%), followed by medical problems (39%), limited social support (18%), and blood transfusions (2%). Only 41% of patients with delayed discharges had documented adverse events (any medical or surgical problem), all of which were minor. The top 4 medical issues were transient hypoxemia (42%), nausea and/or vomiting (13%), electrolyte abnormalities (12%), and altered mental status (10%). In decreasing order of magnitude, the predictors of prolonged LOS were greater number of self-reported allergies, female sex, unmarried patient, diabetes, lower American Shoulder and Elbow Surgeons score, depression, reverse shoulder arthroplasty, and American Society of Anesthesiologists score of 3 or greater. Operative time did not correlate with LOS. Conclusions Prolonged hospitalizations after shoulder arthroplasty are commonly related to pain and limited social support. Sociodemographic and psychological factors seem to have more influence than patient infirmity and technical issues. These findings support a comprehensive approach to care with attention to the physical, mental, and social determinants of health.

As payment models shift toward a focus on value, an accurate understanding of surgical costs and preoperative correlates of high-cost patients is important for effective implementation of cost-saving strategies. This study used time-driven activity-based costing (TDABC) to explore inpatient cost of total shoulder arthroplasty (TSA) and to identify preoperative characteristics of high-cost patients.Using TDABC, we calculated the cost of inpatient care for 415 patients undergoing elective primary TSA between 2016 and 2017. Patients in the top decile of cost were defined as high-cost patients. Multivariable logistic regression modeling was employed to determine preoperative characteristics (e.g., demographics, comorbidities, American Society of Anesthesiologists [ASA] score, and American Shoulder and Elbow Surgeons [ASES] score) associated with high-cost patients.Implant purchase price was the main driver (57%) of total inpatient costs, followed by personnel cost from patient check-in through the time in the operating room (20%). There was a 1.3-fold variation in total cost between patients in the 90th percentile for cost and those in the 10th percentile; the widest cost variation was in personnel cost from the post-anesthesia care unit through discharge (2.5-fold) and in medication cost (2.4-fold). High-cost patients were more likely to be women and chronic opioid users and to have diabetes, depression, an ASA score of ≥3, a higher body mass index (BMI), and a lower preoperative ASES score than non-high-cost patients. After multivariable adjustment, the 3 predictors of high-cost patients were female sex, an ASA score of ≥3, and a lower ASES score. Total inpatient cost correlated strongly with the length of the hospital stay but did not correlate with operative time.Our study provides actionable data to contain costs in the perioperative TSA setting. From the hospital's perspective, efforts to reduce implant purchase prices may translate into rapid substantial cost savings. At the patient level, multidisciplinary initiatives aimed at reducing length of stay and controlling medication expenses for patients at risk for high cost (e.g., infirm women with poor preoperative shoulder function) may prove effective in narrowing the existing patient-to-patient variation in costs.Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

As reimbursement becomes increasingly tied to quality and patient experience, there is growing interest in alleviation of postoperative pain combined with optimal opioid stewardship. We characterized predictors of severe inpatient pain after elective total shoulder arthroplasty and evaluated its association with opioid use, operative time, hospital length of stay, discharge disposition, and cost.We identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017 from our registry. Severe postoperative pain was defined as peak pain intensity ≥75th percentile. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with severe pain, including demographics, emotional health, comorbidities, and American Shoulder and Elbow Surgeons score. Opioid consumption was expressed as oral morphine equivalents (OMEs). Costs were calculated using time-driven activity-based costing.In decreasing order of magnitude, the predictors of severe postoperative pain were greater number of self-reported allergies, preoperative chronic opioid use, lower American Shoulder and Elbow Surgeons score, and depression. Patients reporting severe pain took more opioids (202 vs. 84 mg OMEs), stayed longer in the hospital (2.9 vs. 2.0 days), used postacute inpatient rehabilitation services more frequently (28% vs. 10%), and were more likely to be high-cost patients (23% vs. 5%; all P .001), but they did not have longer operations (166 vs. 165 minutes, P = .86).Efforts to address psychological and social determinants of health might do as much or more than technical improvements to alleviate pain, limit opioid use, and contain costs after shoulder arthroplasty. These findings are important in the redesign of care pathways and bundling initiatives.