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Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study is to identify pre- and postoperative factors that impact range of motion and function after augmented TSA in patients with B2 or B3 glenoid morphology.A retrospective review was performed of all patients who underwent TSA with a step type augment by a single surgeon between 2009 and 2018. Patients with a Walch type B2 or B3 glenoid were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale for pain (VAS). Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and mid-glenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to range of motion and functional outcome scores.Fifty patients (mean age, 68.1 + 8.0) with a mean follow-up of 42.0 months (Range, 24-106 months) were included. Glenoid morphology included 41 B2 and 9 B3 glenoids. One patient had center-peg osteolysis and one patient had glenoid component loosening. The average preoperative FE, ER, and IR was 110°, 21°, and S1, respectively. The average postoperative FE, ER, and IR was 155°, 42°, and L1, respectively. The mean postoperative VAS score was 0.5 + 0.8 and mean SANE score was 94.5 + 5.6. Patients with B3 glenoids were associated with better postoperative internal rotation compared to B2 glenoids (T10 vs L1, p=0.024), with no other differences in range of motion between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative range of motion. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with range of motion in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r= -0.448, p=0.006).Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative range of motion and function had no clinically important associations with pre- or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented total shoulder arthroplasties except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

Adequate subscapularis tendon mobilization and glenoid exposure are critical to a successful anatomic total shoulder arthroplasty. A lesser tuberosity osteotomy allows for direct bone-to-bone healing while maintaining the strong tendon-to-bone attachment of the subscapularis tendon insertion. Excision of the typically thickened and contracted anteroinferior capsule in osteoarthritic shoulders can help mobilize the subscapularis, theoretically allowing for optimal soft-tissue balance, decreased tension on the subscapularis repair, improved glenoid exposure, and anatomic repair. In this Technical Note and accompanying video, we describe our technique for lesser tuberosity osteotomy with anteroinferior capsulectomy for anatomic total shoulder arthroplasty. This technique reliably and reproducibly produces good results in terms of glenoid exposure, soft-tissue balance, and postoperative subscapularis function.

Although risk factors for instability after reverse shoulder arthroplasty (RSA) have been extensively studied, the outcomes of patients who experience instability are unknown. The purpose of this study was to evaluate functional outcomes in patients with instability after RSA.We retrospectively identified patients with instability after RSA with a minimum of 2 years' follow-up from an institutional database. Baseline data were recorded, and all patients we contacted to obtain clinical outcome scores. Patients who required revision surgery and those treated successfully with closed reduction were compared.Fifty patients were included. Of these patients, 40 (80%) required revision surgery whereas 10 (20%) were treated successfully with closed reduction. At an average follow-up of 63.7 months (range, 24-123 months), outcome scores did not differ between groups. Patients who required revision surgery were more likely to have undergone previous shoulder surgery, prior to their index arthroplasty (P = .031). Seventeen patients (42.5%) reported recurrent instability following revision surgery, and 14 (35.0%) required additional revision surgery. Ultimately, stability was never achieved in 7 of 50 patients (14%) after their index instability event.Although instability after RSA can commonly be corrected with reasonable functional results, multiple procedures may be needed and some patients may experience persistent instability.

In cases of severe osteoarthritis, posterior glenoid wear leads to acquired retroversion of the glenoid. Surgical treatment of glenoids with acquired retroversion and posterior humeral subluxation with anatomic total shoulder arthroplasty (aTSA) is controversial. The purpose of this study was to determine mid- to long-term outcomes and reoperation rates of augmented and nonaugmented aTSA for treatment of glenohumeral osteoarthritis with Walch B3 glenoid deformity.This observational cohort study reviewed patients with a Walch B3 glenoid undergoing aTSA at a single institution between 2007 and 2014. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 6 years postoperatively. Outcome measures collected included the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score and Single Alpha Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgery on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again.Thirty-nine patients met inclusion criteria, and thirty-five (89.7%) were able to be contacted for final outcomes evaluation. Mean follow-up was 8.7 years (range 6-13) after surgery. Sixteen patients were treated with an augmented glenoid component, and 19 patients were treated with a standard glenoid component. Of those with standard components, all were partially corrected with asymmetric reaming. At final follow-up, there were no statistically significant differences between those with augmented and standard glenoid components for mean ASES score (93.3 vs. 85.7, P = .217), ASES pain score (47.2 vs. 41.6, P = .161), SANE score (87.8 vs. 86.0, P = .692), and percentage patient satisfaction (95.6% vs. 96.8%, P = .735), forward elevation (148° vs. 149°, P = .852), or external rotation (36° vs. 39°, P = .202). No patient in either group had undergone revision surgery of the operative shoulder over the study period and all patients stated that they would undergo the same surgery again.Both augmented and standard aTSA can provide satisfactory and sustained improvements in patient-reported outcomes in patients with acquired glenoid retroversion due to glenohumeral osteoarthritis. Despite a trend toward alternative treatment options, anatomic shoulder arthroplasty should remain a surgical consideration even in the setting of a Walch B3 glenoid deformity.

Background The number of primary and revision shoulder arthroplasties performed each year continues to increase. Relative value units (RVUs) are currently used by the Centers for Medicare and Medicaid Services (CMS) to determine physician reimbursement based on time, effort, and complexity of services rendered. Compared to primary shoulder arthroplasty, revision shoulder arthroplasties are often more technically challenging, have longer operative times, and pose a greater risk of intraoperative and postoperative complications. This study aims to compare surgeon reimbursement between primary and revision shoulder arthroplasty. Methods Utilizing a single institution shoulder arthroplasty database, we identified patients who underwent primary or revision shoulder arthroplasty between February 2011 and December 2013 by a single shoulder and elbow fellowship trained surgeon with over 20 years of experience at the time of data collection. The RVUs for primary and revision shoulder arthroplasty were obtained from the CMS Physician Fee schedule. Physician reimbursement for primary and revision shoulder arthroplasty was calculated using the CMS RVU to dollar conversion factor of $34.8921 per RVU. The RVU was divided by operative time to calculate an RVU/min for primary and revision shoulder arthroplasty. Monetary reimbursement per minute, case, day, and year was subsequently calculated. Results A total of 190 primary and 100 revision shoulder arthroplasties were performed during the study period. Mean RVU for primary shoulder arthroplasty was 22.13 ± 0.00 vs. 26.24 ± 1.10 for revision shoulder arthroplasty (P Conclusion While the RVU/case is higher for revision shoulder arthroplasty, the difference does not account for the additional operative time and complexity compared to primary shoulder arthroplasty. In light of this data, the current RVU reimbursement model should be reevaluated to account for these differences between primary and revision shoulder arthroplasty. Level of Evidence Level III; Retrospective Comparative Study

Background Anecdotally there is a spectrum of complexity in performing shoulder arthroplasty, however, there is limited information to predict easy versus difficult cases. The purpose of this study was to identify clinical and radiographic factors that are associated with difficult primary shoulder arthroplasty. Methods All consecutive primary shoulder arthroplasties performed by one-of-five high-volume shoulder and elbow fellowship-trained surgeons from 4/2018-8/2018 were included. Mean (range) surgeon years in practice was 19.4 (6-29). Surgeons completed a preoperative questionnaire estimating the level of complexity in performing the operation from very easy, easy, average, difficult, and very difficult. The same questionnaire was completed immediately postoperatively regarding level of complexity. Difficult group was defined if the surgeon rated as difficult or very difficult on the postoperative questionnaire. If the procedure was difficult, the postoperative questionnaire assessed what aspect of the procedure made it difficult. Demographics, clinical and radiographic factors, and procedure time were collected. Results During the study period, 224 primary shoulder arthroplasties were performed (53% reverse, 44% anatomic, 3% hemiarthroplasty with concentric glenoid reaming). Difficult group consisted of 95 shoulder arthroplasties (42.4%). Difficult group procedure time was a mean 21.8 minutes longer (120.7 ± 3.1 min vs. 98.9 ± 2.4 min; P Discussion and conclusion For experienced high-volume shoulder and elbow surgeons performing primary shoulder arthroplasty, cases that were unexpectedly difficult were associated with younger age, males, stiffness, history of instability, large inferior humeral head osteophyte, and posterior glenoid bone loss. Difficulty with glenoid reaming and glenoid component implantation were the most frequent reason for difficult cases. This information may allow surgeons to anticipate difficult cases, appropriately schedule their operative day, and identify potentially difficult cases that warrant referral to high-volume shoulder arthroplasty surgeon. Level of evidence Level III; Prospective Case-Control Study

Background Periprosthetic joint infection following shoulder arthroplasty represents a challenging problem for orthopedic surgeons. Although recent studies have supported 2-stage exchanges, this treatment choice may not be appropriate for all patients. Definitive antibiotic spacer placement represents one treatment strategy with limited reported outcomes in the literature. The purpose of this study was to investigate the mortality rate and functional outcomes associated with definitive spacer placement. Methods A retrospective chart review identified 17 patients who were treated with definitive antibiotic spacer placement (18 spacers) and were followed up for a minimum of 2 years after surgery. The mortality rate over the study period was determined. Demographic information, clinical course, patient-reported outcomes (American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, and Veterans RAND 12 [VR-12] score), infection parameters as defined by International Consensus Meeting criteria, radiographic evaluation findings, and rotator cuff integrity at the time of spacer placement were collected. Results Seventeen patients underwent treatment with retained antibiotic spacers at a mean age of 62.4 years (range, 50-73 years). Ten patients were women, and the mean body mass index was 30.5 (range, 22.9-39.9). Spacer placement occurred at a mean of 6.1 years (range, 0.48-14.9 years) following index arthroplasty. Five patients required spacer exchange. The most common organisms were Cutibacterium acnes (6) and methicillin-sensitive Staphylococcus aureus (6); in addition, methicillin-resistant S aureus (2), coagulase-negative Staphylococcus (2), Serratia marcescens (1), gram-positive cocci (1), Enterobacter faecalis (1), Enterobacter cloacae (1), diphtheroids (1), and an infection with negative culture findings (1) were observed. The mortality rate was 52.9% (9 of 17 patients). Among the 8 surviving patients, the mean American Shoulder and Elbow Surgeons score was 33.9 (range, 13.3-80.0), the mean Single Assessment Numeric Evaluation score was 35.6 (range, 0.0-80.0), the mean VR-12 mental score was 57.2 (range, 36.6-66.9), and the mean VR-12 physical score was 37.1 (range, 21.7-64.0) at a mean of 4.7 years (range, 2.0-8.8 years). Conclusion Definitive antibiotic spacer placement is an acceptable method to treat infection in medically frail patients who have a high mortality risk. Spacer exchange may be necessary because of persistent infection, and functional results are poor.

The purpose of this study is to evaluate whether the amount of measured posterior bone loss on 2- and 3-dimensional (2D and 3D) imaging of Walch B2 glenoids can reliably predict the plan for an augmented anatomic glenoid component.Patients with Walch B2 glenoids and preoperative computed tomography (CT) scans were retrospectively identified. 2D axial CT scans were reviewed and posterior bone loss was measured by 3 independent reviewers. Images were then formatted into BluePrint (Wright Medical) preoperative planning software. The same 3 reviewers again measured posterior bone loss on 3D imaging. Additionally, all cases were planned with BluePrint software. An augment was used when the following criteria were unable to be satisfied with standard implants:10° retroversion,10° superior inclination, ≥90% backside contact,2 mm medial reaming, and ≤1 peg perforation.Forty-two patients were included in the final analysis with a mean age of 63.1 ± 6.3 years. As measured by BluePrint, the mean retroversion was 23° ± 7° (range = 9°-40°), the mean superior inclination was 5° ± 6° (range = -9° to 22°), and the mean posterior subluxation was 80% ± 17% (range = 41%-95%). The mean 2D bone loss measurements (3.5 ± 1.6 mm) were significantly lower than the mean 3D bone loss (4.0 ± 1.8 mm) measurements (P = .03). There was substantial agreement between reviewers on both 2D and 3D measurements with an interclass correlation of 0.815 (95% confidence interval [CI] 0.714-0.889, P.001) and an interclass correlation of 0.802 (95% CI 0.683-0.884, P.001), respectively. Augments were used in 73.8%, 63.4%, and 63.4% of cases by reviewers 1, 2, and 3, respectively, with moderate agreement with a Fleiss kappa of 0.592 (95% CI 0.416-0.769, P.001). Augment size was moderately, positively correlated with the amount of bone loss on 3D imaging but not with 2D imaging. After multivariate logistic regression, both 3D bone loss and retroversion were found to be predictive for a plan to use an augment.Planning for a posterior augment in Walch B2 glenoids is better predicted with 3D imaging than with 2D imaging, as 2D imaging may underestimate posterior bone loss. Additionally, use of a larger augment size is moderately correlated with posterior bone loss on 3D imaging but not 2D imaging. Standard 2D imaging may be limited in cases of posterior bone loss, and 3D imaging may be beneficial for preoperative planning in Walch B2 glenoids.

Venous thromboembolism (VTE) events are infrequent but potentially catastrophic complications following orthopedic surgery. There is currently a paucity of evidence regarding the role of chemoprophylaxis with low-dose aspirin (acetylsalicylic acid [ASA]) after shoulder arthroplasty.We conducted a retrospective review of prospectively collected complications occurring within 90 days of 2394 primary shoulder arthroplasties performed over a 3-year period at a single institution. Patients preoperatively underwent risk stratification into medically high risk, moderate risk, or low risk as part of a standardized navigated-care pathway. For chemoprophylaxis, 81 mg of ASA (low dose) was routinely used once daily for 6 weeks unless alternative medications were deemed necessary by the medical team. Baseline demographic information, medical comorbidities, and postoperative VTE prophylaxis, as well as rates of clinically symptomatic VTE, were assessed.Symptomatic VTE occurred after 0.63% of primary shoulder arthroplasties (15 of 2394). There were 9 patients with deep vein thromboses and 6 with pulmonary embolisms. Eighty-one milligrams of ASA was used in 2141 patients (89.4%), resulting in an overall VTE rate of 0.56%. Medically high-risk patients were significantly more likely to have a VTE (P = .018). Patients with a history of deep vein thrombosis, asthma, and cardiac arrhythmia were significantly more likely to have a VTE (P.05). Complications occurred in 4 patients (0.19%) associated with low-dose ASA and 1 patient (0.63%) associated with a novel oral anticoagulant medication.Routine use of low-dose ASA results in a very low risk of VTE and medication-associated complications following primary shoulder arthroplasty. Preoperative medical risk stratification can potentially identify patients at high risk of postoperative VTE.

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.

Background This study investigated the rate of acromial insufficiency fractures (AIF) in patients undergoing reverse shoulder arthroplasty (RSA) with concomitant distal clavicle excision (DCE). Methods Patients who underwent primary RSA with DCE by a single surgeon from 2010 to 2021 were identified. Exclusion criteria included revision RSA, RSA for fracture, or cases utilizing an augmented baseplate or bone graft. AIF was defined as a radiographically proven acromion or scapular spine fracture. Pain without an identifiable fracture on imaging was defined as an acromial insufficiency reaction. Patient demographics, implant information, and radiograph measurements were compared between patients with and without acromial pathology. Results One hundred and seventy-five patients were included. Mean age was 72.8 years, and 67% of patients were female. There were 3/174 acromial insufficiency fractures (1.7%). AIF occurred at a mean of 9.3 months after surgery. Twelve patients had insufficiency reactions (6.9%). Patients with acromial pathology were more likely to be female ( p = .003) and have a diagnosis of osteoporosis ( p = .047) and inflammatory arthritis ( p = .049). There was no significant difference between groups in terms of other factors. Conclusion The AIF rate in patients who underwent RSA with DCE was 1.7%. These findings suggest that DCE in the setting of RSA may have a protective role against AIF.

Background Humeral stem designs for total shoulder arthroplasty have varied over the years, with a recent trend toward shorter stems. The purpose of this study was to examine the impact of humeral component stem length on the ability to restore the native humeral head anatomy. Methods We performed a retrospective review including patients who underwent total shoulder arthroplasty for primary osteoarthritis between 2007 and 2017 with complete operative reports and adequate radiographs. Surgical data including stem design were collected. Preoperative and postoperative radiographic measurements of the center of rotation (COR), humeral head height (HH), and neck-shaft angle were performed. Restoration of the native humeral anatomy was deemed “acceptable” based on postoperative differences in the COR ≤ 3 mm, HH ≤ 5 mm, and neck-shaft angle > 130°. Deviations between preoperative and postoperative measurements were compared across stem types. All available 2-year stemless implant radiographs were also analyzed. Results In total, 261 patients were included, with 31 stemless, 43 short-stem, and 187 standard-stem implants. There was no significant difference in COR restoration in the x-axis direction (P = .060) or y-axis direction (P = .579). There was no significant difference in restoration of acceptable HH by stem type (P = .339). Stemless arthroplasty implants were more likely to be placed in varus (22.6%) compared with short-stem (7.0%) and standard-stem (3.7%) designs (P Conclusion Restoration of humeral anatomic parameters occurred significantly less with stemless implants than with short- and standard-stem implants. The stem of a shoulder arthroplasty implant aids surgeons in accurately restoring patient-specific anatomy.

The short-term results of total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon in patients with glenoid bone loss have previously been reported. The purpose of this study was to investigate the mid- to long-term clinical and radiographic outcomes of these patients.We identified a cohort of patients who underwent total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon between 2010 and 2019 for severe glenoid dysplasia and/or glenoid bone loss. Patients with a minimum of 2 years' follow-up were evaluated regarding preoperative and postoperative range of motion, radiographic findings, visual analog scale pain scores, and Single Assessment Numeric Evaluation scores.Overall, 39 shoulders in 33 patients were treated with an inlay glenoid component for severe glenoid bone loss. Four patients were lost to follow-up, and 1 patient died with a well-functioning implant in place. The final cohort included 34 shoulders in 28 patients (46.4% female patients [13 of 28] and 53.6% male patients [15 of 28]) with a mean age of 66.9 years (range, 58-81 years) and mean follow-up period of 68.3 months. Of the 34 cases, 5 were revision cases. One patient died following 2-year follow-up. Of the shoulders, 10 were classified as Walch type A2, 4 were classified as Walch type B3, and 15 were classified as Walch type C; 5 shoulders were unable to be classified. We observed statistically significant increases in range of motion (forward elevation, 38.1° [P .001]; external rotation, 18.8° [P .001]) and improvement in the Single Assessment Numeric Evaluation score (from 26.6 to 81.0, P .001). Two patients underwent conversion to reverse shoulder arthroplasty at 2.2 and 1.7 years postoperatively.Inlay glenoid components provide a low rate of revision and improved clinical and functional outcomes at mid- to long-term follow-up.

Whether positive

Whether positive Cutibacterium acnes cultures during revision shoulder arthroplasty represent true periprosthetic joint infection (PJI), deep tissue inoculant, or laboratory contaminant is a point of substantial controversy. The purpose of this study was to review complications of intravenous antibiotics used for treatment of presumed C acnes shoulder PJI. A study population of 26 patients treated for C acnes PJI with a minimum follow-up of 2 years after operative treatment was established. Complication occurrence and severity were obtained through chart review and phone survey. Sixteen (61.5%) patients experienced a therapeutic complication. Twelve (46.2%) patients experienced a total of 47 antibiotic-associated adverse effects and 10 (38.5%) patients experienced 11 total peripherally inserted central catheter line–associated complications. Female sex carried an increased risk for severe complications (relative risk, 3.3; 95% CI, 1.2–9.5; P =.024). Treatment duration of greater than 6 weeks was a significant predictor for the total number of complications experienced [ F (1,23)=5.361; P =.030; adjusted R 2 =0.189]. Age older than 65 years, treatment duration greater than 6 weeks, and female sex were significant predictors for the number of severe complications [ F (3,21)=3.249; P =.042; adjusted R 2 =0.219]. Treating C acnes infection with intravenous antibiotics carries a substantial risk of adverse events, highlighting the importance of accurate diagnosis of shoulder PJI. Further investigations into the efficacy and safety profile of oral antibiotics for shoulder PJI are necessary. [ Orthopedics . 2021;44(3):e422–e426.]

Background The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Revision of failed anatomic arthroplasty to reverse total shoulder arthroplasty has shown promise alongside concerning complication rates. Methods Patients who underwent revision shoulder arthroplasty during a 7-year period at a tertiary care health system were identified. Presurgical and operative data were analyzed for 110 patients who met inclusion and exclusion criteria. Patients were contacted at a mean follow-up of 57 ± 26 months (range, 23-113 months) from revision surgery for functional outcomes scores, reoperations, and implant survival. Results Implant survival was 92% at 2 years and 74% at 5 years. Mean American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, and visual analog scale pain scores were 63 ± 24 (range, 5-97), 60 ± 25 (range, 0-100), and 2.9 ± 2.9 (range, 0-10), respectively. Seventy percent of patients were “very satisfied” or “satisfied with their outcome. Complications occurred in 18 patients (20%), and 10 patients (11%) underwent reoperation. Conclusions Modest patient results and satisfaction can be achieved with revision of a failed anatomic arthroplasty to a reverse total shoulder arthroplasty. As is typical of revision surgery, complications are common and can compromise results. Further study is needed to identify factors that may contribute to successful outcomes.

Background: The purpose of this study was to examine the mid-term functional outcomes, radiographic results,and revision rates of patients treated with the Delta Xtend Reverse Shoulder System for both primary and revisionarthroplasty indications.Methods: A retrospective review was conducted of records for all individuals who underwent a reverse shoulderarthroplasty using the Delta Xtend Reverse Shoulder Prosthesis at a single institution. Radiographic analysis as well aspain and functional measures using the ASES, Quick DASH, SST, SF-12, Penn, SANE, EQ-5D and VAS, and VR-12scores. Patients were evaluated for five-year outcomes.Results: Fifty patients were available for 5-year outcomes. Thirty-three cases were primary arthroplasty cases and17 were revision arthroplasty cases. Postoperative radiographs at five years out from surgery were available for 46patients. The mean AGT overall was 32.6mm: 31.7mm the primary cases and 34.8mm for revision cases. Sirveauxscapular notching was: 65.2% (30/46) at Grade 0, 23.9% (11/46) at Grade 1, and 10.9% (5/46) at Grade 2. Overall,32/46 of stems were in neutral position, 10/46 were in valgus position, and 4/46 were in varus position. There was nosignificant correlation between stem position and scapular notching. The mean outcome scores for all patients at fiveyears were good to excellent. Two revision patients demonstrated loosening of the humeral stem on radiographs. Ninepatients demonstrated calcification of the long head of the triceps tendon.Conclusion: In conclusion, the Delta Xtend Reverse Shoulder System has shown to be a reliable arthroplastysystem for patients with CTA or failed prior arthroplasty. Patients are generally quite functional at five years out fromtheir reverse shoulder arthroplasty using this implant. Radiographic measures used to interpret the status of theimplant demonstrate that AGT is well maintained and scapular notching is minimal for the majority of cases.Level of evidence: IV

Shoulder arthroplasty was first introduced through the developments of Dr. Charles Neer and over the past decade has seen several advancements. Improved recognition and training have heightened the awareness of arthroplasty as a treatment alternative both for surgeons and patients. The addition of reverse shoulder arthroplasty has been the driving force behind the explosive growth of arthroplasty and is now performed more often than anatomic shoulder arthroplasty. Although revision shoulder arthroplasty is primarily of interest to the subspecialist, it is a skill sought by the general orthopaedic surgeon. It is important for the orthopaedic surgeon to be knowledgeable about the planning, necessary skills, and management of basic shoulder arthroplasty.

Purpose The purpose of this study was to evaluate the rate and risk factors for stiffness after reverse shoulder arthroplasty and the ramifications on the patient-reported outcomes. Method A consecutive series of patients who underwent reverse shoulder arthroplasty were prospectively followed for one year. Passive range of motion was measured preoperatively and at regular intervals postoperatively. Patients with passive forward elevation of less than 100° or passive external rotation of less than 30° were defined as stiff. Radiographic parameters and postoperative patient-reported outcome scores were collected. Results Seventy-six patients were available for review. The prevalence of postoperative stiffness following reverse shoulder arthroplasty was 47% at three months, 31% at six months, and 25% at one year. Preoperative shoulder stiffness was associated with three-month postoperative stiffness only. In patients with one-year stiffness, smaller ( p = 0.03) and less lateralized glenospheres ( p = 0.024) were more common. Stiffness was not associated with one-year patient-reported outcome scores. Conclusion Stiffness is common after reverse shoulder arthroplasty and often improves at one-year after surgery. Implant design and selection may be important determinants of passive range of motion. While stiffness does not appear to influence patient-reported outcome scores, one of four patients will potentially have stiffness one year following reverse shoulder arthroplasty. Level of evidence: Level III; retrospective study.

BACKGROUND Glenoid deformity is commonly encountered in patients undergoing reverse shoulder arthroplasty (RSA). Augmented baseplates can correct glenoid deformity while potentially avoiding certain complications encountered with structural bone graft. Limited evidence exists to support the use of metallic augmented baseplates in RSA. METHODS We performed a retrospective review to identify all patients treated with an augmented baseplate during primary RSA with a minimum of 1 year of clinical and radiographic follow-up. Preoperative radiographs and advanced imaging were used to determine glenoid morphology and deformity. Postoperative radiographs were used to evaluate for deformity correction, radiographic complications, and early baseplate loosening or failure. Prospectively collected clinical data and patient-reported outcome scores were determined. RESULTS Primary RSA was performed with an augmented baseplate in 44 patients (mean age, 72 ± 6 years; 15 half-wedge and 29 full-wedge augmentations). Glenoid retroversion was significantly improved for the entire cohort (P = .001). Among the 22 patients with either Walch type B2, B3, or C glenoid morphology, glenoid version improved from 28° ± 8° to 16° ± 8° (P = .001). Glenoid inclination, as determined by the β angle, was significantly improved for the entire cohort (P < .001). Among the 18 patients with Favard type E2 or E3 glenoid morphology, glenoid inclination improved from 67° ± 7° to 81° ± 8° (P < .001). Postoperative range of motion and functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, Single Assessment Numeric Evaluation score, and visual analog scale score for pain significantly improved within the entire cohort (P < .05). No patients had evidence of baseplate loosening or failure of the glenoid component. Acromial stress fractures developed in 5 patients (11.4%), and 2 patients (4.5%) underwent a reoperation unrelated to the glenoid component. DISCUSSION AND CONCLUSION Primary RSA with an augmented baseplate results in excellent short-term clinical outcomes and significant deformity correction in patients with advanced glenoid deformity. There were no complications related to the augmented baseplate or glenoid component. The rate of acromial stress fractures appears higher than typically reported and warrants further investigation.

Background The diagnosis of periprosthetic shoulder infection continues to be difficult to make with confidence. Serum D-dimer has proven to be effective as a screening tool for periprosthetic joint infection in other major joints; however, it has yet to be evaluated for use in periprosthetic shoulder infection. Questions/purposes (1) Is D-dimer elevated in patients with probable or definite periprosthetic shoulder infections? (2) What is the diagnostic accuracy of D-dimer for periprosthetic shoulder infections? (3) What are the diagnostic accuracies of serum tests (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and D-dimer), singly and in combination? Methods Between March 2016 and March 2020, 94 patients undergoing revision total shoulder arthroplasty (anatomic or reverse) at a single institution had preoperative serum testing with CRP, ESR, and D-dimer. These 94 patients were a subset of 189 revision shoulder arthroplasties performed at this institution during the study period who met inclusion criteria and consented to participate. Included patients had a mean ± SD age of 69 ± 8 years, and 56% (53 of 94) were men. Patient records were reviewed to classify patients as definitely having infection, probably having infection, possibly having infection, or unlikely to have an infection, according to the International Consensus Meeting (ICM) definition of periprosthetic shoulder infection. Statistical analyses, including a receiver operating characteristic curve analysis, were performed to quantify the diagnostic value of D-dimer for periprosthetic shoulder infection. Based on the ICM definition, 4% (4 of 94), 15% (14 of 94), 14% (13 of 94), and 67% (63 of 94) of patients had definite, probable, possible, or unlikely periprosthetic shoulder infections. Results D-dimer was elevated in patients with definite or probable infections (median [range] 661 ng/mL [150 to 8205]) compared with those with possible infections or those who were unlikely to have an infection (263 ng/mL [150 to 3060]; median difference 143 ng/mL [95% CI 40 to 503]; p = 0.01). In the receiver operating characteristic curve analysis, D-dimer had an area under the curve of 0.71 (0.50-0.92), demonstrating weak diagnostic value. A D-dimer level of 598 ng/mL provided a sensitivity and specificity of 61% (95% CI 36% to 82%) and 74% (95% CI 62% to 83%), respectively, for diagnosing a definite or probable infection according to the ICM definitions. The specificity of detecting periprosthetic joint infection (88% [95% CI 79% to 94%]) was high when three positive serum markers (ESR, CRP, and D-dimer) were required, at the expense of sensitivity (28% [95% CI 10% to 53%]). Conclusion In periprosthetic shoulder infection, D-dimer is elevated. However, similar to other serum tests, it has limited diagnostic utility in identifying patients with periprosthetic shoulder infection. Further work is needed to understand the process by which D-dimer is associated with active infection. Level of evidence Level III, diagnostic study.

BACKGROUND: Modern glenoid cementing techniques for anatomic total shoulder arthroplasty has improved the ability to achieve a stable cement mantle, but the efficacy of adjunctive agents in glenoid preparation is unclear. The purpose of this study is to compare the early radiolucency rates of glenoids prepared with and without thrombin. METHODS: We identified patients between January 2017 and February 2019 undergoing primary anatomic TSA using two glenoid types. Group A glenoids had a cemented central peg without peripheral peg cementation, and Group B glenoids had cemented peripheral pegs without central peg cementation. The first postoperative radiograph was assessed for radiolucent lines. All patients had the same glenoid preparation except some had the addition of thrombin as a preparation agent. RESULTS: We identified 83 Group A glenoids with and 63 without thrombin glenoid preparation, and109 Group B glenoids with and 48 without thrombin preparation. All Group A glenoids had no radiolucent lines and 5 (3%) Group B glenoids had radiolucent lines. Use of thrombin showed no difference in early radiolucencies (p=1.00) in either Group. CONCLUSION: The addition of thrombin as a preparation agent had no effect on early glenoid radiolucent lines in anatomic TSA, and its routine use should be reconsidered.

Background The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Painful glenoid arthrosis following hemiarthroplasty is a common cause of reoperation, and conversion to anatomic total shoulder arthroplasty is one option. Methods We identified patients who underwent revision of painful hemiarthroplasty to total shoulder arthroplasty over a 15-year period in a single tertiary-care health system. Presurgical and operative data were analyzed for 28 patients who met the inclusion and exclusion criteria. Patients were contacted at a minimum of 2 years' follow-up after revision surgery for functional outcome scores, reoperations, and implant survival. Results The 2- and 5-year implant survival rates were 93% and 86%, respectively. Functional outcomes were obtained from 21 patients with surviving implants. The mean American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Single Assessment Numerical Evaluation score were 78 ± 20, 2.3 ± 2.6, and 71 ± 24, respectively. The mean Short Form 12 mental and physical scores were 49 ± 10 and 43 ± 9, respectively. Of the patients, 17 (81%) were either satisfied or very satisfied with their outcome. Complications were seen in 10 patients (36%), and 6 patients (21%) required reoperation. Conclusions Anatomic total shoulder arthroplasty following hemiarthroplasty can achieve successful outcomes and implant survival rates. Given our poor understanding of reverse shoulder arthroplasty longevity, this procedure should remain an option for patients with glenoid arthrosis and an intact rotator cuff.

Background The purpose of this study was to evaluate the functional outcomes, infection rate, and complications associated with shoulder arthroplasty for sequelae of prior septic arthritis. Methods This is a retrospective cohort study of 17 patients who underwent shoulder arthroplasty for sequelae of septic arthritis. Patients were analyzed for patient-reported outcomes, complications, and reoperations. Results The 17 patients in this cohort were an average age of 65.4 ± 12.2 years old, were 58.8% male, and had an average body mass index of 27.9 ± 4.1 kg/m2. These patients underwent 14 reverse shoulder arthroplasties (RSAs; 11 after antibiotic spacer placement), one anatomic total shoulder arthroplasty after antibiotic spacer placement, and two hemiarthroplasties (both after antibiotic spacer placement). Two patients underwent reoperation (dislocated RSAs). There were four complications (23.5%): two RSA dislocations, one acromial stress fracture, and one atraumatic rotator cuff tear after hemiarthroplasty. There were no cases of postoperative wound complications or infection. At an average of 4.1 ± 1.8 years of follow-up for all 17 of 17 cases, the average visual analogue scale pain score was 4.6 ± 2.3, average Single Assessment Numeric Evaluation Score was 59.3 ± 23.7, average American Shoulder and Elbow Surgeons Score was 57.6 ± 15.5, and average Simple Shoulder Test was 6.9 ± 2.6 based on "yes" responses. Conclusions Shoulder arthroplasty after septic arthritis had inconsistent functional outcomes and high complication rates but no reinfection.

Orthopaedic surgery in the United States is one of the few medical specialties that has consistently lacked diversity in its training programs and workforce for decades, despite increasing awareness of this issue. Is this the case in other English-language speaking countries? Are there inherent national differences, or does orthopaedics as a profession dictate the diversity landscape around the globe?The Carousel group includes the presidents of the major English-language-speaking orthopaedic organizations around the globe-Australia, Canada, New Zealand, South Africa, the United Kingdom, and the United States. Established in 1952, members of this group attend each other's annual scientific meetings during the year of their presidency, learning about our profession in each country and building international relationships. In this article, 13 Carousel presidents from different countries explore diversity in orthopaedics in their training programs and the workforce, with an assessment of the current state and ideas for improvement.

We examined practice patterns and surgical indications in the management of common shoulder procedures by surgeons practicing at physician-owned facilities.This study was a retrospective analysis of 501 patients who underwent arthroscopic shoulder procedures performed by five surgeons in our practice at one of five facilities during an 18-month period. Two of the facilities were physician-owned, and three of the five surgeons were shareholders. Demographics, insurance status, symptom duration, time from injury/symptom onset to the decision to perform surgery (at which time surgical consent is obtained), and time to schedule surgery were studied to determine the influence of facility type and physician shareholder status.Median duration of symptoms before surgery was significantly shorter in workers' compensation patients than in non-workers' compensation patients (47% less; P0.0001) and in men than in women (31% less; P0.001), but was not influenced by shareholder status or facility ownership (P0.05). Time between presentation and surgical consent was not influenced by facility ownership (P = 0.39) or shareholder status (P = 0.50). Time from consent to procedure was 13% faster in physician-owned facilities than in non-physician-owned facilities (P = 0.03) and 35% slower with shareholder physicians than with nonshareholder physicians (P0.0001).The role of physician investment in private healthcare facilities has caused considerable debate in the orthopaedic surgery field. To our knowledge, this study is the first to examine the effects of shareholder status and facility ownership on surgeons' practice patterns, surgical timing, and measures of nonsurgical treatment before shoulder surgery.Neither shareholder status nor facility ownership characteristics influenced the speed with which surgeons determined that shoulder surgery was indicated or surgeons' use of preoperative nonsurgical treatment. After the need for surgery was determined, patients underwent surgery sooner at physician-owned facilities than at non-physician-owned facilities and with nonshareholder physicians than with shareholder physicians.Level III.

Introduction Hemiarthroplasty with concentric glenoid reaming (known as "ream and run") may be an option for treating glenohumeral arthritis in younger patients with a biconcave glenoid. The goal of this study was to evaluate early results of this technique. Methods Two senior, fellowship-trained shoulder surgeons (G.R.W. and M.D.L.) performed a retrospective review of 23 patients (24 shoulders) with a biconcave glenoid and end-stage degenerative glenohumeral arthritis treated with hemiarthroplasty with concentric glenoid reaming. The mean patient age at the time of surgery was 50 years. We evaluated the Penn Shoulder Score (PSS), Single Assessment Numeric Evaluation (SANE) score, and Simple Shoulder Test (SST) score or the time to revision surgery. Results Twenty-four humeral hemiarthroplasties with concentric glenoid reaming were performed in 23 patients. Twenty patients (21 shoulders) reached the end point of 2-year follow-up or revision surgery. Six shoulders (25%) required revision surgery at an average of 2.7 years (range, 0.7 to 7.2 years), and three were lost to follow-up. The remaining 14 patients (15 shoulders) were followed up for an average of 3.7 years (range, 2.3 to 4.9 years). At 2-year follow-up, these 15 shoulders did not require revision surgery and had an average SANE score, PSS, and SST score of 74.5%, 82.9, and 10.4, respectively. Increasing age correlated positively with the SANE score (r = 0.62; P = 0.015), PSS (r = 0.52; P = 0.047), and SST score (r = 0.63; P = 0.012). Early postoperative forward elevation correlated weakly with the PSS (r = 0.24; P = 0.395), and early postoperative external rotation correlated moderately with the PSS (r = 0.53; P = 0.044). Final external rotation correlated moderately with the PSS (r = 0.69; P = 0.005). Discussion Modest results were achieved with a hemiarthroplasty and concentric glenoid reaming in young patients with end-stage glenohumeral arthritis and a biconcave glenoid. Younger age and stiffness were associated with worse outcomes. Given the high revision rate and the percentage of patients who had unsatisfactory results, this procedure should be performed only after careful patient selection. Patients who are willing and able to undergo aggressive physical therapy focused on achieving early range of motion are more likely to have a satisfactory outcome after humeral hemiarthroplasty with concentric glenoid reaming.

Glenoid exposure is the most difficult part of total shoulder arthroplasty. This manuscript will outline 10 tips for glenoid exposure that the author has found useful in achieving good glenoid exposure. These include, tilting the operating table away from the surgical side, having a variety of retractors available, removing all humeral osteophytes, making an accurate humeral cut, achieving optimal humeral positioning, ensuring proper retractor placement, utilizing a laminar spreader in select situations, achieving adequate capsular release on the humeral side, excising the anteroinferior capsule from the glenoid, and releasing the posteroinferior capsule from the glenoid.

Purpose The primary objective of this study was to evaluate if the current mechanisms of preoperative counseling influence patients' expectations of shoulder surgery. Methods Patients were asked to complete the Hospital for Special Surgery's (HSS) Shoulder Surgery Expectations Survey. The first survey was completed before the first appointment with one of four fellowship-trained shoulder surgeons. The second survey was completed after patients consented for surgery. Our analysis also included patient demographics and surgical factors. Results A total of 41 patients completed the HSS Shoulder Surgery Expectations Survey before and after their first appointment with the surgeon during which they consented to shoulder surgery. Before seeing the surgeon, the mean HSS Shoulder Surgery Expectations score was 72.5. After seeing the surgeon and being consented for surgery, the mean HSS Shoulder Surgery Expectations score was 74.8. The mean change in HSS Shoulder Surgery Expectations score (+2.3) was not statistically significant (p value = 0.242). We did not find any significant correlations between patients' expectations and demographics or surgical factors. Total HSS Shoulder Surgery Expectations scores and change in scores were not statistically different between the four surgeons (p = 0.146). Conclusion Patient expectations were not substantially altered after preoperative counseling. Further investigation is necessary to investigate factors correlated with expectations, the implication of unaltered expectations on the postoperative outcome, and methods for improving the preoperative counseling process. Level of Evidence Level II, prospective cohort study.

Background A significant portion of operating room time in shoulder arthroplasty is devoted to nonsurgical tasks. To maximize efficiency and to increase access to care, it is important to accurately quantify surgical and nonsurgical time for shoulder arthroplasty. This study aimed to evaluate surgical vs. nonsurgical time and to assess the viability of using a 1-surgeon, 2-operating room model. Methods An institutional database was used to identify all primary and revision shoulder arthroplasty cases from February 2011 through December 2013. Time intervals were analyzed, including anesthesia and positioning time, surgical time, conclusion time, and turnover time. Results We identified 1062 shoulder arthroplasties. The average anesthesia and positioning time was 48.2 ± 11.7 minutes, surgical time was 122.7 ± 36.4 minutes, and conclusion time was 10.5 ± 7.0 minutes. Average turnover time at our institution was 40 minutes. An average of 58.8 ± 13.8 minutes (33.2%) of the patient's time in the operating room was not surgical. A 1-room surgical model, with each case following the next, would allow 3 arthroplasties to be performed in a 10-hour surgical day. A 2-room model would allow 4 cases to be performed in a 9-hour surgical day or 5 in an 11-hour day. In this 2-room model, there would be no time in which the surgeon is absent for any surgical portion of the case. Conclusion For a high-volume shoulder arthroplasty practice, a 2-room model leads to greater efficiency and patient access to care without sacrificing the surgeon's presence during surgical portions of the case.

Background: Managing posterior glenoid wear and retroversion remains a challenge in shoulder arthroplasty.Correcting glenoid version through asymmetric reaming (AR) with placement of a standard glenoid component and theuse of posteriorly augmented glenoid (PAG) components are two methods used to address this problem. Our objectiveis to report the radiographic outcomes of patients with posterior glenoid wear and/or retroversion treated with eitherapproach.Methods: Patients with posterior glenoid wear and a minimum of 15 degrees of retroversion, treated with AR andstandard glenoid component or with a PAG component (3 mm, 5 mm, or 7 mm posterior augmentation), wereconsecutively identified through retrospective chart review. Pre-operative axillary views were evaluated for version,humeral head subluxation in relation to scapular axis and to mid-glenoid face. Post-operative axillary views werereviewed to measure corrected inversion and humeral head subluxation.Results: There were 48 patients in the AR group and 49 patients in the PAG group. Version improved 6.8 degrees in theAR group. In the PAG group, version improved 8.8 degrees with 3 mm augment, 13.4 degrees with 5 mm augment, and12.8 with 7 mm augments. There were significantly more central peg perforations in the 5 mm PAG group comparedto other groups. The humeral head was re-centered within 6.1% of normal in all groups except 7 mm augments.Conclusion: This study demonstrates that AR and PAGs have the ability to re-center the humeral head when utilizedin patients with retroversion and posterior wear. Use of a PAG component may allow for greater correction of glenoidretroversion, however, there is an increased risk for central peg perforation with the specific implant utilized in this study.Long-term follow-up is ongoing and needed to understand the clinical implications of these findings.Level of evidence: IV

Background Compared with anatomic total shoulder arthroplasty (aTSA), reverse total shoulder arthroplasty (RTSA) is associated with lower preoperative and postoperative outcome scores and range of motion. It is unknown whether patients' preoperative expectations of surgery are lower in RTSA compared with aTSA. The purpose of this study was to assess preoperative patient expectations and postoperative outcomes in aTSA and RTSA. Methods A consecutive series of patients undergoing primary aTSA for diagnosis of osteoarthritis or primary RTSA for diagnosis of rotator cuff tear arthropathy were studied prospectively. Expectations were evaluated using the validated Hospital for Special Surgery's Shoulder Surgery Expectations Survey. Baseline demographics, comorbidities, and social factors were collected. Baseline and 2 years postoperative American Shoulder and Elbow Surgeons (ASES) score, visual analog scale pain, Single Assessment Number Evaluation (SANE), and patient satisfaction were obtained. Results There were 128 patients (64 aTSA and 64 RTSA). There was no significant difference in total preoperative expectations score between groups. On multivariate linear regression analysis, aTSA (p = 0.024) and younger age (p = 0.018) were associated with higher expectations for improved ability to exercise. Changes in preoperative to postoperative ASES (p = 0.004) and SANE (p = 0.001) scores were higher in the aTSA group. Total preoperative expectations score was not correlated with postoperative functional outcomes or satisfaction in either group. In the aTSA group, expectations for participation in exercise were positively correlated with changes in preoperative to postoperative ASES score (p = 0.01) and SANE score (p = 0.01). Conclusion Though patients undergoing primary aTSA demonstrated greater improvement in functional outcome than those undergoing primary RTSA, both groups reported similar aggregate preoperative expectations. Those undergoing aTSA had higher expectations for return to exercise which was positively correlated with postoperative functional outcomes. Level of Evidence Level II, prospective cohort study.

Structural glenoid bone grafting in reverse total shoulder arthroplasty (RSA) has previously been reported to have good functional outcomes and low complication rates. We have observed different complication rates and hypothesized that baseplate fixation and severity of deformity may be predictors of early failure.We retrospectively identified 44 patients who underwent RSA with structural bone grafting for glenoid bone defects. All patients had preoperative and postoperative (Grashey and axillary) radiographs at a minimum of 1 year after surgery and within 3 months of surgery for evaluation of implant and graft positioning. Clinical data and outcome scores were collected at the same intervals.There were 61% females and 39% males, with an average age of 74 ± 8 years at the time of surgery. The median final radiographic follow-up was 20 months, with 37 primary RSA and 7 revision RSA. Graft resorption was found in 11 of 44 patients (25%), and radiographic failure was found in 11 of 44 patients (25%) at a median of 8 months (range 3-51 months). Forward elevation, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores all significantly improved postoperatively (P.0001). Radiographic baseplate failure was associated with graft resorption (P = .002), more retroversion correction (P = .02), and worse SANE scores at final follow-up (P = .01).RSA with structural bone graft improved range of motion and function, but there was a larger than previously reported baseplate loosening rate. This early radiographic loosening appeared to be associated with graft resorption, retroversion correction, and worse outcome scores.

BACKGROUND: Reconstructions of acute acromioclavicular (AC) dislocations have been thought to result in superior outcomes than chronic dislocations. The use of tendon graft in reconstructions has demonstrated favorable biomechanical properties. To determine whether utilizing tendon graft during repair of acute AC dislocations results in superior outcomes and lower complication rate. METHODS: A retrospective review of AC reconstructions was conducted. Reconstructions performed within 3 weeks of injury were included. Inclusion criteria included age over 18, grade 3-5 AC joint separation, and no previous ipsilateral shoulder injury. Primary outcome measure was radiographic loss of reduction. Secondary outcomes included ASES and SANE scores. RESULTS: Of 47 reconstructions of acute AC joint separations, 35 utilized fixation without a tendon graft, while 12 underwent an anatomic reconstruction with tendon graft. Repairs without the use of graft resulted in 8 (23%) cases of loss of reduction, while tendon graft augmented repairs resulted in 5 (42%). This difference was not statistically significant (p = 0.22). No patients required reoperation. There was no statistical difference in the ASES and SANE scores between the two groups. Furthermore, we found no significant difference in ASES or SANE scores in patients who maintained reduction postoperatively versus those that lost reduction. CONCLUSION: A greater but not statistically significant rate of loss of reduction was observed in the group reconstructed with the use of a tendon graft. Further research is needed to determine whether the use of tendon graft is beneficial in the treatment of acute AC joint separations. LEVEL OF EVIDENCE: IV

Background Increased use of reverse total shoulder arthroplasty (RTSA) has led to an understanding of unique complications such as acromial stress fractures (ASFs). The factors associated with ASFs are not fully known. This study investigates the incidence and predictors of ASFs following RTSA. Methods All RTSAs performed at a single tertiary referral hospital were retrospectively reviewed. ASF findings were classified as a definitive acromial or scapular spine stress fracture based on radiographic findings or stress reaction based on clinical findings (pain and tenderness at the acromion or acromial spine) without radiographic changes. Preoperative and postoperative radiographs were reviewed for radiographic predictors of postoperative acromial stress pathology. Clinical factors and implant characteristics were also investigated. Results Between September 2010 and January 2017, a total of 1170 RTSAs were performed, with 958 cases (81.9%) having at least 3 months' clinical follow-up (mean, 407 days; range, 90-1698 days). There were 40 ASFs (4.2%) and 61 acromial stress reactions (6.4%). For fractures and reactions, symptom onset averaged 8.8 and 7.3 months (P = .37), respectively, with durations of 4.5 and 2.9 months (P = .02), respectively, following RTSA. Independent predictors of acromial stress pathology were female sex, decreased change in deltoid length, and increased preoperative glenohumeral center-of-rotation medialization. Conclusion Acromion-related symptoms are common following RTSA. Female patients with increased preoperative center-of-rotation medialization had an increased incidence of ASFs. Although this study establishes which patients are at risk of ASFs, methods for prevention of ASFs in these patients remain unclear.

Venous thromboembolic disease (VTED) is a rare complication following arthroscopic rotator cuff repair (RCR). The American Academy of Orthopaedic Surgeons and the American College of Chest Physicians have no prophylaxis guidelines specific to shoulder arthroscopy, yet many surgeons prescribe aspirin following RCR. The purpose of this study was to evaluate the effectiveness of aspirin and mechanical prophylaxis compared with mechanical prophylaxis alone in preventing VTED following RCR. A total of 914 patients underwent RCR between January 2010 and January 2015. A retrospective case-control study was performed. The control group (n=484) consisted of patients treated with compression boots and early mobilization. The study group (n=430) used compression boots, early mobilization, and 81 mg/d of aspirin. The primary outcome was symptomatic VTED, including deep venous thrombosis (DVT) and pulmonary embolism (PE). A total of 7 VTED events occurred during the study period: 6 DVTs and 1 PE; 1 patient experienced both DVT and PE. The percentage of patients with VTED, DVT, and PE was 0.66%, 0.66%, and 0.11%, respectively. There was no significant difference for DVT or PE between the 2 groups. The incidence of DVT and PE was 0.62% and 0.00%, respectively, for the control group (no aspirin) and 0.70% and 0.23%, respectively, for the study group (aspirin). Aspirin does not lead to a clinically significant reduction in either DVT or PE rate in patients undergoing RCR. The authors conclude that the use of mechanical prophylaxis and early mobilization is a sufficient method of VTED prophylaxis in this low-risk population. [ Orthopedics . 2019; 42(2):e187–e192.]

Total shoulder arthroplasty (TSA) has proved a cost-effective, reproducible procedure for multiple shoulder pathologies. As utilization of TSA continues to grow, it is important to investigate procedure diversity, training, and other characteristics of surgeons performing TSA. To identify surgeons performing TSA in the Medicare population, the Medicare Provider Utilization and Payment Databases from 2012 through 2014 were used. This dataset includes any provider who bills Medicare10 times with a single billing code. A web-based search was performed for each physician performing10 TSA in all years of the study to identify their surgical training characteristics. Between 2012 and 2014, 1374 surgeons (39 females [2.8%]) performed10 TSA in Medicare patients in at least 1 year (71,973 TSA). Only 44.3% (609/1374) of surgeons met this threshold for all 3 years (55,538 TSA). Of these 609 surgeons, 191 (31.3%) were shoulder and elbow fellowship trained (21,444 TSA). Shoulder and elbow fellowship-trained surgeons were at earlier points in their careers and practiced in large referral-based centers with other surgeons performing TSA. In addition to TSA, surgeons performed other non-arthroplasty shoulder procedures (80.2% of surgeons), total knee arthroplasty (46.3%), repairs of traumatic injuries (29.8%), total hip arthroplasty (27.8%), non-arthroplasty knee surgeries (27.2%), elbow procedures (19.6%), and hand surgery (15.4%) during the study period. With less than one-third of TSA performed by shoulder and elbow fellowship-trained surgeons with consistent moderate-volume practices, the impact of consistent high-volume practices and targeted fellowship training on quality must be determined.

The purpose of this study was to examine the mid-term functional outcomes, radiographic results, and revision rates of patients treated with the Delta Xtend Reverse Shoulder System for both primary and revision arthroplasty indications.A retrospective review was conducted of records for all individuals who underwent a reverse shoulder arthroplasty using the Delta Xtend Reverse Shoulder Prosthesis at a single institution. Radiographic analysis as well as pain and functional measures using the ASES, Quick DASH, SST, SF-12, Penn, SANE, EQ-5D and VAS, and VR-12 scores. Patients were evaluated for five-year outcomes.Fifty patients were available for 5-year outcomes. Thirty-three cases were primary arthroplasty cases and 17 were revision arthroplasty cases. Postoperative radiographs at five years out from surgery were available for 46 patients. The mean AGT overall was 32.6mm: 31.7mm the primary cases and 34.8mm for revision cases. Sirveaux scapular notching was: 65.2% (30/46) at Grade 0, 23.9% (11/46) at Grade 1, and 10.9% (5/46) at Grade 2. Overall, 32/46 of stems were in neutral position, 10/46 were in valgus position, and 4/46 were in varus position. There was no significant correlation between stem position and scapular notching. The mean outcome scores for all patients at five years were good to excellent. Two revision patients demonstrated loosening of the humeral stem on radiographs. Nine patients demonstrated calcification of the long head of the triceps tendon.In conclusion, the Delta Xtend Reverse Shoulder System has shown to be a reliable arthroplasty system for patients with CTA or failed prior arthroplasty. Patients are generally quite functional at five years out from their reverse shoulder arthroplasty using this implant. Radiographic measures used to interpret the status of the implant demonstrate that AGT is well maintained and scapular notching is minimal for the majority of cases.IV.

Background: While outcomes of primary anatomic total shoulder arthroplasty (aTSA) are generally favorable, resultsafter revision procedures are less reliable. This study examines the functional outcomes, complications, and implantsurvival in patients who underwent revision of aTSA to aTSA.Methods: Patients who underwent revision aTSA were identified from 2008-2015. Demographic, clinical, surgical,and outcomes data were analyzed. Patient-reported outcomes including the American Shoulder and Elbow SurgeonsScore (ASES), Single Assessment Numerical Evaluation (SANE), Visual Analog Scale for pain (VAS), the Short Form-12 Health Survey (SF-12), and patient satisfaction were recorded.Results: Twenty patients underwent revision from a primary aTSA to aTSA (55% male, 62.0±6.8 years-old). RevisionaTSA occurred at 2.5±3.4 years after index surgery. Seven (35%) required future revision at 1.8±1.9 years after revisionaTSA. Among the 13 patients who did not undergo revision, twelve (92.3%) had over two-year follow-up (4.0±2.4years). Average ASES score was 70.1±23.5, SANE 66.0±29.4, VAS 2.7±3.0, SF-12 Mental 52.4±10.5, SF-12 Physical36.8±8.9, and satisfaction of 3.6±1.2.Conclusion: Results of revision aTSA to aTSA were unpredictable and the revision rate was high. The cases that donot undergo revision had satisfactory, but inconsistent functional results. Reverse arthroplasty may be more reliable inthis patient population.Level of evidence: IV

Displaced proximal humerus fractures that are isolated to the greater tuberosity or the surgical neck are commonly treated operatively. While multiple techniques are described that can lead to reliable outcomes, the proficiency of the surgeon to obtain an anatomic reduction remains the most valuable facet of proximal humerus fixation. In this chapter, we review the surgical options for 2-part proximal humerus fractures and discuss potential pearls and pitfalls of treatment.

Background The purpose of this study was to compare outcomes of patients who underwent bilateral total shoulder arthroplasties (TSAs) for osteoarthritis (OA) versus bilateral reverse shoulder arthroplasties (RSAs) for cuff tear arthropathy (CTA). Methods Inclusion criteria were patients who underwent bilateral TSAs for OA or bilateral RSAs for CTA with at least 2 years of follow-up. Twenty-six TSA patients (52 shoulders) were matched 2 to 1 with 13 RSA patients (26 shoulders) by sex, age at first surgery, and time between surgeries. Outcomes measured were shoulder range of motion (ROM), complications, and patient-reported scores. Results Preoperatively, TSA patients had significantly better forward elevation (FE) of both shoulders than RSA patients (dominant side [Dom]: 103° ± 32° vs. 81° ± 31°, p = 0.047; nondominant side [non-Dom]: 111° ± 28° vs. 70° ± 42°, p = 0.005) without significant differences in external (ER) or internal rotation (IR). Postoperatively, TSA patients had significantly better FE (Dom and non-Dom: 156° ± 12°, 156° ± 14° vs. 134° ± 24°, 137° ± 23°; p = 0.006, p = 0.019) and ER (42° ± 11°, 43° ± 10° vs. 24° ± 12°, 25° ± 10°; p < 0.001, p < 0.001) bilaterally and IR of their dominant arm (L1 vs. L4, p = 0.045). TSA patients had significantly better activities of daily living external and internal rotations (ADLEIR) scores (Dom and non-Dom: 35.3 ± 1.0, 35.5 ± 0.9 vs. 32.1 ± 2.4, 32.5 ± 2.2; p = 0.001, p = 0.001), American Shoulder and Elbow Surgeons scores (94.2 ± 8.4, 94.2 ± 8.2 vs. 84.7 ± 10.0, 84.5 ± 8.0; p = 0.015, p = 0.004), and Single Assessment Numerical Evaluation (SANE) scores (93.5 ± 7.6, 93.8 ± 11.8 vs. 80.5 ± 14.2, 82.3 ± 13.1; p = 0.014, p = 0.025), with no significant difference in visual analog scale pain scores (0.4 ± 1.0, 0.3 ± 1.0 vs. 0.7 ± 1.3, 0.8 ± 1.2) bilaterally. Conclusions Overall, patients with bilateral TSAs and RSAs exhibited improved ROM and patient-reported outcomes. Those with bilateral TSAs had better functional outcomes than those with bilateral RSAs.

This is a consensus statement on rehabilitation developed by the American Society of Shoulder and Elbow Therapists. The purpose of this statement is to aid clinical decision making during the rehabilitation of patients after arthroscopic rotator cuff repair. The overarching philosophy of rehabilitation is centered on the principle of the gradual application of controlled stresses to the healing rotator cuff repair with consideration of rotator cuff tear size, tissue quality, and patient variables. This statement describes a rehabilitation framework that includes a 2-week period of strict immobilization and a staged introduction of protected, passive range of motion during weeks 2-6 postoperatively, followed by restoration of active range of motion, and then progressive strengthening beginning at postoperative week 12. When appropriate, rehabilitation continues with a functional progression for return to athletic or demanding work activities. This document represents the first consensus rehabilitation statement developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients after arthroscopic rotator cuff repair.