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To assess the role of latissimus dorsi tendon transfer concomitant with reverse total shoulder arthroplasty in patients with external rotation deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis.Patients with a positive external lag sign and10⁰ of active external rotation (aER) treated with reverse shoulder arthroplasty (RTSA) at a single institution with a minimum 12 month follow-up were retrospectively identified from a prospective database. Basic demographic information along with preoperative and postoperative range of motion (ROM) measures, American Shoulder and Elbow Surgeons score (ASES), visual analog scale pain (VAS), and Subjective Shoulder Value (SSV) scores were obtained. Statistical analysis was performed to compare ROM and functional outcomes between patients that underwent concomitant LDT and those with no transfer.The latissimus dorsi transfer (LDT [n=31]) and no transfer (NT [n=33]) groups had similar age, sex distributions, and follow-up length average (24 vs 30 months). No differences were found between groups at baseline, final follow-up, or magnitude of change for ASES, VAS pain, and SSV scores. Baseline ROM measures were similar, except for the LDT group having slightly less aER (-8 ⁰ vs 0⁰; P=0.004). In addition, all postoperative ROM measures including aER were similar, except for a slight improvement in active internal rotation (IR) in the NT group. The majority of patients were satisfied with their outcome (LDT 84% (n=26); NT 87% (n=27); P=0.72).Patients with external rotation deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis undergoing RTSA do not have significantly improved external rotation or patient reported outcome measures with LDT.

Morse taper junction tribocorrosion is recognized as an important failure mode in total hip arthroplasty. Although taper junctions are used in almost all shoulder arthroplasty systems currently available in the United States, with large variation in design, limited literature has described comparable analyses of taper damage in these implants. In this study, taper junction damage in retrieved reverse total shoulder arthroplasty (RTSA) implants was assessed and analyzed.Fifty-seven retrieved RTSAs with paired baseplate and glenosphere components with Morse taper junctions were identified via database query; 19 of these also included paired humeral stems and trays or spacers with taper junctions. Components were graded for standard damage modes and for fretting and corrosion with a modified Goldberg-Cusick classification system. Medical records and preoperative radiographs were reviewed. Comparative analyses were performed assessing the impact of various implant, radiographic, and patient factors on taper damage.Standard damage modes were commonly found at the evaluated trunnion junctions, with scratching and edge deformation damage on 76% and 46% of all components, respectively. Fretting and corrosion damage was also common, observed on 86% and 72% of baseplates, respectively, and 23% and 40% of glenospheres, respectively. Baseplates showed greater moderate to severe (grade ≥ 3) fretting (43%) and corrosion (27%) damage than matched glenospheres (fretting, 9%; corrosion, 13%). Humeral stems showed moderate to severe fretting and corrosion on 28% and 30% of implants, respectively; matched humeral trays or spacers showed both less fretting (14%) and less corrosion (17%). On subgroup analysis, large-tapered implants had significantly lower summed fretting and corrosion grades than small-tapered implants (P .001 for both) on glenospheres; paired baseplate corrosion grades were also significantly lower (P = .031) on large-tapered implants. Factorial analysis showed that bolt reinforcement of the taper junction was also associated with less fretting and corrosion damage on both baseplates and glenospheres. Summed fretting and corrosion grades on glenospheres with trunnions (male) were significantly greater than on glenospheres with bores (female) (P .001 for both).Damage to the taper junction is commonly found in retrieved RTSAs and can occur after only months of being implanted. In this study, tribocorrosion predominantly occurred on the taper surface of the baseplate (vs. glenosphere) and on the humeral stem (vs. tray or spacer), which may relate to the flexural rigidity difference between the titanium and cobalt-chrome components. Bolt reinforcement and the use of large-diameter trunnions led to less tribocorrosion of the taper junction. The findings of this study provide evidence for the improved design of RTSA prostheses to decrease tribocorrosion.

Staged bilateral shoulder arthroplasty procedures have been shown to have good functional outcomes. The next step is to explore the option of simultaneous bilateral shoulder arthroplasty (SBSA). We report on the first case series of SBSA in the United States. The purpose of this study was to examine the safety and postoperative complication profile of SBSA and provide a technique reference for surgeons considering performing or investigating this procedure.We conducted a retrospective record review of all the SBSA procedures performed by the senior author between 2007 and 2020. Patient demographic characteristics, surgical information, and postoperative data were collected. Data were compiled, and means, standard deviations, and ranges were calculated. Any readmissions or postoperative complications requiring revision were noted. A cohort of patients matched for age, sex, and body mass index with staged (sequential) bilateral total shoulder arthroplasty was analyzed for comparison.Thirteen patients were identified in the simultaneous group (SBSA). The mean age was 64 ± 15 years, with 9 women (69%) and 4 men (31%); the mean body mass index was 29.1 ± 7.5. The mean American Society of Anesthesiologists score was 2.55 ± 0.7, average blood loss was 364 ± 170 mL (range, 50-600 mL), 5 of 13 patients (38%) underwent blood transfusions, and the mean surgical time was 183 ± 42 minutes. Postoperatively, the mean visual analog scale pain score on postoperative day 1 was 4 ± 2 (range, 0-7), and the mean length of stay was 3.3 days. Postoperative complications included urinary tract infections in 2 patients, urinary retention in 2 patients, and recurrence of paroxysmal atrial fibrillation in 1 patient. No patient was readmitted within 90 days of surgery. One patient underwent a reoperation 2 years postoperatively for symptomatic hardware removal (cerclage cables around the tuberosities). A matched cohort of staged bilateral total shoulder arthroplasty patients was analyzed for comparison. Postoperative complications in the staged group included 1 reverse total shoulder arthroplasty patient with subjective instability that was managed with additional physical therapy. There were no documented readmissions within 90 days or revision arthroplasty procedures in either cohort.SBSA is a reasonable procedure that can be useful in select patients, with promising short-term safety noted in this series. Prospective randomized studies are needed to assess the long-term safety and efficacy of the procedure.

Background: The use of stemless humeral implants for shoulder arthroplasty is becoming increasingly widespread. However, little is known about the difference in clinical, functional, and radiographic outcomes of stemless shoulder arthroplasty between men and women. Men and women do have reported differences in size, strength, and bone quality. As such, the purpose of this study was to evaluate sex-related differences in outcomes when using stemless humeral implants. Methods: A retrospective review of 227 patients (men = 143 and women = 84) undergoing stemless shoulder arthroplasty was compared for sex-related differences. Clinical, functional, and radiographic outcomes were compared, including American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale pain scores, range of motion, radiolucencies, operative data, implant data, and complications. Statistical analysis included descriptive statistics, t-tests, chi-square tests, and logistic regression. Results: Preoperatively, men had a statistically significant greater range of motion of forward elevation (P .99). Mean operating time was 9 minutes longer in male patients (P

Background: The purpose of this study was to compare the accuracy of anatomic reconstruction of three different humeral head designs after anatomic total shoulder arthroplasty. Methods: Postoperative radiographs of 117 patients who underwent anatomic total shoulder arthroplasty with three different implant designs (stemmed spherical, stemless spherical, and stemless elliptical) were analyzed for landmarks that represented the prearthritic state and final implant position. We assessed the change in center of rotati7on and humeral head height on the anteroposterior view and the percentage of prosthesis overhang on the axillary lateral view. A modified anatomic reconstruction index, a compound score that rated each of the 3 parameters from 0 to 2, was created to determine the overall accuracy of the reconstruction. Results: Excellent modified anatomic reconstruction index scores (5 or 6 points) were achieved by 68.1% of the cases in the stemless elliptical group compared with 33.3% of the cases in the stemless spherical group and by 28.3% of the cases in the stemmed spherical group (P = .001).The mean difference in restoration of humeral head height (P

Purpose As the number of shoulder arthroplasty procedures performed rises yearly, so does the number of periprosthetic joint infections (PJIs). In this study, PJI consensus definitions were compared and contrasted in a series of revision shoulder arthroplasty cases preoperatively diagnosed as PJI. Understanding the variations in these definitions may guide PJI diagnoses, thereby improving treatment strategies and patient outcomes in the setting of infected shoulder arthroplasty. Methods All revision shoulder arthroplasty cases with preoperatively-diagnosed or suspected PJI (determined by procedure code) performed from 2008 – 2017 at a single institution by a single surgeon (fellowship-trained in shoulder and elbow surgery) were retrospectively evaluated. Following Institutional Review Board approval, patient demographic, treatment, and laboratory data were collected. Musculoskeletal Infection Society (MSIS; 2011) and International Consensus Meeting on Orthopaedic Infections (ICM; 2013, 2018 Revision, 2018 Shoulder) definitions of PJI were applied to the data. Statistical analysis assessed significant associations between culture status and PJI classification algorithm criteria. Results Thirty-seven patients with suspected PJI were identified; 24 culture-positive (CP) and 13 culture-negative (CN). In this series, the 2018 ICM Shoulder definition for definite infection was met at lower rates than all other definitions (CP; 71% vs. 96%; CN; 62% vs. 69%). 2018 ICM Shoulder major criteria showed stronger correlations to 2011 MSIS, 2013 ICM, and 2018 ICM Revision major criteria when “gross intra-articular pus” was excluded than when pus was included as a major criterion. 2018 ICM Revision cases determined to be infected were very strongly, positively, correlated with the 2018 ICM Shoulder cases determined to have definite or probable infections (ρ = 1.000, P Conclusions In this series, the 2018 ICM Shoulder definition and previous PJI definitions classified cases as PJI at similar rates. However, the inclusion of a third major criterion of “gross intra-articular pus” weakened the correlation with prior definitions. Level of evidence Level IV; Case Series.

PURPOSE OF REVIEW: Baseplate fixation has been known to be the weak link in reverse total shoulder arthroplasty (RTSA). A wide variety of different baseplates options are currently available. This review investigates the recent literature to present the reader with an overview of the currently available baseplate options and modes of fixation. RECENT FINDINGS: The main elements that differentiate baseplates are the central fixation element, the size of the baseplate, the shape, the backside geometry, whether or not an offset central fixation exists, the number of peripheral screws, and the availability of peripheral augmentation. SUMMARY: The wide array of baseplate options indicates that no particular design has proven superiority. As such, surgeons should be aware of their options and choose an implant that the surgeon is comfortable with and one that best suits the individual patient anatomy. With the growing number of RTSA procedures and registries with long-term follow-up, future investigations will hopefully delineate the ideal baseplate design to optimize survivorship.

Background The purpose of this study is to determine the clinical and radiographic outcomes of reverse total shoulder arthroplasty (RTSA) after failed open reduction internal fixation (ORIF) for proximal humerus fracture (PHF) and compare them to outcomes of primary RTSA for PHF. Methods We performed a retrospective comparative study of patients who underwent RTSA between 2008 and 2015 at our institution by one of two fellowship-trained shoulder and elbow surgeons for an acute PHF or for continued pain or functional limitations following ORIF of a PHF. We compared the American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, range-of-motion, and radiographic measurements between cohorts. Results In total, there were 20 patients treated with RTSA after failed ORIF and 30 patients treated acutely with RTSA for PHF. The average ASES score was significantly greater for primary RTSA (82.0±13.5) than for delayed RTSA (64.0±27.2, P=0.016). The average SST score for primary RTSA (69.4%±19.1%) was significantly higher than the average for delayed RTSA (49.1%±8.9%, P=0.020). Forward elevation achieved postoperatively was significantly greater for patients treated with primary RTSA versus those with delayed RTSA (130±31° vs 107±31°, P=0.035). No difference was detected between groups in postoperative external rotation (P=0.152) or internal rotation (P=0.872). In patients with primary RTSA the tuberosities healed in an anatomic position in 70% of the fractures, which was significantly less than for delayed RTSA in which 100% of fractures had anatomic healing of the tuberosities (P=0.007). Conclusions In an elderly population, primary RTSA for PHF resulted in better clinical outcomes compared to RTSA following failed ORIF in this retrospective cohort study. Level of Evidence Level III; Retrospective Comparative Study

Background: Few studies have investigated the biomechanical performance of flat-braided suture tapes versus round-braided sutures after being knotted. Purpose: To compare the loop security and knot strength of a standard round-braided suture with 3 commercially available flat-braided suture tapes using 2 types of arthroscopic knots. Study Design: Controlled laboratory study. Methods: One standard suture (SS) and 3 suture tapes (T1, T2, and T3) were tied with the surgeon’s knot (SK) and the Tennessee slider (TS), 25 times each, by a single surgeon. Each combination of knots and sutures underwent a preload, cyclic loading, and load to failure. Outcomes were loop security (defined by loop stretch after a 5-N preload), load at clinical failure (3 mm of displacement), and load at ultimate failure (suture rupture or knot slippage). Two-way analysis of variance was used for analysis. Results: Overall, the SK group had greater overall loop security than that of the TS group (0.4 ± 0.3 vs 0.5 ± 0.3 mm of stretch, respectively; P = .020). The clinical failure load varied by suture type ( P < .001) but not knot type ( P = .106). For both knot types, the SS had the lowest mean ± SD clinical failure load (SK, 171 ± 49 N; TS, 176 ± 37 N), which was significantly less than that of T2 (247 ± 85 N; P < .001) and T3 (251 ± 96 N; P < .001) for the SK type and T2 (231 ± 67 N; P = .023) for the TS type. T2 sutures had the greatest ultimate failure load for both knot types (SK, 418 ± 45 N; TS, 461 ± 57 N), which was significantly greater than SS, T1, and T3 ( P < .001 for all). The TS knot had greater overall ultimate failure load than the SK (375 ± 64 vs 350 ± 66 N; P < .001). Conclusion: Not all suture tape knots had the same biomechanical properties, although knot security and strength appeared to be adequate for all suture tapes as well as for SS. There was no evidence that suture tape knots are lower profile than SS knots. Clinical Relevance: Surgeons should not use suture tape based only on the assumption that it has superior biomechanical properties to a standard round-braided suture.

The use of reverse total shoulder arthroplasty and stemless anatomic total shoulder replacement has been increasing in the United States every year. Stemless humeral components in reverse total shoulder arthroplasty are only approved for clinical trials in the United States with an investigational device exception with limited data.A systematic review on stemless reverse total shoulder arthroplasty was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search was conducted on November 25, 2020, using the MEDLINE/PubMed, Cochrane, and Embase databases. All articles were reviewed by 2 independent evaluators, with any conflicts or issues resolved by consensus or a final decision by the senior author. The primary outcomes extracted were complications, radiographic results, and outcome scores.We evaluated 10 studies that used either the Total Evolutive Shoulder System (TESS) or Verso implant. There were 430 total patients and 437 total procedures; 266 patients in the TESS group underwent a total of 272 procedures, and 164 patients in the Verso group underwent a total of 165 procedures. The mean age at the time of surgery was 73.8 years (range, 38-93 years). The mean follow-up period ranged from 6.4 to 101.6 months per study. There was an overall trend of improved clinical outcome scores, a 0.2% humeral component loosening rate, and an 11.2% complication rate.This review shows that the clinical and functional outcomes following stemless or metaphyseal reverse total shoulder arthroplasty are quite promising, especially with the low rate of humeral-sided complications. There continues to be a need for additional long-term studies and randomized clinical trials.

Purpose To compare outcomes after conversion of anatomic total shoulder arthroplasty (aTSA) to reverse total shoulder arthroplasty (RTSA) and a matched cohort. Methods Patients converted from aTSA to RTSA for rotator cuff failure or component loosening and a primary RTSA matched cohort were retrospectively identified from a prospective database. Demographics and preoperative and postoperative outcomes were obtained and compared. Results Age, sex, body mass index, follow-up length, and preoperative function were similar between revision (n = 35) and primary (n = 70) groups. At final follow-up, visual analog scale pain (2.4 ± 2.8 versus 1.7 ± 2.8; P = 0.24) and American Shoulder and Elbow Surgeons (68 ± 26 versus 76 ± 24; P = 0.14) scores were similar. The revision group had worse subjective shoulder value scores (63 ± 30 versus 79 ± 21; P = 0.002), satisfaction (74% versus 90%; P = 0.03), and more complications (31% versus 13%; P = 0.02). Conclusion Revision of aTSA to RTSA for component loosening or rotator cuff failure results in function comparable to primary RTSA; however, more complications, worse subjective shoulder value scores, and lower patient satisfaction should be expected. Level of evidence Level III, retrospective comparative.

BACKGROUND Stemless humeral components for anatomic total shoulder arthroplasty (aTSA) have several reported potential benefits compared with stemmed implants. However, we are aware of no Level-I, randomized controlled trials (RCTs) that have compared stemless implants with stemmed implants in patients managed with aTSA. We sought to directly compare the short-term clinical and radiographic outcomes of stemless and stemmed implants to determine if the stemless implant is noninferior to the stemmed implant. METHODS We performed a prospective, multicenter, single-blinded RCT comparing stemless and short-stemmed implants in patients managed with aTSA. Range-of-motion measurements and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant scores were obtained at multiple time points. Device-related complications were recorded. Radiographic evaluation for evidence of loosening, fractures, dislocation, or other component complications was performed. Statistical analysis for noninferiority was performed at 2 years of follow-up for 3 primary end points: ASES score, absence of device-related complications, and radiographic signs of loosening. All other data were compared between cohorts at all time points as secondary measures. RESULTS Two hundred and sixty-five shoulders (including 176 shoulders in male patients and 89 shoulders in female patients) were randomized and received the allocated treatment. The mean age of the patients (and standard deviation) was 62.6 ± 9.3 years, and 99% of the shoulders had a primary diagnosis of osteoarthritis. At 2 years, the mean ASES score was 92.5 ± 14.9 for the stemless cohort and 92.2 ± 13.5 for the stemmed cohort (p value for noninferiority test

Background The glenoid track concept has been proposed to correlate shoulder stability with bone loss. Accurate assessment of Hill-Sachs lesion size preoperatively may affect surgical planning and postoperative outcomes; however, no measurement method has been universally accepted. This study aimed to assess the accuracy and reliability of measuring Hill-Sachs lesion sizes using 3-dimensional (3D) computed tomography (CT). Methods Nine polyurethane humerus bone substitutes were used to create Hill-Sachs lesions of varying sizes with a combination of lesion depth (shallow, intermediate, and deep) and width (small, medium, and large). Specimens were scanned with a clinical CT scanner for size measurements and a micro-CT scanner for measurement of true lesion size. Six evaluators repeated measurements twice in a 2-week interval. Scans were measured by use of 3D CT reconstructions for length, width, and Hill-Sachs interval and with use of 2D CT for depth. The interclass correlation coefficient evaluated interobserver and intraobserver variability and percentage error, and Student t-tests assessed measurement accuracy. Results Interclass correlation coefficient reliability demonstrated strong agreement for all variables measured (0.856-0.975). Percentage error between measured length and measured depth and the true measurement significantly varied with respect to both lesion depth (P = .003 and P = .005, respectively) and lesion size (P = .049 and P = .004, respectively). Discussion and conclusions The 3D CT imaging is effective and reproducible in determining lesion size. Determination of Hill-Sachs interval width is also reliable when it is applied to the glenoid track concept. Measured values on 3D and 2-dimensional imaging using a conventional CT scanner may slightly underestimate true measurements.

Background Larger glenosphere diameters have been used recently to increase prosthesis stability and impingement-free range of motion in reverse total shoulder arthroplasty. The goal of this study was to evaluate the rate of polyethylene wear for 32-mm and 40-mm glenospheres. Methods Glenospheres (32 mm and 40 mm, n = 6/group) and conventional polyethylene humeral liners underwent a 5–million cycle (MC) wear simulation protocol. Abduction-adduction and flexion-extension motion profiles were alternated every 250,000 cycles. At each interval, mass loss was determined and converted to volume loss and wear rate. At 0, 2.5 MC, and 5 MC, liners were imaged using micro–computed tomography to determine surface deviation. White light interferometry was performed on liners and glenospheres at 0 and 5 MC to quantify surface roughness. Wear particle morphology was characterized by environmental scanning electron microscopy. Results Total volume loss was significantly higher in 40-mm liners from 1.5 MC onward ( P 3 /MC vs. 68.0 ± 18.9 mm 3 /MC; P P = .002). Surface roughness measurements showed no difference for liners; however, increased roughness was noted for 40-mm glenospheres at 5 MC compared with 32 mm ( P Conclusion Larger glenospheres underwent significantly greater polyethylene volume loss and volumetric wear rates, whereas smaller glenospheres underwent greater polyethylene surface deviations. The enhanced stability provided by larger glenospheres must be weighed against the potential for increased polyethylene wear.

Patients undergoing reverse total shoulder arthroplasty (RTSA) are at risk of significant perioperative blood loss. To date, few studies have examined the effectiveness of tranexamic acid (TXA) to reduce blood loss in the setting of RTSA.In a prospective, double-blinded, single-surgeon trial, we analyzed 102 patients undergoing primary RTSA who were randomized to receive intravenous TXA (n = 53) or placebo (n = 49). Calculated total blood loss, drain output, and hemoglobin (Hb) drop were measured. Postoperative transfusions were recorded. Complications were assessed out to 6 weeks postoperatively.Total blood loss was less for the TXA group (1122.4 ± 411.6 mL) than the placebo group (1472.6 ± 475.4 mL, P .001). Total drain output was less for the TXA group (221.4 ± 126.2 mL) than the placebo group (371.9 ± 166.3 mL , P .001). Total Hb loss was less in the TXA group (154.57 ± 60.29 g) compared with the placebo group (200.1 ± 65.5 g, P = .001). Transfusion rates differed significantly at postoperative day 1; however, overall transfusion rates did not vary significantly. Seven patients (14.3%) and 12 units were transfused in the placebo group compared with 3 patients (5.7%) and 3 units in the TXA group.In this cohort of patients undergoing primary RTSA, TXA was effective in reducing total drain output, total Hb loss, and total blood loss compared with a placebo control.

BackgroundFew studies report rate of improvement following reverse total shoulder arthroplasty (RTSA) in a single cohort. The purpose of this study was to compare functional scores following RTSA across postoperative time points in patients who have follow-up scores available at all selected time points.MethodsA prospective database was retrospectively queried for patients with functional outcome data from preoperatively and after RTSA at 3 to 6 months, 1 year, and 2 years, excluding any patients with data missing at these points. All patients included had measures from every time point. Collected outcomes included American Shoulder and Elbow Surgeons (ASES), visual analog scale pain, subjective shoulder value (SSV), and range of motion.ResultsOutcomes from 173 shoulders were analyzed. Average age was 68 ± 9 years, 68% were females, and 15% were revision cases. The average preoperative ASES score (33 ± 17) improved to 73 ± 18 at 3 to 6 months, 80 ± 19 at 1 year, and 81 ± 19 at 2 years after RTSA. Only outcomes at 1 and 2 years were not significantly different ( P = 1.0). SSV scores and forward elevation followed this pattern, with large improvements in the first 3 to 6 months, then reaching a plateau at 1 year. External and internal rotations did not improve by 3 to 6 months, but did significantly improve by 1 year, and remained stable through 2 years. Pain scores improved from 6.8 points before surgery to roughly 1.3 points at all subsequent time points.ConclusionsPatients undergoing RTSA can expect significant reductions in pain and the majority of their functional gains to occur in the first 6 months after surgery. At 12 months after RTSA, the average patient will achieve maximal improvement.

Objectives To determine whether uncemented implants would provide similar outcomes while avoiding the complications associated with cement in the treatment of elderly patients with proximal humerus fractures (PHFs) with primary reverse total shoulder arthroplasty (RTSA). Design Case series. Setting A single Level I trauma center. Patients/participants A prospectively obtained cohort of 30 patients who underwent uncemented RTSA as initial treatment for a comminuted PHF: 4 male, 26 female; average age 71 ± 11 years. Intervention Uncemented RTSA. Main outcome measures (1) Radiographic analysis, (2) postoperative clinical range of motion, and (3) functional outcome scores: the American Shoulder and Elbow Surgeons Shoulder score and the Simple Shoulder Test score. Results Radiographic analysis showed 97% achieved stable humeral stem fixation and 70% had healing of the tuberosities in anatomical position. Average range of motion was 130 ± 31 degrees of forward flexion, 32 ± 18 degrees of external rotation, and internal rotation to the midlumbar spine. Average American Shoulder and Elbow Surgeons Shoulder score was 82.0 ± 13.5 (with an average pain rating of 0.8 ± 1.3), and average Simple Shoulder Test score was 69.4% ± 19.1%. Conclusions Our data show that treatment of comminuted PHFs in elderly patients with uncemented RTSA can consistently produce good clinical outcomes with a low rate of complications and suggest that cement may not be necessary for RTSA in the trauma setting. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Stemmed humeral components have been used since the 1950s; canal-sparing (also known as stemless) humeral components became commercially available in Europe in 2004. The Simpliciti total shoulder system (Wright Medical, formerly Tornier) is a press-fit, porous-coated, canal-sparing humeral implant that relies on metaphyseal fixation only. This prospective, single-arm, multicenter study was performed to evaluate the two-year clinical and radiographic results of the Simpliciti prosthesis in the U.S. Methods: One hundred and fifty-seven patients with glenohumeral arthritis were enrolled at fourteen U.S. sites between July 2011 and November 2012 in a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE)-approved protocol. Their range of motion, strength, pain level, Constant score, Simple Shoulder Test (SST) score, and American Shoulder and Elbow Surgeons (ASES) score were compared between the preoperative and two-year postoperative evaluations. Statistical analyses were performed with the Student t test with 95% confidence intervals. Radiographic evaluation was performed at two weeks and one and two years postoperatively. Results: One hundred and forty-nine of the 157 patients were followed for a minimum of two years. The mean age and sex-adjusted Constant, SST, and ASES scores improved from 56% preoperatively to 104% at two years (p < 0.0001), from 4 points preoperatively to 11 points at two years (p < 0.0001), and from 38 points preoperatively to 92 points at two years (p < 0.0001), respectively. The mean forward elevation improved from 103° ± 27° to 147° ± 24° (p < 0.0001) and the mean external rotation, from 31° ± 20° to 56° ± 15° (p < 0.0001). The mean strength in elevation, as recorded with a dynamometer, improved from 12.5 to 15.7 lb (5.7 to 7.1 kg) (p < 0.0001), and the mean pain level, as measured with a visual analog scale, decreased from 5.9 to 0.5 (p < 0.0001). There were three postoperative complications that resulted in revision surgery: infection, glenoid component loosening, and failure of a subscapularis repair. There was no evidence of migration, subsidence, osteolysis, or loosening of the humeral components or surviving glenoid components. Conclusions: The study demonstrated good results at a minimum of two years following use of the Simpliciti canal-sparing humeral component. Clinical results including the range of motion and the Constant, SST, and ASES scores improved significantly, and radiographic analysis showed no signs of loosening, osteolysis, or subsidence of the humeral components or surviving glenoid components. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The increasing use of shoulder arthroplasty over the past two decades brings with it a steady need for qualified surgeons to manage the complications and failures. The most common modes of failure after anatomic total shoulder arthroplasty include glenoid component failure (loosening, wear, fracture), glenohumeral joint instability, and rotator cuff tear or dysfunction. Less common but no less significant complications that can lead to failure include periprosthetic fracture, infection, nerve injury, deltoid injury or dysfunction, and heterotopic ossification. These modes of failure can occur in isolation or in combination. A thorough understanding of the complications is necessary in order to offer patients the most appropriate treatment strategy. Strategies for each mode of failure and reported outcomes will be reviewed in addition to a decision-making treatment algorithm.

Background Although short-term outcomes of reverse total shoulder arthroplasty (rTSA) remain promising, the most commonly cited complication remains prosthetic instability. A retentive rTSA liner is commonly used to increase system constraint; however, no studies have evaluated the rate of polyethylene wear. Our hypothesis was that more constrained retentive liners would have higher wear rates than nonretentive liners. Methods Six nonretentive and six retentive rTSA non-cross-linked polyethylene liners were subjected to 4.5 million cycles of alternating cycles of abduction-adduction and flexion-extension motion loading profiles. The rTSA liners were assessed for gravimetric wear loss, 3-dimensional volumetric loss by novel micro-computed tomography analysis, and particulate wear debris analysis. Results Volumetric wear rates were significant at 7 specific time points (1.0, 2.0, 2.5, 3.25, 3.75, 4.0, and 4.5 million cycles) throughout testing between nonretentive and retentive liners; however, overall mean volumetric wear rate was not statistically significant (P = .076). Total volume loss between liner test groups was found to be significant starting after 3.5 million cycles of testing. Maximum and mean surface deviations were found to be larger for retentive liners vs. nonretentive liners by micro-computed tomography analysis across the entire articulation surface. Discussion and conclusion Retentive liners undergo significantly greater volume loss and greater surface deviation compared with nonretentive liners, most notably at later time points representing extended implantation times. Additional stability afforded by retentive liners should be balanced against the potential for increased wear and potential for subsequent polyethylene wear-induced aseptic loosening.

Ideal management of the glenoid in anatomic shoulder arthroplasty remains controversial. Glenoid component loosening remains a common source of clinical concern and, in young, active patients, implantation of a glenoid prosthesis is often avoided. Efforts to decrease glenoid loosening have resulted in changes to prosthetic design and implantation techniques. Currently, a wide variety of glenoid component options are available, including metal-backed or all-polyethylene, bone ingrowth or ongrowth, inset, and augmented designs. Additionally, several alternatives are available for the young, active patient, including hemiarthroplasty, nonprosthetic resurfacing, and tissue interposition. Many recent clinical and biomechanical studies have examined these implant options. A thorough knowledge of glenoid anatomy, pathology, implant options, indications, and principles of implantation is necessary to optimize the outcome following anatomic shoulder arthroplasty.

Background The “rocking horse” phenomenon is considered the main cause of glenoid component loosening by eccentric loading of the glenoid rim. This study aimed to investigate the influence of increasing glenohumeral implant mismatch on bone-implant interface micromotion in a cemented all-polyethylene pegged glenoid biomechanical model. Methods Five glenoid sizes, 40 mm, 44 mm, 48 mm, 52 mm, and 56 mm, representing +2 mm, +6 mm, +10 mm, +14 mm, and +18 mm glenohumeral mismatch, respectively, were cyclically loaded according to ASTM Standard F2028-08 at a constant frequency of 2 Hz to a size-dependent humeral head subluxation translation. Additional glenoid components were cyclically loaded to their subluxation translations at a constant humeral head rate of 4.4 mm/s. Component micromotion was characterized as compression, distraction, and superior-inferior translation measured by differential variable reluctance transducers. Results During constant frequency tests, 52-mm and 56-mm glenoids were unable to complete cyclic testing because of catastrophic failure of the glenoid-implant interface and permanent glenoid deformation, probably due to increasing severity of testing parameters. When tested at a constant humeral head speed, 48-mm, 52-mm, and 56-mm glenoids had significantly increased glenoid distraction and glenoid translation at cycle 50,000 compared with cycle 1. Distraction and translation measurements for 52-mm and 56-mm glenoids were significantly greater compared with 40-mm, 44-mm, and 48-mm glenoids at 50,000 cycles. Conclusions In a biomechanical model, optimal glenohumeral mismatch in cemented pegged glenoid implants is multifactorial and has not been definitively established. However, our data suggest that a radial mismatch of less than +10 mm may decrease the risk of glenoid micromotion.

Although short-term outcomes of reverse total shoulder arthroplasty have been promising, long-term success may be limited due to device-specific complications, including scapular notching. Scapular notching has been explained primarily as mechanical erosion; however, the generation of wear debris may lead to further biologic changes contributing to the severity of scapular notching.A 12-station hip simulator was converted to a reverse total shoulder arthroplasty wear simulator subjecting conventional and highly cross-linked ultra-high-molecular-weight polyethylene humeral liners to 5 million cycles of alternating abduction-adduction and flexion-extension loading profiles.Highly cross-linked polyethylene liners (36.5 ± 10.0 mm(3)/million cycle) exhibited significantly lower volumetric wear rates compared with conventional polyethylene liners (83.6 ± 20.6 mm(3)/million cycle; P .001). The flexion-extension loading profile exhibited significantly higher wear rates for conventional (P .001) and highly cross-linked polyethylene (P .001) compared with the abduction-adduction loading profile. Highly cross-linked wear particles had an equivalent circle diameter significantly smaller than wear particles from conventional polyethylene (P .001).Highly cross-linked polyethylene liners significantly reduced polyethylene wear and subsequent particle generation. More favorable wear properties with the use of highly cross-linked polyethylene may lead to increased device longevity and fewer complications but must be weighed against the effect of reduced mechanical properties.

Case: We present a case of Takotsubo cardiomyopathy associated with cardiogenic shock following reverse total shoulder arthroplasty in an eighty-three-year-old man with no history of cardiopulmonary medical problems. Takotsubo cardiomyopathy was diagnosed with emergency cardiac catheterization and angiography. The patient was managed with supportive measures that included the placement of a ventricular assist device. Conclusion: The patient recovered without any permanent cardiac sequelae. We review the pathogenesis, diagnosis, and treatment of Takotsubo cardiomyopathy.

The purpose of this study was to compare reverse total shoulder arthroplasty (RTSA) outcomes in normal weight, overweight, and obese patients. A RTSA outcomes registry was reviewed for rotator cuff-deficient patients with a minimum 2-year follow-up. Fractures, rheumatoid arthritis, and revisions were excluded. Based on World Health Organization body mass index (BMI) classification, there were 29 normal weight, 50 overweight, and 51 obese patients. All groups demonstrated significant improvements from preoperative to most recent follow-up in function scores, pain, and forward elevation. Obese and overweight groups had significantly worse preoperative rotation than the normal weight group. Postoperatively, there was no significant difference in absolute values or degree of improvement of rotation between groups. There was no significant difference in the incidence of radiographic or clinical complications between groups. Results of this study suggest that BMI has little influence on outcomes or risk of complication following RTSA. Longer-term studies are needed to determine if these results are maintained. (Journal of Surgical Orthopaedic Advances.

Background: The role of tranexamic acid (TXA) in reducing blood loss following primary shoulder arthroplasty has been demonstrated in small retrospective and controlled clinical trials. This study comprehensively evaluates current literature on the efficacy of TXA to reduce perioperative blood loss and transfusion requirements following shoulder arthroplasty. Methods: PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through October 27, 2016, for all articles evaluating TXA in shoulder arthroplasty. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of the risk of bias and strength of evidence. The primary outcome was change in hemoglobin and the secondary outcomes were drain output, transfusion requirements, and complications. Pooled outcomes assessing changes in hemoglobin, drain output, and transfusion requirements were determined. Results: Five articles (n = 629 patients), including 3 Level-I and 2 Level-III studies, were included. Pooled analysis demonstrated a significant reduction in hemoglobin change (mean difference [MD], -0.64 g/dL; 95% confidence interval [CI], -0.84 to -0.44 g/dL; p < 0.00001) and drain output (MD, -116.80 mL; 95% CI, -139.20 to -94.40 mL; p < 0.00001) with TXA compared with controls. TXA was associated with a point estimate of the treatment effect suggesting lower transfusion requirements (55% lower risk); however, the wide CI rendered this effect statistically nonsignificant (risk ratio, 0.45; 95% CI, 0.18 to 1.09; p = 0.08). Findings were robust with sensitivity analysis of pooled outcomes from only Level-I studies. Conclusions: Moderate-strength evidence supports use of TXA for decreasing blood loss in primary shoulder arthroplasty. Further research is necessary to evaluate the efficacy of TXA in revision shoulder arthroplasty and to identify the optimal dosing and route of administration of TXA in shoulder arthroplasty. Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Retrieved clinically failed anatomic total shoulder arthroplasty (TSA) components as well as associated radiographs and medical records were analyzed in order to investigate the origins of clinical failure(s) of TSA components. Methods Fifty TSA systems were retrieved from 48 patients including 27 females and 21 males; components were implanted for an average of 68 months (range, 2–267). Data obtained through radiographic analysis, medical records review, and damage mode analysis of each component were performed and statistically analyzed. Results Significant correlations were found between glenoid loosening and preoperative pain ( r = 1.00, P

Most studies of reverse total shoulder arthroplasty (RTSA) involve cemented humeral stems. To our knowledge, this is the first study to compare the results of cementless RTSA, using a porous-coated stem designed for uncemented fixation, with cemented RTSA.A prospective database of patients undergoing RTSA was retrospectively reviewed for patients with a diagnosis of cuff tear arthropathy or severe rotator cuff deficiency with minimum 2-year follow-up. Of these, 37 patients had cemented RTSA and 64 patients had cementless RTSA. Outcome measures included Constant-Murley scores, American Shoulder and Elbow Surgeons scores, visual analog pain scale scores, range of motion, patient satisfaction, and radiographic evidence of complication.Compared with preoperative values, both cohorts demonstrated significant improvements (P .01) in all functional scores, active forward elevation, and active internal rotation. There was no significant difference (P .05) in comparing the changes in these values after surgery between the cemented and cementless cohorts. On radiographic evaluation, there was no evidence of loosening or humeral components "at risk" of loosening in either group. There was no significant difference (P = 1.0) in the incidence of humeral component radiolucent lines between the cemented and uncemented cohorts. There was no significant difference (P = .30) in the incidence of scapular notching between the cemented (n = 8) and uncemented (n = 10) cohorts.Cementless fixation of a porous-coated RTSA humeral stem provides clinical and radiographic outcomes equivalent to those of cemented stems at minimum 2-year follow-up. With advantages such as simplified operative technique, no cement-related complications, greater ease of revision, and long-lasting biologic fixation, uncemented fixation may provide several benefits over cemented fixation.

As the incidence of shoulder arthroplasty continues to rise, the orthopedic shoulder surgeon will be increasingly faced with the difficult problem of evaluating a failed shoulder arthroplasty. The patient is usually dissatisfied with the outcome of the previous arthroplasty as a result of pain, but may complain of poor function due to limited range of motion or instability. A thorough and systematic approach is necessary so that the most appropriate treatment pathway can be initiated. A comprehensive history and physical examination are the first steps in the evaluation. Diagnostic studies are numerous and include laboratory values, plain radiography, computed tomography, ultrasound imaging, joint aspiration, nuclear scans, and electromyography. Common causes of early pain after shoulder arthroplasty include technical issues related to the surgery, such as malposition or improper sizing of the prosthesis, periprosthetic infection, neurologic injury, and complex regional pain syndrome. Pain presenting after a symptom-free interval may be related to chronic periprosthetic infection, component wear and loosening, glenoid erosion, rotator cuff degeneration, and fracture. Poor range of motion may result from inadequate postoperative rehabilitation, implant-related factors, and heterotopic ossification. Instability is generally caused by rotator cuff deficiency and implant-related factors. Unfortunately, determining the cause of a failed shoulder arthroplasty can be difficult, and in many situations, the source of pain and disability is multifactorial.

Subscapularis muscle dysfunction after total shoulder arthroplasty (TSA) can be a devastating complication. Recent biomechanical and clinical results suggest the superiority of lesser tuberosity osteotomy (LTO) over subscapularis tenotomy; however, disagreement over the best repair technique remains. This study aimed to characterize the strength of 2 novel repair techniques for LTO fixation compared with standard tenotomy and dual-row tuberosity osteotomies during TSA.Twenty fresh frozen cadaveric shoulders were dissected of all soft tissues except the humeri and attached subscapularis myotendinous unit. Humeri and subscapularis muscle belly were secured to a materials testing frame and subjected to cyclic loading, followed by load to failure for characterization of gap formation, ultimate failure load, and mechanism of failure. Repair techniques investigated were traditional subscapularis tenotomy and dual-row fleck LTO compared with novel techniques of single-cable and 2-suture large LTO repairs.No significant difference in ultimate failure load was noted among the repair techniques (P = .565). The tenotomy repair (6.0 ± 3.9 mm) displayed significantly greater gapping in response to increasing load than LTO repair techniques (P .05). No significant difference was noted between any LTO repairs at specific loads during cyclic testing (P .05).Our study displayed superior repair integrity of LTO vs tenotomy repairs. The advantages of the 2-suture large LTO technique over other LTO techniques include its simple technique, with a minimum amount of suture, avoidance of metallic hardware, and greater access to the glenoid, while providing comparable repair stability. Further research is warranted to fully evaluate these new techniques.

Background Patients undergoing revision shoulder arthroplasty frequently have deficient proximal humeral bone stock. Proximal humeral allograft has been recommended to augment reverse total shoulder arthroplasty (RTSA) to improve stability and function. This study reports the results of RTSA without proximal humeral allograft in patients with proximal humeral bone loss secondary to failed shoulder arthroplasty. Materials and methods From 2005 to 2008, 251 patients were enrolled in a prospective RTSA cohort study. Significant humeral bone loss was demonstrated in 15 of 56 undergoing revision for failed arthroplasty. Average age was 67 years. Average bone loss measured 38.4 mm (range, 26-72 mm). Patients were followed up for a minimum of 2 years with American Shoulder and Elbow Surgeons (ASES), Subjective Shoulder Value (SSV), Constant Score (CS), and visual analog scale (VAS) pain scores, as well as self-reported satisfaction and radiographs. Results Patients demonstrated significant improvement in mean CS (23.0 to 44.2), ASES (38.2 to 68.3), ASES activities of daily living (7.0 to 15.9), SSV (19.2 to 75.8), and VAS pain (4.6 to 1.6) scores. Thirteen of 15 patients reported satisfaction (87%). Range of motion improved in forward flexion (38.3° to 103.2°) and external rotation (−0.5° to 11.9°). Radiographs demonstrated notching in 3 patients (20%), no humeral subsidence or loosening, and prosthetic fracture of 1 modular humeral stem. Conclusions Use of RTSA for failed shoulder arthroplasty and deficient humeral bone stock provides a significant clinical benefit without the need for allograft augmentation. Monoblock humeral component use may diminish risk for prosthetic fracture.

Background Aseptic loosening of all-polyethylene glenoid components remains a limiting factor in achieving long-term implant survival in total shoulder arthroplasty (TSA). This study prospectively evaluated the functional and radiographic outcomes of patients undergoing TSA with a novel, porous, tantalum-backed glenoid component, with a minimum 2 years of follow-up. Materials and methods Porous tantalum-backed glenoid components were used in 19 TSAs in 19 patients. All patients were available for radiographic follow-up at an average of 38 months (range, 24-64 months). Patients were evaluated prospectively using the American Shoulder and Elbow Surgeons (ASES) score and pain on a visual analog scale (VAS). Radiographs were evaluated for component loosening and failure of the porous tantalum backing at a minimum 2 years of follow-up. Results The mean VAS decreased from 8.6 to 2.9 (P < .0001). The mean ASES score improved from 21 to 70 points (P < .05). Mean active forward elevation improved from 75° to 131° (P < .0001). At latest follow-up, all glenoid components except 1 had complete in-growth of the porous tantalum keel; however, 4 components (21%) failed by fracture at the keel–glenoid face junction. Conclusions There was an unacceptably high rate of glenoid component failure (21%) due to fracture at the keel–glenoid face junction in this series. The manufacturer has subsequently revised this early design to reduce the risk of failure. The results of this study illustrate that caution should be exercised in the use of novel implants with an unproven clinical track record.

Use of total shoulder arthroplasty has significantly increased during the past decade. For anatomic total shoulder arthroplasty, controversy exists regarding the best technique for detachment and repair of the subscapularis tendon. Options include tendon tenotomy, peel, lesser tuberosity osteotomy, and even subscapularis-sparing techniques. Inadequate healing of the subscapularis tendon can lead to postoperative pain, weakness, and instability. This review discusses the subscapularis pathoanatomy, different techniques for releasing and repairing the tendon, and reports biomechanical and clinical outcomes for each technique after total shoulder arthroplasty.

Newer glenoid components that allow for hybrid cement fixation via traditional cementation of peripheral pegs and bony ingrowth into an interference-fit central peg introduce the possibility of long-term biological fixation. However, little biomechanical work has been done on the initial stability of these components and the various fixation options. We conducted a study in which all-polyethylene glenoid components with a centrally fluted peg were implanted in polyurethane blocks with interference-fit, hybrid cement, and fully cemented fixation (5 per fixation group). Biomechanical evaluation of glenoid loosening, according to ASTM Standard F-2028-12, subjected the glenoids to 50,000 cycles of rim loading, and glenoid component motion was recorded with 2 differential variable reluctance transducers fixed to each glenoid prosthesis. Fully cemented fixation exhibited significantly less mean distraction in comparison with interference-fit fixation (P.001) and hybrid cement fixation (P.001). Hybrid cement fixation exhibited significantly less distraction (P.001), more compression (P.001), and no significant difference in glenoid translation (P = .793) in comparison with interference-fit fixation. Fully cemented fixation exhibited the most resistance to glenoid motion in comparison with hybrid cement fixation and interference-fit fixation. However, hybrid cement fixation and interference-fit fixation exhibited equivocal motion. Given these results, cementation of peripheral pegs may confer no additional initial stability over that provided by uncemented interference-fit fixation.

The treatment of subacromial impingement syndrome remains a controversial entity among both primary care physicians and orthopaedic surgeons. The initial management of this disorder is usually conservative with directed physiotherapy, subacromial corticosteroid injections and nonsteroidal anti-inflammatories representing the mainstays of treatment. Surgery in the form of arthroscopic bursectomy or acromioplasty is reserved for those patients who fail at least 6 months of conservative management. Traditionally, there have been few high-level studies to guide the practitioner concerning when conservative treatment has failed, which patients are candidates for surgical intervention or which surgical intervention may be most appropriate for a particular patient. However, recent studies have improved our knowledge base of the pathophysiology underlying this disorder and they provide some useful guidance on the conservative and operative management of this complex problem.

Background Although early results with reverse total shoulder arthroplasty (rTSA) have been promising, concern exists about the high reported rates of scapular notching and the potential for catastrophic failure of glenoid component fixation. Generation of polyethylene wear debris may also contribute to notching and osteolysis of the scapula. A testing model for polyethylene wear is currently unavailable for reverse shoulder prostheses. The goal of this study was to develop a testing protocol using a commercially available hip simulator. Component design may also influence the generation of polyethylene debris. It is hypothesized that increased polyethylene wear occurs in glenospheres with holes in the articulating surface. Materials and methods Custom fixtures were fabricated to simulate both glenohumeral abduction and flexion on a 12-station hip wear simulator. Loading profiles for both abduction and flexion were alternated every 250,000 cycles for a total of 5 million cycles. Gravimetric analysis of humeral cups throughout the test was used to characterize wear. Lubricant fluid was collected throughout the test and digested for polyethylene particle analysis. Results Comparisons of volumetric wear rates and total volume loss between glenospheres with and without holes and between flexion and abduction loading profiles showed similar results. Particle analysis displayed fibrillar particles with an equivalent circle diameter of 0.3 ± .1 μm and an aspect ratio of 2.5 ± 1.4. Conclusions This study represents the first wear simulation and particle characterization of reverse shoulder systems. No significant difference in wear was reported between glenospheres with and without holes.

Background Scapular notching is a well-recognized complication of reverse total shoulder arthroplasty (RTSA). This paper analyzes the effects of prosthesis design on scapular notching in RTSA. Methods From a database of all RTSA performed by the senior author, shoulders with minimum 12-month follow-up were included (65 shoulders). Notching in shoulders with a prosthesis neck-shaft angle of 155° and no center-of-rotation (COR) offset (group 1) was compared to notching in shoulders with a neck-shaft angle of 143° and 2.5-mm COR offset (group 2). P values less than .05 were considered significant. Results The notching grade was significantly higher in group 1 than in group 2, even after statistically adjusting for differences in length of follow-up ( P = .0081). The incidence of notching in group 1 at 60.7% was significantly higher than the 16.2% incidence in group 2 ( P = .0107). Conclusion Using prostheses with a smaller neck-shaft angle and increased COR offset can significantly reduce scapular notching in RTSA at 1 year, possibly improving prosthesis survival.

Subscapularis dysfunction after tenotomy for the deltopectoral approach to the shoulder has recently been identified in the orthopedic literature as an under-recognized complication of total shoulder arthroplasty. Attempts to improve the postoperative function of the subscapularis and mitigate rupture of the muscle-tendon unit have focused on alternative methods for subscapularis takedown and repair. Lesser tuberosity osteotomy for release of the subscapularis has been described by multiple authors as an effective way to decrease subscapularis dysfunction and maintain tendon integrity after total shoulder arthroplasty. Proponents of this technique cite maintenance of the integrity of the tendon, direct bone-to-bone healing of the osteotomy, improved strength of repair, and the ability to monitor the integrity of the subscapulairs repair radiographically in the postoperative period as distinct advantages. Short-term clinical studies have documented improved subscapularis function after the osteotomy technique and biomechanical studies have also shown improved strength of repair when compared with tenotomy. However, there are several concerns about the osteotomy technique that have not yet been resolved, including significantly increased operative complexity, inability to medialize the tendon to adjust subscapularis tension, risk of intraoperative humeral fracture, and lack of long-term clinical outcomes. Although lesser tuberosity osteotomy shows promising improvements in short-term clinical results, subscapularis tenotomy has a long proven track record of excellent clinical outcomes and the choice between the 2 methods of subscapularis takedown remains one of surgeon comfort and experience.

Purpose: With health-care utilization becoming an important factor in patient care, we investigated the effect that surgical day of week has on length of hospital stay (LOS) for shoulder arthroplasty patients.Methods: All patients undergoing primary anatomic or reverse total shoulder arthroplasty by a single surgeon on Monday, Wednesday, or Friday over a 10-year period were retrospectively reviewed. A total of 1784 patients met inclusion criteria. Demographics, LOS, and discharge disposition were recorded for all study participants.Results: The overall average LOS was 2.9 ± 1.8 days and was significantly longer for patients having surgery Friday (3.0 ± 1.9 days) versus Wednesday (2.7 ± 1.7 days, P = .002). For those discharged home, the mean LOS was 2.6 ± 1.3 days versus 4.3 ± 3.3 days for those discharged to extended care facilities (ECFs). Patients discharged to ECF with Friday surgery had a significantly longer LOS than Monday ( P = .028) and Wednesday ( P = .010) patients, with 30% of patients with Friday surgery being discharged postoperative day 4 versus 14% and 9% on Monday and Wednesday, respectively. LOS trended toward being longer for Friday surgery in the home disposition group but did not reach significance.Discussion: These results should be considered during surgical scheduling in order to minimize health-care expenditures. Patients at high risk for requiring ECF at discharge should be scheduled at the beginning of the week, while more resources are available to expedite their discharge.

This clinical practice guideline is based on a systematic review of published studies on the treatment of glenohumeral osteoarthritis in the adult patient population. Of the 16 recommendations addressed, nine are inconclusive. Two were reached by consensus-that physicians use perioperative mechanical and/or chemical venous thromboembolism prophylaxis for shoulder arthroplasty patients and that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear. Four options were graded as weak: the use of injectable viscosupplementation; total shoulder arthroplasty and hemiarthroplasty as treatment; avoiding shoulder arthroplasty by surgeons who perform fewer than two shoulder arthroplasties per year (to reduce the risk of immediate postoperative complications); and the use of keeled or pegged all-polyethylene cemented glenoid components. The single moderate-rated recommendation was for the use of total shoulder arthroplasty rather than hemiarthroplasty. Management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved.

Background:Although recent evidence suggests that any prior shoulder surgery may cause inferior shoulder arthroplasty outcomes, there is no consensus on whether previous rotator cuff repair (RCR) is associated with inferior outcomes after reverse total shoulder arthroplasty (RTSA).Purpose:To retrospectively compare outcomes in patients who underwent RTSA with and without previous RCR.Study Design:Cohort study; Level of evidence, 3.Methods:Patients with prior RCR and those without previous shoulder surgery (control) who underwent RTSA for cuff tear arthropathy or irreparable cuff tear were retrospectively identified from a prospective database. Exclusion criteria included revision arthroplasty, fractures, rheumatoid arthritis, dislocations, infection, prior non-RCR procedures, less than 12 months of follow-up, and latissimus dorsi tendon transfer. The American Shoulder and Elbow Surgeons (ASES) score, ASES Activities of Daily Living (ADL) score, visual analog scale (VAS) score for pain, Subjective Shoulder Value (SSV), and range of motion (ROM) were compared between groups.Results:Patients with previous RCR (n = 83 shoulders) were younger (mean ± SD, 67 ± 10 vs 72 ± 8 years; P < .001) and more likely to be male (46% vs 32%, P = .033) than controls (n = 189 shoulders). No differences were found in follow-up duration (25 ± 13 vs 26 ± 13 months, P = .734), body mass index, or any preoperative outcome variable or ROM measure. At final follow-up, patients with previous RCR had significantly lower ASES (76.5 [95% CI, 71.2-81.7] vs 85.0 [82.6-87.5], P = .015), lower SSV (76 [72-81] vs 86 [83-88], P < .001), worse pain (2.0 [1.4-2.6] vs 0.9 [0.6-1.1], P < .001), and less improvement in the ASES, ASES ADL, VAS, SSV, and forward elevation measures than controls. Multivariable linear regression analysis demonstrated that previous RCR was significantly associated with lower postoperative ASES score ( B = –9.5, P < .001), lower ASES improvement ( B = –7.9, P = .012), worse postoperative pain ( B = 0.9, P = .001), worse improvement in pain ( B = –1.0, P = .011), lower postoperative SSV ( B = –9.2, P < .001), lower SSV improvement ( B = –11.1, P = .003), and lower forward elevation ROM improvement ( B = –12.7, P = .008).Conclusion:Patients with previous RCR attempts may experience fewer short-term gains in functional and subjective outcome scores after RTSA compared with patients with no history of shoulder surgery who undergo RTSA. However, the differences between groups were small and below the minimal clinically important differences for the outcome measures analyzed.