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Background: The purposes of this study were to identify changes in tear dimensions, shoulder function, and glenohumeral kinematics when an asymptomatic rotator cuff tear becomes painful and to identify characteristics of individuals who develop pain compared with those who remain asymptomatic.Methods: A cohort of 195 subjects with an asymptomatic rotator cuff tear was prospectively monitored for pain development and examined annually for changes in various parameters such as tear size, fatty degeneration of the rotator cuff muscle, glenohumeral kinematics, and shoulder function. Forty-four subjects were found to have developed new pain, and the parameters before and after pain development were compared. The forty-four subjects were then compared with a group of fifty-five subjects who remained asymptomatic over a two-year period.Results: With pain development, the size of a full-thickness rotator cuff tear increased significantly, with 18% of the full-thickness tears showing an increase of >5 mm, and 40% of the partial-thickness tears had progressed to a full-thickness tear. In comparison with the assessments made before the onset of pain, the American Shoulder and Elbow Surgeons scores for shoulder function were significantly decreased and all measures of shoulder range of motion were decreased except for external rotation at 90° of abduction. There was an increase in compensatory scapulothoracic motion in relation to the glenohumeral motion during early shoulder abduction with pain development. No significant changes were found in external rotation strength or muscular fatty degeneration. Compared with the subjects who remained asymptomatic, the subjects who developed pain were found to have significantly larger tears at the time of initial enrollment.Conclusions: Pain development in shoulders with an asymptomatic rotator cuff tear is associated with an increase in tear size. Larger tears are more likely to develop pain in the short term than are smaller tears. Further research is warranted to investigate the role of prophylactic treatment of asymptomatic shoulders to avoid the development of pain and loss of shoulder function. [ABSTRACT FROM AUTHOR]

Background: It has been theorized that degenerative rotator cuff tears most commonly involve the supraspinatus tendon, initiating at the anterior portion of the supraspinatus insertion and propagating posteriorly. The purposes of this study were to determine the most common location of degenerative rotator cuff tears and to examine tear location patterns associated with various tear sizes.Methods: Ultrasonograms of 360 shoulders with either a full-thickness rotator cuff tear (272) or a partial-thickness rotator cuff tear (eighty-eight) were obtained to measure the width and length of the tear and the distance from the biceps tendon to the anterior margin of the tear. Tears were grouped on the basis of their size (anteroposterior width) and extent (partial or full-thickness). Each tear was represented numerically as a column of consecutive numbers representing the tear width and distance posterior to the biceps tendon. All tears were pooled to graphically represent the width and location of the tears within groups. Frequency histograms of the pooled data were generated, and the mode was determined for each histogram representing various tear groups.Results: The mean age (and standard deviation) of the 233 subjects (360 shoulders) was 64.7 +/- 10.2 years. The mean width and length of the tears were 16.3 +/- 12.1 mm and 17.0 +/- 13.0 mm, respectively. The mean distance from the biceps tendon to the anterior tear margin was 7.8 +/- 5.7 mm (range, 0 to 26 mm). Histograms of the various tear groups invariably showed the location of 15 to 16 mm posterior to the biceps tendon to be the most commonly torn location within the posterior cuff tendons. The histograms of small tears (a width of <10 mm) and partial-thickness tears showed similar distributions of tear locations, indicating that the region approximately 15 mm posterior to the biceps tendon may be where rotator cuff tears most commonly initiate.Conclusions: Degenerative rotator cuff tears most commonly involve a posterior location, near the junction of the supraspinatus and infraspinatus. The patterns of tear location across multiple tear sizes suggest that degenerative cuff tears may initiate in a region 13 to 17 mm posterior to the biceps tendon. [ABSTRACT FROM AUTHOR]

We report the updated results for a previously evaluated cohort of patients who were less than fifty years old when they underwent Charnley total hip arthroplasty with cement. The original cohort consisted of ninety-three total hip arthroplasties performed in sixty-nine patients. The patients were followed for a minimum of twenty-five years after surgery or until death. The present report describes the findings of the radiographic and functional follow-up, which was performed for forty-two of the forty-three living patients. At the time of the latest follow-up, twenty-nine (31%) of the ninety-three total hip replacements had been revised or removed. Eighteen acetabular and five femoral components were revised secondary to aseptic loosening. The combined prevalence of radiographic failure or revision because of aseptic loosening was 13% for the femoral components and 34% for the acetabular components. Comorbid medical conditions significantly hindered results on each functional subscale (p < 0.05). This study demonstrates the durability of cemented total hip replacements in a young patient population. Sixty-nine percent of the original hip replacements were functioning well at the latest follow-up examination or at the time of death, and only 5% required more than one revision arthroplasty. [ABSTRACT FROM AUTHOR]

Background: Descriptions of glenoid deformities in glenohumeral osteoarthritis (GHOA) have focused on the axial plane. Less is known regarding arthritic glenoids with higher amounts of superior inclination and little evidence exists to guide management of inclination or combined version-inclination deformity when performing anatomic total shoulder arthroplasty (aTSA). We hypothesized that biplanar deformities (BD) would be present in a higher proportion of GHOA patients than previously appreciated, and these deformities would be difficult to adequately reconstruct with contemporary aTSA implants., Methods: A retrospective query was performed of GHOA patients indicated for TSA 2012-2017 with a computed tomography (CT) scan within three months of surgery. Images were uploaded to three-dimensional (3D) software for automated measurements. Glenoids with superior inclination ≥10°, and retroversion ≥20° were considered to have BD. Walch classification was determined, and C-type glenoids were excluded. Rotator-cuff muscle cross-sectional area (CSA) was measured and fatty infiltration was graded. Glenoids with BD were virtually planned for aTSA with correction to neutral inclination and version, then with 5° superior inclination and 10° retroversion., Results: Two-hundred and sixty-eight shoulders in 250 patients were included; average age was 65 years, 67% male. There were no differences in inclination between Walch types (P = .25). Twenty-nine shoulders with BD were identified (11%). These deformities were not associated with age (P = .47) or gender (P = .50) but were skewed towards Walch B-type, specifically B2 (P = .03). Acromial index and posterior humeral head subluxation were higher in BD patients (P = .04, P < .001, respectively). Biplanar deformities had similar cuff CSA compared to those without but were less frequently associated with fatty infiltration of the subscapularis (P = .05). When correcting to neutral version and inclination, 41% BD could not be reconstructed. Of those that could, 94% required augmented implants. When correcting to 5° superior inclination and 10° retroversion, 10% could not be reconstructed. Of those that could, 58% required augmented implants. With partial correction, augment use was predicted by retroversion >26° (P = .009). Inclination did not predict augment use (P = .90). Final implant position commonly involved unseating in the posterosuperior quadrant and cancellous exposure in the anteroinferior quadrant., Conclusions: This retrospective computed tomography (CT)-based study of 268 shoulders with GHOA found an 11% prevalence of BD. These deformities were commonly associated with Walch B2 wear patterns. Virtual aTSA planning showed a high failure rate (41%) when correcting to neutral version and inclination. Posteriorly augmented implants were frequently required, and often still involved unseating in the posterosuperior quadrant, increased cancellous exposure in the anteroinferior quadrant, and vault perforation., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: Optimal management of retroversion in anatomic total shoulder arthroplasty (aTSA) remains controversial and limited attention has been directed to the impact of glenoid inclination. Prior biomechanical study suggest that residual glenoid inclination generates shear stresses that may lead to early glenoid loosening. Combined biplanar glenoid deformities may complicate anatomic glenoid reconstruction and affect outcomes. The goal of this matched-cohort analysis was to assess the relationship between biplanar deformities and mid-term radiographic loosening in aTSA., Methods: The study cohort was identified via an institutional repository of 337 preoperative CT scans from 2010-2017. Glenoid retroversion, inclination, and humeral head subluxation were assessed via 3D-planning software. Patients with retroversion ≥ 20˚ and inclination ≥ 10˚ who underwent aTSA with eccentric reaming and non-augmented components were matched by age, sex, retroversion, and Walch classification to patients with retroversion ≥ 20˚ only. Primary outcome was glenoid component Lazarus radiolucency score., Results: Twenty-eight study subjects were matched to 28 controls with retroversion only. No difference in age (61.3 vs. 63.6 years, p=0.26), sex (19 [68%] vs. 19 [68%] male, p=1.0), or follow-up (6.1 vs. 6.4 years, p=0.59). Biplanar deformities had greater inclination (14.5˚ versus 5.3˚, p<0.001), retroversion (30.0˚ versus 25.6˚, p=0.01) and humeral subluxation (86.3% versus 82.1%, p=0.03). Biplanar patients had greater postoperative implant superior inclination (5.9 [4.6] vs. 3.0 [3.6] degrees, p=0.01) but similar rate of complete seating 24 [86%] vs. 24 [86%] p=1.0). At final follow-up, biplanar subjects had higher Lazarus radiolucent scores (2.4 [1.7] vs. 1.6 [1.1], p=0.03) and higher proportion of patients with glenoid radiolucency (19 [68%] vs. 11 [39%], p=0.03). No difference in complete component seating (86% versus 86%, p=0.47) or initial radiolucency grade (0.21 versus 0.29, p=0.55) on immediate postop radiographs. Biplanar patients demonstrated a greater amount of posterior subluxation at immediate postop(3.5% [1.3%] versus 1.8% [0.6%]; p=0.03) and final follow-up (7.6% [2.8%] versus 4.0% [1.8%]; p=0.04). At final radiographic follow-up, biplanar subjects had higher Lazarus radiolucent scores (2.4 [1.7] vs. 1.6 [1.1], p=0.03; ICC=0.82). Bivariate regression analysis demonstrated biplanar deformity was the only significant predictor (OR 3.3, p=0.04) of glenoid radiolucency., Conclusion: Biplanar glenoid deformity resulted in time-zero glenoid implant superior inclination and increased mid-term radiographic loosening and posterior subluxation. Attention to glenoid inclination is important for successful anatomical glenoid reconstruction. Future research is warranted to understand the long-term implications of these findings and impact of utilizing augmented implants or reverse shoulder arthroplasty to manage biplanar deformities., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Reverse total shoulder arthroplasty (RTSA) with structural bone graft has been described as a technique in addressing glenoid bony defects. Studies have demonstrated acceptable outcomes with structural autograft or allograft. However, most of these studies are relatively small and rarely evaluate bone graft incorporation with CT scan. The aim of this study was to assess clinical and radiographic outcomes and report graft incorporation assessed on CT scan after RTSA where structural bone autograft or allograft was used to reconstruct the glenoid., Methods: From May 2011 through June 2016, 38 patients underwent RTSA with structural bone graft. Of these, 35 were available for a minimum 2-year follow-up and retrospectively enrolled. From July 2016 through February 2019, 32 patients undergoing RTSA with structural bone graft were prospectively enrolled. Preoperative and postoperative American Shoulder and Elbow Surgeons and visual analog scale (for pain) scores and radiographs were obtained. CT scan was obtained at least 1 year postoperatively., Results: Thirty-five patients were enrolled retrospectively (52.2%) and 32 prospectively (47.8%). Autograft was used in 46 cases (68.7%) and allograft in 21 cases. The mean American Shoulder and Elbow Surgeons score improved from 33.1 (SD 18.5) to 78.2 (SD 22.4), with P < 0.0001. On postoperative radiographs, 63 cases (94.0%) showed stable RTSA constructs while four cases (6.0%) developed glenoid baseplate subsidence. Postoperative CT scan demonstrated complete graft incorporation in 45 cases (90.0%) while partial incorporation was noted in 4 cases (8.0%), and in 1 case (2.0%), there was no graft incorporation. No correlation was observed between baseplate subsidence and graft type (autograft versus allograft) or primary versus revision surgery., Discussion: Reverse shoulder arthroplasty with structural bone autograft and allograft is reliable for glenoid augmentation in patients undergoing RTSA in both primary and revision settings. Bony incorporation of autograft and allograft as evaluated on CT scan is predictably high., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: The natural history of rotator cuff tears often involves progressive pain development, tear enlargement, and advancing muscle fatty degeneration. Both surgery and conservative management have proven to be effective treatments. Our study purpose was to compare the short- to mid-term effects of rotator cuff repair on shoulder function, progression of tear size, and muscle degeneration compared to controls with asymptomatic tears that developed pain and were managed nonoperatively., Methods: This comparative study consists of 2 separate longitudinal study arms. The control group consisted of asymptomatic degenerative cuff tears followed until pain development and then managed nonoperatively with continued surveillance. The surgical group consisted of subjects with degenerative tears that failed nonoperative treatment and underwent surgical intervention with a minimum of 2 years follow-up. Outcomes included visual analog scale pain, American Shoulder and Elbow Surgeons, active range of motion, strength, and ultrasonography., Results: There were 83 controls and 65 surgical shoulders. The surgical group was younger at enrollment (58.9 ± 5.3 yr vs. 61.2 ± 7.8 yr, P = .04). The median follow-up for control subjects after pain development was 5.1 years (interquartile range [IQR] 3.6) and the median postoperative follow-up for the surgical group was 3.0 years (IQR 0.2). Baseline tear widths (median 14 mm, IQR 9 vs. 13 mm, IQR 8; P = .45) and tear lengths (median 14 mm, IQR 13 vs. median 11 mm, IQR 8; P = .06) were similar between the surgical group and controls. There were no differences in the baseline prevalence of fatty degeneration of the supraspinatus or infraspinatus muscles between groups (P = .43 and P = .58, respectively). At final follow-up, the surgical group demonstrated significantly lower visual analog scale pain (0 [IQR 2] vs. 3.5 [IQR 4], P = .0002), higher composite American Shoulder and Elbow Surgeons (95 [IQR 13] vs. 65.8 [IQR 32], P = .0002), and activities of daily living scores (29 [IQR 4] vs. 22 [IQR 8], P = .0002), greater abduction strength (69.6 N [standard deviation {SD} 29] vs. 35.9 N [SD 29], P = .0002), greater active forward elevation (155° [SD 8] vs. 142° [SD 28], P = .002), greater active external rotation in abduction (mean 98.5°, SD 12 vs. mean 78.2°, SD 20; P = .0002) compared to controls. Additionally, the prevalence of fatty muscle degeneration was lower in the surgical group for the supraspinatus and infraspinatus (25% vs. 41%, P = .05; 17% vs. 34%, P = .03; respectively)., Conclusion: This prospective longitudinal study comparing a surgical cohort undergoing rotator cuff repair with a control group treated nonoperatively supports the notion that surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease. Patients in the surgical group demonstrated clinically relevant differences in pain and functional outcomes. Surgical intervention was protective against progressive muscle degeneration compared to nonoperative treatment., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Total elbow arthroplasty (TEA) remains a valuable tool for treating inflammatory, degenerative, and traumatic elbow conditions. This study aimed to understand the incidence of and risk factors for reoperation following TEA at a high-volume center utilizing an implant with a convertible linkage and the potential for anatomic lateral column reconstruction., Methods: All patients undergoing primary TEA with the Latitude prosthesis (Stryker) from July 2001 to May 2020 were identified. Patient characteristics, the surgical indication, and implant characteristics were obtained. Additionally, the indications and timing were identified for reoperations. Postoperative radiographs were analyzed to assess cement quality, implant position, lateral column reconstruction, and distal humeral bone loss., Results: Two hundred and nineteen TEAs were performed in 206 patients; 162 (74.0%) were in female patients, the mean patient age was 61 years (range, 23 to 95 years), and the mean follow-up was 11.8 years (range, 2 to 21 years). The most common indication for surgery was sequelae of trauma (36%). Ninety elbows (41.1%) required 200 reoperations at a mean of 19.6 months. Forty TEAs (18.3%) required revision of nonmodular implants, with 14 (6.4%) undergoing definitive explantation. The 5 and 10-year survivorship was 86.1% and 79.7%, respectively. The most common of the reasons for revision was aseptic loosening (53.8%), and the most common cause for non-revision reoperation was infection (23%). Younger age and greater follow-up duration were associated with greater revision and reoperation risks. Aseptic ulnar loosening was associated with a short ulnar stem length and component linkage (30% of short linked ulnar stems loosened; p < 0.001). Aseptic humeral loosening was associated with less-than-adequate cement-mantle quality (p = 0.04)., Conclusions: Extended follow-up of the Latitude prosthesis at a high-volume center demonstrates that TEA continues to be hampered by a high reoperation rate, primarily due to infection and aseptic loosening. Technical factors such as good cement-mantle quality, longer stem length, and unlinked implants may play a role in preventing aseptic loosening. Further work is required to optimize long-term outcomes following TEA through improved understanding of appropriate surgical indications, techniques, and implant utilization., Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I63 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

For atraumatic rotator cuff tears, genetics contributes to symptomatic tear risk and may influence rotator cuff healing after surgical repair. But little is known about how genetic factors influence rotator cuff tear patient characteristics at presentation. We collected saliva samples for genotyping from atraumatic rotator cuff tear patients. We examined nine single nucleotide polymorphisms (SNPs) associated with cuff tears in prior literature. We estimated associations of SNP dosage with (1) age at tear diagnosis, (2) bilateral atraumatic tear prevalence, and (3) tear size. Linear regression was used to estimate associations with diagnosis age adjusted for sex and principal components. Logistic regression and ordinal logistic regression were used to estimate associations with bilateral tear prevalence and tear size category, respectively, adjusting for age, sex, and principal components. Of 344 eligible patients, 336 provided sufficient samples for genotyping. Median age at tear diagnosis was 61, 22% (N = 74) had bilateral atraumatic tears, and 9% (N = 29) had massive tears. SNP rs13107325 in the SLC39A8 gene and rs11850957 in the STXBP6 gene were associated with younger diagnosis age even after accounting for multiple comparisons (rs13107325: -4 years, 95% CI = -6.5, -1.4; rs11850957: -2.7 years, 95% CI = -4.3, -1.1). No other significant associations were observed with diagnosis age, tear size, or bilateral tear prevalence. SLC39A8 encodes a Mn transporter. STXBP6 may play a role in inflammatory responses by altering phagocytosis and antigen presentation of monocytes and macrophages. Further research is needed to determine if genetic markers can be used alongside patient characteristics to aid in identifying optimal surgical repair candidates., (© 2023 Orthopaedic Research Society.)

Background: The prevalence of failed reverse total shoulder arthroplasty (rTSA) is increasing. This can often present a challenging clinical situation with substantial bone loss and limited reconstruction options. This study reports a single tertiary referral center's experience with revision of failed rTSA managed with revision rTSA of bone-interfacing components., Methods: After institutional review board approval, all revision shoulder arthroplasty cases performed at a single institution between 2012 and 2020 were reviewed. Cases in which rTSA was revised to a new rTSA construct with revision of at least 1 bone-interfacing implant (humeral stem and/or baseplate) with a minimum 2-year follow-up were identified. Characteristics of revision cases-including indications, bony stock, revised components, and use of bone graft-were collected. All patients were contacted for patient-reported outcome measures at a minimum of 2 years after surgery. In addition, the incidence and indication for any reoperation after revision were determined., Results: Thirty-three patients with an average age of 66 years (range: 46-82 years), with 19 (58%) being female, met the inclusion criteria and had a mean follow-up of 4.2 years (range: 2-8 years). The most common indication for revision rTSA included humeral component loosening (33%; 11/33), baseplate loosening (27%; 9/33), and instability (21%; 7/33). Prerevision infectious workup demonstrated no cases of periprosthetic shoulder infection. Thirteen cases had massive bone loss-5 treated with humeral allograft prosthetic composite, 5 with glenoid bone grafting, and 3 with custom glenoid implant. In total, 10 of 33 cases (30%) required reoperation at a mean of 13 months (range: 1-44 months) for instability (4), humeral loosening (2), infection (1), baseplate loosening (1), or periprosthetic fracture (1). The reoperation rate for patients with revised baseplates only, humerus only, or combined was 23% (3/13), 28% (5/18), and 27% (3/11), respectively. Overall, the visual analog scale pain score improved from 6.5 preoperatively to 2.0 (P < .001), and the American Shoulder and Elbow Surgeons score improved from 30.7 to 67.5 (P < .001). However, the postoperative Single Assessment Numeric Evaluation score averaged only 51.2% (range: 2-100%)., Conclusion: This study demonstrates that failed rTSA can be salvaged with a revision rTSA. However, patient expectations for functional improvements should be tempered, and a high reoperation rate should be expected., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Prior rotator cuff disease natural history studies have focused on tear-related factors that predict disease progression within a given shoulder. The purpose of this study was to examine both patient- and tear-related characteristics of a painful rotator cuff tear that predict future pain development and functional impairment in a shoulder with a contralateral asymptomatic cuff tear., Methods: This was a prospective longitudinal cohort study of patients aged ≤65 years who underwent surgery for a painful degenerative rotator cuff tear and possessed an asymptomatic contralateral tear. Patients were followed up prospectively by shoulder ultrasound, physical examination, and functional score assessment. The primary outcome was change in the American Shoulder and Elbow Surgeons (ASES) score at 2 years. Secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, Patient-Reported Outcomes Measurement Information System (PROMIS) score, Hospital Anxiety Depression Scale (HADS) depression and anxiety scores, and Veterans RAND-12 (VR-12) mental component score (MCS)., Results: Sixty-five patients were included, with a mean follow-up period of 37 months (range, 24-42 months). In 17 patients (26%), contralateral shoulder pain developed at a median of 15.2 months (interquartile range [IQR], 10.5 months). No difference in age, sex, Charlson Comorbidity Index, or occupational demand was noted between patients in whom pain developed and those in whom pain did not develop. In the presenting painful shoulder, there was no difference in baseline tear size, muscle degeneration, or biceps pathology between groups. The mean baseline tear length (8.6 mm vs. 3.8 mm, P = .0008) and width (8.4 mm vs. 3.2 mm, P = .0004) were larger in asymptomatic shoulders in which pain subsequently developed compared with those in which pain did not develop. However, there was no difference in mean tear enlargement (P = .51 for length and P = .90 for width). There were no differences in baseline ASES, WORC, Patient-Reported Outcomes Measurement Information System (PROMIS), or HADS depression and anxiety scores between shoulders in which pain developed and those in which pain did not develop; however, patients in whom pain developed reported a lower baseline VR-12 MCS (53.3 vs. 57.6, P = .04). Shoulders in which pain developed had higher visual analog scale pain scores (2.9 [standard deviation (SD), 2.5] vs. 0.6 [SD, 1.0]; P = .016), lower ASES scores 75 [SD, 33] vs. 100 [SD, 11.6]; P = .001), and significant changes in all WORC scales with pain onset compared with those that remained asymptomatic. The study showed no significant difference in changes in the HADS anxiety and depression scores but found a significant increase in the VR-12 MCS in patients in whom pain developed (7.1 [interquartile range, 12.6] vs. -1.9 [interquartile range, 8.7]; P = .036)., Conclusion: In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. Our analysis showed that only the baseline tear size of the asymptomatic shoulder was predictive of pain development. There were no tear-related features of the presenting painful rotator cuff tear or indices of mental health and physical function or occupational demand that were predictive of future pain development at short-term follow-up., (Copyright © 2023. Published by Elsevier Inc.)

Background: The purpose of this prospective study is to describe the mid- to long-term natural history of untreated asymptomatic degenerative rotator cuff tears in patients 65 years and younger., Methods: Subjects with an asymptomatic rotator cuff tear in one shoulder and a contralateral painful cuff tear aged 65 years or younger were enrolled in a previously described prospective longitudinal study. Annual physical and ultrasonographic evaluations and surveillance for pain development were performed using independent examiners for the asymptomatic shoulder., Results: Two hundred twenty-nine participants (mean age 57.1 years) were followed for a median of 7.1 (range 0.3-13.1) years. Tear enlargement occurred in 138 (60%) shoulders. Full-thickness tears were at greater risk for enlargement compared with partial-thickness (hazard ratio [HR] 2.93, 95% confidence interval [CI] 1.71-5.03, P < .0001) and control shoulders (HR 18.8, 95% CI 4.63-76.1, P < .0001). Mean survival rates from Kaplan-Meier analyses indicate that full-thickness tears enlarged earlier (mean 4.7, 95% CI 4.1-5.2 years) than partial-thickness (mean 7.4, 95% CI 6.2-8.5 years) and control shoulders (mean 9.7, 95% CI 9.0-10.4 years). Tear presence in the dominant shoulder was associated with a greater enlargement risk (HR 1.70, 95% CI 1.21-1.39, P = .002). Patient age (P = .37) and gender (P = .74) were not associated with tear enlargement. The 2-, 5-, and 8-year survivorship free of tear enlargement for full-thickness tears was 74%, 42%, and 20%, respectively. Shoulder pain developed in 131 (57%) shoulders. Pain development was associated with tear enlargement (HR 1.79, 95% CI 1.24-2.58, P = .002) and was more common in full-thickness tears compared with controls (P = .0003) and partial tears (P = .01). An analysis of progression of muscle degeneration was performed in 138 shoulders with full-thickness tears. Tear enlargement was seen in 104 of 138 (75%) of these shoulders during follow-up (median 7.7 [interquartile range 6.0] years). Progression of muscle fatty degeneration was seen in the supraspinatus in 46 (33%) and the infraspinatus in 40 (29%) shoulders. Adjusting for age, both the presence of fatty muscle degeneration and the progression of muscle changes for both the supraspinatus (P < .0001) and infraspinatus (P < .0001) muscles were associated with tear size. For both the supraspinatus (P = .03) and infraspinatus (P = .03) muscles, tear enlargement was significantly associated with progression of muscle fatty degeneration. Anterior cable integrity was significantly associated with the risk of muscle degeneration progression for both the supraspinatus (P < .0001) and the infraspinatus (P = .005) muscles., Conclusions: Asymptomatic degenerative rotator cuff tears progress in patient 65 years and younger. Full-thickness rotator cuff tears have a higher risk of continued tear enlargement, progression of fatty muscle degeneration, and pain development than partial-thickness tears., (Copyright © 2023. Published by Elsevier Inc.)

Background: The management of Walch B2 glenoid deformities in primary glenohumeral osteoarthritis is frequently debated. Previous literature has shown that the treatment of B2 glenoids with high-side reaming and anatomic total shoulder arthroplasty (aTSA) perform well in the short-term but is associated with an increased glenoid component failure rate in severe deformities. Therefore, many have explored alternative options, including augmented anatomic glenoid components and reverse shoulder arthroplasty. Our goal in this study is to provide mid-term radiographic and clinical outcomes after high-side reaming and aTSA for B2 glenoids., Methods: Patients were followed both clinically and radiographically. Preoperative computed tomography scans were used for retrospective analysis of deformity. Both preoperative and postoperative visual analog scale pain, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test scores were collected. Radiographs were analyzed preoperatively and postoperatively for humeral head decentering relative to the glenoid vault, immediate glenoid seating, and final glenoid peg radiolucency., Results: Of the original cohort of 59 patients (6 now deceased) reported at a mean radiographic follow-up of 3.4 years, 34 shoulders in 33 patients with B2 glenoids (mean retroversion 18.9°, range 4°-32°) were available for follow-up at a mean of 8.6 years (range 5.5-11.2) after high-side glenoid reaming with aTSA. Three (5.1%) of the original 59 shoulder were revised. At final follow-up, 3 of 30 (10.0%) shoulders had radiographic glenoid component failure, but were unrevised. Glenoid component failure was associated with worse initial glenoid component seating (mean Lazarus score 1.2 vs. 2.0, P = .002). Glenoid failure was also associated with increased posterior humeral head subluxation at 2-4 year follow-up (mean 5.6% vs. 12.6%, P = .045) and at final follow-up (mean 7.0% vs. 21%, P = .002). There was no association between glenoid component failure and preoperative retroversion, inclination, or humeral head subluxation (all P > .05). Glenoid component failure was associated with worse American Shoulder and Elbow Surgeons (88 vs. 73) and visual analog scale pain (0.8 vs. 2.1) scores (both P = .03)., Conclusions: At a mean of 8.6 years, 88% of shoulders available for follow-up had well-fixed glenoid components. Glenoid component failure was associated with poor initial glenoid component seating, with failed components having an average of 25% of the glenoid component not seated. Preoperative deformity such as glenoid retroversion, inclination, or humeral head subluxation did not predict glenoid component failure. This study supports that initial glenoid component seating and recurrence of posterior humeral head subluxation may be the most important factors for mid-term glenoid component survival in aTSA in patients with B2 glenoids., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity., Methods: This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again., Results: In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again., Discussion: Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Shoulder instability can occur in any direction and presents across a broad spectrum including traumatic dislocations, repetitive microinstability events or subluxations, and global joint laxity. The development of pain, functional decline, and articular pathologic condition is a multifaceted process that is influenced by the underlying bony morphology, biology of the surrounding soft tissue structures, dynamic coordination of the periscapular musculature, and patient factors such as age, activity level, and associated injuries. This article will focus on the younger, active patient with instability due to deficiencies in the capsulolabral complex and dynamic stabilizers., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To compare range of motion (ROM) and patient-reported outcomes (PROs) between a structured home exercise program (HEP) and active, supervised physiotherapy (PT) after primary Reverse total shoulder arthroplasty (RTSA) by performing a multicenter randomized clinical trial., Methods: Patients undergoing primary RTSA at 2 centers were randomized to either a HEP group, in which they were given a handout and a rope pulley, or a PT group, in which they were given a standardized prescription. Surgical technique and implants were standardized. At baseline, 6 weeks, 3 months, and 1 year postoperatively, we obtained American Shoulder and Elbow Surgeons scores, Western Ontario Osteoarthritis Scores, visual analogue scale for pain scores, and measured ROM via videotape. On video, ROM was then measured by blinded observers. At all study visits, patients were asked how many days per week they were in PT and how many days a week they completed HEP to determine compliance and crossover. An a priori power analysis suggested 29 patients per group, 56 patients total to detect a difference of 30° in active forward elevation with a power of 0.8 at a 2-sided alpha of 0.05., Results: 89 patients were randomized, 43 to PT, and 46 to HEP. We obtained 1-year PRO follow-up on 83 patients (93%) and ROM follow-up on 73 patients (82%). Nine patients (20%) crossed over from HEP to PT and 2 patients (4%) crossed over from PT to HEP. Complications occurred in 13% of HEP and 17% of PT patients (P = .629). Using mixed models that account for baseline values, there were no significant differences between groups in PROs or ROM at final follow-up., Conclusion: In this 2-center, randomized clinical trial, there were no significant differences in patient outcomes or ROM between HEP and PT after RTSA. These findings suggest that it may not be necessary to recommend PT as a protocol for all patients after RTSA., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Reverse total shoulder arthroplasty (RTSA) has been well-described as a surgical solution to manage rotator cuff tear arthropathy in elderly, low demand paitents. As experience has increased along with improvements in technique and implant design, RTSA has become increasingly used to manage more varied pathologic conditions of the shoulder in younger, more active patients. This study evaluates outcomes in a consecutive series of patients aged 60 years old and younger after undergoing RTSA., Methods: There were 94 shoulders in 89 patients enrolled. Mean age of the cohort was 54.8 (range 18-60 years). Surgical indications included rotator cuff tear arthropathy, irreparable rotator cuff tear without arthritis, glenohumeral arthritis with erosive glenoid deformity, inflammatory arthropathy, proximal humerus fracture nonunion/malunion and failed prior shoulder arthroplasty. Sixty-one shoulders (70%) had undergone at least one prior surgery. Of these, 6 shoulders (6% of total cohort) had a prior failed arthroplasty. Clinical outcomes (American Shoulder and Elbow Surgeons score, Western Ontario Osteoarthritis of the Shoulder index; visual analog scale pain), radiographic outcomes and complications were analyzed and assessed for correlation with patient demographic factors., Results: The mean follow-up for this cohort was 4.9 years (range 2-12 years). Subjects experienced improvements in ASES score and pain ( P  < .001) and active forward elevation (88° preop to 135° postop, P  < .001). Prior operation correlated with worse postoperative ASES and WOOS scores. Higher demand occupation correlated with less improvement in pain scores. The overall complication rate was 12%. Seven shoulders (7%) underwent an additional procedure. There was a 2% incidence of dislocation and a 4% incidence of acromial stress fracture. There was a 36% incidence of notching., Conclusion: With medium-term follow-up, RTSA is a reliable and predictable operation to manage various pathologic conditions in patients aged 60 years or less. Patients predictably experience significant improvements in pain and range of motion while assuming a modest complication risk. Long-term study is needed to understand potential for late complications or implant failure., (© 2023 The Author(s).)

Objectives: Physically-demanding occupations may increase rotator cuff disease (RCD) risk and need for surgery. We linked a job-exposure matrix (JEM) to the UK Biobank cohort study to measure physical occupational exposures and estimate associations with RCD surgery., Methods: Jobs and UK Standard Occupational Classification (SOC) codes were recorded during the UK Biobank verbal interview. Lifetime job histories were captured through a web-based survey. UK SOC codes were linked to a JEM based on the US O*NET database. O*NET-based scores [static strength, dynamic strength, general physical activities, handling/moving objects (range=1-7), time spent using hands, whole body vibration, and cramped/awkward positions (range=1-5)] were assigned to jobs. RCD surgeries were identified through linked national hospital inpatient records. Multivariable Cox regression was used to calculate hazard ratios (HR) as estimates of associations with RCD surgery. Among those with lifetime job histories, associations were estimated for duration of time with greatest exposure (top quartile of exposure)., Results: Of 277 808 people reporting jobs, 1997 (0.7%) had an inpatient RCD surgery. After adjusting for age, sex, race, education, area deprivation, and body mass index, all O*NET variables considered were associated with RCD surgery (HR per point increase range=1.10-1.45, all P<0.005). A total of 100 929 people reported lifetime job histories, in which greater exposures were significantly associated with RCD surgery after >10 years of work (eg, HR for 11-20 versus 0 years with static strength score ≥4 = 2.06, 95% confidence interval 1.39-3.04)., Conclusions: Workplace physical demands are an important risk factor for RCD surgery, particularly for workers with more than a decade of exposure.

Objectives: Internal rotation (IR) remains unpredictable following reverse total shoulder arthroplasty (rTSA). This study aimed to determine if increasing IR limits range of motion in other planes, and to determine pre- and intra-operative factors associated with post-operative IR., Methods: A retrospective analysis of a single surgeon's primary rTSA with a single implant was undertaken, excluding patients with acute fracture or infection. A lesser tuberosity osteotomy (LTO) or subscapularis peel tenotomy was performed and repaired at the surgeon's discretion. One hundred sixty rTSA were included; 142 (88.8%) had documented IR both pre-operatively and at one-year follow-up. Variables were collected to determine their effect on IR at the 1-year follow-up point. A multivariate logistic regression was used to determine independent predictors of sufficient IR., Results: Average age was 69.8 (range: 55-86) years and 55% (88/160) were female. Preoperatively, 20.4% of patients (29/142) had sufficient IR. This improved to 32.4% (46/142) one year following surgery, p<0.001). Factors associated with sufficient post-operative IR were female sex (p=0.05), decreasing body mass index (p=0.04), pre-operative IR (p=0.01), preoperative external rotation (ER) in adduction (p<0.001), radiographic evidence of LTO healing (p=0.02), increased one-year postoperative forward elevation (p<0.001), and increased one-year postoperative ER (p<0.001). Increased postoperative IR did not adversely affect forward elevation or ER. On multivariate analysis, higher preoperative IR and one-year postoperative forward elevation were independently associated with sufficient one-year postoperative IR., Conclusion: IR following rTSA continues to be modest and unpredictable. Independent predictors of sufficient post-operative internal rotation were higher preoperative IR and one-year postoperative forward elevation. In a Grammont-style rTSA system, humeral version, glenosphere lateralization, and glenosphere size do not appear to impact IR. Importantly, achieving sufficient IR does not come at the expense of other planes of motion., Competing Interests: Jay D. Keener MD receives research support from National Institute of Health, is a consultant for Shoulder Innovations and Wright Medical, receives royalties from Shoulder Innovations and Wright Medical, is an assistant editor of the Journal of Shoulder and Elbow Surgery, and is associated editor of Seminars in Shoulder Arthroplasty: JSES Benjamin Zmistowski MD is a consultant for Zimmer Biomet.

Reverse shoulder arthroplasty has become the predominant shoulder arthroplasty procedure. Despite newer design modifications, complications still occur after reverse shoulder arthroplasty. Early complications include instability, acromial and scapular spine stress fractures, periprosthetic fractures, periprosthetic joint infections, and neurologic injury. It is important to discuss the diagnosis and management of these early complications.

Reverse total shoulder arthroplasty implantation has increased dramatically over the past 4 decades since it was first introduced in France in 1985. It has greatly improved the ability to treat patients with cuff tear arthropathy, proximal humeral fractures, and osteoarthritis with severe bone loss. However, with the increased implementation of reverse total shoulder arthroplasty, there has been a corresponding rise in complications. Five of the most common complications following reverse total shoulder arthroplasty are instability, scapular fractures, periprosthetic humeral fractures, glenoid baseplate loosening, and infection.

Background: Evidence is building that a functional subscapularis improves function-specifically internal rotation tasks-following reverse total shoulder arthroplasty (rTSA). However, the optimal method for subscapularis repair during rTSA remains unknown with variable healing rates reported. This study aims to investigate the rate of and predictors for healing a lesser tuberosity osteotomy (LTO) following rTSA., Methods: Following local institutional review board approval, patients with at least one-year follow-up for rTSA managed with an LTO and subsequent repair between March, 2017 and March, 2020 were retrospectively identified. Shoulders were selected for LTO repair based upon preoperative imaging and intraoperative assessment of subscapularis quality. All patients were implanted with a system consisting of a 150° or 155° (constrained) humeral neck-shaft angle and 2.5 to 4.5 millimeters (mm) of glenoid lateralization (Trabecular Metal Reverse Shoulder System; Zimmer Biomet, Warsaw, IN, USA). At a minimum of six months, radiographs were reviewed for an assessment of LTO healing by three independent reviewers. Healing was classified as displaced, fibrous union, or ossified union. For assessing predictors, the repair was considered intact if the LTO fragment was not displaced (fibrous union or ossified union)., Results: Sixty-five rTSA with LTO repair were performed in 64 patients. These patients had an average age of 67.2 years (range, 31-81) and 36 (55.4%; 36/65) were female. At an average follow-up of 15.2 months (range, 8-38), 50 cases (76.9%; 50/65) were classified as having an ossified union. The radiographic healing could not be assessed in a single case. Of the 14 cases without ossific union, 8 (12.3%; 8/65) were displaced and 6 (9.2%; 6/65) were classified as a fibrous union. In logistic regression, only combined humeral liner height predicted LTO displacement (odds ratio = 1.4 [95% confidence interval = 1.1-1.8]; P  = .01). Humeral loosening was not found in any cases following LTO., Conclusion: This analysis demonstrates that radiographic healing of LTO repair is more favorable than published rates of healing after subscapularis tenotomy or peel in the setting of rTSA. Subscapularis management with LTO provides the ability to monitor repair integrity with plain radiographs and a predictable radiographic healing rate. The integrity of subscapularis repair may be influenced by the use of thicker humeral liners. Further investigation is needed to determine the functional impact of a healed subscapularis following rTSA.

Introduction: The rate of aseptic humeral component loosening with standard-length stems is historically so low (0.3%) that presence of humeral loosening was given substantial weight in defining periprosthetic shoulder infection by the International Consensus Meeting (ICM) in 2018. This study aims to confirm that the historically low rate of humeral stem aseptic loosening is not affected by the adoption of a novel short humeral stem., Methods: Following institutional review board approval, this retrospective multi-institutional study was undertaken. A review of anatomic total shoulder arthroplasty (TSA) cases at 3 institutions provided 184 shoulders that received TSA with a grit-blasted, rectangular short humeral stem without ingrowth coating (Univers Apex; Arthrex). The average patient age was 62.1 years (range: 30-84), and 57.1% (105/184) were male. One-year radiographic follow-up was achieved in 64.7%. Patient clinical charts were reviewed for onset of newly painful shoulders, radiographic evidence of loosening, and return to the operating room for any reason. All patients with concern for clinically significant humeral loosening underwent workup for periprosthetic shoulder infection. Immediate postoperative films were reviewed to identify any differences in prosthetic canal fit. The definition of periprosthetic shoulder infection used was provided by the recent ICM shoulder guidelines., Results: Twenty-three (12.5%) patients presented with a painful shoulder and radiographic concern for potential humeral loosening at a mean follow-up of 1.5 years (range: 1.5 months-3.4 years). Thirteen (7.1%) of these underwent revision shoulder arthroplasty where a loose stem was confirmed. All revisions underwent tissue culture, and 3 cases were consistent with probable or possible periprosthetic infection at the time of revision arthroplasty. The rate of symptomatic aseptic humeral loosening in this series was 10.9% (20/184), with 5.4% undergoing revision surgery. Patients with symptomatic aseptic humeral loosening were more likely to be male (90.5%) than those patients without symptoms (52.8%, P < .001). There were no differences in canal fit between patients with concern for symptomatic loosening and those with pain-free, stable implants., Conclusion: In this multisurgeon, multicenter study, the early humeral loosening rate for this stem design far outpaces previously reported rates, and this study likely under-reports the true incidence of clinically significant loosening as it only contains limited short-term follow-up. The perception that humeral loosening is nearly pathognomonic for periprosthetic shoulder infection should be reconsidered for certain short humeral stem designs., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Prior US studies have shown increasing rotator cuff repair rates through 2009. We hypothesize that rotator cuff repair rates are continuing to increase and the comorbidity profiles of patients are becoming more complex over time., Methods: We identified rotator cuff repairs in a large US cohort of people 18-64 years of age with ≥1 year of commercial insurance coverage. Repair rate trends across time were standardized by age, sex, and geographic region. Procedures were categorized as inpatient vs. outpatient and as arthroscopic vs. open. Prevalent comorbidities were defined as 1 inpatient diagnosis claim or 2 outpatient diagnosis claims during the year before rotator cuff repair. General population comorbidity prevalence was determined based on a random 5% sample of the commercially insured population and compared with patients with rotator cuff repair using standardized morbidity ratios., Results: From 2007 to 2016, 314,239 rotator cuff repairs were identified (165 repairs per 100,000 person-years). Rotator cuff repairs were performed more frequently in men, older people, and in the Midwest. Across time, cuff repair rates increased by 1.6% per year (95% confidence interval [CI] = +1.4%-1.7%) adjusting for demographics. The highest increases in repair rates were observed among patients aged 50-64 years (+2.0%, 95% CI = +1.8%-2.2%). Rotator cuff repairs were more frequently performed using an arthroscopic approach and in an outpatient setting in later calendar years. In 2016, 83% of rotator cuff repairs were arthroscopic procedures and 99% were performed as outpatient procedures. Comorbidity prevalence in rotator cuff repair patients increased across calendar time by 4.5% per year for hypertension (95% CI = +4.2%-4.7%), 2.3% per year for diabetes (+1.9%-2.7%), 0.9% per year for hypercholesterolemia (+0.3%-1.5%), 2.9% for congestive heart failure (+0.8%-4.9%), 4.2% for peripheral vascular disease (+2.4%-6.0%), and 4.2% for chronic pulmonary disease (+3.6%-4.8%). Comorbidity prevalence in repair patients was higher than prevalence in the general population, and prevalence relative to the general population was most heightened during later calendar years. For example, hypertension prevalence was 1.58 times higher in repair patients than the general population in 2007 (95% CI = 1.53-1.62), and 2.06 times higher in 2016 (95% CI = 2.02-2.11)., Conclusion: Rotator cuff repair is becoming more frequent in the US commercially insured population, particularly in those 50-64 years of age. More rotator cuff repairs are being performed using an arthroscopic approach and in an outpatient setting. Over time, the comorbidity profile of patients undergoing rotator cuff repair is becoming more complex with greater prevalence of numerous conditions, including hypertension, peripheral vascular disease, and chronic pulmonary disease.

Background: While evidence indicates that familial predisposition influences the risk of developing degenerative rotator cuff disease (RCD), knowledge of specific genetic markers is limited. We conducted a genome-wide association study of RCD surgery using the UK Biobank, a prospective cohort of 500,000 people (40 to 69 years of age at enrollment) with genotype data., Methods: Cases with surgery for degenerative RCD were identified using linked hospital records. The cases were defined as an International Classification of Diseases, Tenth Revision (ICD-10) code of M75.1 determined by a trauma/orthopaedic specialist and surgery consistent with RCD treatment. Cases were excluded if a diagnosis of traumatic injury had been made during the same hospital visit. For each case, up to 5 controls matched by age, sex, and follow-up time were chosen from the UK Biobank. Analyses were limited to European-ancestry individuals who were not third-degree or closer relations. We used logistic regression to test for genetic association of 674,405 typed and >10 million imputed markers, after adjusting for age, sex, population principal components, and follow-up., Results: We identified 2,917 RCD surgery cases and 14,158 matched controls. We observed 1 genome-wide significant signal (p < 5 × 10-8) for a novel locus tagged by rs2237352 in the CREB5 gene on chromosome 7 (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.11 to 1.24). The single-nucleotide polymorphism (SNP) rs2237352 was imputed with a high degree of confidence (info score = 0.9847) and is common, with a minor allele frequency of 47%. After expanding the control sample to include additional unmatched non-cases, rs2237352 and another SNP in the CREB5 gene, rs12700903, were genome-wide significant. We did not detect genome-wide significant signals at loci associated with RCD in previous studies., Conclusions: We identified a novel association between a variant in the CREB5 gene and RCD surgery. Validation of this finding in studies with imaging data to confirm diagnoses will be an important next step., Clinical Relevance: Identification of genetic RCD susceptibility markers can guide understanding of biological processes in rotator cuff degeneration and help inform disease risk in the clinical setting., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: E.L.Y. received funding from the National Institutes of Health K01AR073318 and the Orthopaedic Research and Education Foundation/American Society of Shoulder and Elbow Surgeons Rockwood Clinical Research Grant in Shoulder Care. B.A.E. received funding from the U.S. National Institute for Occupational Safety and Health R01 OH011076. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G490)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Despite advances in implant design and surgical technique, instability remains the most common early complication and reason for early revision after reverse shoulder arthroplasty (RSA). The purpose of this study is to evaluate the glenoid implant inclination, as measured by the β-angle, as an independent risk factor for instability after primary RSA., Methods: A retrospective case-control study was conducted matching cases with instability after primary RSA using a single implant to controls without instability. Controls were matched to age, sex, body mass index, and baseplate type (1:3 ratio of cases to controls). The preoperative, postoperative, and the change in pre- to postoperative glenoid inclination (β-angle) were compared between groups., Results: Thirty-four cases (mean age, 66.2 years) were matched to 102 controls (mean age, 67.0 years). There was a wide range of postoperative (63° to 100°) and pre- to postoperative change (-16.5° to +30.5°) in β-angles collectively. There was no significant difference in the postoperative β-angle (mean, 80.8° vs. 82.7°, P = .19) or the change in β-angle (mean, +1.7° vs. +3.4°, P = .35) between cases and controls, respectively. Regression analysis demonstrated no increased odds of instability with the postoperative β-angle, odds ratio 0.965 (confidence interval [CI] = 0.916-1.02, P = .19). Likewise, for the preoperative to postoperative change in β-angle, there was no significantly increased odds of instability, odds ratio 0.978 (CI = 0.934-1.03, P = .35). Finally, there was no difference in risk of instability in patients whose implant positioning resulted in a net superior increase in inclination, relative risk 0.85 (95% CI = 0.46-1.56, P = .28)., Conclusions: Neither the final prosthetic glenoid inclination nor the change in glenoid inclination, as measured by the β-angle, significantly influences the risk of prosthetic instability after primary RSA., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Restoration of muscular strength is predicated on restoration of muscle length. The purpose of this study was to describe infraspinatus and deltoid length preoperative to reverse total shoulder arthroplasty (RTSA) to guide distalization and lateralization to restore preoperative muscle length., Methods: This was a retrospective radiographic study. We measured the infraspinatus length on preoperative computed tomographic images and the deltoid length on preoperative radiographs. For all measurements, reliability was first established by comparing measurements between 2 observers, and intraclass correlation coefficients (ICCs) were calculated. We then calculated descriptive statistics for these muscle lengths and developed a formula to predict these muscle lengths from patient demographics., Results: We measured infraspinatus length in 97 patients and deltoid length in 108 patients. Inter-rater reliability was excellent, with all ICCs >0.886. The mean infraspinatus length was 15.5 cm (standard deviation 1.3) and ranged from 12.6-18.9 cm, whereas the deltoid length was 16.2±1.7 cm and ranged from 12.5-20.2 cm. Both infraspinatus (r = 0.775, P < .001) and deltoid length (r = 0.717, P < .001) were highly correlated with patient height but did not differ between diagnoses. Formulae developed through linear regression allowed prediction of muscle length to within 1 cm in 78% and within 2 cm in 100% for the infraspinatus and 60% and 88% for the deltoid., Conclusion: Deltoid and infraspinatus length are variable but highly correlated with patient height. To maintain tension, 2 mm of lateralization and distalization should be added for every 6 inches (∼15 cm) of height above average for a Grammont-style RTSA., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: To address severe posterior subluxation associated with the Walch B2 glenoid deformity, the eccentricity of the prosthetic humeral head can be reversed, allowing the humerus to remain in a relatively posterior position while the prosthetic humeral head remains well-centered on the glenoid. This study describes the short-term outcomes after anatomic total shoulder arthroplasty (TSA) using this technique., Methods: We retrospectively reviewed a consecutive series of patients with a B2 glenoid who underwent TSA with the prosthetic eccentric humeral head rotated anteriorly for excessive posterior subluxation noted intraoperatively. Medical records were reviewed for visual analog scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Simple Shoulder Test (SST) scores. Final radiographs were analyzed for instability, lesser tuberosity osteotomy healing, and glenoid loosening., Results: Twenty patients were included with outcome scores at a mean of 48 months. Mean VAS ( P  < .0001), ASES ( P < .0001), and SST ( P < .0001) scores improved significantly. Using the Lazarus classification for glenoid loosening, 5 patients had grade 1 lucency and 2 had grade 2 lucency at a mean of 24 months' follow-up. The remaining 13 patients had no glenoid lucencies. Radiographic decentering was reduced from a mean of 9.9% ± 5.7% preoperatively to 0.5% ± 3.0% postoperatively ( P < .001). There were no cases of lesser tuberosity repair failures or revision surgery., Conclusion: TSA in patients with a B2 glenoid with a reversed, anterior-offset humeral head to address residual posterior subluxation resulted in excellent functional outcomes at short-term follow-up with improvement in humeral head centering. Early radiographic follow-up suggests low risks of progressive glenoid lucencies and component loosening., (© 2020 The Authors.)

Aims: Few risk factors for rotator cuff disease (RCD) and corresponding treatment have been firmly established. The aim of this study was to evaluate the relationship between numerous risk factors and the incidence of surgery for RCD in a large cohort., Methods: A population-based cohort of people aged between 40 and 69 years in the UK (the UK Biobank) was studied. People who underwent surgery for RCD were identified through a link with NHS inpatient records covering a mean of eight years after enrolment. Multivariate Cox proportional hazards regression was used to calculate hazard ratios (HRs) as estimates of associations with surgery for RCD accounting for confounders. The risk factors which were considered included age, sex, race, education, Townsend deprivation index, body mass index (BMI), occupational demands, and exposure to smoking., Results: Of the 421,894 people who were included, 47% were male. The mean age at the time of enrolment was 56 years (40 to 69). A total of 2,156 people were identified who underwent surgery for RCD. Each decade increase in age was associated with a 55% increase in the incidence of RCD surgery (95% confidence interval (CI) 46% to 64%). Male sex, non-white race, lower deprivation score, and higher BMI were significantly associated with a higher risk of surgery for RCD (all p < 0.050). Greater occupational physical demands were significantly associated with higher rates of RCD surgery (HR = 2.1, 1.8, and 1.4 for 'always', 'usually', and 'sometimes' doing heavy manual labour vs 'never', all p < 0.001). Former smokers had significantly higher rates of RCD surgery than those who had never smoked (HR 1.23 (95% CI 1.12 to 1.35), p < 0.001), while current smokers had similar rates to those who had never smoked (HR 0.94 (95% CI 0.80 to 1.11)). Among those who had never smoked, the risk of surgery was higher among those with more than one household member who smoked (HR 1.78 (95% CI 1.08 to 2.92)). The risk of RCD surgery was not significantly related to other measurements of secondhand smoking., Conclusion: Many factors were independently associated with surgery for RCD, including older age, male sex, higher BMI, lower deprivation score, and higher occupational physical demands. Several of the risk factors which were identified are modifiable, suggesting that the healthcare burden of RCD might be reduced through the pursuit of public health goals, such as reducing obesity and modifying occupational demands. Cite this article: Bone Joint J 2020;102-B(3):352-359.

Introduction: As the indications for reverse shoulder arthroplasty (RSA) expand beyond traditional cuff tear arthropathy, the role of RSA in elderly patients with glenohumeral arthritis and an intact rotator cuff remains unclear., Methods: This retrospective cohort study included 135 patients who underwent RSA or total shoulder arthroplasty (TSA) at a single tertiary orthopedic center between 2005 and 2015 and were 70 years of age or older at the time of surgery. All patients had preoperative advanced imaging confirming an intact rotator cuff but active forward elevation less than 90°. Complications, reoperations, and patient survival were recorded from the medical record. Patient-reported outcomes (Pain visual analog scale, Satisfaction Score, American Shoulder and Elbow Surgeons [ASES], and Western Ontario Osteoarthritis of the Shoulder [WOOS]) and patient-reported range of motion were collected at a minimum of 2 years after procedure., Results: There was no significant difference in complication rate or revision surgery rate between patients undergoing TSA and RSA (complications 13.7% versus 12.1%, P = 0.810; reoperations 6.9% vs 3.0%, P = 0.418). There were no differences in patient-reported outcome measures between the two groups. Mean pain visual analog scale scores were low in both groups (0.72, SD 1.93 for TSA and 0.31, SD 0.72 for RSA). Satisfaction scores were high (86.1, SD 23.3 for TSA and 91.8, SD 9.0 for RSA, P = 0.286). Mean ASES and WOOS scores were also high in both groups (86 [SD 15.6] for TSA and 83 [SD 12.6] for RSA for ASES [P = 0.400] and 86 [SD 18.3] for TSA and 89 [SD 10.2] for RSA for WOOS [P = 0.400]). One hundred percent of subjects following RSA and 98% of subjects following TSA rated their forward elevation as full or nearly full (>135°) (P = 0.516)., Discussion: Given the good clinical outcomes after both TSA and RSA, there may be an increased role for RSA in this elderly cohort to provide effective treatment of glenohumeral osteoarthritis., Level of Evidence: Level III, retrospective comparative study.

Background: The prevalence of subscapularis and long head of biceps (LHB) in relation to the presence and severity of posterosuperior (PS) rotator cuff disease is not known., Methods: Subjects with asymptomatic rotator cuff tears were enrolled for this prospective longitudinal study (n = 354) and followed annually with shoulder ultrasonography and clinical evaluations to assess for the presence of subscapularis, LHB, and PS rotator cuff pathology and pain development., Results: Subscapularis pathology developed in 14% of shoulders over a median follow-up of 5 years, with partial-thickness tearing occurring most commonly (83%). Age, sex, and hand dominance were not associated with subscapularis pathology. A greater proportion of concomitant full-thickness PS cuff tears were observed in shoulders that developed subscapularis tears (76% vs. 50%, P = .002). The PS cuff tear width (10 mm vs. 14 mm, P = .01) at the time of enrollment and both tear width (10 mm vs. 15 mm, P = .003) and length (12 mm vs. 15.5 mm, P = .02) at the time of diagnosis of subscapularis pathology were greater in subscapularis-torn shoulders. LHB pathology was prevalent in 34% of shoulders, with dislocation/subluxation occurring in 63% and higher prevalence in subscapularis-torn shoulders (71% vs. 12%, P < .01). Subscapularis-torn shoulders were more likely to develop pain (67% vs. 45%, P = .004), and concomitant PS cuff tear enlargement was associated with greater risk for pain development (76% vs. 36%, P = .01)., Conclusions: The development of subscapularis and LHB pathology is significantly related to the size of the PS cuff tear. Subscapularis involvement is associated with greater risk of pain development in degenerative rotator cuff disease., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Cutibacterium acnes is the most commonly isolated organism involved in periprosthetic shoulder infections. C acnes has traditionally been difficult to isolate, and much debate exists over appropriate culture methods. Recently, our institution initiated a 10-day culture method using a Brucella blood agar medium to enhance anaerobic growth specifically for C acnes in shoulder specimens., Methods: A retrospective review of shoulder cultures from 2014-2017 of patients undergoing workup for possible infected shoulder arthroplasty was performed. Cultures were obtained in patients either preoperatively or intraoperatively at the time of revision. Presence of infection was determined based on at least 1 positive culture and treatment with either prolonged antibiotics, placement of an antibiotic spacer at the time of revision, or repeat surgical débridement., Results: The records of 85 patients with 136 cultures were reviewed. Eighty-two patients had full records with at least 1-year clinical follow-up. Fifty-eight cultures were positive, with C acnes as the most commonly recovered organism (57% of positive cultures). Clinical follow-up of patients with negative cultures found no incidence of missed periprosthetic infection., Conclusions: Use of a 10-day culture incubation method to enhance anaerobic bacterial growth is able to accurately detect periprosthetic infection in the shoulder including those related to C acnes. Our results suggest that by adopting more uniform culture methods, a shorter culture incubation time may be adequate. Ultimately, prospective studies with rigorous microbiologic methods are needed to best understand the clinical significance of unexpected positive bacterial cultures in shoulder arthroplasty., (© 2020 The Authors.)

Background: Patient pain and clinical function are important factors in decision-making for patients with glenohumeral osteoarthritis (GHOA). The correlation between radiographic severity of arthritis and demographic factors with modern patient-reported outcome measures has not yet been well defined., Methods: This cross-sectional study included 256 shoulders in 246 patients presenting with isolated GHOA. All patients obtained standard radiographs and completed the American Shoulder and Elbow Surgeons score, Simple Shoulder Test (SST), Shoulder Activity Scale, Visual Analog Scale, and Patient-Reported Outcome Measurement Information System (PROMIS) computer adaptive tests at the time of presentation. Radiographs were graded according to the Samilson-Prieto classification. Mean pain and functional scores were compared between the radiographic grades of osteoarthritis (OA) and demographic factors., Results: There were 6 shoulders rated as grade 1 OA, 41 shoulders as grade 2, 149 shoulders as grade 3a, and 65 shoulders as grade 3b. There was excellent interobserver reliability in grade of OA (κ = 0.77). There were no significant differences in patient-reported pain or any validated measure of clinical function between radiographic grades of OA ( P  >   .05). Males reported higher function and lower pain scores than females ( P  =   .001-.066), although only the values for the SST and PROMIS physical function test were clinically relevant., Discussion: While gender correlated with pain and function, the clinical relevance is limited. Radiographic severity of GHOA does not correlate with patient-reported pain and function, and symptoms should remain the primary determinants of surgical decision-making. Further investigation is necessary to examine whether radiographic severity of OA influences improvement following operative intervention in this population., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article. Dr Keener is a paid consultant for Arthrex and Wright Medical, receives research support from the National Institutes of Health and Zimmer/Biomet, receives royalties from Shoulder Innovations and Wright Medical, and is on the editorial staff for the Journal of Shoulder and Elbow Surgery. Dr Chamberlain is a paid consultant for DePuy Synthes, Wright Medical, and Arthrex and received research support from the National Institutes of Health, Zimmer/Biomet, and the Orthopaedic Research and Education Foundation. Dr Aleem, Dr Kohan, Dr Hill, and Dr Lamplot have no conflicts to disclose., (© The Author(s) 2020.)

Introduction: In the setting of the opioid epidemic, physicians continue to scrutinize ways to minimize exposure to narcotic medications. Several studies emphasize improvements in perioperative pain management following total shoulder arthroplasty (TSA). However, there is a paucity of literature describing outpatient narcotic consumption requirements following TSA., Methods: A single-institution, prospective study of patients undergoing primary TSA was performed. Preoperative demographics including exposure to narcotics, smoking history, and alcohol exposure were collected. The primary outcome was measurement of total outpatient narcotic consumption 6 weeks from surgery. Narcotic consumption was verified by counting leftover pills at the final follow-up visit., Results: Overall, 50 patients were enrolled. The median narcotic consumption in the cohort was 193 morphine equivalent units (MEUs), approximately 25 (5-mg) tablets of oxycodone, and the mean consumption was 246 MEUs, approximately 32 (5-mg) tablets. Almost 25% of patients consumed fewer than 10 total tablets, with 10% of patients taking no narcotics at home. Multivariate regression found preoperative narcotic exposure associated with increased consumption of 31 MEUs ( P  = .004). Older age was found to be protective of narcotic consumption, with increasing age by 1 year associated with 0.75 MEU decrease in consumption ( P  = .04)., Conclusions: Anatomic total shoulder arthroplasty in general provides quick, reliable pain relief and does not require a significant amount of narcotic medication postoperatively. For most patients, it is reasonable to prescribe the equivalent of 25-30 (5-mg) oxycodone tablets following TSA., (© 2019 The Authors.)

Background: The patient-related factors for the perceived need for surgery for degenerative rotator cuff tears are not known. The purpose of this study is to examine patient- and tear-specific factors leading to surgery in newly painful degenerative rotator cuff tears., Methods: Asymptomatic, degenerative rotator cuff tears were followed prospectively to identify the onset of pain and tear enlargement. Newly painful tears were continually monitored with a focus on identifying patient-specific (age, occupation, activity level) and tear-specific (tear type and size, tear progression, American Shoulder and Elbow Surgeons score, muscle degeneration) factors that are associated with surgical intervention., Results: Forty-eight of 169 newly painful shoulders were eventually managed surgically. Factors associated with surgical treatment included younger age (P = .0004), pain development earlier in surveillance (P = .0002), a greater increase in pain (P = .0001), a decline in American Shoulder and Elbow Surgeons score (P < .0001), and a history of contralateral shoulder surgery (P = .0006). Eighty-five of the 169 tears (50%) enlarged either before or within 2 years of pain development. Neither tear type (P = .13), tear enlargement (P = .67) nor tear size (P = .51) was associated with surgery. Neither the severity of muscle degeneration, occupational status, hand dominance, Shoulder Activity Score, nor changes in RAND-12 mental or physical scales differed between groups., Discussion: For newly painful rotator cuff tears, patient-specific factors such as younger age and prior surgery on the contralateral shoulder are more predictive of future surgery than tear-specific factors or changes in tear size over time., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Shoulder arthroplasty, especially reverse shoulder arthroplasty (RSA), continues to increase in volume. Limitations in internal rotation can be challenging following RSA. Current patient-reported outcome measures are limited in assessing a patient's functional internal rotation following shoulder arthroplasty. To address this limitation, a questionnaire was developed., Methods: A single-center prospective comparative cohort study was performed to determine the reliability of the questionnaire. A pilot group of patients who had at least 1 year of follow-up following shoulder arthroplasty was asked to complete the questionnaire. Reliability testing was performed using Cronbach's alpha test. Additionally, individual questions and total questionnaire scores were compared between patients who underwent anatomic total shoulder arthroplasty (TSA) and RSA., Results: The questionnaire showed high reliability with all questions. A group of 23 anatomic TSA and 20 RSA patients were compared. RSA patients scored significantly lower on the questionnaire (35.2 out of 50 vs. 43.9, P  = .001)., Conclusion: The questionnaire can be used in conjunction with other patient-reported outcome measures to help surgeons better assess patients' results following shoulder arthroplasty. The initial findings from our internal reliability study found that RSA patients had significantly lower scores and higher variability in internal rotation function vs. patients with TSA. Further studies are needed to determine the clinical importance of this questionnaire., (© 2019 The Author(s).)

Background: Although glenoid morphology has been associated with fatty infiltration of the rotator cuff in arthritic shoulders, the association of rotator cuff muscle area with specific patterns of glenoid wear has not been studied. The purpose of our study was to assess the associations of glenoid deformity in primary glenohumeral osteoarthritis and rotator cuff muscle area., Methods: A retrospective study of 370 computed tomographic (CT) scans of osteoarthritic shoulders was performed. Glenoid deformity according to the modified Walch classification was determined, and retroversion, inclination, and humeral-head subluxation were calculated using automated 3-dimensional software. Rotator cuff muscle area was measured on sagittal CT scan reconstructions. A ratio of the area of the posterior rotator cuff muscles to the subscapularis was calculated to approximate axial plane potential force imbalance. Univariate and multivariate analyses to determine associations with glenoid bone deformity and rotator cuff measurements were performed., Results: Patient age and sex were significantly related to cuff muscle area across glenoid types. Multivariate analysis did not find significant differences in individual rotator cuff cross-sectional areas across glenoid types, with the exception of a larger supraspinatus area in Type-B2 glenoids compared with Type-A glenoids (odds ratio [OR], 1.5; p = 0.04). An increased ratio of the posterior cuff area to the subscapularis area was associated with increased odds of a Type-B2 deformity (OR, 1.3; p = 0.002). Similarly, an increase in this ratio was significantly associated with increased glenoid retroversion (beta = 0.92; p = 0.01) and humeral-head subluxation (beta = 1.48; p = 0.001). Within the Type-B glenoids, only posterior humeral subluxation was related to the ratio of the posterior cuff to the subscapularis (beta = 1.15; p = 0.001)., Conclusions: Age and sex are significantly associated with cuff muscle area in arthritic shoulders. Asymmetric glenoid wear and humeral-head subluxation in osteoarthritis are associated with asymmetric atrophy within the rotator cuff transverse plane. Increased posterior rotator cuff muscle area compared with anterior rotator cuff muscle area is associated with greater posterior glenoid wear and subluxation. It is unclear if the results are causative or associative; further research is required to clarify the relationship., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Walch B2 glenoid is characterized by a biconcave glenoid deformity, acquired glenoid retroversion, and posterior subluxation of the humeral head. Surgical reconstruction of the B2 glenoid is often challenging due to the complexity of the deformity. Bone graft augmentation using humeral head autograft is a valuable adjunct to anatomic total shoulder arthroplasty in the B2 glenoid, particularly in the young, highly active patient with severe glenoid retroversion (>25°-30°). Although this technique affords the ability to correct glenoid version and simultaneously enhances glenoid bone stock, it is technically challenging. The potential for graft-related complications also exists, which may further impact glenoid implant longevity and functional outcome. This review article aims to describe the B2 glenoid morphology, discuss the challenges in managing the B2 deformity, and provide further insight specifically regarding autografting at the time of anatomic total shoulder arthroplasty for reconstruction of the B2 glenoid., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Degenerative rotator cuff tears are the most common cause of shoulder pain and have a strong association with advanced aging. Considerable variation exists in surgeons' perceptions on the recommended treatment of patients with painful rotator cuff tears. Natural history studies have better outlined the risks of tear enlargement, progression of muscle degeneration, and decline in the function over time. This information combined with the known factors potentially influencing the rate of successful tendon healing such as age, tear size, and severity of muscle degenerative changes can be used to better refine appropriate surgical indications. Although conservative treatment can be successful in the management of many of these tears, risks to nonsurgical treatment also exist. The application of natural history data can stratify atraumatic degenerative tears according to the risk of nonsurgical treatment and better identify tears where early surgical intervention should be considered.

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) assessment includes computerized adaptive tests (CATs) that assess function, pain, depression, and anxiety. The influence of mental health on patients' self-reported pain and function has not been explored using PROMIS in patients with symptomatic glenohumeral osteoarthritis., Methods: This cross-sectional study included 284 shoulders in 276 patients presenting with isolated glenohumeral osteoarthritis. All patients completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), Visual Analog Pain Scale (VAS), and PROMIS CATs at the time of presentation. PROMIS anxiety and depression scores were converted into Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 scores, respectively, using the PROsetta Stone "crosswalk" tool. Mean pain and functional scores were compared between patients with and without PROMIS-converted scores corresponding to a diagnosis of anxiety or depression, as well as between scores corresponding to varying degrees of anxiety or depression., Results: Patients with scores corresponding to a diagnosis of anxiety or depression reported lower functional and higher pain scores compared to those with scores in the normal range (P < .001). Analysis of variance showed progressively lower functional and higher pain scores as anxiety severity increased (P < .001). Similar results were seen with ASES, upper extremity CAT, and pain scores as depression severity increased (P < .001). Functional ASES (P = .004), SST (P < .001), and physical function CAT (P = .002) scores were statistically significantly lower in patients with moderate to severe depression than those without depression or with mild depression., Discussion: In patients with glenohumeral osteoarthritis, PROMIS-reported anxiety and depression scores, particularly in those with moderate-to-severe scores, correlate with lower functional and higher pain scores. Further investigation is necessary to examine the influence that mental health has on outcomes after operative intervention in this population., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Humeral bone loss is commonly encountered during revision shoulder arthroplasty and anticipating humeral bone defects can help the revision surgeon make appropriate plans to achieve adequate fixation and stability. No validated classification system exists to characterize humeral bone loss in the setting of revision shoulder arthroplasty., Questions/purposes: The purposes of this study were (1) to create a classification system for humeral bone loss in revision shoulder arthroplasty; (2) to determine the classification system's reliability; and (3) to determine whether humeral bone loss type is associated with intraoperative humeral-related reconstruction characteristics., Methods: This was a comparative retrospective radiographic study. First, six surgeons from five centers collaborated to create a classification by consensus. Second, two surgeons from two other centers who had fellowship training in shoulder and elbow surgery, who were blinded to each other's grades and all patient details other than plain radiographs, and who were not involved in creation of the system, classified true AP, AP, and lateral (axillary and/or scapular-Y) radiographs from 108 revision (413 radiographs) from one center that were performed between November 15, 2006, and January 4, 2018. Interobserver reliability was calculated by comparing those two reviews and determining Cohen's κ. In addition, one reviewer repeated his assessments twice, 4 months apart, to determine intraobserver reliability using Cohen's κ. Third, we performed a retrospective chart study of these same revisions to determine intraoperative humeral-related reconstruction characteristics such as the use of greater tuberosity fixation, stem length, humeral bone grafting, and the use of proximal humeral replacement or total humeral replacement; at the center where these revisions were performed during that timespan, no attempt to classify bone loss was made. During that period, the general indications for greater tuberosity fixation included the absence of a stable osseous connection between the greater tuberosity and the shaft of the humerus with a tuberosity amendable to repair; the general indications for use of longer stems were inability to obtain a minimum of two cortical widths of overlap between the implant and the humeral diaphysis and/or loss of the greater tuberosity; and the general indications for proximal and total humeral replacement were bone loss that was felt to be too severe to allow reconstruction with allograft., Results: The classification system consists of three types of humeral bone loss: Type 1 is loss of the epiphysis with subtypes for loss of the calcar and loss of the greater tuberosity; Type 2 is loss of the metadiaphysis above the deltoid attachment with a subtype for cortical thinning; and Type 3 is bone loss extending below the deltoid attachment with a subtype for cortical thinning. We studied 108 revisions: 38 (35%) without bone loss, 34 (31%) Type 1, 27 (25%) Type 2, and nine (8%) Type 3. For reliability, interrater κ was 0.545 and in 71% (77 of 108) of revisions, the two raters agreed on a numeric type. Intrarater κ was 0.615 and in 77% (83 of 108) of revisions, the rater agreed with himself as to the numeric type. Stem length increased with class type (Type 1 median [range] 130 [70-210], Type 2 150 [70-210], Type 3 190 [70-240], p = 0.005). Most greater tuberosity fixation for intraoperative fracture was in Types 1 and 2 (13 of 18 compared with the five of 18 of greater tuberosity fixation that was within Types 0 and 3, p = 0.043). Most bone grafting was in Types 2 and 3 (eight of 13 compared with five of 13 of bone grafting was in Types 0 and 1, p = 0.044). Most proximal humeral and total humeral replacements were in Type 3 (three of four compared with one of four, p < 0.001)., Conclusions: We developed the Proximal Humeral Arthroplasty Revision Osseous inSufficiency (PHAROS) system, which has adequate, if imperfect, reliability to classify humeral bone loss in the setting of revision shoulder arthroplasty. This classification system may be useful to anticipate the complexity of humeral reconstruction. Further validation incorporating advanced imaging and further evaluators will be necessary., Level of Evidence: Level III, diagnostic study.

Introduction: The purpose of this study was to determine how reverse and total shoulder arthroplasty (RTSA and TSA) comparative utilization, postoperative diagnoses, demographics, and perioperative data have changed between 2005 and 2015., Methods: This was a single-center retrospective review of all primary TSAs and RTSAs., Results: Our cohort included 1,192 RTSAs and 1,600 TSAs. Although both RTSA and TSA volume increased, RTSA increased from 27% to 52% of shoulder arthroplasty. The number of RTSAs performed for osteoarthritis and irreparable rotator cuff tears increased, and the proportion of RTSAs performed for rotator cuff tear arthropathy decreased. The mean age decreased for RTSA and TSA, and American Society of Anesthesiologists scores increased for both., Discussion: Over the past decade, RTSA has become the most common primary shoulder arthroplasty, reflecting the clinical success of the procedure. This increase is due to both an increase in the number of RTSAs performed for rotator cuff tear arthropathy as well as expanding surgical indications for RTSA., Level of Evidence: Retrospective, level IV.

Background: Rotator cuff muscle volume is associated with outcomes after cuff repair and total shoulder arthroplasty. Muscle area on select magnetic resonance imaging (MRI) slices has been shown to be a surrogate for muscle volume. The purpose of this study was to determine whether computed tomography (CT) provides an equivalent measurement of cuff muscle area to a previously validated MRI measurement., Methods: We included 30 patients before they were undergoing total shoulder arthroplasty with both preoperative CT and MRI scans performed within 30 days of one another at 1 institution using a consistent protocol. We reoriented CT sagittal and MRI sagittal T1 series orthogonal to the scapular plane. On both CT and MRI scans, we measured the area of the supraspinatus, infraspinatus-teres minor, and subscapularis on 2 standardized slices as previously described. We calculated intraclass correlation coefficients and mean differences., Results: For the 30 subjects included, when MRI and CT were compared, the mean intraclass correlation coefficients were 0.989 (95% confidence interval [CI], 0.976-0.995) for the supraspinatus, 0.978 (95% CI, 0.954-0.989) for the infraspinatus-teres minor, and 0.977 (95% CI, 0.952-0.989) for the subscapularis. The mean differences were 0.2 cm 2 (95% CI, 0.0-0.4 cm 2 ) for the supraspinatus (P = .052), 0.8 cm 2 (95% CI, 0.1-1.4 cm 2 ) for the infraspinatus-teres minor (P = .029), and -0.3 cm 2 (95% CI, -1.2 to 0.5 cm 2 ) for the subscapularis (P = .407)., Conclusion: CT provides nearly equivalent measures of cuff muscle area to an MRI technique with previously validated reliability and accuracy. While CT underestimates the infraspinatus area as compared with MRI, the difference is less than 1 cm 2 and thus likely clinically insignificant., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)