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Purpose Obesity has been associated with increased perioperative complications following shoulder arthroplasty, though this finding has not been consistently reported. The purpose of this systematic review is to summarize the correlation between elevated body mass index (BMI) and the prevalence of perioperative complications and clinical outcomes following anatomic total shoulder arthroplasty (aTSA). Methods An extensive literature search of PubMed, Embase, ScienceDirect, and Google Scholar was conducted up until October 2020. Clinical studies that specifically examined the association between BMI and/or various categories of obesity with perioperative complications and functional outcomes following aTSA were included. Public databases (NIS, ACS-NSQIP, PearlDiver, and statewide databases) were largely excluded from the analysis unless procedural codes allowed for differentiation between reverse total shoulder arthroplasty (rTSA) and aTSA. Results Eleven studies were included in this systematic review - 9 studies reported solely on perioperative complications, 1 study solely on functional outcomes, and 1 study on both complications and outcomes following aTSA. Seven papers had a MINORS (Methodological Index for Non-Randomized Studies) score of Discussion Increasing BMI was not found to be associated with an elevated risk for the majority of perioperative complications following aTSA. Range of motion and patient reported functional outcomes can be expected to improve, even amongst morbidly obese patients. Level of Evidence Level IV; Review Article

Health literacy is defined as the degree to which an individual obtains and processes basic health information and services so as to make appropriate and informed health decisions. Limited health literacy (LHL), as assessed by various validated instruments, remains prevalent amongst older adult patients, non-Caucasian ethnicities, and those of lower socioeconomic backgrounds. Of concern, LHL has been associated with decreased medical knowledge, disuse of preventative medical services, worse chronic disease control and increased use of emergency services. Within orthopedics specifically, LHL has been associated with lower expectations regarding outcomes and ambulation following total hip and knee surgery and fewer questions asked regarding diagnosis and treatment in the outpatient care setting. In some cases, LHL has been independently correlated with worse patient-reported outcome measures (PROMs), though this finding may be due in part to the reading level required of the PROMs. There is growing evidence that active intervention by the orthopedic provider and demonstration of empathy improves patient comprehension of the nature of their musculoskeletal complaints, aids informed decision-making and, ultimately, maximizes patient satisfaction. Recognition of the associated factors for LHL will ensure improved physician-patient communication through the implementation of health literate interventions focused on those most at-risk.

OBJECTIVES: There have been conflicting reports regarding the effects of obesity on both surgical time and blood loss following anatomic shoulder arthroplasty. Varying categories of obesity has made comparison amongst existing studies difficult. METHODS: A retrospective review of consecutive anatomic shoulder arthroplasty cases (aTSA) was undertaken. Demographic data, including age, gender, body mass index (BMI), age-adjusted Charleson Comorbidity Index (ACCI), operative time, hospital length of stay (LOS), and both POD#1 and discharge visual analogue score (VAS) was collected. Intra-operative total blood volume loss (ITBVL) and need for transfusion was calculated. BMI was categorized as non-obese (

Purpose Obesity has been studied in relation to perioperative medical and surgical complications, as well as clinical outcomes following reverse total shoulder arthroplasty (rTSA), with often inconsistent conclusions reached. The purpose of this systematic review is to synthesize the reported correlations between elevated body mass index (BMI) and both the complications and clinical outcomes following rTSA. Methods An extensive literature search of the PubMed, Embase, ScienceDirect, and Google Scholar databases was conducted through March 2020. Clinical studies that specifically examined the relationship between BMI and perioperative complications and functional outcomes following rTSA were included. Public databases (NIS, ACS-NSQIP, PearlDiver, and statewide databases) were largely excluded from the analysis unless procedural codes allowed for differentiation between rTSA, anatomic total shoulder arthroplasty (aTSA), and humeral head replacement. Results Nineteen studies were included in this systematic review—11 reported solely on perioperative complications, 2 solely on functional outcomes, and 6 on both complications and outcomes following rTSA. There was no association found between obesity and an increased risk for periprosthetic fracture, scapular stress fracture, periprosthetic infection, instability, overall complications, perioperative medical and surgical complications, mortality, extended length of stay (LOS), increased need for transfusion and likelihood of 90-day readmission. Obesity was associated with prolonged operative time, increased absolute hospital LOS, increased blood loss, higher hospital costs, lower risk for scapular notching, higher likelihood of discharge to a rehabilitation facility, and higher risk for revision surgery. Range of motion of the operative shoulder, pain, and patient-reported outcome measures have generally demonstrated significant improvement following rTSA. Conclusion Despite some conflicting results in the existing literature regarding the effect of BMI and complications following rTSA, obesity is not universally associated with increased perioperative complications. Range of motion and patient-reported functional outcomes can be expected to improve, even among patients with morbid obesity. Level of evidence Level IV; Review

BACKGROUND: Reliably recognizing the overall pattern and specific characteristics of proximal humerus fractures may aid in surgical decision-making. With conventional onscreen imaging modalities, there is considerable and undesired interobserver variability, even when observers receive training in the application of the classification systems used. It is unclear whether three-dimensional (3D) models, which now can be fabricated with desktop printers at relatively little cost, can decrease interobserver variability in fracture classification. QUESTIONS/PURPOSES: Do 3D-printed handheld models of proximal humerus fractures improve agreement among residents and attending surgeons regarding (1) specific fracture characteristics and (2) patterns according to the Neer and Hertel classification systems? METHODS: Plain radiographs, as well as two-dimensional (2D) and 3D CT images, were collected from 20 patients (aged 18 years or older) who sustained a three-part or four-part proximal humerus fracture treated at a Level I trauma center between 2015 and 2019. The included images were chosen to comprise images from patients whose fractures were considered as difficult-to-classify, displaced fractures. Consequently, the images were assessed for eight fracture characteristics and categorized according to the Neer and Hertel classifications by four orthopaedic residents and four attending orthopaedic surgeons during two separate sessions. In the first session, the assessment was performed with conventional onscreen imaging (radiographs and 2D and 3D CT images). In the second session, 3D-printed handheld models were used for assessment, while onscreen imaging was also available. Although proximal humerus classifications such as the Neer classification have, in the past, been shown to have low interobserver reliability, we theorized that by receiving direct tactile and visual feedback from 3D-printed handheld fracture models, clinicians would be able to recognize the complex 3D aspects of classification systems reliably. Interobserver agreement was determined with the multirater Fleiss kappa and scored according to the categorical rating by Landis and Koch. To determine whether there was a difference between the two sessions, we calculated the delta (difference in the) kappa value with 95% confidence intervals and a two-tailed p value. Post hoc power analysis revealed that with the current sample size, a delta kappa value of 0.40 could be detected with 80% power at alpha = 0.05. RESULTS: Using 3D-printed models in addition to conventional imaging did not improve interobserver agreement of the following fracture characteristics: more than 2 mm medial hinge displacement, more than 8 mm metaphyseal extension, surgical neck fracture, anatomic neck fracture, displacement of the humeral head, more than 10 mm lesser tuberosity displacement, and more than 10 mm greater tuberosity displacement. Agreement regarding the presence of a humeral head–splitting fracture was improved but only to a level that was insufficient for clinical or scientific use (fair to substantial, delta kappa = 0.33 [95% CI 0.02 to 0.64]). Assessing 3D-printed handheld models adjunct to onscreen conventional imaging did not improve the interobserver agreement for pattern recognition according to Neer (delta kappa = 0.02 [95% CI -0.11 to 0.07]) and Hertel (delta kappa = 0.01 [95% CI -0.11 to 0.08]). There were no differences between residents and attending surgeons in terms of whether 3D models helped them classify the fractures, but there were few differences to identify fracture characteristics. However, none of the identified differences improved to almost perfect agreement (kappa value above 0.80), so even those few differences are unlikely to be clinically useful. CONCLUSION: Using 3D-printed handheld fracture models in addition to conventional onscreen imaging of three-part and four-part proximal humerus fractures does not improve agreement among residents and attending surgeons on specific fracture characteristics and patterns. Therefore, we do not recommend that clinicians expend the time and costs needed to create these models if the goal is to classify or describe patients’ fracture characteristics or pattern, since doing so is unlikely to improve clinicians’ abilities to select treatment or estimate prognosis. LEVEL OF EVIDENCE: Level III, diagnostic study.

There has been increasing interest in the use of stemless humeral implants for total shoulder arthroplasty when compared with both short-stem (SS) and standard-length implants. Although evidence for decreased surgical time and blood loss exists for stemless versus standard-length stems, far less literature exists comparing these clinical parameters for stemless versus SS implants.A retrospective review of consecutive anatomic total shoulder arthroplasty (aTSA) cases conducted by a single, fellowship-trained shoulder surgeon was undertaken from January 2016 through January 2022 with the exception of March 2020 through January 2021 secondary to the COVID-19 pandemic. Demographic patient and surgical data, including age, sex, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson Comorbidity Index, prior ipsilateral shoulder arthroscopy, surgical time, use of a Hemovac drain and/or tranexamic acid, hospital length of stay (LOS), and both postoperative day #1 (POD 1) and discharge visual analog scores. The use of a stemless or SS implant was recorded. Intraoperative total blood volume loss (TBVL) was calculated, in addition to the need for either intraoperative or postoperative transfusions. Nonparametric analysis of covariance was used to examine effects of stemless versus SS aTSA on surgical time and intraoperative TBVL adjusted for demographic, clinical, and surgical variables.There were 47 SS and 83 stemless anatomic implants included, of which 74 patients (57%) overall were women. The median surgical time for the stemless cohort was 111 minutes (IQR 96-130) versus 137 minutes (IQR 113-169) for the SS cohort (P0.00001). The median intraoperative TBVL for the stemless cohort was 298.3 mL (IQR 212.6-402.8) versus 359.7 mL (IQR 253.9-415.0) for the SS cohort (P = 0.05). After multivariable regression analysis, use of stemless humeral implants was independently associated with both decreased surgical time and intraoperative blood loss (P0.001 and P = 0.005, respectively). There was a shorter median hospital LOS in the stemless group (2 days [IQR 1-2] versus 2 days [IQR 2-3], P = 0.03). The visual analog score pain score at discharge was lower among the stemless cohort (0 [IQR 0-3] versus 4 [IQR 2-6], P0.00001). Increased surgical time was associated with intraoperative TBVL (r = 0.340, P0.0001).Stemless aTSA is associated with a markedly decreased surgical time and intraoperative TBVL when compared with a SS aTSA. Furthermore, the use of a stemless implant results in a shorter hospital LOS and lower discharge pain scores.

Short-term cancellation of elective ambulatory orthopaedic surgery can result in disruption to the process flow of the operating room, with resultant negative financial implications for the health system. The risk factors for patient-related short-term cancellations within 24 hours of the surgical date have not been well defined.A retrospective review of a single orthopaedic surgery electronic internal database was done to identify all cancellations from January 1, 2016, through December 31, 2019, which were made within 24 hours of the surgical date. Inclusion criteria included elective arthroscopic procedures canceled solely for patient-related issues. Any cancellation for surgeon-related or ambulatory center-related reasons was excluded. Demographic patient and surgical data, including insurance type, employment status, previous history of cancellation for the same surgery, socioeconomic status based on the Area Deprivation Index, and surgery type, were tabulated. Each cancellation was matched 1:2 with noncanceled cases based on the anatomic site of the arthroscopy scheduled. Multivariable logistic regression was used to examine associations of patient demographic and medical characteristics with surgical cancellation.There were 4,715 total arthroscopic procedures done during the study period, of which 126 (2.7%) were canceled within 24 hours of the surgery date. The mean age of the canceled cases was 44.9 ± 16.1 years (range, 14 to 77 years), with 46 females (43%) included. The presence of MRI of the involved joint within 6 months of surgery (adjusted odds ratio [aOR], 0.39, 95% confidence interval [CI], 0.17 to 0.91) and current employment (aOR, 0.56, 95% CI, 0.33-0.94) were independently predictive of noncancellation. Current smokers were more likely to cancel within 24 hours of surgery (aOR, 2.63, 95% CI, 1.4-4.9). Finally, having previously canceled the same surgery was significantly associated with a current surgical cancellation (P = 0.004).Identification of the factors associated with short-term patient-related cancellation of elective arthroscopy may serve as the basis for preoperative interventions aimed specifically at those more likely to cancel. In turn, these interventions can minimize preventable cancellations.

BACKGROUND: Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns. QUESTIONS/PURPOSES: (1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables. METHODS: In an institutional review board–approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture. RESULTS: The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences. CONCLUSION: Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention. LEVEL OF EVIDENCE: Level IV, therapeutic study.

BACKGROUND: The critical shoulder angle (CSA) has been associated with full-thickness rotator cuff tears both in the presence and absence of glenohumeral arthritis. It is unclear whether the CSA can be reliably measured from plain radiographs of concentric glenohumeral osteoarthritis amongst examiners at differing levels of training. METHODS: We retrospectively reviewed the radiographs of consecutive patients who underwent shoulder arthroplasty for glenohumeral osteoarthritis. The CSA was measured on a standardized AP scapular view at baseline and then 4 weeks later by fellowship-trained orthopaedic surgeons, a shoulder fellow and a senior orthopaedic resident. Grade of arthritis was categorized using the Samilson and Prieto method. The inter- and intra-observer reliability was then determined for all examiners, as well as for increasing severity of radiographic arthritis. The relationship between the CSA and grade of arthritis was assessed. RESULTS: There were 166 included patients comprised of 104 females (63%) and 62 males (37%) with a mean age of 65.9 ± 10.4 years. The inter- and intra-observer reliability for measuring the CSA amongst all examiners was found to be excellent, with an intra-class coefficient (ICC) of >0.9 (p

INTRODUCTION Plain radiographs of the shoulder are routinely obtained for patients presenting with atraumatic shoulder pain, although the diagnostic utility of this imaging modality is unclear. Despite this, patients often prefer to obtain radiographs and may associate them with a more satisfactory visit. METHODS New patients presenting with atraumatic shoulder pain were provided with information regarding the potential advantages and disadvantages of plain radiographs as part of their visit. Patients then decided whether to receive radiographs and baseline patient demographics were collected. A detailed physical examination and history was performed by a fellowship-trained provider, and a preliminary diagnosis and tentative treatment plan was formulated. The radiographs were then reviewed to determine whether the diagnosis and treatment plan was altered by addition of the radiographs. Patients who opted for radiographs then reported whether they felt the radiographs aided in diagnosis and treatment and whether the addition of the radiograph influenced their visit satisfaction. RESULTS A total of 220 patients met the inclusion criteria. Overall, 121 patients (55%) requested a radiograph. The mean age was 57.1 ± 16.1 years (range, 18 to 91 years). Lack of bachelor's degree (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.2 to 6.2; P = 0.01), lack of previous contralateral shoulder pain (OR, 4.0; 95% CI, 2.0 to 8.2; P = 0.0001), and lack of a previous shoulder radiograph (OR, 8.4; 95% CI, 4.1 to 16.9; P < 0.0001) or MRI within the last 6 months (OR, 6.2; 95% CI, 1.4 to 26.8; P = 0.01) were independently associated with patient preference to obtain radiographs for atraumatic shoulder pain. Of the 121 patients who requested radiographs, 117 (96.7%) felt that radiographs improved their satisfaction. DISCUSSION Patients who obtained radiographs overwhelmingly reported its importance in improving visit satisfaction and diagnostic accuracy. Given the increasing emphasis on shared decision making, further study of patient factors influencing the decision to obtain routine radiographs will lead to more efficient practice management and potentially improved patient satisfaction. LEVEL OF EVIDENCE Level II (Diagnostic).

To report on the effectiveness of a standardized patient positioning and padding protocol in reducing lateral femoral cutaneous nerve (LFCN) palsy in obese patients who have undergone shoulder surgery in the beach chair position.We retrospectively reviewed the medical records of 400 consecutive patients with a body mass index (BMI) of ≥30 kg/m who underwent either open or arthroscopic shoulder surgery in the beach chair position by a single surgeon. Before June 2013, all patients were placed in standard beach chair positioning with no extra padding. After June 2013, patients had foam padding placed over their thighs underneath a wide safety strap and underneath the abdominal pannus. Flexion at the waist was minimized, and reverse Trendelenburg was used to position the shoulder appropriately. Patient demographic and surgical data, including age, sex, weight, BMI, presence of diabetes, procedure duration, American Society of Anesthesiologists (ASA) grade, and anesthesia type (general, regional, regional/general) were recorded. Symptoms of LFCN palsy were specifically elicited postoperatively in a prospective fashion and identified clinically by focal pain, numbness, and/or tingling over the anterolateral thigh.The median age was 58.0 years, and the study consisted of 142 male (36%) and 258 female (64%) subjects. Five cases (3.6%) of LFCN palsy occurred with conventional beach chair positioning, and a single case (0.4%) occurred with the standardized positioning and padding technique (P = 0.02). Median age, sex, presence of diabetes, median BMI, surgery type, and surgical time were not significantly different between the patients who did and did not develop LFCN palsy. All cases resolved completely within 6 months.The occurrence of LFCN palsy following shoulder surgery in the beach chair position remains uncommon, even among obese patients. Use of a standardized positioning and padding protocol for obese patients in the beach chair position reduced the prevalence of LFCN palsy.Level III (prognostic).

Currently, there seems to be a paradigm change in the surgical treatment of proximal humeral fractures in patients aged 65 years and older, with a considerable increase in the use of reverse total shoulder arthroplasty (RTSA) compared with angular stable internal fixation (locking plate fixation). However, even among shoulder specialists there is controversy regarding the best treatment strategy.To evaluate for (1) a greater risk of in-hospital major adverse events, (2) a greater risk for in-hospital surgical complications, and (3) a greater risk of 30-day mortality, locking plate fixation and RTSA were compared for the treatment of proximal humerus fractures of patients aged 65 years and older after controlling for potentially confounding variables in a large-database analysis.Health claims data of the largest German insurance company including approximately one-third of the population (26.5 million policyholders) between 2010 and 2018 were analyzed. This database was chosen because of its size, nationwide distribution, and high quality/completeness. In total, 55,070 patients (≥ 65 years of age) treated with locking plate fixation (75% [41,216]) or RTSA (25% [13,854]) for proximal humeral fracture were compared. As primary endpoints, major adverse events (including acute myocardial infarction, stroke, organ failure, resuscitation, and death) and surgical complications (infection, hematoma, loss of reduction, dislocation, and revision surgery) were analyzed. The risk of all endpoints was analyzed with multivariable logistic regression models in the context of comorbidities to address existing group differences.After controlling for potentially confounding variables such as age, sex, and risk profile, RTSA was associated with a higher risk for major adverse events (OR 1.40 [95% CI 1.29 to 1.53]; p0.001) and surgical complications (OR 1.13 [95% CI 1.05 to 1.21]; p0.01) compared with locking plate fixation. There was no evidence for an increase in mortality (OR 0.98 [95% CI 0.86 to 1.12]; p = 0.81).The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with RTSA for proximal humeral fractures in patients 65 years and older. Treatment decisions should be based on individual risk estimation to avoid potential harmful events. Future studies must include long-term outcomes and quality of life to enlighten these findings in a broader context.Level III, therapeutic study.