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The primary purpose of this study was to compare 2-year anatomic total shoulder arthroplasty (TSA) functional and radiographic outcomes between Walch type A and B glenoids treated with an all-polyethylene glenoid designed for hybrid fixation with peripheral cement and central osseous integration. The secondary purpose was to evaluate outcomes based on central peg technique. The hypotheses were that there would be no difference in short-term radiographic or functional outcome scores based on preoperative glenoid morphology or central peg technique.We performed a multicenter retrospective review of patients who underwent TSA with the same hybrid all-polyethylene glenoid and had minimum 2-year follow-up. Patient-reported outcomes and radiographic outcomes were analyzed based on preoperative Walch morphology and central peg technique. Radiographic analysis included preoperative glenoid morphology; preoperative and postoperative glenoid version, glenoid inclination, and posterior humeral head subluxation; and postoperative glenoid radiolucencies according to the Wirth and Lazarus classifications.A total of 266 patients with a mean age of 64.9 ± 8.2 years were evaluated at a mean of 28 months postoperatively. Postoperatively, there were significant improvements in all functional outcome measures (P .001), range-of-motion measures (forward elevation, external rotation at 0°, external rotation at 90°, internal rotation by spinal level, and internal rotation at 90°; P .001), and strength measures (Constant, external rotation, and modified belly press; P .001). There were no clinically meaningful differences in functional outcomes or statistically significant differences in radiographic appearance between Walch type A and B glenoids. Subgroup analysis revealed that glenoids with a cemented central peg had the worst radiographic outcomes based on Lazarus scoring.Patients undergoing TSA with a hybrid in-line pegged glenoid have excellent clinical outcomes at short-term follow-up regardless of preoperative glenoid morphology. Different central peg techniques do not appear to play a significant role in the risk of glenoid component lucencies at 2 years postoperatively.

Although reverse total shoulder arthroplasty (RTSA) has excellent reported outcomes and satisfaction, patients often have postoperative limitations in range of motion (ROM), specifically internal rotation. Increased lateralization is thought to improve ROM following RTSA. The purpose of this study was to evaluate the association between radiographic measurements of lateralization and postoperative ROM and clinical outcome scores following RTSA. The authors hypothesized that increased radiographic lateralization would be associated with improved postoperative ROM, specifically internal rotation, but have no significant association with clinical outcome scores.Patients who underwent RTSA with a 135° neck-shaft angle prosthesis and minimum 2-year clinical and radiographic follow-up were included and retrospectively reviewed. Postoperative radiographs were evaluated for several lateralization measurements including the lateralization shoulder angle (LSA), distance from the lateral border of the acromion to the lateral portion of the glenosphere, distance from the glenoid to the most lateral aspect of the greater tuberosity, and the distance from the lateral aspect of the acromion to the most lateral aspect of the greater tuberosity. Linear regression analyses were used to evaluate the independent association of each radiographic measurement of lateralization on forward flexion, external rotation, internal rotation, and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) index score at 2 years postoperation. Receiver operating characteristic (ROC) curves were constructed to identify significant thresholds of each radiographic lateralization measurement.A total of 203 patients were included. For internal rotation, a greater LSA (P = .007), shorter acromion to glenosphere distance (meaning more glenoid lateralization) (P = .005), and a greater acromion to greater tuberosity distance (with the tuberosity more lateral to the acromion) (P = .021) were associated with improved internal rotation. Overall, ROC analysis demonstrated very little significant data, the most notable of which was the LSA, which had a significant cutoff of 82° (sensitivity 57%, specificity 68%, P = .012).Of the numerous radiographic measures of lateralization after RTSA, the LSA is the most significantly associated with outcomes, including improved internal rotation and a decrease in forward flexion and ASES score. The clinical significance of these statistically significant findings requires further study, as the observed associations were for very small changes that may not represent clinical significance.

Background The patient acceptable symptom state (PASS) was developed to improve the subjective interpretation of patient reported outcomes (PROs) and the minimum score necessary for the patient to “feel good.” The purpose of this study was to compare range of motion (ROM), final PROs, and individual responses on PROs between patients achieving or failing to meet a PASS after reverse shoulder arthroplasty (RSA). Methods A retrospective review of multi-center prospectively maintained database of RSAs between 2015 and 2018 was conducted. Primary RSAs with minimum 2-year follow-up were included. Patients were stratified into 2 groups by whether they achieved or failed to meet PASS scores at a minimum of 2 years of 76 for the ASES score or 75.5 for the SANE score. The primary goals of the study were to compare outcomes, range of motion (ROM) and individual ASES and WOOS survey responses for patients above and below the PASS score. Results 87 patients were included. Using the ASES cutoff for PASS, 33% failed to meet a PASS while 45% failed to meet a PASS defined by the SANE. The most notable difference between patients above and below ASES PASS was a significant difference in VAS pain scores (3.1 vs. 0.3; P Conclusions At least one quarter of patients do not achieve a PASS after RSA. Pain appears to be the primary driver for this finding, while ROM is very similar between patients achieving or failing to meet a PASS regardless of PRO used to define the PASS. Patients who fail to achieve PASS after RSA report doing poorly in all domains of their outcome. Level of evidence Level III; Retrospective Comparative Study

Background Improvement in internal rotation (IR) is not reliably achieved after reverse total shoulder arthroplasty (RSA). The purpose of this study was to evaluate the relationship between postoperative IR and glenoid-sided lateralization following RSA in an implant using metallic lateralization. Methods A multicenter retrospective study of RSAs with minimum 1-year clinical follow-up was performed. Patients were stratified based on the amount of glenoid-sided implant lateralization into 4 groups: 0-2 mm (n = 57), 4 mm (n =238), 6 mm (n = 95), and 8 mm (n = 65). The primary study outcome was active IR at a minimum of 1 year postoperatively, measured both by spinal level and in degrees with the shoulder abducted to 90°. Secondary outcomes were active forward flexion and external rotation, belly press strength, and subjective patient-reported outcome (PRO) measures. Comparisons were made with 1-way analyses of variance. Linear regression analyses evaluating for the association of glenoid lateralization with active IR were also performed to control for additional confounders, including demographics and other implant variables such as glenosphere diameter, humeral lateralization, humeral version, and whether the subscapularis was repaired. Results A total of 455 patients were included in the study. The mean age was 69 years, and 48% of patients were male. IR differences varied by the method of measurement (spinal level vs. IR in degrees with arm abducted). Overall, patients with 8 mm of glenoid lateralization had significantly improved IR compared with all other lateralization groups. Patients with 6 mm of glenoid lateralization had significantly improved IR compared with the 0-2- and 4-mm groups. There were no significant differences in the secondary outcomes or PROs between lateralization groups. In the regression analysis, glenoid lateralization was the only implant-related variable that was significantly associated with improved IR for both measurement methods. Glenosphere diameter and humeral version were both significantly associated with IR measured in degrees with the arm abducted but not spinal level. Conclusions For the studied implant system, glenoid lateralization of 6-8 mm was associated with improved active IR at 1 year compared to patients with less glenoid lateralization with no significant differences in active forward flexion, external rotation, or PROs. In a multivariable analysis, increased humeral retroversion was associated with increased IR at 90° and increasing glenosphere diameter was associated with decreased IR at 90°, whereas BMI, subscapularis repair, and humeral lateralization did not significantly affect active IR.

Background The relationship of numerous implant design and positioning-related variables with range of motion and clinical outcomes have been investigated for reverse shoulder arthroplasty (RSA). While glenosphere inclination has been investigated with regards to implant fixation and scapular notching, little research has been done on the association between glenosphere inclination and clinical outcomes. Therefore, the primary objective of this study was to investigate the relationship between preoperative glenoid inclination, postoperative glenosphere inclination and inclination change (∆INC) from pre- to postoperative on clinical outcomes after RSA. Methods A multicenter retrospective study was conducted of RSAs with minimum 2-year clinical follow-up. All included patients had the same RSA prosthesis. Preoperative, postoperative, and ∆INC from pre-to postoperatively were measured for each patient. The primary study outcome was the minimum 2-year ASES score. Secondary outcomes were active range of motion, Constant-Murley score and Western Ontario Ostearthritis Shoulder (WOOS) score at a minimum of 2 years postoperatively. Receiver-operator characteristic curve analyses were performed to determine if any significant thresholds in inclination existed. Univariate analyses were performed with ANOVA to compare subgroup means. Finally, a multivariate logistic regression was performed to examine each inclination variable as a predictor of clinical outcome while controlling for patient and implant-related variables. Results Eighty seven patients were included in the study. The mean age was 70 years and 53% of patients were male. The examiners had excellent reliability determined by intraclass correlation coefficients for all 3 measurements. There was no apparent correlation between preoperative inclination, postoperative inclination or ∆INC with minimum 2-year ASES scores. This was confirmed in the receiver-operator characteristic analyses, where no significant thresholds were found for each of the 3 assessed measurements (P> .05 for all analyses). A subgroup analysis comparing patients with low preoperative inclination ( 10°) stratified by the ∆INC demonstrated no significant association with inclination (P > .05 for all comparisons). In the multivariate regression analysis, inclination had no significant association with the minimum 2-year ASES scores. Conclusion For the studied implant system, preoperative inclination, postoperative inclination and ∆INC did not have a significant association with postoperative clinical outcomes after RSA. Level of evidence Level III; Retrospective Comparison Study

Background Reverse shoulder arthroplasty (RSA) is rapidly growing in the United States. As the number of procedures increases, the number of complications and need for additional surgeries correspondingly continues to grow. The purpose of this study was to describe clinical and functional outcomes of revision of RSA to RSA. Methods A retrospective review of 29 patients from 2 centers who underwent revision surgery following RSA to RSA from 2007 to 2017 was conducted. The reasons for revision were recorded. Clinical outcome measures including shoulder range of motion, American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, simple shoulder test and Visual analog scale scores were collected for all patients at an average follow-up of 29 months. Postoperative complications were also recorded. Results A total of 29 patients were identified. The average time between index RSA and revision was 2.3 years (30 days – 7 years). Mean follow-up duration for clinical outcome measures was 29.1 months (12-114 months). The most common indication for revision surgery was aseptic loosening (13/29, 44.8%), followed by instability (7/29, 24.1%), fracture (5/29, 17.2%), and infection (4/29, 13.7%). The average Visual analog scale decreased from 7 to 3 (P Conclusion A failed RSA can be managed with revision RSA with acceptable clinical outcomes although outcome is inferior to primary RSA with a high rate of complications. Level of Evidence Level IV; Retrospective Case Series

The number of total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) procedures performed each year has continued to rise. While these procedures were historically done in the inpatient setting, many surgeons have migrated to performing TSA and RTSA in the outpatient setting. This can either involve sending patients home the same day from the hospital or performing these in an outpatient center. Specific protocols should be followed in regard to patient selection to minimize the risk of complications and readmission. Similarly, a team approach between the anesthesiologist and the surgeon is critical to ensure adequate pain control. Use of tranexamic acid (TXA), a preoperative nerve block as well as specific combinations of preoperative and postoperative medications are helpful in creating an optimal environment in which to perform the shoulder arthroplasty for the patient. When done well, TSA and RTSA can successfully be performed as an outpatient with a very high success rate and a low risk of complications.

Background: Latarjet has become a common treatment option for patients with shoulder instability in the setting of bone loss. The coracoid is commonly secured with screws Methods: All patients who underwent Latarjet with suture-button fixation with minimum 1-year follow-up were eligible for inclusion. Preoperative demographic and clinical outcome data including American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), and Visual Analog Scale (VAS) were recorded and compared with postoperative scores. Radiographs were reviewed for signs of nonunion. Complications were recorded. Results: Overall 21 patients (76% male, average age: 30.4 ± 11.3 years) underwent Latarjet with suture-button fixation. Significant improvements at 1 year were seen in ASES (P < 0.001), SANE (P < 0.001), and VAS (P = 0.011) scores compared with preoperative scores. Of the 21 patients who had reached 1-year follow-up, 17 (81%) reached 2-year follow-up. For the 17 patients who reached 2-year follow-up, there were significant improvements in ASES (P = 0.001), SANE (P = 0.001), and VAS (P = 0.005) scores from preoperative values. When isolating the 17 patients with 2-year follow-up, there were no significant differences between their 1-year and 2-year ASES (P = 0.73), SANE (P = 0.17), and VAS (P = 0.37) scores. Overall, 3 patients (14%) sustained a complication (one redislocation, one with coracoid migration and a fibrous union, and one superior labral tear requiring biceps tenodesis and superior labral repair). Conclusion: Suture-button fixation of the coracoid during the Latarjet provides encouraging clinical and radiographic outcomes at 1 and 2 years.

Background Total shoulder arthroplasty (TSA) is an effective treatment option for glenohumeral arthritis. Historically, this surgical procedure was performed on an inpatient basis. There has been a recent trend in performing TSA on an outpatient basis in the proper candidates. Methods All patients who underwent outpatient TSA performed by a single surgeon between 2015 and 2017 were included. Demographic information and clinical outcome scores, as well as data on complications, readmissions, and revision surgical procedures, were recorded. This group of patients was then compared with a matched cohort of patients who underwent inpatient TSA over the same period. Results Overall, 94 patients (average age, 60.4 years; 67.0% male patients) underwent outpatient TSA and were included. Patients who underwent outpatient TSA showed significant improvement in all clinical outcome scores at both 1 and 2 years postoperatively. The control group consisted of 77 patients who underwent inpatient TSA (average age, 62.6 years; 53.2% male patients). No significant differences in complications or improvements in clinical outcome scores were found between the inpatient and outpatient groups. Conclusion TSA performed in an outpatient setting is a safe and reliable procedure that provides significant improvement in clinical outcome scores and no difference in complication rates compared with inpatient TSA.

Reverse total shoulder arthroplasty (RTSA) is an effective treatment option for many shoulder conditions. Historically, this surgical procedure was performed on an inpatient basis. There has been a recent trend to perform RTSA on an outpatient basis in proper candidates.All patients who underwent outpatient RTSA performed by a single surgeon between 2015 and 2017 were included. Demographic information and clinical outcome scores (American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores), as well as data on complications, readmission, and revision surgery, were recorded. This group of patients was then compared with a cohort of patients who underwent RTSA in the inpatient setting during the same period.Overall, 241 patients (average age, 68.9 years; 52.3% female patients) underwent outpatient RTSA and were included. Patients who underwent outpatient RTSA showed significant improvements in all clinical outcome scores at both 1 and 2 year postoperatively (all P.0001). The control group of patients who underwent RTSA as inpatients consisted of 373 patients (average age, 72 years; 66% female patients). Significantly more controls had diabetes (P = .007), and controls had a higher body mass index (P = .022). No significant differences existed in improvements in clinical outcome scores between the inpatient and outpatient groups. Complication rates were significantly lower for outpatient cases than for inpatient controls (7.0% vs. 12.7%, P = .023).RTSA performed in an outpatient setting is a safe and reliable procedure that provides significant improvements in clinical outcome scores with fewer complications compared with inpatient RTSA.

Background The purpose of this study was to compare the functional outcome and radiographic appearance of total shoulder arthroplasties (TSAs) performed with an entirely cemented all-polyethylene glenoid to a hybrid all-polyethylene glenoid designed for hybrid fixation with peripheral cement and central osseous integration. The hypothesis was that there would be no difference in functional outcome or radiographic appearance between the two components at two year follow-up. Methods A multicenter retrospective comparative study was conducted on primary TSAs performed with a press-fit humeral stem and an entirely cemented or hybrid all-polyethylene glenoid from 2015–2017. Functional outcomes and radiographic appearance of the glenoid based on the Lazarus and Churchill classifications were reviewed at a minimum of 2 years postoperatively. Results 96 patients were included in the study; 62 with a hybrid all-polyethylene glenoid and 34 with an entirely cemented pegged glenoid. The mean Lazarus score was 1.03 in the cemented group compared to 0.60 in the hybrid group (p = 0.032). The mean Churchill score in the hybrid group was 0.47, which was also significantly lower than the cemented group Lazarus score (p = 0.006). There were no statistically significant differences in 2-year functional outcomes, range of motion, complications, or revision between the two groups. Conclusion A hybrid all-polyethylene glenoid for TSA results in lower radiolucencies scores at 2 years postoperatively compared to an entirely cemented, pegged component. There were no differences in functional outcome scores or range of motion between patients with the two glenoid types at 2 years. Level of evidence Level III; Retrospective Comparative Study.

Several methods are available for subscapularis management in total shoulder arthroplasty (TSA). The goal of this study was to compare radiographic and clinical outcomes of short-stem TSA stratified by subscapularis management technique. A multicenter trial was completed evaluating primary short-stem TSA performed with a subscapularis peel (n=80) or lesser tuberosity osteotomy (LTO) (n=59). The primary outcome measure was subscapularis function, as measured by internal rotation and strength at 1 year postoperatively. Secondary outcomes included patient-reported outcomes, radiographic changes, and implant loosening. Patients in the peel group obtained better active internal rotation by spinal level ( P =.004). No difference was seen between groups for internal rotation with 90° shoulder abduction ( P =.862) or belly press ( P =.903). Statistically significant improvements in functional outcomes were seen without clinical differences. Radiographic changes showed no difference in stem shift, subsidence, or at-risk loosening rate. Anterior subluxation of the humerus was observed among 2% of the LTO group vs 17% of the peel group ( P =.006). At short-term follow-up, those in the peel group appear to have a better final spinal level of internal rotation, whereas those in the LTO group have a significantly lower rate of anterior humeral subluxation. Both LTO and subscapularis peel appear safe for short-stem TSA, with no radiographic evidence of loosening. [ Orthopedics . 2022;45(3):151–155.]

In an effort to preserve bone, humeral stems in reverse total shoulder arthroplasty (RTSA) have gradually decreased in length. The purpose of this study was to compare the immediate postoperative radiographic appearance of short-length with standard-length RTSA stems.Patients who underwent RTSA using a press-fit standard-length or short-length humeral implant with a consistent geometry (Univers Revers or Revers Apex) were evaluated in a multicenter retrospective review. Initial postoperative radiographs were used to assess initial alignment and filling ratios. In addition, radiographs were evaluated for early signs of stress shielding and/or loosening. Clinical outcome scores and range of motion were also evaluated.Overall, 137 short-length stems and 139 standard-length stems were analyzed. Initial radiographs demonstrated a significantly higher percentage of stems placed in neutral alignment in the short-stem group (95.6% vs 89.2%, P = 0.045). Similar metaphyseal filling ratios were seen between groups, but a significantly higher diaphyseal filling ratio was observed in the short-stem group (57% vs 34%, P0.001). Less calcar osteolysis (2.2% vs 12.9%; P = 0.001) and fewer overall number of radiographic changes (tuberosity resorption, lucencies, and subsidence) (0.7% vs 5.0%; P = 0.033) were seen with short stems compared with the standard-length stems.RTSA with a short-stem humeral implant demonstrates excellent radiographic outcomes, including low rates of loosening and subsidence at 1 year, with less early calcar osteolysis compared with a standard-length stem.III (Case-control).

The influence of the humeral inclination in reverse total shoulder arthroplasty (RTSA) is not well understood. The purpose of this study was to determine outcomes and complications after RTSA with an inclination of 135° or 155° in a modular prosthesis. American Shoulder and Elbow Surgeons (ASES), visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores, as well as forward elevation (FE), abduction (ABD), and external rotation (ER), were assessed after a minimum 2-year follow-up. Scapular notching and radiolucency were assessed according to Sirveaux and Lévigne. A total of 121 patients with a mean age of 69.7±7.3 years were evaluated after a mean of 36.5±8 months. The inclination was set to 135° in 80.2% and to 155° in 19.8% of patients. There was no significant difference between the groups for ASES, VAS, SANE, and SST scores. The FE ( P =.022) and ABD ( P =.002) were significantly higher for the 155° inclination group. Complication rates were not significantly different between the groups. Scapular notching was significantly more common with a 155° inclination ( P =.01), whereas humeral radiolucency was not correlated. All outcome scores improved significantly from pre- to postoperative ( P ≤.001). Reverse total shoulder arthroplasty leads to significant improvements in pain, range of motion, and outcome scores after mid-term follow-up. Overall, the inclination angle does not significantly affect clinical outcomes or the complication rate after RTSA at mid-term follow-up. However, an inclination of 155° shows significantly greater FE and ABD, although it results in a significantly higher rate of scapular notching. Cases with scapular notching are associated with significantly reduced mean ASES scores and ER as well as significantly higher VAS scores. [ Orthopedics . 2021;44(4):e527–e533.]

Background Glenoid loosening remains one of the most common concerns at mid- to long-term follow-up after total shoulder arthroplasty (TSA). Pegged and keeled designs have been compared at short-term follow-up, but few studies have compared outcomes at mid-term follow-up. Our purpose was to compare minimum 5-year outcomes of pegged and keeled cemented, all-polyethylene glenoids in TSA. The hypothesis was that no difference in functional outcomes or loosening would be found between the 2 components. Methods We performed a multicenter retrospective study of TSAs with either a pegged or keeled cemented glenoid. At a minimum of 5 years postoperatively, functional outcomes and radiographic loosening were compared. Results Forty-seven TSAs were available for follow-up, including 20 pegged and 27 keeled components, at a mean of 79 months (range, 60-114 months) postoperatively. Overall, functional outcomes improved in both groups from preoperatively to postoperatively, and no difference was found between the 2 groups. Radiographic glenoid loosening (score ≥ 3) was observed in 9 of 27 keeled glenoids (33.3%) compared with 5 of 20 pegged glenoids (25%) (P = .54). Loosening was associated with lower postoperative forward flexion (P = .026), lower American Shoulder and Elbow Surgeons scores (P = .030), and higher visual analog scale pain scores (P = .007). Conclusion Radiographic glenoid loosening of a cemented, all-polyethylene component was associated with decreased functional outcomes at minimum 5-year follow-up of TSAs. However, this study showed no difference in loosening rates between keeled and pegged components.

Treatment of focal osteochondral defects of the humeral head poses a challenge to orthopedic surgeons. Patients with this kind of pathology often present with loss of function and pain. Smaller osteochondral defects of the humeral head are often missed as a source of the patient's pain and are usually incidentally reported at the time of surgery. Good outcomes have been reported with open surgical techniques for the treatment of focal osteochondral defects. Smaller defects are usually more difficult to manage due to restrictions and limitations in the surgical approaches and techniques needed to access the affected area in order to properly assess the defect. This article describes a pioneered all-arthroscopic surgical technique for the treatment of focal osteochondral defects of the humeral head lesions.

The purpose of this randomized controlled trial was to compare humeral inclinations of 135° and 155° in patients undergoing primary reverse shoulder arthroplasty (RSA). Our hypothesis was that forward flexion would be higher in the 155° group but be associated with a higher rate of scapular notching.A randomized controlled trial was conducted on 100 primary RSAs performed with a humeral inclination of either 135° or 155°. The prostheses were otherwise identical and a neutral glenosphere was used in all cases. Functional outcome, forward flexion, external rotation, and scapular notching were assessed at a minimum of 2 years postoperatively.There was no difference in range of motion or functional outcome scores between the 2 groups. In the 155° group, forward flexion improved from 76° to 135° (P.001) and external rotation remained unchanged (29° vs. 30°; P = .835). In the 135° group, postoperative forward flexion improved from 78° to 132° (P.001) and external rotation was unchanged (28° vs. 29°; P = .814). Scapular notching was observed in 58% of cases with a 155° inclination compared with 21% with a 135° inclination (P = .009).With a neutral glenosphere there was no difference in postoperative forward flexion or external rotation after an RSA with a humeral inclination of 135° compared with 155°. Scapular notching was reduced with the use of 135° design compared with a 155° design but persists at a rate of 21% at 2-year follow-up in the absence of a lateralized glenosphere.

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF��), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.

Background Some patients who have shoulder surgery on 1 shoulder go on to have surgery on their contralateral shoulder. It is unclear whether the clinical improvements following the second surgical procedure are as significant as the improvements after the first surgical procedure. Methods All patients who underwent surgery on both shoulders performed by a single surgeon between March 2013 and June 2018 were eligible for inclusion. Visual analog scale (VAS) scores were obtained preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years for both shoulders. Scores were then compared based on hand dominance and which shoulder was treated first. Complications were also recorded. Results Overall, 105 patients (210 surgical procedures) were included. Of the patients, 66 underwent bilateral open shoulder surgery and 39 underwent bilateral arthroscopic shoulder surgery. There was a significant reduction in VAS scores from preoperative to postoperative levels following surgery (5.9 before surgery vs. 1.7 after surgery). We found no difference in VAS scores at any time point when comparing whether the dominant or nondominant shoulder was operated on first. Significantly higher VAS scores were observed at 2 weeks, 6 weeks, and 3 months following the first shoulder operation compared with the second; by 6 months and beyond, there was no longer a difference. Conclusion Patients who undergo bilateral shoulder surgery have more pain in the first 3 months following their first shoulder operation compared with their second. However, there is no difference in pain scores at 6 months and beyond between shoulders.

Previous attempts to measure lateralization, distalization or inclination after reverse total shoulder arthroplasty (rTSA) and to correlate them with clinical outcomes have been made in the past years. However, this is considered to be too demanding and challenging for daily clinical practice. Additionally, the reported findings were obtained from heterogeneous rTSA cohorts using 145° and 155° designs and are limited in external validity. The purpose of this study was to investigate the prognostic preoperative and postoperative radiographic factors affecting clinical outcomes in patients following rTSA using a 135° prosthesis design. In a multi-center design, patients undergoing primary rTSA using a 135° design were included. Radiographic analysis included center of rotation (COR), acromiohumeral distance (AHD), lateral humeral offset (LHO), distalization shoulder angle (DSA), lateralization shoulder angle (LSA), critical shoulder angle (CSA), and glenoid and baseplate inclination. Radiographic measurements were correlated to clinical and functional outcomes, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (STT), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) score, active forward elevation (AFE), external rotation (AER), and abduction (AABD), at a minimum 2-year follow-up. There was a significant correlation between both DSA (r = 0.299, p = 0.020) and LSA (r = −0.276, p = 0.033) and the degree of AFE at final follow-up. However, no correlation between DSA (r = 0.133, p = 0.317) and LSA (r = −0.096, p = 0.471) and AER was observed. Postoperative AHD demonstrated a significant correlation with final AFE (r = 0.398, p = 0.002) and SST (r = 0.293, p = 0.025). Further, postoperative LHO showed a significant correlation with ASES (r = −0.281, p = 0.030) and LSA showed a significant correlation with ASES (r = −0.327, p = 0.011), SANE (r = −0.308, p = 0.012), SST (r = −0.410, p = 0.001), and VAS (r = 0.272, p = 0.034) at terminal follow-up. All other correlations were found to be non-significant (p &gt, 0.05, respectively). Negligible correlations between pre- and postoperative radiographic measurements and clinical outcomes following primary rTSA using a 135° prosthesis design were demonstrated, however, these observations are of limited predictive value for outcomes following rTSA. Subsequently, there remains a debate regarding the ideal placement of the components during rTSA to most sufficiently restore active ROM while minimizing complications such as component loosening and scapular notching. Additionally, as the data from this study show, there is still a considerable lack of data in assessing radiographic prosthesis positioning in correlation to clinical outcomes. As such, the importance of radiographic measurements and their correlation with clinical and functional outcomes following rTSA may be limited.

Background Humeral stem length in anatomic total shoulder arthroplasty (TSA) continues to decrease in an attempt to preserve bone. Outcomes following short-stem TSA are not well documented. The purpose was to systematically review and report the outcomes and revisions following short-stem humeral implants for TSA. Methods A systematic review was registered with PROSPERO and performed with PRISMA guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting TSA outcomes of short-stem implants with levels of evidence I-IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and described. Results Thirteen studies were included (average follow-up: 33 months, range 24-84 months; 8 studies [62%] were multicenter and 6 [46%] were from Europe). All studies were published in the last 8 years, and almost all (12/13, 92%) reported results of uncemented components. Most of the studies (9/13, 70%) reported results from the Aequalis Ascend or Ascend Flex Stem (Tornier). Improvements were seen in all measured range of motion planes and patient-reported outcome scores. Complications were infrequent, with a 2% humeral loosening rate, a 3% overall revision rate, and a 1% rate of revision for aseptic humeral loosening. Radiographic results showed a 13% rate of radiolucent lines, a 16% rate of condensation lines, and a 22% rate of calcar osteolysis. Conclusion Short-stem TSA humeral implants provide excellent results, with low revision rates in the short term. Long-term follow-up will be necessary to understand the clinical impact of radiographic calcar osteolysis.

All-polyethylene glenoid components designed for osseous integration of the central peg can be placed with no graft (NG), autogenous bone graft (ABG), or demineralized bone matrix (DBM). The purpose of this study was to compare osseous integration with these 3 techniques. A randomized controlled trial was performed of 153 total shoulder arthroplasties using a pegged allpolyethylene glenoid component designed for osseous integration. Central peg treatment included NG, ABG, or DBM. The primary outcome was central peg osseous integration defined as bone presence between the central fins 1 year postoperatively. Central osseous integration was observed in 90% of cases treated with ABG, 68% of cases treated with DBM, and 68% of cases treated with NG ( P =.022). Postoperative Wirth grading revealed radiolucency around the central peg (grade 1) in 2.4% of cases with ABG, 5.4% of cases with DBM, and 9.8% of cases with NG ( P =.134). At short-term follow-up, osseous integration of the central peg of an all-polyethylene glenoid designed for bony growth between the central fins appears to be highest when treating the central peg with ABG compared with leaving the central peg untreated or using DBM. [ Orthopedics . 2020;43(5):278–283.]

Background The purpose of this study was to compare the 5 year radiographic and clinical outcomes of anatomic total shoulder arthroplasties (TSA) performed with either a standard length (SL) or short stem. The hypothesis was there would be no difference in radiographic or clinical outcomes based on stem length. Methods A multicenter retrospective review was performed of primary TSAs performed with a press-fit humeral component. Fifty SL and 72 short stems were available for review, of which 43 SL and 60 short stems had minimum 5 year follow-up. Functional outcome was assessed according to range of motion (ROM), visual analog scale (VAS) American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numeric Evaluation (SANE) scores. Radiographs were reviewed for signs of humeral component loosening and stress shielding. Results At final follow-up there were no differences in ROM, or ASES or SANE scores between groups (P>.05). Postoperative VAS scores were lower in the SL compared to the short stems (0.8 vs. 1.6; P = .053). All-cause revision was similar between the SL and short stems (16% vs. 22.2%; P = .395). Among SL stems there were no revisions for humeral loosening and none were considered radiographically at risk. Six short stems were revised for loosening (8.3%; P =.036 vs. SL). An additional 5 short stems were considered to be radiographically at risk for loosening for a total revision or at risk rate of 15.3% (P = .003 vs. SL). Conclusion There is no difference in functional outcome at mid-term follow-up of TSA based on stem length with a grit-blasted humeral component. Revision for loosening and radiographic risk for loosening may be higher with a short stem compared a standard length humeral stem placed with press-fit fixation using grit blasting. Level of evidence Level III; Retrospective Comparative Study.

Uncemented press-fit humeral stems were developed with the goal of decreasing operative time, preserving bone stock, and easing revision. In recent years, short stems and stemless humeral implants have also become available. These press-fit humeral implants have varying designs that can lead to changes in stress distribution in the proximal humerus. Such stress shielding manifests as bony adaptations and may affect long-term functional outcome and the ability to perform revision. However, current studies of humeral fixation during total shoulder arthroplasty are complicated because a variety of classification systems have been used to report findings. The purpose of this report is to review the current literature on press-fit fixation of the humeral component during total shoulder arthroplasty and propose minimum requirements for radiographic descriptions of stress shielding.

The purpose of this study was to evaluate functional outcome and healing of a subscapularis peel with a stem-based repair after total shoulder arthroplasty (TSA). The hypothesis was that the repair would lead to subscapularis healing in the majority of cases.A prospective analysis was performed on a consecutive series of TSAs. Range of motion and functional outcome were assessed according to American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Simple Shoulder Test, and visual analog scale scores at a minimum follow-up of 1 year. Belly-press and lift-off tests were also performed. An ultrasound evaluation assessed subscapularis healing at final follow-up.At a mean follow-up of 15 months, 60 patients (mean age, 64 years) were examined. Mean forward flexion improved from 115° to 137°. External rotation at the side improved from 27° to 52°, and internal rotation improved from L4 to L2 (P .05). American Shoulder and Elbow Surgeons score improved from 34.3 to 79.8 (P .001). Likewise, the Single Assessment Numeric Evaluation and Simple Shoulder Test scores showed significant improvement from 33.1 to 85.3 and 4.3 to 10.2, respectively (P .001). The visual analog scale score for pain decreased from 5.8 to 0.7 (P .001). On ultrasound examination, the subscapularis was healed intact in 55 cases (91.7%), attenuated in 3 cases (5%), and torn in 2 cases (3.3%).A stem-based repair of a subscapularis peel after TSA leads to functional improvement in the majority of cases with90% postoperative healing of the subscapularis.

Total shoulder arthroplasty (TSA) for the treatment of osteoarthritis has shown excellent pain relief with durable outcomes. The trend toward less-invasive shoulder surgery and preservation of as much normal anatomy has led to the development of short-stem humeral implants. This technology helped in reducing stress shielding and facilitation of revision surgeries. With limited literature on stemless humeral implants, emerging studies have shown favorable outcomes and ease of use compared to traditional implants. Future analysis and assessment of new short-stem implant designs is warranted.

New techniques have been developed to assist in surgical repair of acromioclavicular joint(ACJ) injuries. The most common complication of treatment is loss of fixation and recurrent ACJ instability. Other common complications include: Fracture of the coracoid or clavicle, hardware failure, and infection. This chapter reviews the common intraoperative and postoperative complications of ACJ procedures.

Purpose Examine demographic factors of all patients treated for adhesive capsulitis by a single surgeon, report the treatments and outcomes of these patients, and determine the effectiveness of various treatments, including corticosteroid injections and operative intervention in relation to risk factors for adhesive capsulitis. Methods All patients treated for adhesive capsulitis by a single surgeon between 2008 to 2014 with minimum 2 years' follow-up were identified via charts and operative reports and were eligible for inclusion. Demographic information including sex and medical comorbidities was documented. Preintervention and postintervention shoulder range of motion was recorded. Specific treatment information (number of corticosteroid injections, etc) was collected. Treatment outcomes were then compared as an aggregate and among varying comorbidities. Results Overall, 1377 patients were treated for adhesive capsulitis (946 women vs 431 men [P = .001]). For patients with adhesive capsulitis: a higher percentage of men than women had diabetes (24.8% vs 17.3% [P = .001]); nondiabetic patients had better forward flexion at initial presentation than patients with diabetes (114° vs 108° [P = .015]); more patients with diabetes required capsular release than nondiabetic patients (13% vs 7.3% [P = .003]); more nondiabetic patients resolved adhesive capsulitis without corticosteroid or surgical intervention than patients with diabetes (83.6% vs 61.7% [P = .001]); more nondiabetic patients resolved adhesive capsulitis after single corticosteroid injection than did patients with diabetes (95.9% vs 86.7% [P = .001]). Multiple intraarticular corticosteroid injections provided no added benefit over a single injection in resolving adhesive capsulitis in patients with diabetes and nondiabetic patients. Conclusion In shoulder adhesive capsulitis, women and patients with diabetes are more commonly affected, patients with diabetes respond less favorably to physical therapy in isolation and physical therapy plus corticosteroid injections than nondiabetic patients. No benefit from multiple intraarticular corticosteroid injections was seen compared with a single intraarticular corticosteroid injection in patients with diabetes and nondiabetic patients. Patients with diabetes and nondiabetic patients have functional improvement after capsular release and manipulation if conservative treatment for adhesive capsulitis fails. Level of Evidence III, case control.