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As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-naïve (P <.001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-naïve patients (P <.001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-naïve (P <.001). This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA. [ABSTRACT FROM AUTHOR]

The decision to treat shoulder osteoarthritis (OA) definitively with shoulder arthroplasty (SA) is multifactorial, considering objective findings, subjective information, and patient goals. The first goal of this study was to determine if Patient Reported Outcome Measurement Information System (PROMIS) measures correlated with patients with shoulder OA who underwent SA within 1 year. The second goal of this study was to determine if score cut-offs in PROMIS domains could further discriminate which shoulder OA patients underwent SA within 1 year. This retrospective case-control study examined patients with a diagnosis of shoulder OA who consulted an orthopedic provider from November 1, 2020 to May 23, 2022, and recorded PROMIS measures in the domains of Physical Function, Depression, and/or Pain Interference. A surgical group was defined as patients who underwent SA within 1 year of the most recent PROMIS measures and the nonsurgical patients were defined as the control group. Mean PROMIS scores were compared between the surgical and control groups. Separate logistic regression models controlling for age, race, ethnicity, and comorbidity count were performed for each PROMIS domain as a 1) continuous variable, and then as 2) binary variable defined by PROMIS score cut-off points to determine which scores correlated with undergoing SA to further characterize the potential clinical utility of PROMIS score cut-offs in relating to undergoing SA. The surgical group of 478 patients was older (68.2 vs. 63.8 years), more often of White race (82.6% vs. 70.9%), and less often of Hispanic Ethnicity (1.5% vs. 2.9%) than the control group of 3343 patients. Using optimal cut-offs in PROMIS scores, Pain Interference ≥63 (odds ratio [OR] = 2.97 (2.41-3.64), P <.001), Physical Function ≤39 (OR = 1.81 (95% confidence interval, 1.48-2.22), P <.001), and depression ≥49 (OR = 1.82 (95% confidence interval, 1.50-2.22), P <.001) were all found to correlate with undergoing SA within 1 year in multivariable logistic regressions. The results of this study demonstrate that cut-off scores for PROMIS measures differentiated patients undergoing SA within 1 year. These cut-off scores may have clinical utility in aiding in decision-making regarding surgical candidates for SA. Further research is needed to validate these cut-off scores and determine how they relate to patient outcomes after SA. [ABSTRACT FROM AUTHOR]

Superior augment use may help avoid superior tilt while minimizing removal of inferior glenoid bone. Therefore, our goal was to compare superior augments vs. no-augment baseplates in reverse shoulder arthroplasty (RSA) for patients with rotator cuff dysfunction and no significant superior glenoid erosion. A multicenter retrospective analysis of 145 patients who underwent RSA with intraoperative navigation (Equinoxe GPS; Exactech) and 3-year follow-up (mean 32 months' follow-up, range 20-61 months) who had preoperative superior inclination less than 10° and retroversion less than 15°. Patient demographics, radiographic measurements, surgical characteristics, patient-reported outcomes at preoperative and postoperative visit closest to 3 years, and adverse events at final follow-up were obtained. Operative time, planned inclination, and planned version of the baseplate were obtained. χ2 test was used to compare categorical variables, and Student t test was used to compare the augment and no-augment cohorts. The study population consisted of 54 superior augment patients and 91 no-augment patients. The augment cohort had lower body mass index (27.2 vs. 29.4, P =.023) and higher native superior inclination (5.9° vs. 1.4°, P <.001). No difference between the augment and no-augment cohorts was found regarding age (P =.643), gender (P =.314), medical comorbidities (P >.05), surgical indication (P =.082), and native glenoid version (P =.564). The augment cohort had higher internal rotation score (4.6 vs. 3.9, P =.023), and all remaining range of motion (ROM) and patient-reported outcomes (PROs) preoperatively were not significantly different. At final follow-up, active ROM in all planes was not different between the cohorts. Regarding PROs, the postoperative Shoulder Arthroplasty Smart score was significantly higher (78.0 vs. 73.6, P =.042), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score trended toward higher (83.6 vs. 77.5, P =.063) in the augment cohort. The augment cohort had a significantly lower proportion of patients who planned to have superior baseplate tilt (1.9% vs. 14.3%, P =.012) and had greater mean inclination correction (6.3° vs. 1.3°, P <.001), compared with the no-augment cohort. Adverse events were rare, and there was no significant difference found between the augment and no-augment cohorts (5.6% vs. 3.3%, P =.509). Superior augmented baseplate in RSA with minimal superior glenoid erosion is associated with similar ROM and adverse events with somewhat improved postoperative PROs compared with nonaugmented baseplates at the 3-year follow-up. Additionally, superior augments resulted in a greater proportion of baseplates planned to avoid superior tilt, and trended toward shorter operative times. Further investigation of long-term glenoid baseplate loosening is imperative to fully understand the cost-effectiveness of superior augments in the setting of minimal glenoid deformity. [ABSTRACT FROM AUTHOR]

Porous metallic prosthesis components can now be manufactured using additive manufacturing techniques, and may prove beneficial for promoting bony ingrowth, for accommodating drug delivery systems, and for reducing stress shielding. Using finite element modeling techniques, 36 scenarios (three porous stems, three bone densities, and four held arm positions) were analysed to assess the viability of porous humeral stems for use in total shoulder arthroplasty, and their resulting mechanobiological impact on the surrounding humerus bone. All three porous stems were predicted to experience stresses below the yield strength of Ti6Al4V (880 MPa) and to be capable of withstanding more than 10 million cycles of each loading scenario before failure. There was an indication that within an 80 mm region of the proximal humerus, there would be a reduction in bone resorption as stem porosity increased. Overall, this study shows promise that these porous structures are mechanically viable for incorporation into permanent shoulder prostheses to combat orthopedic infections. [ABSTRACT FROM AUTHOR]

There has been limited evaluation of surgeon-specific factors on outcomes after total shoulder arthroplasty (TSA). The goals of this study were (1) to determine the impact of surgeon procedural volume, career duration, practice type, and fellowship training on TSA outcomes at 2-year follow-up and (2) to evaluate the relative importance of surgeon variables in relation to patient variables in influencing outcomes. The PearlDiver Mariner database was queried to identify all surgeons who performed a minimum of 11 TSA procedures from 2010 to 2018. An Internet search of publicly available data was performed to determine the career duration, practice type, and fellowship training of each surgeon. Multivariate logistic regression models were built to determine the relationship between surgeon-specific variables and 2-year surgical complications and revisions and 90-day readmissions. Variable importance of patient-specific and surgeon-specific factors was determined by the Akaike information criterion increase of these models. A total of 2188 surgeons who performed 93,122 TSA procedures were identified in this database. Higher reverse TSA surgical volume was associated with fewer surgical complications and revisions, although such a relationship was not observed for anatomic TSA. Revision after anatomic TSA was more common among surgeons who were in their first 5 years of practice. There was a higher risk of surgical complication and readmission among academic surgeons, but this did not equate with a higher risk of revision. The impact of these surgeon-specific factors on outcomes was small in relation to patient-level variables, such as age, sex, and number of medical comorbidities. Surgeon procedural volume, career duration, and practice setting influence the surgical complication, revision, and readmission rates after TSA. The impact of surgeon factors was small relative to patient variables, highlighting the importance of patient selection in mitigating adverse outcomes. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infections (PJIs) are devastating potential complications after arthroplasty surgery with significant therapeutic challenges. Many authors advocate for two-stage revision arthroplasty for PJI of the shoulder which includes explanation with antibiotic spacer placement. The optimal antibiotic/cement combination for PJI in the shoulder is not known. The purpose of this study is to analyze various cement and antibiotic concentrations against Coagulase negative staphylococcus species, S. epidermidis and S. lugdunensis. Five strains of coagulase negative Staph were taken from clinically documented orthopedic infections Both Simplex and Palacos cement were used to create antibiotic laden beads and mixed with either ertapenem, vancomycin, gentamicin, or a combination of ertapenem + vancomycin or ertapenem + gentamicin. The bacteria were plated on lysogeny broth agar plates and 3 beads were added per plate. Samples were analyzed for zone of inhibition at 24 hours, 72 hours, and 1 week. After 1 week, beads were transferred to new plates with bacteria and the process was repeated for 6 weeks. Results showed that ertapenem beads with both Simplex and Palacos cement showed the largest zones of inhibition for all samples. Vancomycin in Palacos cement and vancomycin in combination with ertapenem in Simplex and Palacos cement showed consistent zones of inhibition for the duration of the experiments. Ertapenem in combination with either vancomycin or gentamicin may allow for a powerful initial burst of killing followed by consistent antibiotic elution as opposed to gentamicin alone. While many premade spacers on the market are infused with gentamicin, our in vitro models demonstrate more efficacious bacterial eradication for antibiotics such as ertapenem and vancomycin specifically for certain low virulence organisms that are commonly found in PJI around the shoulder. [ABSTRACT FROM AUTHOR]

In total shoulder arthroplasty, the subscapularis tendon is routinely mobilized, by tenotomy, peel, or lesser tuberosity osteotomy, to visualize the joint and allow proper implant positioning. Careful mobilization of the subscapularis is undertaken to achieve an anatomic tension-free repair. This cadaveric study tests the biomechanical differences of 2 repair techniques of the subscapularis peel (SP) compared to the classically described technique. We hypothesize that adaptation of this SP technique using a custom-designed polyether-ether-ketone (PEEK) barrel in the bicipital groove may further stabilize suture repair of the subscapularis. Twenty paired cadaveric shoulder specimens underwent SP and repair via transosseous suture fixation. The PEEK barrel used was a laboratory prototype designed for the study (Catalyst OrthoScience, Naples, FL, USA). Five specimens were repaired using a traditional Mason-Allen suture; their paired shoulders were repaired using the PEEK barrel and a Mason-Allen suture. Five specimens were repaired using the Krackow suture; their paired shoulders were repaired using the PEEK barrel and a Krackow suture. Mechanical testing was performed using a uni-axial materials testing system with primary outcome of gap displacement and secondary outcomes of maximum load to failure and method of failure. The Krackow repair method with and without PEEK augmentation was significantly stiffer than the Mason-Allen repair method with and without PEEK augmentation (P <.001 across all groups). Adding augmentation changed the strength of the Mason-Allen repair without achieving statistical significance (P =.0925). Intergroup differences in cyclic displacement were not statistically significant. The Krackow repair methods had higher mean maximal load at failure than the Mason-Allen repairs of 534 ± 108 N and 266 ± 98 N, respectively (P <.001). Maximum load at 5 mm displacement was significantly different across groups (P =.004). Methods of failure in the Mason-Allen technique groups included knot and tendon failure, and in the Krackow technique groups included suture failure and lesser tuberosity fracture. Repairing the subscapularis with a Krackow suture is significantly stronger than a Mason-Allen repair in stiffness as well as load to failure. The results reported here compare a Krackow suture with a more common Mason-Allen suture configuration, and demonstrate the application of PEEK augmentation to subscapularis repair techniques. This study can guide surgeon selection of an ideal subscapularis repair technique for stemmed or stemless total shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) are proven surgical treatment options for both traumatic and degenerative conditions of the shoulder. Our objective is to report both clinical and patient-reported outcomes (PROs) of patients over the age of 75 at the time of arthroplasty. We hypothesize no functional difference in outcomes between patient groups. Patients over the age of 75 at the time of surgery who received primary aTSA or rTSA between 2009 and 2020 with a minimum of two-year follow-up were selected. A retrospective chart review was performed. Patients 60-75 were included as a control group. 2:1 propensity matching using sex, Charlson Comorbidity Index, preoperative forward elevation (FE), and external rotation (ER) was used in selecting a comparison cohort of patients 60-75. Statistical analysis included the t -test, Wilcoxon signed-rank test, and chi-squared test. For aTSA, 25 patients older than 75 years fit the inclusion criteria. The mean follow-up time was 4.2 (2.0-12.0) years. aTSA patients over the age of 75 had significant improvements in FE 111 to 141 degrees (P =.007), ER 28 to 44 degrees (P <.001), and internal rotation (IR) sacrum to L4 (P =.003). There were also improvements in FE strength (FES) 4+/5 to 5/5 (P =.0303) and IR strength (IRS) but not ER strength (ERS) from 4+/5 to 5/5 (P =.098). There was no significant difference in range of motion (ROM), strength, or PROs between age groups (>75 years vs. 60-74 years). For rTSA, 47 patients older than 75 years fit the inclusion criteria. Average clinical follow-up was 3.5 (2.0-10.6) years. Patients demonstrated ROM improvements in ER (31 to 40 degrees, P =.0413), FE (96 to 138 degrees, P <.001) but not IR (L5 to L4, P =.3509). There were significant improvements in postoperative strength in FES (4-/5 to 4+/5, P <.001), ERS (4-/5 to 4+/5, P <.001), and IRS (4/5 to 5/5, P <.001). The only significant difference between propensity-matched age groups was postoperative IR (L4 to L5, P =.013). There were no significant differences in PROs between different age groups. aTSA and rTSA provide significant improvements in ER, FE, ROM, ERS, FES, and IRS in patients over the age of 75 with no significant difference in outcomes compared to a younger cohort. [ABSTRACT FROM AUTHOR]

The purpose of this investigation is to compare Cutibacterium acnes diagnosis using culturing vs. genomic DNA sequencing (NextGen) at various timepoints and locations during primary total shoulder arthroplasty. Additionally, we intend to compare the effects of hydrogen peroxide on standard culture technique results with genomic DNA sequencing. A prospective diagnostic study of 40 patients undergoing primary total shoulder arthroplasty was performed. Intraoperatively, 4 tissue samples were collected per patient: subdermal skin edge following initial skin incision, subdermal skin edge following hydrogen peroxide soak for 5 minutes, glenohumeral joint capsule, and subdermal skin edge prior to wound closure. Each tissue specimen was collected twice (one for culture analysis and the other for genomic (NextGen) DNA sequencing analysis) for a total of 8 specimens per patient and 320 tissue specimens in total. All anaerobic cultures were held for 14 days. Each culture plate was divided into quadrants and the amount of growth was quantified. Tissue samples were collected for genomic sequencing DNA analysis. Genomic sequencing results provided relative percentage of bacteria for each specimen detected. There were 18/40 males (45%) and no postoperative complications. Average age was 72.2 ± 11.8. Overall, 18% (29/160) of standard anaerobic cultures were positive for C. Acnes and 26% (942/160) were positive with genomic (Nextgen) DNA sequencing. When comparing the NextGen results with anaerobic standard cultures, there was a calculated negative predictive value of 85.6% and positive predictive value of 28.6%. Sensitivity of the NextGen was 41.4% and specificity was 77.1%. Bacterial culture rates did not significantly change from the beginning to the end of surgery as demonstrated on standard culturing and the NextGen analysis (P >.05). After treatment with hydrogen peroxide, the standard culturing technique showed no significant difference between the samples; however, there was a significant increase in bacterial burden (12.4%) noted with NextGen analysis (P =.0147). NextGen culturing is a novel technique to help identify shoulder prosthetic joint infections. These results show that, NextGen is better at identifying the absence of infection, but has a high false positive rate indicative of its ability to identify contaminants as compared to standard anaerobic culturing methods. The increase in bacterial burden after peroxide treatment noted with NextGen could also be secondary to the test's increased ability to identify both living and dead bacterial pathogens. [ABSTRACT FROM AUTHOR]

Increased body mass index (BMI) is a potential risk factor for poorer outcomes and complications. However, the influence of BMI on the long-term outcomes of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) remains to be fully elucidated. Institutional records were queried to identify patients who underwent primary total shoulder arthroplasty (TSA) between 2009 and 2020 with a minimum of 2 years of clinical follow-up. Retrospective review was performed to collect demographic characteristics; comorbidity status; and range-of-motion and strength measurements in forward elevation, external rotation, and internal rotation. Patients were contacted by telephone to provide patient-reported outcomes (PROs). Patients were stratified into 3 cohorts by BMI: underweight or normal weight (U/NW, BMI ≤25 kg/m2), overweight (OW, BMI >25 to ≤30 kg/m2), and obese (BMI >30 kg/m2). Among 466 TSA patients, 245 underwent aTSA whereas 221 underwent rTSA. In the aTSA cohort, 40 patients were classified as U/NW; 72, as OW; and 133, as obese. Comparatively, the rTSA cohort was composed of 33 U/NW, 79 OW, and 209 obese patients. Patients in the aTSA and rTSA cohorts had an average follow-up period of 5.8 ± 3.2 years and 4.5 ± 2.3 years, respectively. No differences in age at surgery were found in the aTSA group (U/NW vs. obese, 65.2 ± 7.9 years vs. 61.9 ± 8.9 years; P =.133); however, in the rTSA cohort, BMI was found to be inversely related to age at surgery (U/NW vs. obese, 72.4 ± 8.8 years vs. 65.7 ± 8.3 years; P <.001). Across all BMI cohorts, patients saw great improvements in range of motion and strength. Postoperative PROs after TSA did not vary by BMI in terms of Single Assessment Numeric Evaluation, Simple Shoulder Test, visual analog scale pain, and American Shoulder and Elbow Surgeons scores. There was no significant difference in survival rates at 10-year follow-up in the aTSA cohort (U/NW vs. obese, 95.8% vs. 93.2%; P =.753) or rTSA cohort (U/NW vs. obese, 94.7% vs. 94.5%; P =.791). With dramatic improvements in range of motion, minimal differences in PROs, and high rates of implant survival, TSA is a safe and effective treatment option for all patients, including overweight and obese patients. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Background: Neglected anterior glenohumeral dislocations provide a challenging problem for physicians. For many patients with these injuries, reverse shoulder arthroplasty has been the treatment of choice, although the preservation of the patient's own humeral head might have significant advantages. Methods: We present a case of a 66-year-old male with a neglected anterior glenohumeral dislocation that he sustained 6 weeks prior when he was hit by a car as a pedestrian. Radiographic imaging revealed a large off-track Hill-Sachs deformity and a fracture of the greater tuberosity in addition to the persisting glenohumeral dislocation. We performed open reduction and to aid stability, an infraspinatus tendon remplissage and a Latarjet procedure were performed. Results: Apart from minor and self-limiting neuropraxia, recovery was without complications. At 24 month follow-up, the patient had no impairment in general activities, had no residual pain, and had a good active range of motion. Conclusions: The authors, therefore, believe that a combination of infraspinatus tendon remplissage and the Latarjet procedure seems a feasible alternative for reverse shoulder arthroplasty and can preserve the patient's own humeral head. [ABSTRACT FROM AUTHOR]

Prior research has shown that industry funding can impact the outcomes reported in medical literature. Limited data exist on the degree of bias that industry funding may have on shoulder arthroplasty literature outside of the Journal of Shoulder and Elbow Surgery. The purpose of this study is to characterize the type and frequency of funding for recently published shoulder arthroplasty studies and the impact of industry funding on reported outcomes. We hypothesized that studies with industry funding are more likely to report positive outcomes than those without. We performed a retrospective study searching all articles with the term "shoulder arthroplasty," "reverse shoulder arthroplasty," "anatomic total shoulder arthroplasty," or "total shoulder arthroplasty" on PubMed from the years January 2020 to December 2022. The primary outcome of studies was coded as either positive, negative, or neutral. A positive result was defined as one in which the null hypothesis was rejected. A negative result was defined as one in which the result did not favor the group in which the industry-funded implant was used. A neutral result was defined as one in which the null hypothesis was confirmed. Article funding type, subcategorized as National Institutes of Health funding or industry funding was recorded. Author disclosures were recorded to determine conflicts of interest. Statistical analysis was conducted using the χ2 test and Fisher exact test. A total of 750 articles reported on either conflict of interest or funding source and were included in the study. Of the total number of industry-funded studies, the majority were found to have a positive primary endpoint (58.1%, 104 of 179), as compared to a negative (7.8%, 14 of 179) or neutral endpoint (33.5%, 60 of 179) (P =.004). Overall, 363 articles reported an author conflict of interest, and the majority of these studies had positive primary endpoint (55.6%, 202 of 363) as compared to negative (9.1%, 33 of 363) or neutral endpoints (34.4%, 125 of 363) (P =.002). The results of this study suggest that there is a significant relationship between conflicts of interest and the primary outcome of shoulder arthroplasty studies, beyond the overall positive publication bias. Studies with industry funding and author conflicts of interest both report positive outcomes more frequently than negative outcomes. Shoulder surgeons should be aware of this potential bias when choosing to base clinical practice on published data. [ABSTRACT FROM AUTHOR]

Allograft prosthetic composite (APC) reconstruction is performed after resection of proximal humerus tumors or failure of arthroplasty implants. There is limited literature on the postoperative outcomes of this technique. We sought to assess implant survival, failure rates, and postoperative functional outcomes after APC reconstruction of the proximal humerus. A systematic review of the PubMed and Embase databases was conducted. The study was registered on PROSPERO (ID: 448,663). The Strengthening of the Reporting of Observational Studies in Epidemiology checklist was used for quality assessment. Implant failure was determined using the Henderson classification for biological reconstruction. Functional outcome was primarily assessed using the Musculoskeletal Tumor Society score at last follow-up. Twenty-five studies with a total of 488 patients were included. Mean follow-up in reporting studies ranged from 2.5 to 10 years. Five-year revision-free survival for implants ranged from 41% to 92%. Overall implant failure rate ranged from 9% to 54%, and reoperation rate ranged from 0% to 55%. Graft host nonunion (type 2) was the most common mode of failure, with rates ranging from 0% to 75%. The mean Musculoskeletal Tumor Society scores at last follow-up ranged from 57% to 90% across studies. A trend towards better functional outcomes was seen in patients having an APC with a reverse total shoulder arthroplasty (rTSA) compared with those with hemiarthroplasty. APCs show promise in proximal shoulder reconstruction, with heterogeneous functional outcomes that are noninferior to other reconstruction techniques. Graft host nonunion is a common mode of failure and remains a concern in this type of prosthesis. Future studies should compare rTSA-APCs and rTSA endoprostheses while controlling for potential confounders. [ABSTRACT FROM AUTHOR]

Glenoid placement is critical for successful outcomes in total shoulder arthroplasty (TSA). Preoperative templating with three-dimensional imaging has improved implant positioning, but deviations from the planned inclination and version still occur. Mixed-Reality (MR) is a novel technology that allows surgeons intra-operative access to three-dimensional imaging and templates, capable of overlaying the surgical field to help guide component positioning. The purpose of this study was to compare the execution of preoperative templates using MR vs.standard instruments (SIs). Retrospective review of 97 total shoulder arthroplasties (18 anatomic, 79 reverse) from a single high-volume shoulder surgeon between January 2021 and February 2023, including only primary diagnoses of osteoarthritis, rotator cuff arthropathy, or a massive irreparable rotator cuff tear. To be included, patients needed a templated preoperative plan and then a postoperative computed tomography scan. Allocation to MR vs. SI was based on availability of the MR headset, industry technical personnel, and the templated preoperative plan loaded into the software, but preoperative or intraoperative patient factors did not contribute to the allocation decision. Postoperative inclination and version were measured by two independent, blinded physicians and compared to the preoperative template. From these measurements, we calculated the mean difference, standard deviation (SD), and variance to compare MR and SI. Comparing 25 MR to 72 SI cases, MR significantly improved both inclination (P <.001) and version (P <.001). Specifically, MR improved the mean difference from preoperative templates (by 1.9° inclination, 2.4° version), narrowed the SD (by 1.7° inclination, 1.8° version), and decreased the variance (11.7-3.0 inclination, 14.9-4.3 version). A scatterplot of the data demonstrates a concentration of MR cases within 5° of plan relative to SI cases typically within 10° of plan. There was no difference in operative time. MR improved the accuracy and precision of glenoid positioning. Although it is unlikely that 2° makes a detectable clinical difference, our results demonstrate the potential ability for technology like MR to narrow the bell curve and decrease the outliers in glenoid placement. This will be particularly relevant as MR and other similar technologies continue to evolve into more effective methods in guiding surgical execution. [ABSTRACT FROM AUTHOR]

Reducing differences in the gender representation of shoulder arthroplasty surgeons may help optimize patient care. This work aimed to determine (1) the current gender distribution of surgeons performing shoulder arthroplasty, (2) how gender relates to practice patterns among shoulder arthroplasty surgeons, and (3) how gender distribution has been changing over time. The Medicare Provider Utilization and Payment Data for the years 2012-2020 were used to identify orthopedic surgeons performing anatomic and reverse total shoulder arthroplasty (Current Procedural Terminology code 23472). The data set provides self-reported gender, credentials, National Provider Identifier, annual volume of all procedures (based on Current Procedural Terminology codes) that were performed ≥11 times in the calendar year, and location for all included providers. The data set was linked to the Medicare Physician Compare data set using National Provider Identifiers to determine hospital affiliations, year of medical school graduation, and graduating medical school. All included hospitals were queried to determine academic status (affiliated orthopedic residency or fellowship program). The American Shoulder and Elbow Surgeons (ASES) directory was reviewed to determine the gender breakdown of current members. The number of surgeons performing ≥11 shoulder arthroplasties annually increased from 821 (13 women [1.6%]) in 2012 to 1840 (53 women [2.9%], P =.05) in 2019. One female surgeon ranked in the top 100 surgeons by shoulder arthroplasty volume in 2012 and in 2020. Female surgeons graduated more recently from medical school (mean, 2005) compared with male surgeons (mean, 1997; P <.001). About 10% of female surgeons (10.8%, 12 of 111) and male surgeons (9.1%, 229 of 2528) practiced at hospitals with orthopedic residents (P =.50). Female surgeons performing shoulder arthroplasty were less likely than male surgeons to perform total knee arthroplasty (29.4% vs. 54.1%, P <.001) and total hip arthroplasty (12.6% vs. 34.7%, P <.001). There were 86 female members of ASES (6.7%, 86 of 1275), with a significant difference in the proportion of women in differing membership categories (P =.017). A diverse cohort of high-volume shoulder replacement surgeons is integral to delivering high-quality shoulder arthroplasty. Currently, the proportion of women performing high-volume shoulder replacement in the United States is small, with little improvement in recent years. However, women performing shoulder arthroplasty are younger and are often involved in academic practices, and the membership of ASES is increasingly female. Continued efforts to promote orthopedics—and to mentor female residents and medical students interested in shoulder surgery—may bring real change to the gender differences among shoulder replacement surgeons over the coming years. [ABSTRACT FROM AUTHOR]

Artificial intelligence (AI) and large language models (LLMs) offer a new potential resource for patient education. The answers by Chat Generative Pre-Trained Transformer (ChatGPT), a LLM AI text bot, to frequently asked questions (FAQs) were compared to answers provided by a contemporary Google search to determine the reliability of information provided by these sources for patient education in upper extremity arthroplasty. "Total shoulder arthroplasty" (TSA) and "total elbow arthroplasty" (TEA) were entered into Google Search and ChatGPT 3.0 to determine the ten most FAQs. On Google, the FAQs were obtained through the "people also ask" section, while ChatGPT was asked to provide the ten most FAQs. Each question, answer, and reference(s) cited were recorded. A modified version of the Rothwell system was used to categorize questions into 10 subtopics: special activities, timeline of recovery, restrictions, technical details, cost, indications/management, risks and complications, pain, longevity, and evaluation of surgery. Each reference was categorized into the following groups: commercial, academic, medical practice, single surgeon personal, or social media. Questions for TSA and TEA were combined for analysis and compared between Google and ChatGPT with a 2 sample Z-test for proportions. Overall, most questions were related to procedural indications or management (17.5%). There were no significant differences between Google and ChatGPT between question categories. The majority of references were from academic websites (65%). ChatGPT produced a greater number of academic references compared to Google (80% vs. 50%; P =.047), while Google more commonly provided medical practice references (25% vs. 0%; P =.017). In conjunction with patient-physician discussions, AI LLMs may provide a reliable resource for patients. By providing information based on academic references, these tools have the potential to improve health literacy and improved shared decision making for patients searching for information about TSA and TEA. With the rising prevalence of AI programs, it is essential to understand how these applications affect patient education in medicine. [ABSTRACT FROM AUTHOR]

Background: In the last years, there has been increasing use of shoulder arthroplasty. As a result, an increasing incidence of periprosthetic humerus fractures (PPHF) is expected. Therefore, this retrospective, multicenter analysis aimed to collect demographic data from patients with PPHF, their treatment strategies, and associated complications. Methods: Demographics of patients with PPHF were collected retrospectively from the database of six trauma hospitals between January 2000 and December 2020. All fractures were categorized according to the Wright and Cofield, and Worland classifications. In addition, the type of treatment for PPHF, as well as subsequent complications, were evaluated. Results: A total of 72 patients with a PPHF were identified. The mean age of the 55 female and 17 male patients was 77 years. PPHF occurred a mean of 50 months after primary arthroplasty implantation, almost exclusively as a result of a fall from standing height (n = 67). In-situ implant was a RTSA in 40 patients and a hemiarthroplasty in 32 patients. More than half of the fractures (n = 38) were type B fractures, according to Wright and Cofield. According to Worland, the majority of patients also had a type B fracture (type B1 (n = 22), type B2 (n = 28), type B3 (n = 10)). Associated comorbidities were found in 21 patients. A total of 31 patients were treated non-operatively, 27 with Open Reduction Internal Fixation (ORIF), and 14 with a revision arthroplasty. Nine primary radial nerve palsies were found (pre-operatively), and seven secondarily (post-operatively). Nine patients suffered from non-union (ORIF 4, non operative 4, stem replacement 1). Conclusion: The treatment strategy for PPHF is primarily tailored to the individual patient. Decisive factors such as patient's age, fracture type, and primary palsies have to be considered for optimal treatment. In type B1 fractures, there is a recommendation for ORIF because of high non-union rates under non-operative treatment. In contrast, in type B2 fractures, a non-operative approach should be preferred, provided there are no radial nerve lesions. Level of evidence: Level IV, epidemiologic study. [ABSTRACT FROM AUTHOR]

Revision shoulder arthroplasty (SA) is a surgical procedure performed to address complications or failures of primary total SA. However, limited evidence exists regarding the functional outcomes and longevity of implants following revision. A retrospective analysis was conducted on patients who underwent revision SA for failed primary arthroplasty at a single institution between 2009 and 2021 with a minimum of 2-years follow-up. Data was collected from medical records, including type of arthroplasty (anatomic total SA [TSA], reverse total SA [RSA], or hemi-SA [HSA]), demographics and patient-specific information, functional measurements, and implant survival. Patient reported outcomes were obtained during follow-up by phone. The mean age at index and revision surgeries was 60.5 ± 12.1 years and 64.8 ± 11.1 years, respectively, and average total follow-up was 5.5 ± 3.5 years. The average time to revision was 4.5 ± 5.2 years (range 0.01–24.5 years). Among 99 revision shoulder arthroplasty procedures, 28 were TSA/HA to TSA/HA, 51 were TSA/HA to RSA, 18 were RSA to RSA, and 2 were RSA to HA. Revision surgery significantly improved functional outcomes in forward elevation (preoperative: 79.8 ± 41.0 vs postoperative: 118.5 ± 38.3; p < 0.001), external rotation (preoperative: 27.8 ± 19.3 vs postoperative: 34.3 ± 16.2; p = 0.028), internal rotation (preoperative: glute vs postoperative: S1; p = 0.002), and forward elevation strength (preoperative: 4+/5 vs postoperative: 5/5; p = 0.002). Postoperative patient reported outcomes included: VAS pain (2.2 ± 2.9), SANE (72.6 ± 21.5), ASES (73.3 ± 20.4), and SST (7.7 ± 2.8) scores. The overall 2-, 5-, and 10-year post-revision implant survival rate was 85.48%, 83.06%, and 79.84%, respectively. Patients who had an initial RSA and were revised to RSA were at higher risk of implant failure and subsequent re-revision (RSA to RSA: 1.5 ± 2.5 years vs. TSA/HA to RSA: 2.5 ± 2.1 years vs. TSA/HA to TSA/HA: 4.0 ± 3.5 years; p = 0.0046) Revision shoulder arthroplasty improved patient outcomes post-index arthroplasty failure. Revisions were more likely to be successful when revising from TSA/HA to RSA. Level III – retrospective comparative study. [ABSTRACT FROM AUTHOR]

ObjectiveWe aimed to evaluate the difference in 30-day outcomes after surgical management of proximal humerus fractures (PHFs) between patients with and without chronic liver disease as defined by a MELD score greater than 10.DesignThis was a retrospective database review.SettingAll centers participating in the American College of Surgeons National Surgical Quality Improvement Program database were included.Patients/participantsPatients with proximal humerus fractures who (1) underwent ORIF, HA, or SA and (2) had calculable MELD scores were included.InterventionOpen reduction and internal fixation, hemiarthroplasty, or shoulder arthroplasty was used for treatment.Main outcome measurementsThirty-day complications, mortality, readmission, and reoperation rates were measured.ResultsOf the total 1732 PHF patients identified, 300 had a MELD score higher than 10. After propensity matching by significant covariates, MELD score higher than 10 was found to be significantly associated with higher rates of 30-day mortality, 30-day readmission, transfusion within 72 hours, and systemic complications. Among patients with a MELD score higher than 10, treatment with SA or HA instead of ORIF was associated with a higher rate of transfusion and longer operative time. There were no significant differences between treatment cohorts regarding mortality, reoperation, readmission, or complications.ConclusionsA MELD score higher than 10 is associated with higher risk of surgical complications, transfusion, and death in patients undergoing surgery for proximal humerus fractures. Among patients with a MELD score higher than 10, ORIF was associated with a lower transfusion rate and shorter operative time than arthroplasty or hemiarthroplasty.Level of evidencePrognostic Level III.

BACKGROUND: End-stage renal disease (ESRD) and renal transplant (RT) patients are known to have more perioperative and postoperative complications after arthroplasty surgeries when compared to patients without. We hypothesize that RT patients undergoing shoulder arthroplasty (SA) have fewer systemic and surgical complications when compared to ESRD patients undergoing SA. METHODS: This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone primary total and reverse shoulder arthroplasty, respectively, and subsequent surgical revisions. Unadjusted univariate analysis of patient demographics, Charlson Cormorbidty Index, and surgical complications at 90 days, 1 year, and 2 years after was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for systemic complications and prosthesis outcomes at all time points. RESULTS: Of 1191 patients with ESRD or previous RT and who underwent either total shoulder arthroplasty or reverse total shoulder arthroplasty, 1042 (87.5%) had ESRD and 149 (12.5%) had a previous RT. ESRD SA patients were more likely to have hypertension, liver disease, coronary artery disease, and hypothyroidism. Interestingly no statistical significance was found in multivariate analysis for systemic complications at 90 days, nor for surgical complications at the 90-day, 1-year, or 2-year mark between ESRD and RT cohorts. CONCLUSION: SAs have comparable outcomes in ESRD and RT patients. The differing conclusions among studies might be partially accounted for by the demographic differences and comorbidities between these 2 patient populations. Providers should continue to provide appropriate counseling concerning risks, benefits, and timing of SA for these patients.

Purpose: Shoulder arthroscopy and arthroplasty are increasingly common procedures used to address shoulder pathologies. This study sought to evaluate the incidence of hand-related pathologies, including carpal tunnel syndrome (CTS), cubital tunnel syndrome (CuTS), trigger finger (TF), de Quervain tenosynovitis, and Dupuytren disease following shoulder arthroscopy and arthroplasty procedures. We hypothesized that patients undergoing shoulder surgery would have a higher incidence of hand-related pathologies within 1 year of surgery compared to controls. Methods: This was a retrospective analysis of 12,179 patients who underwent shoulder arthroscopy or arthroplasty surgery that were subsequently diagnosed with CTS, CuTS, TF, de Quervain tenosynovitis, or Dupuytren disease within 1 year after surgery. Relative risk of having associated hand pathologies following shoulder surgery was compared to controls. Results: In total, 10,285 patients underwent shoulder arthroscopy procedures during this period, of whom 815 (7.9%) had an associated hand pathology within 1 year from their shoulder procedure. Arthroscopic surgery was associated with an increased likelihood of having a hand pathology (RR 1.65, 95% CI 1.54–1.76), CTS (RR 1.57, 95% CI 1.42–1.73), CuTS (RR 2.25, 95% CI 1.94–2.61), TF (RR 1.76, 95% CI 1.53–2.03), and Dupuytren disease (RR 2.02, 95% CI 1.54–2.65), but was not associated with a higher likelihood of having de Quervain tenosynovitis. In total, 1,894 patients underwent shoulder arthroplasty procedures during this period, of whom 188 (9.9%) had an associated hand pathology within 1 year. Shoulder arthroplasty was associated with an increased likelihood of having a hand pathology (RR 2.04, 95% CI 1.78–2.34), CTS (RR 2.10, 95% CI 1.72–2.57), CuTS (RR 3.29, 95% CI 2.48–4.39), and TF (RR 1.99, 95% CI 1.47–2.70), but was not associated with an increased likelihood of having de Quervain tenosynovitis or Dupuytren disease. Conclusions: Shoulder arthroscopy and arthroplasty procedures were associated with an increased likelihood of having a CTS, CuTS, or a TF diagnosis made within 1 year of surgery. Only shoulder arthroscopy procedures were associated with a higher likelihood of having Dupuytren disease. Neither shoulder arthroscopy nor arthroplasty procedures were associated with an increased likelihood of a diagnosis of de Quervain tenosynovitis. These associations, however, do not necessarily imply causation, and further investigation is warranted to delineate this relationship. Type of study/level of evidence: Differential Diagnosis/Symptom Prevalence Study Level 3.

This communication aims to present that shoulder arthroplasty has established itself as a treatment method for proximal humerus fractures. The use in clinical practice of the inverted type of shoulder arthroplasty, combined with rotator cuff repair, has expanded the options for surgeons and enabled better clinical outcomes in the treatment of this type of damage. Purpose: Presenting the early results of reverse shoulder endoprosthesis when combined with restoration of the rotator cuff tendons. Material and methods: We present five patients with proximal humerus fractures, in which a humeral reverse endoprosthesis was used, combined with repair and reinsertion of rotator cuff tendons. Results: From the achieved results, the rapid progress in restoring the range of motion in the shoulder joint and the mild limitation of external rotation are impressive, and we rate these early results as very good. Conclusions: We believe that rotator cuff structures restoration is important to ensure the stability of the shoulder joint in reverse shoulder arthroplasty and has a direct relation with the achievement of good clinical results in the early postoperative period.

Background: Shoulder arthroplasty has become an increasingly common procedure used to treat degenerative, inflammatory, and traumatic conditions of the glenohumeral joint. With a significant increase in primary anatomic and reverse total shoulder arthroplasty, revision procedures have likewise increased. Updates in shoulder arthroplasty have allowed for the convertibility of implants, which allows for the retention of both glenoid and humeral components during revision surgery. This review aims to highlight the epidemiology, indications, and outcomes of convertible-platform total shoulder arthroplasty procedures. Methods: A review of the current literature surrounding convertible-platform shoulder arthroplasty was completed to highlight the advantages and disadvantages of commercially available instrumentation and implant systems as well as their outcomes. Discussion: Leading causes of shoulder arthroplasty revision surgery include glenoid failure, implant instability, and rotator cuff dysfunction. Variations in implant design between inlay and onlay humeral components and metal-backed glenoid components are important considerations at the time of revision surgery. Advantages of convertible-platform systems include increased efficiency and decreased complications during revision procedures as well as shorter recovery, lower cost, and better functional outcomes. Limitations of convertible systems include poorly positioned components during the index procedure, excessive soft-tissue tensioning, and problems associated with metal-backed glenoid implants. Changes in arm length have also been documented. These findings indicate the benefit of additional research and design to improve the effectiveness and utility of convertible-platform shoulder arthroplasty systems.

A lesser tuberosity osteotomy (LTO) is commonly performed during total shoulder arthroplasty to access the glenohumeral joint. Healing of the LTO is critical to optimizing the outcome of the procedure and is enhanced by a repair that provides stability and compression across the osteotomy site. The purpose of this article is to describe a technique that uses a tensionable suture construct to repair the LTO during anatomic total shoulder arthroplasty using a stemless humeral component. The technique involves passing a row of high-tensile sutures through bone tunnels lateral to the osteotomy site (transosseous sutures) and another row of sutures through the humeral implant (implant sutures). One limb of each bone tunnel suture is then tied to its corresponding limb of implant suture and the remaining free strands of the tied sutures are manually tensioned and tied to each other. This technique is an efficient and reproducible method for creating compression and stability across the osteotomy site that facilitates bony healing.

Background: Preoperative 3D planning is routinely used in primary shoulder arthroplasty, while specific challenges in the revision setting make such approaches more cumbersome and less accessible. Recently, an established preoperative planning software (Blueprint; Stryker, Tornier SAS, Montbonnot-Saint-Martin, France) was expanded to offer a capability for planning of revision and complex primary shoulder arthroplasty cases. The aim of this study was to survey experienced surgeons on their perception of the new software feature for preoperative 3D planning in the setting of revision shoulder arthroplasty. Methods: An observational survey was conducted from January 2022 to October 2022 among orthopedic surgeons performing revision shoulder arthroplasty cases. The survey was part of the Early Product Surveillance program, with the primary goal of obtaining observational data from surgical experience in a real-world setting. A two-staged survey process was applied with separate questionnaires to seek voluntary feedback on the preoperative planning phase as well as on the intraoperative evaluation of the software planning features in revision shoulder arthroplasty. Results: Twenty-five fellowship-trained orthopedic surgeons from the USA and Canada participated in the survey and reported their feedback on 34 revision shoulder arthroplasty cases that were preoperatively planned with the use of Blueprint revision planning software. The surgeons were largely in favor of the revision software planning features and confirmed perceived benefits of its use in the preoperative planning stage of revision shoulder arthroplasty cases. Reported benefits in the preoperative planning phase included increased efficiency and improved ease of creating an appropriate surgical plan as well as increased confidence to execute revision shoulder arthroplasty cases. Surgeons also noted improvements in translation of preoperative planning to intraoperative execution of revision cases, including more appropriate implant selection and improved accuracy of implant placement. Conclusion: The feedback from fellowship-trained shoulder arthroplasty surgeons on the use of the new software feature for preoperative 3D planning of revision shoulder arthroplasty is largely favorable. Further research should be conducted to investigate whether these surgeon-perceived benefits can lead to improved clinical outcomes for patients.

Aims: Shoulder arthroplasty is effective in the management of end-stage glenohumeral joint arthritis. However, it is major surgery and patients must balance multiple factors when considering the procedure. An understanding of patients’ decision-making processes may facilitate greater support of those considering shoulder arthroplasty and inform the outcomes of future research. Methods: Participants were recruited from waiting lists of three consultant upper limb surgeons across two NHS hospitals. Semi-structured interviews were conducted with 12 participants who were awaiting elective shoulder arthroplasty. Transcribed interviews were analyzed using a grounded theory approach. Systematic coding was performed; initial codes were categorized and further developed into summary narratives through a process of discussion and refinement. Data collection and analyses continued until thematic saturation was reached. Results: Two overall categories emerged: the motivations to consider surgery, and the information participants used to inform their decision-making. Motivations were, broadly, the relief of pain and the opportunity to get on with life and regain independence. When participants’ symptoms and restrictions prevented them enjoying life to a sufficient extent, this provided the motivation to proceed with surgery. Younger participants tended to focus on maintaining employment and recreational activities, and older patients were eager to make the most of their remaining lifetime. Participants gathered information from a range of sources and were keen to optimize their recovery where possible. An important factor for participants was whether they trusted their surgeon and were prepared to delegate responsibility for elements of their care. Conclusion: Relief of pain and the opportunity to get on with life were the primary reasons to undergo shoulder arthroplasty. Participants highlighted the importance of the patient-surgeon relationship and the need for accurate information in an accessible format which is relevant to people of different ages and functional demands. Cite this article: Bone Jt Open 2024;5(7):543–549.

John Twomey-Kozak, Kwabena Adu-Kwarteng,&ast; Kiera Lunn,&ast; Damon Vernon Briggs, Eoghan Hurley, Oke A Anakwenze, Christopher S Klifto Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA&ast;These authors contributed equally to this workCorrespondence: John Twomey-Kozak, Duke University Medical Center, Department of Orthopaedic Surgery, Durham, NC, USA, Email jnt25@duke.eduPurpose of Review: This narrative review comprehensively aims to analyze recent advancements in shoulder arthroplasty, focusing on implant systems and their impact on patient outcomes. The purpose is to provide a nuanced understanding of the evolving landscape in shoulder arthroplasty, incorporating scientific, regulatory, and ethical dimensions.Recent Findings: The review synthesizes recent literature on stemless implants, augmented glenoid components, inlay vs onlay configurations, convertible stems, and associated complications. Notable findings include improved patient-reported outcomes with stemless implants, variations in outcomes between inlay and onlay configurations, and the potential advantages of convertible stems. Additionally, the regulatory landscape, particularly the FDA’s 510(k) pathway, is explored alongside ethical considerations, emphasizing the need for standardized international regulations.Summary: Recent innovations in shoulder arthroplasty showcase promising advancements, with stemless implants demonstrating improved patient outcomes. The review underscores the necessity for ongoing research to address unresolved aspects and highlights the importance of a standardized regulatory framework to ensure patient safety globally. The synthesis of recent findings contributes to a comprehensive understanding of the current state of shoulder arthroplasty, guiding future research and clinical practices.Keywords: shoulder arthroplasty, rTSA, stemless implants, glenoid components, patient outcomes, innovations in arthroplasty

Accurate component placement in shoulder arthroplasty is crucial for avoiding complications, achieving superior biomechanical performance and optimizing functional outcomes. Shoulder and elbow surgeons have explored various methods to improve surgical understanding and precise execution including preoperative planning with 3D computed tomography (CT), patient-specific instrumentation (PSI), intraoperative navigation, and mixed reality (MR). 3D preoperative planning facilitated by CT scans and advanced software, enhances surgical precision, influences decision-making for implant types and approaches, reduces errors in guide pin placement, and contributes to cost-effectiveness. Navigation demonstrates benefits in reducing malpositioning, optimizing baseplate stability, improving humeral cut, and potentially conserving bone stock, although challenges such as varied operating times and costs warrant further investigation. The personalized patient care and enhanced operational efficiency associated with PSI are not only attractive for achieving desired component positions but also hold promise for improved outcomes in complex cases involving glenoid bone loss. Augmented reality (AR) and virtual reality (VR) technologies play a pivotal role in reshaping shoulder arthroplasty. They offer benefits in preoperative planning, intraoperative guidance, and interactive surgery. Studies demonstrate their effectiveness in AR-guided guidewire placement, providing real-time surgical advice during reverse total shoulder arthroplasty (RTSA). Additionally, these technologies show promise in orthopedic training, delivering superior realism and accelerating learning compared to conventional methods.

Abstract Background The use of reverse total shoulder arthroplasty (RTSA) has increased at a greater rate than other shoulder procedures. In general, clinical and functional outcomes after RTSA have been favorable regardless of indication. However, little evidence exists regarding patient specific factors associated with clinical improvement after RTSA. Predicting postoperative outcomes after RTSA may support patients and physicians to establish more accurate patient expectations and contribute in treatment decisions. The aim of this study was to determine predictive factors for postoperative outcomes after RTSA for patients with degenerative shoulder disorders. Methods EMBASE, PubMed, Cochrane Library and PEDro were searched to identify cohort studies reporting on predictive factors for postoperative outcomes after RTSA. Authors independently screened publications on eligibility. Risk of bias for each publication was assessed using the QUIPS tool. A qualitative description of the results was given. The GRADE framework was used to establish the quality of evidence. Results A total of 1986 references were found of which 11 relevant articles were included in the analysis. Risk of bias was assessed as low (N = 7, 63.6%) or moderate (N = 4, 36.4%). According to the evidence synthesis there was moderate-quality evidence indicating that greater height predicts better postoperative shoulder function, and greater preoperative range of motion (ROM) predicts increased postoperative ROM following. Conclusion Preoperative predictive factors that may predict postoperative outcomes are: patient height and preoperative range of motion. These factors should be considered in the preoperative decision making for a RTSA, and can potentially be used to aid in preoperative decision making. Level of evidence Level I; Systematic review.

Abstract Purpose This systematic review aims to provide an overview of the current knowledge on the role of the metaverse, augmented reality, and virtual reality in reverse shoulder arthroplasty. Methods A systematic review was performed using the PRISMA guidelines. A comprehensive review of the applications of the metaverse, augmented reality, and virtual reality in in-vivo intraoperative navigation, in the training of orthopedic residents, and in the latest innovations proposed in ex-vivo studies was conducted. Results A total of 22 articles were included in the review. Data on navigated shoulder arthroplasty was extracted from 14 articles: seven hundred ninety-three patients treated with intraoperative navigated rTSA or aTSA were included. Also, three randomized control trials (RCTs) reported outcomes on a total of fifty-three orthopedics surgical residents and doctors receiving VR-based training for rTSA, which were also included in the review. Three studies reporting the latest VR and AR-based rTSA applications and two proof of concept studies were also included in the review. Conclusions The metaverse, augmented reality, and virtual reality present immense potential for the future of orthopedic surgery. As these technologies advance, it is crucial to conduct additional research, foster development, and seamlessly integrate them into surgical education to fully harness their capabilities and transform the field. This evolution promises enhanced accuracy, expanded training opportunities, and improved surgical planning capabilities.

Abstract Background Artificial intelligence (AI) uses computer systems to simulate cognitive capacities to accomplish goals like problem-solving and decision-making. Machine learning (ML), a branch of AI, makes algorithms find connections between preset variables, thereby producing prediction models. ML can aid shoulder surgeons in determining which patients may be susceptible to worse outcomes and complications following shoulder arthroplasty (SA) and align patient expectations following SA. However, limited literature is available on ML utilization in total shoulder arthroplasty (TSA) and reverse TSA. Methods A systematic literature review in accordance with PRISMA guidelines was performed to identify primary research articles evaluating ML’s ability to predict SA outcomes. With duplicates removed, the initial query yielded 327 articles, and after applying inclusion and exclusion criteria, 12 articles that had at least 1 month follow-up time were included. Results ML can predict 30-day postoperative complications with a 90% accuracy, postoperative range of motion with a higher-than-85% accuracy, and clinical improvement in patient-reported outcome measures above minimal clinically important differences with a 93%–99% accuracy. ML can predict length of stay, operative time, discharge disposition, and hospitalization costs. Conclusion ML can accurately predict outcomes and complications following SA and healthcare utilization. Outcomes are highly dependent on the type of algorithms used, data input, and features selected for the model. Level of Evidence III

Purpose: The influence of the subscapularis tendon on reverse total shoulder arthroplasty (RTSA) has been discussed controversially. The aim of the study was to investigate the subscapularis-sparing approach for RTSA and the effect of the intact subscapularis tendon. Methods: This retrospective comparative study included 93 patients. Among these, 55 underwent the deltopectoral subscapularis-sparing approach, and in 38 cases, the standard deltopectoral approach with subscapularis tenotomy was applied. At the final follow-up, representative shoulder scores were measured, radiographs were taken in two planes, and shoulder sonography was performed. Results: The subscapularis-sparing group showed a significantly higher Constant score (71.8 vs. 65.9 points) and adapted Constant score if the subscapularis tendon was shown to be intact in the postoperative sonography (85.2% vs. 78.6%) (p = 0.005; p = 0.041). Furthermore, these patients had improved abduction (128.2 vs. 116.8, p = 0.009) and external rotation (34.6 vs. 27.1, p = 0.047). However, no significant differences were found for the degree of internal rotation and internal rotation strength. No dislocation or infection was observed. The degree of scapular notching was not significantly different between the two groups (p = 0.082). However, independently from the integrity of the subscapularis the subscapularis-sparing approach showed no difference in clinical and radiographic outcome (Constant score scapularis-sparing 70.0 points vs. tenotomy 66.8 points; p = 0.27). Conclusion: The subscapularis-sparing approach RTSA showed improved clinical outcome, abduction, and external rotation, if the subscapularis was shown to be intact at time of follow-up. Both groups showed no difference in internal rotation. [ABSTRACT FROM AUTHOR]

Artificial intelligence (AI) is amongst the most rapidly growing technologies in orthopedic surgery. With the exponential growth in healthcare data, computing power, and complex predictive algorithms, this technology is poised to aid providers in data processing and clinical decision support throughout the continuum of orthopedic care. Understanding the utility and limitations of this technology is vital to practicing orthopedic surgeons, as these applications will become more common place in everyday practice. AI has already demonstrated its utility in shoulder and elbow surgery for imaging-based diagnosis, predictive modeling of clinical outcomes, implant identification, and automated image segmentation. The future integration of AI and robotic surgery represents the largest potential application of AI in shoulder and elbow surgery with the potential for significant clinical and financial impact. This editorial's purpose is to summarize common AI terms, provide a framework to understand and interpret AI model results, and discuss current applications and future directions within shoulder and elbow surgery. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infections (PJI) of the shoulder are a devastating complication of shoulder arthroplasty and are commonly caused by Staphylococcus and Cutibacterium acnes. Absorbable calcium sulfate (CS) beads are sometimes used for delivering antibiotics in PJI. This study evaluates the in vitro effect of different combinations of gentamicin, vancomycin, and ertapenem in beads made from CS cement on the growth of C acnes and coagulase-negative Staphylococcus (CNS) strains. Three strains of C acnes and 5 strains of CNS from clinically proven shoulder PJI were cultured and plated with CS beads containing combinations of vancomycin, gentamicin, and ertapenem. Plates with C acnes were incubated anaerobically while plates with Staphylococcus were incubated aerobically at 37 °C. Zones of inhibition were measured at intervals of 3 and 7 days using a modified Kirby Bauer technique, and beads were moved to plates containing freshly streaked bacteria every seventh day. This process was run in triplicate over the course of 56 days. Statistical analysis was conducted using SPSS v. 28 with repeated measures analysis of variance (ANOVA) and pairwise comparisons with Tukey correction. In experiments with C acnes , beads containing ertapenem + vancomycin and vancomycin alone formed the largest zones of inhibition over time (P <.001). In experiments with Staphylococcus , beads containing vancomycin alone formed the largest zones of inhibition over time for all 5 strains (P <.001). Zones of inhibition were 1.4x larger for C acnes than for Staphylococcus with beads containing vancomycin alone. For both C acnes and Staphylococcus , beads containing ertapenem had the strongest initial effect, preventing all bacterial growth in C acnes and almost all growth for Staphylococcus during the first week but dropping substantially by the second week. Beads containing gentamicin alone consistently created smaller zones of inhibition than beads containing vancomycin alone, with vancomycin producing zones 5.3x larger than gentamicin in C acnes and 1.3x larger in Staphylococcus (P <.001). These data suggest that for both C acnes and Staphylococcal species, CS beads impregnated with vancomycin were most effective at producing a robust antibiotic effect. Additionally, ertapenem may be a viable supplement in order to create a more potent initial antibiotic effect but is not as effective as vancomycin when used alone. Gentamicin alone was not effective in maintaining consistent and long-term antibiotic effects. These results indicate that amongst the antibiotics currently commercially available to be used with CS, vancomycin is consistently superior to gentamicin in the setting of C. acnes and CNS. [ABSTRACT FROM AUTHOR]

Home health services provide patients with additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complication and reduce health care utilization. The aim of this investigation was to determine if patients assigned home health services following total shoulder arthroplasty (anatomic [TSA] and reverse [RSA]) exhibited lower rates of medical complications, lower health care utilization, and lower cost of care compared with patients not receiving these services. A national insurance database was retrospectively reviewed to identify all patients undergoing primary TSA and RSA from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home without services. We compared medical complication rates, emergency department (ED) visits, readmissions, and 90-day cost of care between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on all outcomes. A total of 1119 patients received home health services and were matched to 11,190 patients who were discharged home without services. There was no significant difference in patients who received home health services compared with those who did not receive home health services with respect to rates of ED visits within 30 days (OR 1.293; P =.0328) and 90 days (OR 1.215; P =.0378), whereas the home health group demonstrated increased readmissions within 90 days (OR 1.663; P <.001). For all medical complications, there was no difference between cohorts. Episode-of-care costs for home health patients were higher than those discharged without these services ($12,521.04 vs. $9303.48; P <.001). Patients assigned home health care services exhibited higher cost of care and readmission rates without a reduction in the rate of complication or early return to the ED. These findings suggest that home health care services should be strongly analyzed on a case-by-case basis to determine if a patient may benefit from its implementation. [ABSTRACT FROM AUTHOR]

Background: Patients suffering from osteoarthritis particularly complain about pain during day and night as well as loss of function. This consequently leads to impaired quality of life and therefore psychological stress. The surgical therapy of choice is joint replacement. Regarding the outcome after operation, expectations might differ between the patient and the surgeon. This can lead to dissatisfaction on both sides. This study aimed to document patients' expectations of a planned shoulder joint replacement. The results were compared with assessments made by shoulder surgeons. Methods: In total, 50 patients scheduled for operative shoulder joint replacement were included in this study, as well as 10 shoulder surgeons. Patients were requested to fill out questionnaires preoperatively to provide sociodemographic data, PROMS (Patient-Reported Outcome Measures) with regard to the pathology and their expectations about surgery in terms of pain relief, gain of range of motion, strength as well as the impact on activities of daily and professional life and sports. In addition, surgeons were asked what they thought their patients expect. Results: The most important goal to achieve for patients was to relieve daytime pain, followed by improvement of self-care and the ability to reach above shoulder level. The most important factors for patients to achieve after operation were 'pain relief' in first place, 'movement' in second and 'strength' in third. This also applied to shoulder surgeons, who ranked 'pain relief' first, followed by 'movement' and 'strength'. When patients where asked what is most important when it comes to choosing their surgeon, 68% voted for 'surgical skills', 28% for 'age/experience', followed by 'empathy', 'sympathy' and 'appearance'. For surgeons, 'age/experience' obtained rank one, 'surgical skills' was ranked second, followed by 'sympathy', 'empathy' and 'appearance'. Surgeons significantly underrated the factor 'empathy' in favor of 'sympathy'. Conclusions: This study shows that patients' expectations for shoulder joint replacement and surgeons' assessments do not differ significantly. Relief from pain and better shoulder movement were crucial for patients to achieve after operation, which was in line with surgeons' expectations. The most important factor for choosing the surgeon was 'surgical skills' for patients, while surgeons thought they would care more about 'age and experience'. This underlines that patients' expectations should be taken into account within the preoperative medical interview. This might allow an optimization of compliance of the patients and lead to a better satisfaction on both sides. [ABSTRACT FROM AUTHOR]

Two designs of primary reverse total shoulder arthroplasty (rTSA), inlay reverse total shoulder arthroplasty (in-rTSA) and onlay reverse total shoulder arthroplasty (on-rTSA) that had undergone an aseptic revision were compared to determine differences in the rate of rerevision. In this comparative observational national registry study between January 1, 2012, and December 31, 2021, all rTSA utilizing either a modular inlay or onlay metaphyseal humeral component that had been revised for aseptic reasons formed 2 cohort groups. The cumulative percentage rerevision (2nd CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazard models adjusted for age and sex. A minor category revision involved exchange of parts not fixed to bone whilst major revisions did. The primary and revision diagnoses, surgeon primary volume experience, and revision category were compared. Shoulder Modular Replacement (SMR)/SMR L1 or L2 combination (Lima Corporate, San Daniele del Friuli, Italy) was excluded at subanalysis. The 2nd CPR at 3 years was 20.4% (95% confidence interval 17.1, 24.1) for in-rTSA (n = 571) and 16.1%(11.6, 22.2) for on-rTSA (n = 249). The risk of rerevision was not different between the 2 cohort groups. Primary diagnosis fracture was associated with an increased risk of rerevision for on-rTSA (entire period on-rTSA HR = 3.16(1.50, 6.68), P =.002), and in-rTSA at subanalysis (entire period on-rTSA HR = 2.91(1.33, 6.33), P =.007). 59.9% of in-rTSA and 24.1% of on-rTSA aseptic revisions were minor. The revision diagnosis, the surgical experience of rTSA and if the revision was major or minor did not change the rate of rerevision. The most common reason for both in-rTSA (50%) and (43.2%) on-rTSA rerevision was instability/dislocation. Rerevision rates of in-rTSA and on-rTSA after aseptic revision are high. The primary rather the revision diagnosis changed rerevision rates in contemporary rTSA surgery. Minor revisions did not reduce rerevision rates for in-rTSA or on-rTSA compared to humeral/glenoid revision. Increased surgical experience of primary rTSA did not change the rate of rerevision of in-rTSA or on-rTSA. [ABSTRACT FROM AUTHOR]

This study aims to compare short-term functional outcomes and conversion rates to reverse shoulder arthroplasty between patients who underwent total shoulder arthroplasty (TSA) using a modular metal-backed glenoid component, a hybrid glenoid component, and an all-polyethylene component. A retrospective review of individuals undergoing TSA between October 2014 and December 2020 was performed. Inclusion criteria included patients undergoing primary TSA for osteoarthritis during this time frame by 1 surgeon. Preoperative and postoperative variables included demographic information, American Shoulder and Elbow Surgeons score (ASES), and range of motion. Revision rates were also documented. Summary statistics were performed, using a 1-way analysis of variance with Tukey post hoc pairwise comparisons when the outcome reached significance. Fifty-two patients were included with age averaging 68 ± 8.1 years, with body mass index of 31 ± 5.8. 54% of patients were female with 12% having diabetes and only 2% were smokers. Follow-up averaged 42 months with patients undergoing metal-backed glenoid having longer follow-up at 56.5 months (P <.001). ASES, forward elevation, and external rotation (ER) for every implant type improved significantly postoperatively (P <.001) besides internal rotation and ER within the poly group (P =.072). No difference was found between the 3 groups for preoperative and postoperative ASES scores, forward elevation, internal rotation, and ER (P >.05). Two patients within the poly group required revision due to rotator cuff tear (P =.225). At 2 years, functional outcomes and patient-reported outcomes are similar in all 3 glenoid groups. There were slightly higher revision rates within the all-polyethylene group. If outcomes are similar among all groups, modular implant systems may be favorable to make conversion to revision TSA easier. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is associated with negative outcomes after hip and knee arthroplasty due to higher rates of infection, aseptic loosening, and transfusion. The purpose of this study was to compare clinical outcome scores and complication rate after shoulder arthroplasty (SA) for patients with and without CKD. We conducted a retrospective cohort study of prospectively collected data and reviewed all patients who underwent primary SA from January 2015 to December 2019 by one surgeon at one institution. Revision arthroplasty patients were excluded. We evaluated results from patients with CKD (glomerular filtration rate [GFR] ≤ 59) and without CKD (GFR ≥ 60). Outcome measures including visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores were compared between cohorts. Minimum clinically important difference (MCID) and substantial clinical benefit also were determined for this cohort. Univariate and multivariable regression was performed to assess the influence of CKD on outcome measures and risk of complications. 518 patients met inclusion criteria; 4 patients did not have recorded GFR, leaving 514 patients for analysis. 389 patients had normal GFR; 125 had CKD. Patients with CKD had lower overall preoperative and postoperative ASES, SST, and SANE scores but demonstrated similar levels of clinical improvement from preoperative to postoperative time points (Δ ASES 41.4 ± 21.8 vs. 42.9 ± 21.4, P =.55), (Δ SST 4.8 ± 3.4 vs. 4.9 ± 3.3, P =.08), (Δ SANE 40.7 ± 29.1 vs. 42.4 ± 26.5, P =.77). Both cohorts achieved MCID for ASES, SST, and SANE scores. Univariately, patients with CKD were at high risk to require transfusion (OR 16.2 (1.9, 139.7), P =.01) despite similar intraoperative estimated blood loss (156.9 ± 132.5mL vs. 153.8 ± 89.7mL, P =.77). CKD patients also were at higher risk for intraoperative fracture (OR 5.4 (1.3, 23.0), P =.02). CKD patients were not at higher risk for prosthetic joint infection (OR 3.2 (0.2, 50.8), P =.42), medical complications (OR 0.9 (0.2, 4.4), P =.89), or revision (OR 1.9 (0.7, 4.9), P =.19) in this cohort. Multivariable analysis of any complication after SA demonstrated that renal disease was not an independent risk factor for overall complication risk in this cohort (OR 1.1 (0.7, 1.8) P =.650). Surgeons can be assured that patients who have CKD achieve similar gains in clinical outcomes as other patients. Despite experiencing a higher risk for transfusion and intraoperative fracture, renal disease was not an independent risk factor for complications after SA in this small cohort. [ABSTRACT FROM AUTHOR]

YouTube videos on shoulder arthroplasty cover a broad range of topics, from patient testimonials to surgical techniques. Inherent to this platform, there are no quality control measures to monitor this content. The purpose of this study is to evaluate the quality and popularity of videos on shoulder arthroplasty on YouTube, using both previously described scores and a proposed novel shoulder arthroplasty–specific score assessing educational content. A search was performed using the keywords "shoulder arthroplasty" and "shoulder replacement" on YouTube. Videos were sorted by relevance and the first 50 videos for each keyword were included in a playlist. The videos in the playlist were then sorted by popularity and the first 50 were included for analysis. Videos in a non-English language, duplicate videos, or those lacking audio were excluded. Video source, content, time since upload, duration, like and dislike count, were inputted for analysis. The view ratio and video power index were used to assess for popularity. Quality, reliability and educational content were evaluated with the Global Quality Score (GQS), Journal of the American Medical Association (JAMA), and the novel Shoulder Arthroplasty Video Content (SAVC) score, respectively. The 50 videos had an average of 285,375 views and a mean duration of 10.8 minutes. Video content was comprised of primarily surgical technique (46%) and patient experience (44%), with most of the videos uploaded from university-affiliated physicians (30%), non-affiliated physicians (28%), and medical (i.e., animations from health websites) (26%) sources. Mean GQS (i.e., quality) and JAMA (i.e., reliability) scores for all videos were 3.2 ± 1.2 out of 5 and 2.4 ± 1.4 out of 4, respectively. Median GQS was comparable across sources, content, and procedure type. Although median JAMA scores were similar among procedure and content type, academic and medical sources showed significantly higher scores among video source categories (P =.04). The mean SAVC score was 19.5 ± 10.7 out of 45 possible points. While there was no significant difference in SAVC scores when categorized by procedure type, a significant difference was observed when assessed by source (P =.02) and content (P =.01). Specifically, medical sources had the highest median score for video source and patient experience for content. Shoulder arthroplasty videos on YouTube reach a considerable audience, but the educational content and reliability are low. Understanding this can help caution patients on the limitations of educational content on YouTube. [ABSTRACT FROM AUTHOR]

Elective shoulder arthroplasty is commonly performed in elderly patients with end-stage arthritis. However, a significant number of young patients also undergo this procedure. The surgical outcomes for young patients are not extensively studied compared to older patients. This study aimed to assess the short-term outcomes of anatomic total shoulder arthroplasty (aTSA) in patients aged 18-50 years with primary glenohumeral arthritis and compare them to patients aged 65-75 years. A retrospective review was conducted on aTSA procedures performed for glenohumeral arthritis at a single hospital system between January 1st, 2005, to September 15th, 2023. Patients aged 18-50 years with a minimum 2-years of follow-up were compared to a cohort of patients aged 65-75 years. Data included range of motion and patient-reported outcome measures (Disabilities of the Arm, Shoulder, and Hand [DASH], American Shoulder and Elbow Surgeons, Simple Shoulder [SS], and Visual Analog Scale pain scores), which were compared between the two groups preoperatively and at final follow-up. The younger group included 19 shoulders with a mean age of 44.2 ± 6.4 years at the time of surgery and a mean follow-up of 3.9 ± 1.9 years. The older group included 27 shoulders with a mean age of 70.3 ± 3.0 years at the time of surgery and a mean follow-up of 2.5 ± 0.8 years. The younger group failed to show improvements in all range of motion parameters at final follow-up, while the older group demonstrated improvement in range of motion for all measures. The older group had superior forward elevation and abduction at final follow-up. Both groups exhibited improvements in pain and shoulder function at final follow-up. The younger group did not show significant improvement in DASH scores at final follow-up. Preoperatively, the older group had significantly better DASH and SS scores compared to the younger group. The older group had significantly better DASH, American Shoulder and Elbow Surgeons, SS, and pain scores at final follow-up compared to the younger group. Both groups experienced significant improvement in pain and subjective outcome measures after a 2-year follow-up. Despite this, the younger cohort had worse shoulder range of motion outcomes and lower function and higher pain scores than the older cohort. Nonetheless, aTSA remains a valuable treatment option for young patients in the short-term. However, it is crucial to consider that younger patients may experience dissatisfaction and receive less pain relief compared to older patients, and these factors should be considered when determining the suitability of this treatment approach. [ABSTRACT FROM AUTHOR]

Current teaching maintains that reverse total shoulder arthroplasty (RTSA) is unlikely to restore external rotation (ER) without a functional posterior rotator cuff, specifically the teres minor (TM). This study compared restoration of ER in TM-deficient (TMD) with TM-intact (TMI) shoulders after RTSA. All patients who underwent lateralized RTSA using an onlay prosthesis with no adjunct tendon transfers between January 2014 and July 2020 and with 2-year follow-up were identified. Preoperative imaging review identified patients with TMD, and propensity score matching was used to create a control group of equal size. TMD was divided into three subgroups: 1) atrophy; 2) fracture/malunion/nonunion (proximal humerus); and 3) endoprosthesis. Primary outcome measures were active ER range of motion (ROM) measured at the side, ΔER ROM from baseline, ER strength, and American Shoulder and Elbow Surgeons subscore question, "can you reach back of head." Thirty-nine patients with TMD shoulders (atrophy: n = 15; fracture n = 14; endoprosthesis: n = 10) were matched with 39 patients with TMI shoulders. Although TMD was associated with reduced baseline ER ROM (13.6 vs. 28.8; P =.004), the TMD group achieved greater ΔER ROM 2 years after RTSA (24.6 vs. 10.3; P =.014) and demonstrated comparable 2-year ER ROM (38.6 vs. 40.7; P =.484). The TMD group had a higher rate of ER weakness (12% vs. 0%; P =.044) but no difference in ability to reach back of head (unable: 24% vs. 20%; P =.686) or patient-reported functional scores (2-year American Shoulder and Elbow Surgeons: 76.2 vs. 74.8; P =.793). This study suggests that patients with an insufficient or absent teres minor can achieve satisfactory ER ROM and function after lateralized RTSA similar to their TMI peers. Future study will seek to identify muscle activation patterns of the shoulder girdle that allow TMD patients to overcome this insufficiency to perform activities requiring ER. [ABSTRACT FROM AUTHOR]

Anatomic total shoulder arthroplasty (aTSA) remains the gold-standard for management of end-stage glenohumeral arthritis. However, in the setting of failed hemiarthroplasty or aTSA, the appropriate utilization of revision to an anatomic vs. reverse TSA remains unknown. This study aims to assess the outcomes of revision to aTSA. All revision shoulder arthroplasty cases at a single institution by one of five fellowship-trained surgeons were reviewed. All aseptic revision cases where the revision construct was an aTSA were included. Attempts were made to contact each case for enrollment in the institution's shoulder registry and ascertain any cases requiring revision surgery. Patient-reported outcome measures: American Shoulder and Elbow Surgeons score, single assessment numeric evaluation, visual analog scale for pain, patient satisfaction, and a validated scale of patient-reported shoulder range-of-motion were collected. Twenty eight cases underwent revision aTSA between 2004 and 2019. The average age was 53.4 years (range: 23-66), 16 (57%) were male, and 14 (50%) were revised from a hemiarthroplasty while the remainder were revised from an aTSA. Seven (25%) cases required revision surgery at a mean 1.8 years. Three of these cases had been revised from hemiarthroplasty. Reasons for revision included: glenoid loosening (1), infection (1), rotator cuff failure (3), and persistent pain of nonspecific etiology (2). Ultimately, 6 (21%; 6/28) were revised to reverse TSA at a mean of 2 years (range: 1 month-5.7 years) postoperatively. Patients requiring further revision surgery were older (58.8 vs. 51.4 years; P =.06) than those not requiring further revision. Of the patients managed with lesser tuberosity osteotomy, the revision rate was 7.1% (1/14) compared to 42.9% (6/14) for the remainder of the cohort (P =.08). Of the 21 patients with retained aTSA, 15 (71%) provided clinical follow-up at an average of 4 years (range: 1-8). These patients had a mean American Shoulder and Elbow Surgeons score of 70.2 (range: 41-94), visual analog scale pain score of 2.8 (range: 0-6), single assessment numeric evaluation score of 52.1% (range: 14-92), and satisfaction of 73% (range: 1-100). The outcomes of revision shoulder arthroplasty to an aTSA construct are varied. While in the appropriately indicated young patient high-quality results can be achieved, there is a high revision rate and highly variable patient-reported outcomes. Surgeons should be selective when recommending revision to an aTSA. Further study is needed to better predict successful outcomes in this patient population. [ABSTRACT FROM AUTHOR]

The use of total shoulder arthroplasty is continuing to rise with its expanding indications. For patients with chronic conditions, such as glenohumeral arthritis and rotator cuff arthropathy, nonoperative treatment is typically done prior to arthroplasty and often includes corticosteroid injections (CSIs). Recent studies in the shoulder arthroplasty literature as well as applied from the hip and knee literature have focused on the risk of periprosthetic infection. Literature is lacking as to whether the judicious use of corticosteroids in the year prior to arthroplasty influences patient-reported outcomes (PROs). The purpose of this study was to determine if preoperative CSIs prior to shoulder arthroplasty affected 2-year PROs. Retrospective review of anatomic and reverse total shoulder arthroplasty (RSA) patients (n = 230) was performed at a single institution including multiple surgeons. Patients were included if they had preoperative and a minimum of 2-year postoperative PROs, including: American Shoulder and Elbow Surgeons (ASES), visual analog scale, Single Assessment Numeric Evaluation, Veteran's RAND 12 Physical Component Score, and Veteran's RAND 12 Mental Component Score. Patients were included in the injection group if they had received an injection, either glenohumeral or subacromial, within 12 months prior to arthroplasty (inject = 134). Subgroup analysis included anatomic (total shoulder arthroplasty [TSA] = 92) and RSA (RSA = 138) as well as those with no injection within 12 months prior to surgery. An analysis of variance was used to compare outcomes between patients who received an injection and those who did not prior to TSA and RSA. There were 230 patients included with 134 patients in the injection group and 96 in the no injection group. Patients who received an injection in the year prior to arthroplasty displayed a significantly higher ASES (82 [16.23 standard deviation] vs. 76 [19.43 standard deviation], P <.01) and Single Assessment Numeric Evaluation (70 [24.49 standard deviation] vs. 63 [29.22 standard deviation], P <.01) scores vs. those who had not received injection. There was no difference when comparing preoperative injection vs. no injection in patients undergoing TSA. Those patients undergoing RSA displayed significantly higher ASES scores (P <.01). There were no significant differences in visual analog scale, Veteran's RAND 12 Physical Component Score, and Veteran's RAND 12 Mental Component Score among any analysis (P >.05), and the minimal clinically important difference in ASES was not different between groups (P.09). CSIs within 12 months prior to anatomic and RSA do not compromise PROs during a minimum of 2-year follow-up. Although more complications occurred in the injection group, it did not reach statistical significance and warrants further study in a larger population. [ABSTRACT FROM AUTHOR]

Severe glenoid bone loss in the setting of both primary and revision reverse total shoulder arthroplasty (rTSA) continues to remain a significant challenge. The purpose of this study was to report on radiographic and clinical outcomes of primary and revision rTSA using a patient-matched, 3-dimensionally printed metal glenoid implant to address severe glenoid bone deficiency. This is a follow-up study to previously reported preliminary results. A retrospective review was performed on 62 patients with severe glenoid bone deficiency who underwent either primary or revision rTSA using the Comprehensive Vault Reconstruction System (VRS) (Zimmer Biomet) at a single institution. Preoperative and postoperative values for the Disabilities of the Arm, Shoulder and Hand (DASH), Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) pain scores as well as active range of motion (ROM) were collected and compared using the Wilcoxon signed rank test with the level of statistical significance set at P <.05. The percentage of patients achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also calculated. Fifty-five of 62 shoulders (88.7%) were able to be contacted at a minimum of 2 years postoperatively, with 47 of 62 (75.8%) having complete clinical and radiographic follow-up with a mean age of 67.5 years (range, 48-85 years) and follow-up of 39.2 months (range, 25-56 months). There were 19 primary and 28 revision rTSAs. Significant improvements were seen in mean active forward flexion (63.1° ± 30.3° to 116.8° ± 35°), abduction (48.1° ± 16.1 to 76.2° ± 13.4°) (P <.001), external rotation (16° ± 23.7° to 32.1° ± 24.5°) (P <.005), DASH (59.9 ± 17.7 to 35.7 ± 24.3), Constant (23.4 ± 13.1 to 53.1 ± 17.4), ASES (27.8 ± 16.2 to 69.1 ± 25.2), SST (3.3 ± 2.5 to 7.6 ± 3.5), SANE (28.9 ± 18.3 to 66.7 ± 21.2), and VAS pain (7.1 ± 2.4 to 1.8 ± 2.6) scores (P <.001). MCID and SCB was achieved in a majority of patients postoperatively. The overall complication rate was 29.1%, with only 1 baseplate failure. This study demonstrates promising evidence that the VRS implant can be used as a viable option to achieve clinically important improvement in a majority of patients treated for severe glenoid bone deficiency with rTSA in both the primary and revision setting. [ABSTRACT FROM AUTHOR]

Reverse total shoulder arthroplasty (RSA) has been increasingly utilized for a variety of shoulder pathologies that are difficult to treat with anatomical total shoulder arthroplasty (TSA). Few studies have compared the outcomes of TSA vs. RSA in patients with cuff intact glenohumeral osteoarthritis and poor preoperative forward elevation. This study aimed to determine whether there is a difference in functional outcomes and postoperative range of motion (ROM) between TSA and RSA in these patients. This retrospective cohort study included 116 patients who underwent RSA or TSA between 2013 and 2022 for the treatment of rotator cuff intact primary osteoarthritis with restricted preoperative forward flexion (FF) and a minimum 1-year follow-up. Each arthroplasty group was divided into 2 subgroups: patients with preoperative FF between 91° and 120° or FF lower than or equal to 90°. Patients' clinical outcomes, including active ROM, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective shoulder value were collected. Clinical and radiographic complications were evaluated. There was no significant difference between RSA and TSA in terms of sex (58.3% male vs. 62.2% male, P =.692), or follow-up duration (20.1 months vs. 17.7 months, P =.230). However, the RSA cohort was significantly older (72.0 ± 8.2 vs. 65.4 ± 10.6, P =.012) and weaker in FF and (ER) before surgery (P <.001). There was no difference between RSA (57 patients) and TSA (59 patients) in visual analog scale pain score (1.2 ± 2.3 vs. 1.3 ± 2.3, P =.925), subjective shoulder value score (90 ± 15 vs. 90 ± 15, P =.859), or American Shoulder and Elbow Surgeons score (78.4 ± 20.5 vs. 82.1 ± 23.2, P =.476). Postoperative active ROM was statistically similar between RSA and TSA cohorts in FF (145 ± 26 vs. 146 ± 23, P =.728) and ER (39 ± 15 vs. 41 ± 15, P =.584). However, internal rotation was lower in the RSA cohort (P <.001). This was also true in each subgroup. RSA led to faster postoperative FF and ER achievement at 3 months (P <.001). There was no statistically significant difference in complication rates between cohorts. This study demonstrates that patients with glenohumeral osteoarthritis who have a structurally intact rotator cuff but limited preoperative forward elevation can achieve predictable clinical improvement in pain, ROM, and function after either TSA or RSA. Reverse arthroplasty may be a reliable treatment option in patients at risk for developing rotator cuff failure. [ABSTRACT FROM AUTHOR]

Postoperative scapular stress fractures (SSFs) are a formidable problem after reverse shoulder arthroplasty (RSA). Less is known about patients who have these fractures preoperatively. The primary aim of this study was to examine postoperative satisfaction in patients undergoing primary RSA who have preoperative SSF and compared to a matched cohort without preoperative fracture. The secondary aim was to examine the differences in patient-reported outcomes between and within study cohorts. A retrospective chart review of primary RSAs performed by a single surgeon from 2000 to 2020 was conducted. Patients diagnosed with cuff tear arthropathy (CTA), massive cuff tear (MCT), or rheumatoid arthritis (RA) were included. Five hundred twenty-five shoulders met inclusion criteria. Fractures identified on preoperative computed tomography scans were divided into 3 groups: (1) os acromiale, (2) multifragments (MFs), and (3) Levy types. Seventy-two shoulders had an occurrence of SSF. The remaining 453 shoulders were separated into a nonfractured cohort. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and visual analog scale (VAS) scores were compared pre- and postoperatively in the total fracture group and the nonfractured group cohort. The multifragment subgroup was also compared to the pooled Os/Levy subgroup. The total incidence of SSF in all shoulders was 13.7%. There was a difference in satisfaction scores at all time points between the nonfracture (7.9 ± 2.8) and total fracture group (5.4 ± 3.6, P <.001, at last visit). There was also a greater ASES total score in the nonfractured group vs the total fracture group at the final visit (69.4 ± 23.4 and 62.1 ± 24.2; P =.02). The MF group had worse ASES functional or VAS functional scores than the Os/Levy group at all time points: at 1 year, ASES function: MF 24.2 ± 14.5 and Os/Levy 30.7 ± 14.2 (P =.045); at 2 years, ASES function: MF 21.4 ± 14.4 and Os/Levy 35.5 ± 10.6 (P <.001); and at last follow-up, VAS function: MF 4.8 ± 2.8 and Os/Levy 6.4 ± 3.2 (P =.023). Scapular fractures were proportionally most common in patients diagnosed with CTA (16.3%) compared with a 9.2% and 8.6% incidence in patients diagnosed with MCT and RA, respectively. Patients with preoperative SSF still see an improvement in ASES scores after RSA but do have lower satisfaction scores compared with the nonfractured cohort. The multifragment fracture group has lower functional and satisfaction scores at all postoperative time points compared with both the nonfracture and the Os/Levy fracture group. [ABSTRACT FROM AUTHOR]

Prognostic factors for total shoulder arthroplasty (TSA) clinical outcomes are incompletely understood. This study investigates the associations of preoperative patient, disease-specific, and surgical factors with 1-year postoperative PENN Shoulder Score (PSS) in patients undergoing primary TSA. Cleveland Clinic patients undergoing primary anatomic TSA (aTSA) or reverse TSA (rTSA) for glenohumeral osteoarthritis (GHOA) or rotator cuff tear arthropathy (CTA) between February 2015 and August 2019, and having complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs), were included. Twenty preselected preoperative patient, disease-specific, and surgical factors were used to fit multivariable models for 1-year PSS and its subscores. Of 1427 eligible primary TSAs, 1174 had 1-year follow-up by PROMs (82%), with 1042 analyzed after additional exclusions, including 30% rTSAs for CTA (n = 308), 26% rTSAs for GHOA (n = 275), and 44% aTSAs for GHOA (n = 459). All PROMs showed statistically significant improvements postoperatively, with 89% of patients reaching an acceptable symptom state. Lower 1-year PSS was associated with younger age, female sex, current smoking, chronic pain diagnosis, history of prior surgery, worker's compensation claim, lower preoperative mental health, lower baseline PSS, absence of glenoid bone loss, and diagnosis-arthroplasty type (CTA-rTSA < GHOA-rTSA < GHOA-aTSA). The most important prognostic factors associated with 1-year PSS were diagnosis-arthroplasty type, baseline mental health status, and insurance status. Disease diagnosis, arthroplasty type, and several other baseline factors are strongly and individually associated with PROMs following primary TSA, with patients undergoing aTSA for GHOA demonstrating the highest PROM scores at 1-year follow-up. Patient, disease-specific, and surgical factors can be used to guide postoperative prognosis following primary TSA for improved preoperative patient counseling regarding expected outcomes of these procedures. [ABSTRACT FROM AUTHOR]