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Background: This systematic review and meta-analysis sought to compare the clinical outcomes after proximal humerus reconstruction with a reverse allograft-prosthetic composite (APC) versus reverse endoprosthesis. Methods: Per PRISMA guidelines, we queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of reverse APC or reverse endoprosthesis reconstruction of the proximal humerus for massive bone loss secondary to tumor, fracture, or failed arthroplasty. We compared postoperative range of motion, outcome scores, and the incidence of complications and revision surgery. Results: Of 259 unique articles, 18 articles were included (267 APC, 260 endoprosthesis). There were no significant differences between the APC and endoprosthesis cohort for postoperative forward elevation (P =.231), external rotation (P =.634), ASES score (P =.420), Constant score (P =.414), MSTS (P =.815), SST (P =.367), or VAS (P =.714). Rate of complications was 15% (31/213) in the APC cohort and 19% (27/144) in the endoprosthesis cohort. The rate of revision surgery was 12% after APC cohort and 7% after endoprosthesis. APC-specific complications included a 10% APC nonunion/malunion/resorption rate and 6% APC fracture/fragmentation rate. Discussion: Reverse APC and endoprosthesis are reasonable options for proximal humerus reconstruction. APC carries additional risks for complications, warranting evaluation of patients' healing capacity and surgeon experience. Level of Evidence: Level IV; Systematic Review. [ABSTRACT FROM AUTHOR]

The preferred surgical approach for surgical treatment of advanced glenohumeral arthritis is shoulder arthroplasty (SA). Considering the growing volume and success of SA, patients with bilateral shoulder disease are likely to undergo surgery on both shoulders. There are numerous studies evaluating the outcomes of bilateral hip and knee arthroplasty, but a paucity of information examining bilateral SA. This study intends to evaluate the clinical outcomes of patients undergoing staged bilateral anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA). Institutional records were queried for patients who underwent staged bilateral aTSA or rTSA from 2009 to 2020. Patient records were retrospectively reviewed to assess preoperative and postoperative range of motion (ROM) and strength measurements, demographic information, and complications. Mean ± standard deviation was reported for all continuous variables. Mean functional measurements were compared using a 2-Sample t -Test, ordinal variables via Wilcoxon-Mann Whitney test, and categorical variables via Chi-squared test. Patients were included in the outcome analysis if they had a bilateral TSA with the same procedure (i.e. aTSA on both sides, or rTSA on both sides). 43 patients (15 male, 28 female) were included. There was an average time of 1.8 years between surgeries. Of the 43 patients, 26 patients had staged bilateral aTSAs and 14 had staged bilateral rTSAs with three patients who had different surgeries on each shoulder. The three patients with different surgeries on each shoulder were excluded from outcome analysis. Patients who had staged aTSA operations demonstrated significant improvement in external rotation (P =.0191, P <.001), forward elevation (FE) (P =.0004, P <.001), and internal rotation (IR) (P =.0183, P =.0166) after the first and second surgeries. Staged rTSA patients showed significant improvement in FE after the first (P =.0043) and second surgeries (P =.016). Patients demonstrated significant increase in strength of external rotation (P =.0136), FE (P =.0088), and IR (P =.0206) after the first rTSA. There was no corresponding increase in strength testing after the second bilateral rTSA surgery. The average Single Assessment Numeric Evaluation, Contralateral Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Simple Shoulder Test scores for all surgeries were 84 ± 10, 83 ± 13, 75 ± 20, and 9 ± 2, respectively for the first surgery and 82 ± 13, 83 ± 13, 71 ± 21, and 8 ± 3 for the second surgery. Individuals that undergo staged aTSA procedures gain a better ROM and IR strength after both operations. However, individuals that undergo staged rTSA procedures have an improved ROM and strength after the first surgery but limited improvement after the second. [ABSTRACT FROM AUTHOR]

Within reverse total shoulder arthroplasty (RSA), prior studies have suggested that smaller glenosphere diameters may result in higher rates of scapular notching and polyethylene wear, while lateralized glenospheres may allow for better range of motion (ROM); however, supportive data remains limited. Therefore, the purpose of this study was to report the outcomes of a prospective randomized clinical trial comparing 4 different glenosphere configurations based on diameter and lateral offset. Between 2016 and 2020, 113 primary RSAs with a diagnosis of either rotator cuff tear arthropathy (n = 48, 42%), irreparable rotator cuff tears (n = 22, 19%), or primary glenohumeral osteoarthritis with subluxation or glenoid bone loss (n = 43, 38%) were enrolled into a blinded prospective randomized clinical trial. The mean age of the patients included in the study was 73 ± 7 (range, 50-89) years, and 58 (51.3%) were males. All procedures were performed by two surgeons utilizing the ReUnion RSA system (Stryker, Mahwah, NJ, USA). Patients were randomized into four possible groups based on the diameter and lateral offset of the glenosphere implanted: 36 mm diameter with 2 mm (n = 34, 30.1%) or 6 mm (n = 28, 24.8%) of lateralization and 40 mm diameter with 2 mm (n = 29, 25.7%) or 6 mm (n = 22, 19.5%) of lateralization. Outcomes collected included pain, active ROM, strength, satisfaction, patient-reported outcome measures (PROMs), complications, reoperations, and revisions. PROMs included the Oxford Shoulder Score, the American Shoulder and Elbow Surgeons, and the quick Disabilities of the Arm, Shoulder and Hand questionnaire. All patients were followed for a minimum of 2 years. With the numbers available, glenosphere diameter and lateralization resulted in no differences in pain, ROM, strength, satisfaction, and PROMs at 1 year, 2 years, or final follow-up (All P >.05). However, all 3 complications (10.7% vs. 0% vs. 0% vs. 0%; P =.025) and 2 revision surgeries (7.1% vs. 0% vs. 0% vs. 0%; P =.103) occurred in males, with the 36 + 6 cohort. Using this particular RSA design, implantation of glenospheres with 36 mm or 40 mm of diameter and 2 mm or 6 mm of sphere lateralization did not translate into significant differences when primary RSA was performed in shoulders with rotator cuff tear arthropathy, irreparable cuff tears, or primary glenohumeral osteoarthritis. However, all observed complications occurred in males with the smallest diameter and lateralized glenosphere. [ABSTRACT FROM AUTHOR]

Although the Favard classification is commonly utilized by surgeons to describe the supero-inferior morphology of the glenoid when treating rotator cuff arthropathy (RCA), its utility in prognosticating patients' clinical state before and after reverse shoulder arthroplasty (RSA) remains unproven. We assessed the prognostic value of the Favard glenoid classification on preoperative clinical state and postoperative clinical and radiographic outcomes in RSA. A prospectively collected, multicenter database for a single-platform shoulder arthroplasty system was queried for patients with RCA who underwent RSA with a minimum 2-year clinical follow-up. Differences in patient reported outcome scores (PROMs) (Simple Shoulder Test, American Shoulder and Elbow Surgeons, Shoulder Pain and Disability Index, visual analog scale pain, Shoulder Function score), combined patient-reported and clinical-input scores (Constant, University of California Los Angeles, Shoulder Arthroplasty Smart), active range of motion values (forward elevation, abduction, external rotation [ER], internal rotation [IR]), radiographic outcomes (humeral radiolucency line rates, scapular notching rate), and the incidence of postoperative complications and revision surgery were compared by glenoid deformity type per the Favard classification. Comparisons were performed to assess the ability of the Favard classification to prognosticate the preoperative, postoperative, and improved state after RSA. 400 RSAs performed for RCA were included. Comparison of outcomes between Favard glenoid types resulted in 6 pairwise comparisons of 12 clinical outcome metrics, yielding 72 total Favard glenoid pairwise comparisons for each clinical state (preoperative, postoperative, improvement). Of the 216 possible pairwise Favard glenoid type/metric comparisons, statistical significance was only reached for 3% of the combinations (7/216). Among E0, E1, and E2 glenoids, the only statistically significant pairwise comparison identified among all three clinical states was a more favorable preoperative American Shoulder and Elbow Surgeons score for E0 vs. E2 glenoids. Preoperatively, E3 glenoids had poorer ER, IR, and Shoulder Arthroplasty Smart scores compared to E0 glenoids and poorer ER compared to E2 glenoids. Postoperatively, E3 glenoids had a poorer IR score compared to E0 glenoids and poorer ER compared to E1 glenoids. No pairwise differences in preoperative to postoperative improvement were found. There were no statistically significant pairwise differences in humeral lucency rate, scapular notching rate, complication rates, or revision rates between Favard glenoid types. Although useful for describing degenerative changes to the glenohumeral joint, the Favard classification offers little prognostic information regarding patient outcomes before and after RSA aside from poorer preoperative and postoperative axial rotation in E3 glenoids. Alternative glenoid classification systems or predictive models should be considered for more precise prognoses of patients undergoing RSA for RCA. [ABSTRACT FROM AUTHOR]

Sleep apnea (SA) has been shown to negatively affect cognition, immunity, and bone mineralization. There is conflicting evidence for the contribution of SA to outcomes following total shoulder arthroplasty. However, the impact of SA on reverse shoulder arthroplasty (RSA) has not been elucidated. A substantial increase in utilization of RSA is projected through the 2030s. Our objective was to assess postoperative medical and implant-related complications and healthcare utilization in patients with SA undergoing RSA. A retrospective review of a private insurance claims database was conducted from 2010 to 2021. All cases of RSA and those with a prior diagnosis of SA were identified using their corresponding diagnosis and procedural codes. Patients undergoing RSA with a diagnosis of SA were matched to control patients 1:2 based on demographic and comorbidity profiles. A total of 18,229 SA patients were matched to 35,988 control patients. The SA cohort had significantly greater odds of all medical complications assessed compared to the control cohort. The SA cohort had greater odds of all implant-related complications including dislocation and mechanical loosening when compared to the control cohort. Mean length of stay was significantly greater in the SA group. The current data demonstrate that SA patients may have an increased risk of complications and healthcare burden following RSA compared to RSA patients without SA. These findings indicate potential value in preoperative screening for SA prior to RSA. [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]

Introduction: The indication for shoulder resurfacing arthroplasty is controversial, and survival of these implants is somewhat inconsistent. This study aimed to evaluate the long-term survivorship of resurfacing humeral head implants (RHHIs) and determine risk factors for complications and revisions. Materials and methods: This retrospective cohort study consisted of 275 cases and two types of RHHIs. The survival rate was evaluated using the Kaplan–Meier method and Cox regression for risk factor analysis. Demographic factors were studied, and the change in the humerus centre of rotation (COR) was measured. Results: The mean follow-up time was 8.7 years (SD 2.7 months, range 2.8–15.9 years). The mean age of the patients was 67.6 years (SD 9.6, range 33.5–84.9). Ten-year cumulative RHHI survival was 94.1%. The cumulative estimate without any complication was 98.9% at 5 years, 80.0% at 10 years and at 15 years it was 61.5%. The most common complication was persistent pain in 13.8% of the RHHIs. The risk factors for complications and revisions were implant type, preoperative conditions and change of COR > 5 mm. Conclusions: RRHIs showed excellent long-term survival, but many complications were found. The most common complication was persistent pain, which seemed to be caused by a change of COR and was more related to one type of implant. [ABSTRACT FROM AUTHOR]

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: The anatomic interplay and overlap between the cervical spine and the shoulder constitutes a challenge for shoulder and spine surgeons, as symptoms of spine and shoulder pathologies are often similar and may lead to entity misdiagnosis. Methods: PubMed, Cochrane, and Google Scholar (page 1-20) searches were updated to October 2023 in search of the qualified papers. Boolean Operators were used with a combination of the keywords “spine” OR “neck” And “Shoulder”. Furthermore, reference lists from papers were also searched to find literature. Results: It is of pivotal importance to conduct comprehensive preoperative clinical investigation to appropriately evaluate and assess the source of the pathology and the leading causes behind it. Certain markers can help guide surgeons towards etiologies, and these include areas of pain and physical exam findings with the arm squeeze test having the highest sensitivity and specificity for diagnosing cervical radiculopathy. As for the shoulder, despite its low sensitivity, the Yergason test had the highest specificity for diagnosing subacromial impingement. Local anesthetic injection can help as well in the diagnostic approach. Moreover, the interplay between these anatomic locations is not solely related to preoperative diagnosis. Studies have shown that previous surgery for cervical spine pathology may negatively affect the outcomes of shoulder procedures like arthroplasties. Conclusion: Shoulder and spine surgeons should be wary and vigilant of accurately diagnosing the etiology of the presenting symptoms to ensure proper management and optimize prognosis.

Background: Higher bone or metal glenoid offset in reverse shoulder arthroplasty (RSA) reduces scapular notching, improves range of motion (ROM), and reduces postoperative instability. This retrospective multicenter study compared two implant designs to evaluate the short-term clinical and radiologic results of bone increased offset RSA (BIO-RSA) and metal increased offset RSA (MIO-RSA) in reverse shoulder. We hypothesized no difference between groups. Methods: This study analyzed n = 62 BIO-RSA and n = 90 MIO-RSA cases with a mean follow-up of 29.7 ± 6.0 months (BIO-RSA, range 24-49 months) and 24.0 ± 1.1 months (MIO-RSA, range 22-28 months). A 145°-onlay humeral stem was utilized in BIO-RSA cases, while a 135°-semi-inlay humeral stem was implanted in all MIO-RSA cases. Preoperative and postoperative radiologic imaging was reviewed to identify signs of scapular notching. Additionally, lateralization was evaluated according to Erickson et al. The constant score, subjective shoulder value, and ROM were evaluated during the baseline and follow-up consultations, and the findings of both groups were subsequently compared. Results: Scapular notching was observed in 7.0% (n = 8) of MIO-RSA cases and 8.1% (n = 5) of BIO-RSA cases (P = .801). MIO-group had a higher lateralization angle (P = .020) and the BIO-group had a higher distalization angle (P = .005). At baseline, mean constant score in the MIO-RSA group was higher than in the BIO-RSA group (P

Clinically significant outcome (CSO) benchmarks have been previously established for shoulder arthroplasty by assimilating preoperative diagnoses and arthroplasty types. The purpose of this study was to establish unique CSO thresholds and compare the time-to-achievement of these for reverse shoulder arthroplasty (RSA) for osteoarthritis (GHOA), RSA for rotator cuff arthropathy (RCA), and total shoulder arthroplasty (TSA) for GHOA. Consecutive patients who underwent elective RSA for GHOA, TSA for GHOA, or RSA for RCA between February 2015 and May 2020, with 2-year minimum follow-up, were retrospectively identified from a prospectively maintained single surgeon registry. The American Shoulder and Elbow Surgeons (ASES) score was administered preoperatively and postoperatively at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year timepoints. Satisfaction and subjective overall improvement anchor questionnaires were administered at the time of final follow-up. Distribution-based methods were used to calculate the Minimal Clinically Important Difference (MCID), and anchor-based methods were used to calculate the Substantial Clinical Benefit (SCB) and the Patient Acceptable Symptom State (PASS) for each patient group. Median time to achievement, individual incidence of achievement at each time point, and cumulative incidence of achievement calculated using Kaplan–Meier survival curve analysis with interval censoring were compared between groups for each CSO. Cox-regression analyses were also performed to determine which patient factors were significantly associated with early or delayed achievement of CSOs. There were 471 patients eligible for study analysis: 276 RSA for GHOA, 107 TSA for GHOA, and 88 RSA for RCA. The calculated MCID, SCB, and PASS scores differed for each group. There were no significant differences in median time to achievement of any CSO between groups. Log-rank testing revealed that cumulative achievements significantly differed between groups for MCID (P =.014) but not for SCB (P =.053) or PASS (P =.620). On cox regression analysis, TSA patients had earlier achievement of SCB, whereas TSA and RSA for GHOA patients had earlier achievement of MCID. At 2-years, a significantly higher percentage of RSA for GHOA patients achieved MCID and SCB compared to RSA for RCA (MCID:100%, 95.5%, P =.003, SCB:94.6%, 86.4%, P =.036). Calculated CSO thresholds differ according to preoperative diagnosis and shoulder arthroplasty type. Patients undergoing TSA and RSA for GHOA achieve CSOs earlier than RSA for RCA patients, and a significantly higher percentage of RSA for GHOA patients achieve CSOs by 2 years compared to RSA for RCA patients. [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]

"Dr. Google" has long been a resource for health information-seeking individuals. With the well-established presence of artificial intelligence in the healthcare world, it is reasonable to imagine that ChatGPT, an artificial intelligence-powered online chatbot, could become the next outlet for seeking medical advice online. Similar to Mika et al, this study aims to analyze the ChatGPT's ability to answer frequently asked questions (FAQs) regarding total shoulder arthroplasty (TSA). Ten FAQs regarding TSA were presented to ChatGPT and initial responses were recorded and analyzed against evidence-based literature. Responses were rated as "excellent response requiring no clarification," "satisfactory response requiring minimal clarification," "satisfactory response requiring moderate clarification," or "unsatisfactory response requiring substantial clarification." Only one response from ChatGPT was rated unsatisfactory and required substantial clarification. While no responses received an excellent rating, the average rating was considered to only require minimal or moderate clarification. ChatGPT was able to provide largely accurate responses to FAQs regarding TSA while appropriately reiterating the importance of always consulting a medical professional. ChatGPT could prove to be another avenue for supplementary medical information regarding TSA. [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]

The ideal timing between bilateral total shoulder arthroplasty (TSA) is unclear. The purpose of this study is to determine whether early outcomes after first TSA can be used to predict clinical outcomes after TSA of the contralateral shoulder and to evaluate the ideal time after TSA to perform the contralateral shoulder. A single-institution prospectively collected shoulder arthroplasty database was reviewed. Patients who underwent bilateral primary anatomic or reverse TSA (aTSA + rTSA) without an indication of fracture, tumor, or infection were identified. Included patients had minimum 2-year follow-up on their second TSA and postoperative follow-up after their first TSA at 3 months, 6 months, 1 year, or 2 years. Our primary outcome was whether outcome scores and motion at 3-month, 6-month, 1-year, and 2-year follow-up after first TSA predicted clinical success after second TSA at final follow-up, defined as achieving the patient acceptable symptomatic state (PASS = the highest level of symptoms beyond which patients consider themselves well). Outcomes included the American Shoulder and Elbow Surgeons and Constant scores, abduction, forward elevation, and external/internal-rotation. Multivariable logistic regression determined whether postoperative outcomes after first TSA were predictive of achieving the PASS after second TSA independent of age, sex, and body mass index. Receiver operating characteristic analysis determined cutoffs of postoperative outcomes after first TSA at each time point that best predicted achieving the prosthesis-specific PASS after second TSA. One hundred thirty-four patients were included in the final analysis (110 aTSA and 158 rTSA). Range of motion and outcome scores at late (1- or 2-year) follow-up after first aTSA were more predictive of achieving the second TSA PASS compared with early (3- or 6-month) outcomes. In contrast, outcomes after early and late follow-up after first rTSA were similarly predictive of achieving the second TSA PASS. Specifically, the Constant score threshold at 2 years after first aTSA (79.4; area under the curve [AUC] = 0.804) better differentiated achieving the second TSA PASS vs. the 6-month threshold (72.0; AUC = 0.600). In contrast, the Constant score threshold at 2 years after first rTSA (76.4; AUC = 0.703) was similarly discriminant of achieving the second TSA PASS compared with the 6-month threshold (65.8; AUC = 0.711). Patients with good outcomes after first rTSA can be counseled on contralateral TSA as early as 3 months postoperatively with confidence of a similar result on the contralateral side. In contrast, success after first aTSA does not reliably predict contralateral success until ≥1 year. [ABSTRACT FROM AUTHOR]

Background: The primary cause of medium- to long-term complications in reverse shoulder arthroplasty (RSA) is the failure of the glenoid component. The purpose of this study was to evaluate both the achievement of planning through computer-assisted navigation and the clinical outcomes at a minimum follow-up (FU) of 12 months. Methods: From December 2019 to December 2022, 57 Equinoxe RSAs with computer-assisted navigation were performed. The average age was 72.8 ± 6.6 years. Using the Orthoblue software, the version and inclination of the glenoid were evaluated from a preoperative CT scan, and planning was performed. Intraoperative navigation data were evaluated, and the clinical outcomes were assessed at a minimum follow-up of 12 months. Results: The average follow-up was 30.7 ± 13.5 months. The planning was reproduced in all implants. No errors in the computer-assisted navigation system were detected. No intraoperative or postoperative complications were recorded. At the final FU, the average active anterior elevation was 143° ± 36°, external rotation was 34° ± 5°, QuickDASH score was 19 ± 16 points, and constant score was 77 ± 18. Conclusions: Computer-assisted navigation is a reliable system for positioning prosthetic implants on challenging glenoids. A longer follow-up period is necessary to confirm the reduction in postoperative complications and the increase in survival compared to traditional RSA. [ABSTRACT FROM AUTHOR]

Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA. We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA. Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P <.001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P <.001); this difference persisted when stratified by type of prosthesis for first and second TSA. Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to compare outcomes in patients that underwent bilateral anatomic total shoulder arthroplasty (aTSA) vs. aTSA/ reverse total shoulder arthroplasty (rTSA) for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA) to further elucidate the role of rTSA in this patient population. Methods: A single-institution prospectively collected shoulder arthroplasty database was reviewed for patients undergoing bilateral total shoulder arthroplasty (TSA) for RCI-GHOA with a primary aTSA and subsequent contralateral aTSA or rTSA. Outcome scores (SPADI, SST, ASES, UCLA, Constant) and active range of motion (abduction, forward elevation [FE], external and internal rotation [ER and IR]) were evaluated. Clinically relevant benchmarks (minimal clinically important difference [MCID], substantial clinical benefit [SCB], and patient acceptable symptomatic state [PASS]) were evaluated against values in prior literature. Incidence of surgical complications and revision rates were examined in qualifying patients as well as those without .05). The 2nd TSAs between groups were similar preoperatively, but aTSA/rTSA had superior outcome scores, overhead motion, and active abduction compared to patients that underwent aTSA/aTSA. There were no differences in active ER and IR scores or complication rates between groups. Conclusion: Patients with RCI-GHOA have excellent clinical outcomes after either aTSA/aTSA or aTSA/rTSA. [ABSTRACT FROM AUTHOR]

Background: Restoration of external (ER) and internal rotation (IR) after Grammont-style reverse shoulder arthroplasty (RSA) is often unreliable. The purpose of this systematic review was to evaluate the influence of RSA medio-lateral offset and subscapularis repair on axial rotation after RSA. Methods: We conducted a systematic review of studies evaluating axial rotation (ER, IR, or both) after RSA with a defined implant design. Medio-lateral implant classification was adopted from Werthel et al. Meta-analysis was conducted using a random-effects model. Results: Thirty-two studies reporting 2,233 RSAs were included (mean patient age, 72.5 years; follow-up, 43 months; 64% female). The subscapularis was repaired in 91% (n=2,032) of shoulders and did not differ based on global implant lateralization (91% for both, P=0.602). On meta-analysis, globally lateralized implants achieved greater postoperative ER (40° [36°-44°] vs. 27° [22°-32°], P<0.001) and postoperative improvement in ER (20° [15°-26°] vs. 10° [5°-15°], P<0.001). Lateralized implants with subscapularis repair or medialized implants without subscapularis repair had significantly greater postoperative ER and postoperative improvement in ER compared to globally medialized implants with subscapularis repair (P<0.001 for both). Mean postoperative IR was reported in 56% (n=18) of studies and achieved the minimum necessary IR in 51% of lateralized (n=325, 5 cohorts) versus 36% (n=177, 5 cohorts) of medialized implants. Conclusions: Lateralized RSA produces superior axial rotation compared to medialized RSA. Lateralized RSA with subscapularis repair and medialized RSA without subscapularis repair provide greater axial rotation compared to medialized RSA with subscapularis repair. Level of evidence: 2A. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infections occur in 1%-4% of primary total shoulder arthroplasties (TSAs). Cutibacterium acnes is the most commonly implicated organism and has been shown to persist in the dermis despite use of preoperative antibiotics and standard skin preparations. Studies have shown decreased rates of cultures positive for C acnes with use of preoperative benzoyl peroxide or hydrogen peroxide (H 2 O 2), but even with this positive deep cultures remain common. We sought to determine whether an additional application of H 2 O 2 directly to the dermis following skin incision would further decrease deep culture positivity rates. We performed a randomized controlled trial comparing tissue culture results in primary TSA in patients who received a standard skin preparation with H 2 O 2 , ethanol, and ChloraPrep (CareFusion, Leawood, KS, USA) vs. an additional application of H 2 O 2 to the dermis immediately after skin incision. Given the sexual dimorphism seen in the shoulder microbiome regarding C acnes colonization rates, only male patients were included. Bivariable and multivariable analyses were performed to compare rates of positive cultures based on demographic and surgical factors. Dermal cultures were found to be positive for C acnes at similar rates between the experimental and control cohorts for the initial (22% vs. 28%, P =.600) and final (61% vs. 50%, P >.999) dermal swabs. On bivariable analysis, the rate of positive deep cultures for C acnes was lower in the experimental group, but this difference was not statistically significant (28% vs. 44%, P =.130). However, patients who underwent anatomic TSA were found to have a significantly greater rate of deep cultures positive for C acnes (57% vs. 28%, P =.048); when controlling for this on multivariable analysis, the experimental cohort was found to be associated with significantly lower odds of having positive deep cultures (odds ratio, 0.37 [95% confidence interval, 0.16-0.90], P =.023). There were no wound complications in either cohort. An additional H 2 O 2 application directly to the dermis following skin incision resulted in a small but statistically significant decrease in the odds of having deep cultures positive for C acnes without any obvious adverse effects on wound healing. Given its cost-effectiveness, use of a post-incisional dermal decontamination protocol may be considered as an adjuvant to preoperative use of benzoyl peroxide or H 2 O 2 to decrease C acnes contamination. [ABSTRACT FROM AUTHOR]

When patients require reoperation after primary shoulder arthroplasty, revision reverse total shoulder arthroplasty (rTSA) is most commonly performed. However, defining clinically important improvement in these patients is challenging because benchmarks have not been previously defined. Furthermore, although the minimal clinically important difference and substantial clinical benefit are commonly used to assess clinically relevant success, these metrics are limited by ceiling effects that may cause inaccurate estimates of patient success. Our purpose was to define the minimal and substantial clinically important percentage of maximal possible improvement (MCI-%MPI and SCI-%MPI) for commonly used pain and functional outcome scores after revision rTSA and to quantify the proportion of patients achieving clinically relevant success. This retrospective cohort study used a prospectively collected single-institution database of patients who underwent first revision rTSA between August 2015 and December 2019. Patients with a diagnosis of periprosthetic fracture or infection were excluded. Outcome scores included the American Shoulder and Elbow Surgeons (ASES), raw and normalized Constant, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), and University of California, Los Angeles (UCLA) scores. We used an anchor-based method to calculate the MCI-%MPI and SCI-%MPI. In addition, we calculated the MCI-%MPI using a distribution-based method for historical comparison. The proportions of patients achieving each threshold were assessed. The influence of sex, type of primary shoulder arthroplasty, and reason for revision rTSA were also assessed by calculating cohort-specific thresholds. Ninety-three revision rTSAs with minimum 2-year follow-up were evaluated. The mean age of the patients was 67 years; 56% were female, and the average follow-up was 54 months. Revision rTSA was performed most commonly for failed anatomic TSA (n = 47), followed by hemiarthroplasty (n = 21), rTSA (n = 15), and humeral head resurfacing (n = 10). The indication for revision rTSA was most commonly glenoid loosening (n = 24), followed by rotator cuff failure (n = 23) and subluxation and unexplained pain (n = 11 for both). The anchor-based MCI-%MPI thresholds (% of patients achieving) were ASES = 33% (49%), raw Constant = 23% (64%), normalized Constant = 30% (61%), UCLA = 51% (53%), SST = 26% (68%), and SPADI = 29% (58%). The anchor-based SCI-%MPI thresholds (% of patients achieving) were ASES = 55% (31%), raw Constant = 41% (27%), normalized Constant = 52% (22%), UCLA = 66% (37%), SST = 74% (25%), and SPADI = 49% (34%). This study is the first to establish thresholds for the MCI-%MPI and SCI-%MPI at minimum 2 years after revision rTSA, providing physicians an evidence-based method to assess patient outcomes postoperatively. [ABSTRACT FROM AUTHOR]

Purpose: One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high. Methods: A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders. Results: There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction. Conclusions: One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation. [ABSTRACT FROM AUTHOR]

Purpose: Shoulder arthroplasty, a dependable and successful method to relieve pain and restore joint mobility, is increasingly chosen by a large number of individuals. The recent rise in interest in a return to sport (RTS) after shoulder arthroplasty prompts a comprehensive review of RTS outcomes in this context. Methods: This systematic review was conducted to extensively examine RTS elements following shoulder arthroplasty. The review included searches from various databases, including Web of Science, PEDRO, Google Scholar, PubMed, ScienceDirect, SCOPUS, and CINAHL, spanning from January 2000 to May 2023. Additionally, a thorough manual search was undertaken, including a comprehensive review of article sources. Results: Among 18 articles, we found significant RTS rates (>80%), level (high/excellent), time to RTS (5.3 months to 9.1 months), and a high number of RTS patients in swimming after shoulder arthroplasty. After shoulder arthroplasty, patients returned to some sports activities, such as swimming, tennis, golf, leg sports, skiing, and so on. Conclusion: This systematic review showed significantly high RTS rates, levels, and number of patients among different arthroplasty types, such as total shoulder arthroplasty (TSA) and reversed total shoulder arthroplasty (RTSA). The most prevalent sport was swimming among patients. We hope this comprehensive systematic review provides insight into coaches and trainers to help patients increase their quality of life and have successful RTS after shoulder arthroplasty.

Background: Although substantial motion at the acromioclavicular joint (ACJ) occurs during overhead shoulder motion, the influence of ACJ arthritis on postoperative outcomes of patients undergoing reverse total shoulder arthroplasty (rTSA) is unclear. We assessed the influence of ACJ arthritis, defined by degenerative radiographic changes, and its severity on clinical outcomes after primary rTSA. Methods: We conducted a retrospective review of a prospectively collected shoulder arthroplasty database of patients that underwent primary rTSA with a minimum 2-year clinical follow-up. Imaging studies of included patients were evaluated to assess ACJ arthritis classified by radiographic degenerative changes of the ACJ; severity was based upon size and location of osteophytes. Both the Petersson classification and the King classification (a modified Petersson classification addressing superior osteophytes and size of the largest osteophyte) were used to evaluate the severity of degenerative ACJ radiographic changes. Severe ACJ arthritis was characterized by large osteophytes (≥2 mm). Active range of motion (ROM) in abduction, forward elevation, and external and internal rotation as well as clinical outcome scores (American Shoulder and Elbow Surgeons Shoulder, Constant, Shoulder Pain and Disability Index, simple shoulder test, University of California, Los Angeles scores) were assessed both preoperatively and at the latest follow-up; outcomes were compared based on severity of ACJ arthritis. Multivariable linear regression models were used to determine whether increasing severity of ACJ arthritis was associated with poorer outcomes. Results: A total of 341 patients were included with a mean age of 71 ± 8 years and 55% were female. The mean follow-up was 5.1 ± 2.4 years. Preoperatively, there were no differences in outcomes based on the severity of ACJ pathology. Postoperatively, there were no differences in outcomes based upon the severity of ACJ arthritis except for greater preoperative to postoperative improvement in active internal rotation in patients with normal or grade 1 ACJ arthritis vs. grade 2 and 3 (3 ± 2 vs. 1 ± 2 and 1 ± 3, P = .029). Patients with ACJ arthritis and osteophytes ≥2 mm had less favorable Shoulder Pain and Disability Index scores, corresponding to greater pain (−49.3 ± 21.5 vs. −41.3 ± 26.8, P = .015). On multivariable linear regression, increased severity of ACJ arthritis was not independently associated with poorer postoperative ROM or outcome scores. Conclusion: Overall, our results demonstrate that greater ACJ arthritis severity score is not associated with poorer outcome scores and has minimal effect on ROM. However, patients with the largest osteophytes (≥2 mm) did have slightly worse pain postoperatively. Radiographic presence of high-stage ACJ arthritis should not alter the decision to undergo rTSA.

Background: Native glenoid bone loss presents technical challenges in shoulder arthroplasty. The purpose of this study is to report the mid-term clinical and radiographic outcomes of patients treated with structural humeral head autograft reconstruction of glenoid bone loss in the setting of reverse total shoulder arthroplasty (rTSA). Methods: Retrospective review of 30 shoulders in 28 patients undergoing rTSA with a structural humeral head autograft to correct glenoid bone loss. Demographics, comorbidities, anatomic details, and patient-reported outcome measures were collected for analysis. Results: Range of motion and patient-reported outcome measures were all significantly improved postoperatively (P

Background Restoration of external (ER) and internal rotation (IR) after Grammont-style reverse shoulder arthroplasty (RSA) is often unreliable. The purpose of this systematic review was to evaluate the influence of RSA medio-lateral offset and subscapularis repair on axial rotation after RSA. Methods We conducted a systematic review of studies evaluating axial rotation (ER, IR, or both) after RSA with a defined implant design. Medio-lateral implant classification was adopted from Werthel et al. Meta-analysis was conducted using a random-effects model. Results Thirty-two studies reporting 2,233 RSAs were included (mean patient age, 72.5 years; follow-up, 43 months; 64% female). The subscapularis was repaired in 91% (n=2,032) of shoulders and did not differ based on global implant lateralization (91% for both, P=0.602). On meta-analysis, globally lateralized implants achieved greater postoperative ER (40° [36°–44°] vs. 27° [22°–32°], P

Background: While the use of computer-assisted navigation systems in prosthetic implantation is steadily increasing, its utility in reverse shoulder arthroplasty (RSA) remains unclear. The purpose of this study was to evaluate the clinical utility of an intraoperative navigation system in patients undergoing RSA. Materials and methods: Patients undergoing navigated or standard RSA at a single institution between September 2020 and December 2021 were prospectively enrolled. Exclusion criteria included noncompliance with study procedures or humeral fracture. Outcome measures included postoperative version and inclination, range of motion (ROM), complications, and patient-reported outcome measurements (PROMs: American Shoulder and Elbow Surgeons score [ASES], Disabilities of the Arm, Shoulder, and Hand score [DASH], Simple Shoulder Test [SST], and Visual Analog Scale [VAS]) at final follow-up. Results: The final cohort contained 16 patients with navigation and 17 with standard RSA at a mean follow-up of 16 months (range 12–18 months). Average age was 72 years (range 66–80 years), 8 male (24%) and 25 female (76%). There were no differences in demographics between groups (p > 0.05). At baseline, the navigated group had a greater proportion of Walch B1 and B2 glenoids (p = 0.04). There were no differences between groups regarding baseplate type and native/planned/postoperative glenoid version and inclination. In both groups, planned and postoperative versions were not significantly different (p = 0.76). Patients who did not have navigation demonstrated significant differences between planned and postoperative inclination (p = 0.04), while those with navigation did not (p = 0.09). PROM scores did not differ between groups at final follow-up for SST (p = 0.64), DASH (p = 0.38), ASES (p = 0.77), or VAS (p = 0.1). No difference in final ROM was found between groups (p > 0.05). Over 50% of all screws in both groups were positioned outside the second cortex (p = 0.37), albeit with no complications. Conclusions: There were no statistically significant differences in ROM, PROMs, and satisfaction between patients receiving computer-navigated and standard RSA at a short-term follow-up. Despite more severe preoperative glenoid erosion in the navigated group, all patients were able to achieve an appropriate neutral axis postoperatively. The cost effectiveness and appropriate use of computer-navigated RSA warrant specific investigation in future studies. Level of evidence: II, prospective cohort study. Trial registration: 9/1/2020 to 12/31/2021. [ABSTRACT FROM AUTHOR]

Purpose: Shoulder arthroplasty, a dependable and successful method to relieve pain and restore joint mobility, is increasingly chosen by a large number of individuals. The recent rise in interest in a return to sport (RTS) after shoulder arthroplasty prompts a comprehensive review of RTS outcomes in this context. Methods: This systematic review was conducted to extensively examine RTS elements following shoulder arthroplasty. The review included searches from various databases, including Web of Science, PEDRO, Google Scholar, PubMed, ScienceDirect, SCOPUS, and CINAHL, spanning from January 2000 to May 2023. Additionally, a thorough manual search was undertaken, including a comprehensive review of article sources. Results: Among 18 articles, we found significant RTS rates (>80%), level (high/excellent), time to RTS (5.3 months to 9.1 months), and a high number of RTS patients in swimming after shoulder arthroplasty. After shoulder arthroplasty, patients returned to some sports activities, such as swimming, tennis, golf, leg sports, skiing, and so on. Conclusion: This systematic review showed significantly high RTS rates, levels, and number of patients among different arthroplasty types, such as total shoulder arthroplasty (TSA) and reversed total shoulder arthroplasty (RTSA). The most prevalent sport was swimming among patients. We hope this comprehensive systematic review provides insight into coaches and trainers to help patients increase their quality of life and have successful RTS after shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Purpose: We sought to define the risk of persistent shoulder dysfunction after anatomic total shoulder arthroplasty (aTSA) beyond the early postoperative period and identify risk factors for persistent poor performance. Methods: We retrospectively identified 144 primary aTSAs performed for primary osteoarthritis with early poor performance and 2-year minimum follow-up. Early poor performance was defined as a postoperative ASES score below the 20th percentile at 3- or 6-months (62 and 72 points, respectively). Persistent poor performance at 2 years was defined as failing to achieve the patient acceptable symptomatic state (PASS) [ASES = 81.7 points]. Results: At 2-year follow-up, 51% (n = 74) of patients with early poor performance at either 3- or 6-month follow-up had persistent poor performance. There was no difference in the rate of persistent poor performance if patients were poor performers at the 3-, 6-month follow-up, or both (50% vs. 49% vs. 56%, P =.795). Of aTSAs achieving the PASS at 2-year follow-up, a greater proportion exceeded the minimal clinically important differences (MCID) [Forward elevation, external rotation, and all outcome scores] and substantial clinical benefit (SCB) [external rotation and all outcome scores] compared to persistent poor performers. However, over half of persistent poor performers still exceeded the MCID for all outcome measures (56–85%). Independent predictors of persistent poor performance were hypertension (2.61 [1.01–6.72], P =.044) and diabetes (5.14 [1.00–26.4], P =.039). Conclusion: Over half of aTSAs with an ASES score < 20th percentile at early follow-up had continued poor shoulder function at 2-years postoperatively. Persistent poor performance was best projected by preoperative hypertension and diabetes. Level of evidence: Level III; Retrospective Cohort Comparison using Large Database; Treatment Study [ABSTRACT FROM AUTHOR]

Changes in preoperative to postoperative outcome scores are often used to quantify success after reverse total shoulder arthroplasty (rTSA). However, ceiling effects associated with many outcome scores limit the ability to differentiate success among high-functioning patients. The percentage of maximal possible improvement (%MPI) was introduced to simplify and better stratify patient success. The primary purpose of this study was to define the %MPI thresholds associated with substantial clinical improvement following primary rTSA and compare the rates of success as defined by those achieving the substantial clinical benefit (SCB) compared to the 30% MPI for different outcome scores. A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary rTSAs performed using a single implant system with a minimum 2-year follow-up were reviewed. Preoperative and postoperative outcome scores were evaluated for all patients to calculate improvement. Six outcome scores were assessed: the Simple Shoulder Test (SST), Constant, American Shoulder and Elbow Surgeons (ASES), University of California Los Angeles (UCLA), Shoulder Pain and Disability Index (SPADI), and Shoulder Arthroplasty Smart (SAS) scores. The proportion of patients achieving the SCB and 30% MPI was determined for each outcome score. Thresholds for the substantial clinically important %MPI (SCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex. Of total, 2573 shoulders with a mean follow-up of 47 months were included. Outcome scores with known ceiling effects (SST, ASES, UCLA, SPADI) had higher rates of patients achieving the 30% MPI compared to scores without ceiling effects (Constant, SAS). However, scores without ceiling effects had higher rates of patients achieving the SCB. The SCI-%MPI differed among outcome scores, and mean values were 47% for the SST, 35% for the Constant score, 50% for the ASES score, 52% for the UCLA score, 47% for the SPADI score, and 45% for the SAS score. The SCI-%MPI increased in patients older than 60 years (P <.001) except for the SAS and Constant scores. SCI-%MPI was greater in females for all scores assessed except the Constant and SPADI scores (P <.001 for all). The higher SCI-%MPI thresholds in these populations mean that these patients required a greater fraction of the MPI to have substantial improvement. The %MPI judged relative to patient-reported substantial clinical improvement offers an alternative method to quickly assess improvements across patient outcome scores. Given considerable variation in the %MPI corresponding to substantial clinical improvement, we recommend utilizing score-specific estimates of the SCI-%MPI to gauge success when evaluating patients undergoing primary rTSA. [ABSTRACT FROM AUTHOR]

To forecast the number of primary total shoulder replacements (TSR) in Australia to the year 2035, and associated costs. De-identified TSR data for 2009–2019 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data, including population projections to 2035, were obtained from the Australian Bureau of Statistics. Three forecasting scenarios were used: constant TSR rates from 2019 onwards (Scenario 1, conservative); continued growth in TSR rates using negative binomial regression (Scenario 2, exponential); and continued growth using negative binomial regression with monotone B-splines (Scenario 3, moderate). Healthcare costs were estimated using TSR projections and average procedure costs, inflated to 2035 Australian dollars. The use of TSR increased by 242% in Australia from 2009 to 2019 (from 1983 to 6789 procedures for people ≥40 years). Under Scenario 1, the incidence of TSR is conservatively projected to rise to 9676 procedures by 2035 (43% increase from 2019), at a cost of $AUD 312.6 million to the health system. Under Scenario 2, TSR incidence would increase to 45,295 procedures by 2035 (567% increase), costing $AUD 1.46 billion. Under Scenario 3, 28,257 TSR procedures are forecast in 2035 (316% increase) at a cost of $913 million. Recent growth in TSR likely relates to prosthesis improvements, greater surgeon proficiency, and expanded clinical indications. Under moderate and exponential scenarios that consider rising TSR rates and population projections, Australia would face three- to five-fold growth in procedures by 2035. This would have profound implications for the healthcare budget, clinical workforce, and infrastructure. [ABSTRACT FROM AUTHOR]

Percentage maximal possible improvement (%MPI) has been described as a threshold by which to evaluate patient improvement after anatomic total shoulder arthroplasty (aTSA) that has favorable psychometric properties. The primary purpose of this study was to define the percentage maximal possible improvement (%MPI) thresholds associated with substantial clinical improvement following primary anatomic total shoulder arthroplasty (aTSA) and compare the rates of success as defined by those achieving the substantial clinical benefit (SCB) compared with the 30% MPI for different outcome scores. A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary aTSAs performed using a single implant system with minimum 2-year follow-up were reviewed. Pre- and postoperative outcome scores were evaluated for all patients to calculate improvement. Six outcome scores were assessed: the Simple Shoulder Test (SST), Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), University of California–Los Angeles shoulder score (UCLA), Shoulder Pain and Disability Index (SPADI), and Shoulder Arthroplasty Smart (SAS) scores. The proportion of patients achieving the SCB and 30% MPI were determined for each outcome score. Thresholds for the substantial clinically important %MPI (SCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex. A total of 1593 shoulders with a mean follow-up of 59.3 months were included. Outcome scores with known ceiling effects (SST, ASES, UCLA) had higher rates of patients achieving the 30% MPI but not the previously reported SCB compared to scores without ceiling effects (Constant, SAS). The SCI-%MPI differed among outcome scores, and mean values were as follows: 48% for the SST, 39% for the Constant score, 53% for the ASES score, 55% for the UCLA score, 50% for the SPADI score, and 42% for the SAS score. The SCI-%MPI increased in patients older than 60 years (P ≤.006 for all) and was greater in females for all scores assessed except the Constant score (P <.001 for all), meaning that patients with higher thresholds required a greater fraction of the maximum possible improvement for a given score to have substantial improvement. The %MPI judged relative to patient-reported substantial clinical improvement offers a new method to assess improvements across patient outcome scores. Given considerable variation in the %MPI corresponding to substantial clinical improvement, we recommend utilizing score-specific estimates of the SCI-%MPI to gauge success when evaluating patients undergoing primary aTSA. [ABSTRACT FROM AUTHOR]

In high functioning patients, the ceiling effect associated with many patient-reported outcome measures (PROMs) limits the ability to appropriately stratify success. The percentage maximal possible improvement (%MPI) was introduced as another evaluation tool, with a proposed threshold of success at 30%. It remains unclear if this threshold correlates with perceived patient success following shoulder arthroplasty. The purpose of this study was to compare the proportion of patients that achieved the minimal clinically important difference (MCID) and %MPI for different outcome scores and to define the %MPI thresholds associated with patient satisfaction following primary reverse total shoulder arthroplasty (rTSA). A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary rTSAs performed using a single implant system with minimum 2-year follow-up were reviewed. Pre- and postoperative outcome scores were evaluated for all patients to determine the raw improvement and %MPI. The proportion of patients achieving the MCID and 30% MPI were determined for each outcome score. Thresholds for the minimal clinically important %MPI (MCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex. A total of 2573 shoulders with a mean follow-up of 47 months were included. Outcome scores with known ceiling effects (Simple Shoulder Test [SST], Shoulder Pain and Disability Index [SPADI], University of California–Los Angeles shoulder score [UCLA]) had higher rates of patients achieving the 30% MPI but not the previously reported MCID. Inversely, outcome scores without significant ceiling effects (Constant and Shoulder Arthroplasty Smart [SAS] scores) had higher rates of patients achieving the MCID, but not the 30% MPI. The MCI-%MPI differed among outcome scores and mean values were as follows: 33% for the SST, 27% for the Constant score, 35% for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, 43% for the UCLA score, 34% for the SPADI score, and 30% for the SAS score. The MCI-%MPI increased with greater age for SPADI (P <.04) and SAS (P <.01) scores, meaning that patients with higher thresholds required a greater fraction of the possible improvement for a given score to be satisfied but did not reach statistical significance for other scores. Females had a greater MCI-%MPI for the SAS and ASES scores and a lower MCI-MPI% for the SPADI score. The %MPI offers a simple method to quickly assess improvements across patient outcome scores. However, the %MPI that represents patient improvement after surgery is not uniformly the previously established 30% threshold. Surgeons should use score-specific estimates of the MCI-%MPI to gauge success when evaluating patients undergoing primary rTSA. [ABSTRACT FROM AUTHOR]

Background: There are little published data on return to sports (RTS) after reverse total shoulder arthroplasty (RTSA). Purpose: To (1) determine the rate and timing of RTS after RTSA in an Asian population, (2) analyze predictive factors for RTS, and (3) determine the relationship between RTS after RTSA and clinical/radiological outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review was performed on consecutive patients with diagnosis of irreparable rotator cuff tear (RCT), cuff tear arthropathy (CTA), or degenerative osteoarthritis who underwent RTSA between May 2017 and May 2020. Included were patients who played sports preoperatively in ≤3 years and had ≥2-year follow-up. Patients were divided into 2 groups based on responses to a telephone survey about RTS after RTSA: those who returned to sports (group A) and those who did not (group B). Patient characteristics, pre- and postoperative clinical features and functional scores, and radiologic outcomes (acromial fracture, scapular notching, heterotopic ossification, and loosening of humeral and glenoid component) were compared between the groups. Results: Of 59 eligible patients, 44 patients (28 in group A, 16 in group B) were included. The RTS rate after RTSA was 63.6%, and the mean RTS time was 9.1 months (range, 3-36 months). There was a significant group difference in body mass index (BMI) (group A, 24.3 ± 2.1; group B, 27.1 ± 4.4; P =.01) and preoperative diagnosis (CTA/irreparable RCT/degenerative osteoarthritis diagnoses: group A, 13/12/3; group B, 3/6/7; P =.03). Patients in group A showed significantly higher forward flexion (P =.03) and higher Simple Shoulder Test score (P =.02) than group B at final clinical follow-up. No significant difference in radiological outcomes was found between the groups. Conclusion: Patients with a low BMI and those diagnosed with CTA or irreparable RCT were found to have better RTS rates after undergoing RTSA, and forward flexion and Simple Shoulder Test scores at final follow-up were significantly higher in the RTS group, with no significant differences in complications. [ABSTRACT FROM AUTHOR]

Abstract Background The aim of this study was to forecast future patient demand for shoulder replacement surgery in England and investigate any geographic and socioeconomic inequalities in service provision and patient outcomes. Methods For this cohort study, all elective shoulder replacements carried out by NHS hospitals and NHS-funded care in England from 1999 to 2020 were identified using Hospital Episode Statistics data. Eligible patients were aged 18 years and older. Shoulder replacements for malignancy or acute trauma were excluded. Population estimates and projections were obtained from the Office for National Statistics. Standardised incidence rates and the risks of serious adverse events (SAEs) and revision surgery were calculated and stratified by geographical region, socioeconomic deprivation, sex, and age band. Hospital costs for each admission were calculated using Healthcare Resource Group codes and NHS Reference Costs based on the National Reimbursement System. Projected rates and hospital costs were predicted until the year 2050 for two scenarios of future growth. Results A total of 77,613 elective primary and 5847 revision shoulder replacements were available for analysis. Between 1999 and 2020, the standardised incidence of primary shoulder replacements in England quadrupled from 2.6 to 10.4 per 100,000 population, increasing predominantly in patients aged over 65 years. As many as 1 in 6 patients needed to travel to a different region for their surgery indicating inequality of service provision. A temporal increase in SAEs was observed: the 30-day risk increased from 1.3 to 4.8% and the 90-day risk increased from 2.4 to 6.0%. Patients from the more deprived socioeconomic groups appeared to have a higher risk of SAEs and revision surgery. Shoulder replacements are forecast to increase by up to 234% by 2050 in England, reaching 20,912 procedures per year with an associated annual cost to hospitals of £235 million. Conclusions This study reports a rising incidence of shoulder replacements, regional disparities in service provision, and an overall increasing risk of SAEs, especially in more deprived socioeconomic groups. These findings highlight the need for better healthcare planning to match local population demand, while more research is needed to understand and prevent the increase observed in SAEs.

Background Many patients use online resources to educate themselves on surgical procedures and make well-informed healthcare decisions. The aim of our study was to evaluate the quality and readability of online resources exploring shoulder arthroplasty. Methods An internet search pertaining to shoulder arthroplasty (partial, anatomic, and reverse) was conducted using the three most popular online search engines. The top 25 results generated from each term in each search engine were included. Webpages were excluded if they were duplicates, advertised by search engines, subpages of other pages, required payments or subscription, or were irrelevant to our scope. Webpages were classified into different source categories. Quality of information was assessed by HONcode certification, Journal of the American Medical Association (JAMA) criteria, and DISCERN benchmark criteria. Webpage readability was assessed using the Flesch reading ease score (FRES). Results Our final dataset included 125 web pages. Academic sources were the most common with 45 web pages (36.0%) followed by physician/private practice with 39 web pages (31.2%). The mean JAMA and DISCERN scores for all web pages were 1.96±1.31 and 51.4±10.7, respectively. The total mean FRES score was 44.0±11.0. Only nine web pages (7.2%) were HONcode certified. Websites specified for healthcare professionals had the highest JAMA and DISCERN scores with means of 2.92±0.90 and 57.96±8.91, respectively (P

Background In the past decade, the number of anatomic total shoulder arthroplasty (aTSA) procedures has steadily increased. Patients over 65 years of age comprise the vast majority of recipients, and outcomes have been well documented; however, patients are opting for definitive surgical treatment at younger ages.We aim to report on the effects of age on the long-term clinical outcomes following aTSA. Methods Among the patients who underwent TSA, 119 shoulders were retrospectively analyzed. Preoperative and postoperative clinical outcome data were collected. Linear regression analysis (univariate and multivariate) was conducted to evaluate the associations of clinical outcomes with age. Kaplan-Meier curves and Cox regression analyses were performed to evaluate implant survival. Results At final follow-up, patients of all ages undergoing aTSA experienced significant and sustained improvements in all primary outcome measures compared with preoperative values. Based on multivariate analysis, age at the time of surgery was a significant predictor of postoperative outcomes. Excellent implant survival was observed over the course of this study, and Cox regression survival analysis indicated age and sex to not be associated with an increased risk of implant failure. Conclusions When controlling for sex and follow-up duration, older age was associated with significantly better patient-reported outcome measures. Despite this difference, we noted no significant effects on range of motion or implant survival. Level of evidenceIV.

Background: The aim of this study was to forecast future patient demand for shoulder replacement surgery in England and investigate any geographic and socioeconomic inequalities in service provision and patient outcomes. Methods: For this cohort study, all elective shoulder replacements carried out by NHS hospitals and NHS-funded care in England from 1999 to 2020 were identified using Hospital Episode Statistics data. Eligible patients were aged 18 years and older. Shoulder replacements for malignancy or acute trauma were excluded. Population estimates and projections were obtained from the Office for National Statistics. Standardised incidence rates and the risks of serious adverse events (SAEs) and revision surgery were calculated and stratified by geographical region, socioeconomic deprivation, sex, and age band. Hospital costs for each admission were calculated using Healthcare Resource Group codes and NHS Reference Costs based on the National Reimbursement System. Projected rates and hospital costs were predicted until the year 2050 for two scenarios of future growth. Results: A total of 77,613 elective primary and 5847 revision shoulder replacements were available for analysis. Between 1999 and 2020, the standardised incidence of primary shoulder replacements in England quadrupled from 2.6 to 10.4 per 100,000 population, increasing predominantly in patients aged over 65 years. As many as 1 in 6 patients needed to travel to a different region for their surgery indicating inequality of service provision. A temporal increase in SAEs was observed: the 30-day risk increased from 1.3 to 4.8% and the 90-day risk increased from 2.4 to 6.0%. Patients from the more deprived socioeconomic groups appeared to have a higher risk of SAEs and revision surgery. Shoulder replacements are forecast to increase by up to 234% by 2050 in England, reaching 20,912 procedures per year with an associated annual cost to hospitals of £235 million. Conclusions: This study reports a rising incidence of shoulder replacements, regional disparities in service provision, and an overall increasing risk of SAEs, especially in more deprived socioeconomic groups. These findings highlight the need for better healthcare planning to match local population demand, while more research is needed to understand and prevent the increase observed in SAEs. [ABSTRACT FROM AUTHOR]

Purpose: Accurate glenoid component placement in total shoulder arthroplasty (TSA) remains challenging even with preoperative planning, especially for variable glenoid erosion patterns in the coronal plane. Methods: We retrospectively reviewed 170 primary TSAs in which preoperative planning software was used. After registration of intraoperative bony landmarks, surgeons were blinded to the navigation screen and attempted to implement their plan by simulating placement of a central-axis guide pin: 230 screenshots of simulated guide pin placement were included (aTSA = 66, rTSA = 164). Displacement, error in version and inclination, and overall malposition from the preoperatively-planned target point were stratified by the Favard classification describing superior-inferior glenoid wear: E0 (n = 89); E1 (n = 81); E2 (n = 29); E3(n = 29); E4(n = 2). Malposition was considered > 10° for version/inclination errors or > 4 mm displacement from the starting point. Results: Mean displacement error was 3.5 ± 2.7 mm (aTSA = 2.7 ± 2.3 mm, rTSA = 3.8 ± 2.9 mm), version error was 5.7 ± 4.7° (aTSA = 5.8 ± 4.4°, rTSA = 5.7 ± 4.8°), inclination error was 7.1 ± 5.6 (aTSA = 4.8 ± 4.8°, rTSA = 8.1 ± 5.7°), and malposition rate was 53% (aTSA = 38%, rTSA = 59%). When compared by Favard classification, there were no differences in any measure; when stratified by TSA type, version error differed for rTSAs (P =.038), with E1 having the greatest version error (6.9 ± 5.2°) and E3 the least (4.2 ± 3.4°). When comparing glenoids without wear (E0) and glenoids with superior wear (E2 and E3), the only difference was greater version error in glenoids without wear (6.0 ± 4.9° vs. 4.6 ± 3.7°, P =.041). Conclusions: Glenoid malposition did not differ based on coronal glenoid morphology. Although, malposition was relatively high, suggesting surgeons should consider alternate techniques beyond preoperative planning and standard instrumentation in TSA. Level of evidence III: Retrospective Cohort Study. [ABSTRACT FROM AUTHOR]

When patients require revision of primary shoulder arthroplasty, revision reverse total shoulder arthroplasty (rTSA) is most commonly performed. However, defining clinically important improvement in these patients is challenging because benchmarks have not been previously defined. Our purpose was to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for outcome scores and range of motion (ROM) after revision rTSA and to quantify the proportion of patients achieving clinically relevant success. This retrospective cohort study used a prospectively collected single-institution database of patients undergoing first revision rTSA between August 2015 and December 2019. Patients with a diagnosis of periprosthetic fracture or infection were excluded. Outcomes scores included the ASES, raw and normalized Constant, SPADI, SST, and University of California, Los Angeles (UCLA) scores. ROM measures included abduction, forward elevation (FE), external rotation (ER), and internal rotation (IR) score. Anchor-based and distribution-based methods were used to calculate the MCID, SCB, and PASS. The proportions of patients achieving each threshold were assessed. Ninety-three revision rTSAs with minimum 2-year follow-up were evaluated. Mean age was 67 years, 56% were female, and average follow-up was 54 months. Revision rTSA was performed most commonly for failed anatomic TSA (n = 47), followed by hemiarthroplasty (n = 21), rTSA (n = 15), and resurfacing (n = 10). The indication for revision rTSA was most commonly glenoid loosening (n = 24), followed by rotator cuff failure (n = 23), subluxation and unexplained pain (n = 11 for both). The anchor-based MCID thresholds (% of patients achieving) were as follows: ASES, 20.1 (42%); normalized Constant, 12.6 (80%); UCLA, 10.2 (54%); SST, 0.9 (78%); SPADI, −18.4 (58%); abduction, 13° (83%); FE, 18° (82%); ER, 4° (49%); and IR, 0.8 (34%). The SCB thresholds (% of patients achieving) were as follows: ASES, 34.1 (25%); normalized Constant, 26.6 (43%); UCLA, 14.1 (28%); SST, 3.9 (48%); SPADI, −36.4 (33%); abduction, 20° (77%); FE, 28° (71%); ER, 15° (15%); and IR, 1.0 (29%). The PASS thresholds (% of patients achieving) were as follows: ASES, 63.5 (53%); normalized Constant, 59.1 (61%); UCLA, 25.4 (48%); SST, 7.0 (55%); SPADI, 42.4 (59%); abduction, 98° (61%); FE, 110° (56%); ER, 19° (73%); and IR, 3.3 (59%). This study establishes thresholds for the MCID, SCB, and PASS at minimum 2-years after revision rTSA, providing physicians an evidence-based method to counsel patients and assess patient outcomes postoperatively. [ABSTRACT FROM AUTHOR]

Patient satisfaction after reverse shoulder arthroplasty (RSA) partly relies on restoring functional internal rotation (IR). Although postoperative assessment of IR includes objective appraisal by the surgeon and subjective report from the patient, these evaluations may not vary together uniformly. We assessed the relationship between objective, surgeon-reported assessments of IR and subjective, patient-reported ability to perform IR-related activities of daily living (IRADLs). Our institutional shoulder arthroplasty database was queried for patients undergoing primary RSA with a medialized-glenoid lateralized-humerus design between 2007-2019 and minimum 2-year follow-up. Patients who were wheelchair bound or had a preoperative diagnosis of infection, fracture, and tumor were excluded. Objective IR was measured to the highest vertebral level reached with the thumb. Subjective IR was reported based on patients' rating (normal, slightly difficult, very difficult, or unable) of their ability to perform 4 IRADLs (tuck in shirt with hand behind back, wash back or fasten bra, personal hygiene, and remove object from back pocket). Objective IR was assessed preoperatively and at latest follow-up and reported as median and interquartile ranges. A total of 443 patients were included (52% female) at a mean follow-up of 4.4 ± 2.3 years. Objective IR improved pre- to postoperatively from L4-L5 (buttocks to L1-L3) to L1-L3 (L4-L5 to T8-T12) (P <.001). Preoperatively reported IRADLs of "very difficult" or "unable" significantly decreased postoperatively for all IRADLs (P ≤.004) except those unable to perform personal hygiene (3.2% vs. 1.8%, P >.99). The proportions of patients who improved, maintained, and lost objective and subjective IR was similar between IRADLs; 14%-20% improved objective IR but lost or maintained subjective IR and 19%-21% lost or maintained the same objective IR but improved subjective IR depending on the specific IRADL assessed. When ability to perform IRADLs improved postoperatively, objective IR also increased (P <.001). In contrast, when subjective IRADLs worsened postoperatively, objective IR did not significantly worsen for 2 of 4 IRADLs assessed. When examining patients who reported no change in ability to perform IRADLs pre- vs. postoperatively, statistically significant increases in objective IR were found for 3 of 4 IRADLs assessed. Objective improvement in IR parallels improvements in subjective functional gains uniformly. However, in patients with worse or equivalent IR, the ability to perform IRADLs postoperatively does not uniformly correlate with objective IR. When attempting to elucidate how surgeons can ensure patients will have sufficient IR after RSA, future investigations may need to use patient-reported ability to perform IRADLs as the primary outcome measure rather than objective measures of IR. [ABSTRACT FROM AUTHOR]

Background: Australian healthcare relies on both private and public sectors to meet the demand for surgical care. Rapid growth of shoulder replacement surgery highlights a disparity in service provision, with two‐thirds occurring privately. This study aimed to assess the influence of hospital setting on shoulder replacement revision rate at a national level. Methods: All primary shoulder replacements recorded by the Australian Orthopaedic Association National Joint Replacement Registry from April 2004 to December 2020 were included. Private and public settings were compared for stemmed total shoulder replacement (sTSR) for osteoarthritis (OA), reverse total shoulder replacement (rTSR) for OA/cuff arthropathy (CA), and rTSR for fracture. The primary outcome was cumulative percent revision (CPR), with Kaplan–Meier estimates of survivorship to determine differences between private and public hospitals, recorded as hazard ratios (HR). Secondary analyses investigated differences between hospital settings, targeting hospital outliers for revision and prosthesis selection. Results: Primary sTSR (OA) demonstrated a higher revision rate in private hospitals compared to public hospitals (HR = 1.27; P = 0.001), as did rTSR (OA/CA) after 3 months (HR = 1.33; P = 0.003). However, no significant difference was observed for primary rTSR (fracture) (HR = 1.10; P = 0.484). Restricting rTSR (OA/CA) to the best performing prosthesis combinations eliminated the difference between private and public outcomes (HR 1.10; P = 0.415). No other secondary analysis altered the primary result. Conclusions: Differences exist between private and public hospitals for revision rate following primary shoulder replacement. Prosthesis selection accounts for some of the variation. Further analysis into patient specific characteristics is necessary to better understand these disparities. [ABSTRACT FROM AUTHOR]

(1) Background: Allograft prosthetic composite (APC) represents one of the techniques used for reconstruction in large proximal humeral bone deficits. The present systematic review aimed at summarizing the state of the art of the technique and analyzing its outcomes. (2) Methods: The PRISMA guidelines were followed to perform this systematic review. A systematic electronic search was performed using PubMed (MEDLINE), EMBASE, and the Cochrane Library databases. All the studies analyzing the rates of allograft prosthesis composite were pooled, and the data were extracted and analyzed. (3) Results: A total of 10 studies were eligible for inclusion in this systematic review for a total of 239 patients. The rate of patient satisfaction with surgery was reported in 7 studies with a mean of 86.4% ± 13.64. The mean constant score was 45.7 ± 3.51, the mean ASES score was 63.58 ± 8.37, and the mean SST was 4.6 ± 1.04. The mean revision rate observed was 10.32% ± 3.63 and the mean implant survival was 83.66% ± 14.98. (4) Conclusions: Based on the currently available data, allograft prosthesis composite represents a valuable option for the reconstruction of proximal humeral deficits. All studies analyzed showed the favorable impact of this surgical technique on clinical outcomes and patient satisfaction. [ABSTRACT FROM AUTHOR]

Objective: The number of shoulder arthroplasties is increasing along with the need for revision surgeries. Determining the stability of the implant is crucial in preoperative planning. This study aims to investigate whether radiolucent lines (RLL) in preoperative radiographs predict component loosening. Materials and methods: Preoperative radiographs of 93 cases in 88 patients who underwent shoulder arthroplasty revision were evaluated regarding the presence of RLL. Correlation analyses were performed for radiographic findings and demographic factors (age, gender, BMI, prior surgeries) compared to intraoperative findings. Results: The presence of RLL around the humeral component correlated with loosening (p < 0.001, Phi 0.511), and the distal zones 3 and 5 showed the strongest correlation (Phi 0.536). While RLL in only one zone did not predict loosening (p = 0.337), RLL present in two or more zones showed correlation with loosening (p < 0.001). Risk factors associated with loosening were a higher age at the time of revision surgery (p = 0.030) and the number of zones with RLL (p < 0.001). The glenoid component was loose in 39.0% of the cases; 5.5% of the glenoid components with RLL were stable. Nevertheless, the presence of RLL was highly associated with loosening (p < 0.001, Phi 0.603). A longer time between implantation and revision correlated with loosening of the glenoid component (p = 0.046). Conclusion: While RLL do not predict loosening of the implant in general, occurrence in more than one zone correlates with loosening. If located in distal zones and with increasing number of zones with RLL, the correlation becomes even stronger and loosening is more likely. [ABSTRACT FROM AUTHOR]

Background: Many patients use online resources to educate themselves on surgical procedures and make well-informed healthcare decisions. The aim of our study was to evaluate the quality and readability of online resources exploring shoulder arthroplasty. Methods: An internet search pertaining to shoulder arthroplasty (partial, anatomic, and reverse) was conducted using the three most popular online search engines. The top 25 results generated from each term in each search engine were included. Webpages were excluded if they were duplicates, advertised by search engines, subpages of other pages, required payments or subscription, or were irrelevant to our scope. Webpages were classified into different source categories. Quality of information was assessed by HONcode certification, Journal of the American Medical Association (JAMA) criteria, and DISCERN benchmark criteria. Webpage readability was assessed using the Flesch reading ease score (FRES). Results: Our final dataset included 125 web pages. Academic sources were the most common with 45 web pages (36.0%) followed by physician/private practice with 39 web pages (31.2%). The mean JAMA and DISCERN scores for all web pages were 1.96±1.31 and 51.4±10.7, respectively. The total mean FRES score was 44.0±11.0. Only nine web pages (7.2%) were HONcode certified. Websites specified for healthcare professionals had the highest JAMA and DISCERN scores with means of 2.92±0.90 and 57.96±8.91, respectively (P<0.001). HONcode-certified webpages had higher quality and readability scores than other web pages. Conclusions: Web-based patient resources for shoulder arthroplasty information did not show high-quality scores and easy readability. When presenting medical information, sources should maintain a balance between readability and quality and should seek HONcode certification as it helps establish the reliability and accessibility of the presented information. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Background: In the past decade, the number of anatomic total shoulder arthroplasty (aTSA) procedures has steadily increased. Patients over 65 years of age comprise the vast majority of recipients, and outcomes have been well documented; however, patients are opting for definitive surgical treatment at younger ages. We aim to report on the effects of age on the long-term clinical outcomes following aTSA. Methods: Among the patients who underwent TSA, 119 shoulders were retrospectively analyzed. Preoperative and postoperative clinical outcome data were collected. Linear regression analysis (univariate and multivariate) was conducted to evaluate the associations of clinical outcomes with age. Kaplan-Meier curves and Cox regression analyses were performed to evaluate implant survival. Results: At final follow-up, patients of all ages undergoing aTSA experienced significant and sustained improvements in all primary outcome measures compared with preoperative values. Based on multivariate analysis, age at the time of surgery was a significant predictor of postoperative outcomes. Excellent implant survival was observed over the course of this study, and Cox regression survival analysis indicated age and sex to not be associated with an increased risk of implant failure. Conclusions: When controlling for sex and follow-up duration, older age was associated with significantly better patient-reported outcome measures. Despite this difference, we noted no significant effects on range of motion or implant survival. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

This study aims to assess the quality and readability of online resources regarding postoperative pain control for patients having undergone total shoulder arthroplasty (TSA), along with identifying gaps among the types of information. Three search engines were used to conduct internet searches utilizing a combination of TSA and pain management search phrases. The top 20 web pages from each search engine were gathered, reviewed, and scored by five different evaluators. Scoring was performed using 30-point criteria, integrated into an overall quality of resource (QR) score considered significant for patient education about TSA and pain management according to American Pain Society and American Academy of Orthopaedic Surgeons' published recommendations (Table I). Domain scores (route of administration, type of analgesia, opioid-specific, and general guidance) were calculated by summing the total points and dividing by the total possible score for each domain. The reading level of the Flesch-Kinkaid grade level, the Flesch reading ease, and the simple measure of gobbledygook index was also assessed. The overall readability was low, with a mean Flesch-Kincaid grade level score of 10.3 ± 2.0 and Simple Measure of Gobbledygook score of 9.9 ± 1.5. According to this index, only one website (2.3%) was written below the suggested 6th grade reading level. There was a mean QR score of 9.6/30 points, ranging from 2 to 22 (Table II). Most resources (90.9%) did not achieve greater than 50% of the total available points (greater than 15 out of 30). Of the domains, the mean score for route of administration was 31.8%, types of analgesia was 43.6%, opioid-specific was 11.4%, and general guidance was 43.2%. Opioid-specific scores were lower than all three other domain scores (all P <.001). According to our findings, current online resources for pain management following TSA are written above the average literacy level for adults in the United States and lack educational content, especially regarding opioid-specific discussion and recommendations. Resources must target gaps in online patient education to better inform patients of postoperative pain control, convey expectations, and encourage patient-physician conversations and decision-making. [ABSTRACT FROM AUTHOR]

Patients undergoing a total shoulder arthroplasty (TSA) through a deltopectoral approach will require repair of the subscapularis tendon. There are no universal postoperative guidelines for rehabilitation of the subscapularis specifically. We hypothesize that the addition of a subscapularis-specific regimen will result in improved subscapularis strength and function. Adult patients undergoing anatomic TSA for the treatment of primary glenohumeral osteoarthritis were included. Patients were randomized into either the traditional rehabilitation (TR) control group or the subscapularis rehabilitation (SR) group, which consisted of the traditional therapy along with early and additional subscapularis exercises. Baseline demographics, patient-reported outcome measures (PROMs), range of motion (ROM), provocative tests, and subscapularis strength using a handheld dynamometer were measured preoperatively at the initial clinic visit (ICV) as well as 3 months, 6 months, and 1 year postoperatively. The primary outcome of interest was a comparison of subscapularis strength between cohorts relative to preoperative baseline, whereas secondary outcomes were functional, ROM, and PROMs. Sixty-six patients were included in the final analysis (32 TR vs. 34 SR). There were no statistically significant differences between cohorts at the ICV with regard to demographics, baseline subscapularis strength, functional testing, or PROMs. All postoperative time points demonstrated similar subscapularis strength testing between TR and SR groups (P >.05). Additionally, peak and average subscapularis strength testing at 3, 6, and 12 months postoperatively were similar to baseline ICV testing in both groups. Both groups demonstrated improvements across several provocative tests, ROM, and PROM outcome metrics at every postoperative time point as compared to baseline ICV values (P <.05). Patients undergoing anatomic TSA return to baseline internal rotation strength by 3 months postoperatively and demonstrate significant improvements in function, ROM, and several patient-reported outcome measures. The addition of early and focused subscapularis strengthening exercises does not appear to significantly impact any outcomes when compared to traditional rehabilitation programs. [ABSTRACT FROM AUTHOR]