The purpose of this study is to evaluate the inter- and intra-reliability of measurements for shoulder range of motion, muscle strength, and proprioception in patients with shoulder arthroplasty, assessing both the prosthetic and healthy sides.

A test-retest design assessing intra- and inter-rater reliability within a single session of measurements for shoulder range of motion, strength, and proprioception. The study included 24 total shoulder arthroplasty patients, 12 months post-operative.

Intraclass correlation coefficients (ICCs) for shoulder range of motion (ROM) and shoulder muscle strength measurements ranged from 0.73 to 0.94 for inter-rater reliability, reflecting moderate to excellent reliability. Weighted Kappa values for functional internal and external rotation showed moderate to almost perfect agreement, ranging from 0.57 to 0.85. For intra-rater reliability, ICCs values for ROM and muscle strength ranged from 0.86 to 0.97, reflecting good to excellent reliability and weighted kappa values showed moderate to perfect agreement, ranging from 0.52 to 1. Measurements for proprioception were largely unreliable, with ICCs ranging from 0 to 0.71.

Thus, the measurements demonstrate strong reliability for ROM and muscle strength, making it a valuable tool for clinical follow-up. The proprioception component, however, requires further research and development.

Obesity and osteoarthritis are two of the most common conditions in the United States and often co-occur. Obese patients with osteoarthritis are at increased risk for complications when undergoing total shoulder arthroplasty (TSA). The ethical consideration relevant to the decision to perform TSA in obese and morbidly obese patients who may benefit from surgery is not well understood. We performed an ethical analysis for patients undergoing TSA who are obese by analyzing the 4 core bioethical principles, beneficence, nonmaleficence, autonomy, and justice. To provide the most benefit to patients, counseling patients on weight loss before surgery should be attempted including bariatric surgery or weight loss medication in select patients. To respect the ethical principles of beneficence and nonmaleficence, the surgeon must carefully weigh the potential for debilitating progression of disease, pain, and the psychological toll of osteoarthritis against the concern that obese patients may have a higher risk of complications. Respecting patient autonomy requires a rigorous, standardized consent process, which is informed by an understanding of common cognitive biases that affect patient understanding and minimization of perverse incentives that make it more difficult for the surgeon to spend adequate time and resources counseling the patient. Improving incentives for hospitals and physician alike to treat patients with obesity and other comorbidities will provide most just care while minimizing long-term harmful effects to the patient, surgeon, and health-care system.

Anatomic total shoulder arthroplasty (aTSA) using an ellipsoid-shaped stem-free humeral head implant and a multiplanar osteotomy technique has demonstrated advantages in cadaver, biomechanical, radiographic, and short-term clinical studies in reproducing anatomy, reducing outliers, and demonstrating improved early range of motion and good early outcomes. The purpose of this study was to report the outcomes of this implant and method after a minimum 5-year follow-up and compare them with other mid-term reports of implants in the literature.

This retrospective study of prospectively collected data included 239 shoulders in 209 patients who underwent aTSA with an ellipsoid stem-free humerus prosthesis and an all-polyethylene glenoid component from the Catalyst CSR Shoulder System between August 2016 and September 2019. Inclusion criteria were patients with advanced glenohumeral joint arthritis with an intact rotator cuff regardless of patient age. Clinical outcomes including range of motion, patient-reported outcome measures, and radiographs were evaluated at multiple time points postoperatively, with a minimum 5-year follow-up.

Five-year follow-up or more was achieved in 92% of living patients. There were 206 shoulders in 179 patients that were included in the study with mean follow-up of 71 months (range: 60-100). Mean age at surgery was 72 years (range: 56-90). Forward elevation improved from 113° to 146° (P < .001), external rotation improved from 25° to 49° (P < .001), and internal rotation improved from L5 to L2 (P < .001). There were statistically significant improvements in American Shoulder and Elbow Surgeons score (37 to 94, P < .001), Single Assessment Numeric Evaluation (36 to 95, P < .001), and visual analog scale (6.7 to 0.4, P < .001), all exceeding thresholds of minimal clinically important difference and substantial clinical benefit. Seventy seven percent of patients reported a Single Assessment Numeric Evaluation score ≥ 95 at final follow-up. Preoperative glenoid morphology did not appear to have an effect on clinical or functional outcome scores. There were no implant failures of the humerus component in any patients and no radiographic signs of humerus loosening in any of the 140 shoulders that had final radiographs. Implant revision rate for any cause was 3% at nearly 6 years. Low-grade medial calcar stress shielding was observed in 1% of patients.

At 5-year minimum follow-up, the Catalyst CSR stem-free ellipsoid aTSA reliably restores anatomy, provides excellent patient satisfaction, clinical improvement in all outcome measures studied, low rates of revision, and no radiographic signs of humerus loosening.

This retrospective, observational study aimed to assess the revision rates and survival curves in total shoulder arthroplasty (TSA) and hemi-shoulder arthroplasty (HSA) patients, including a subanalysis to investigate the impact of a pyrocarbon humeral head in revision rates.

Data collected from 7 surgeons who performed primary HSA in 92 patients and primary TSA in 508 patients at a large private clinic were analyzed. The study focused on revision rates and identified factors leading to revisions, including rotator cuff insufficiency, dislocation, aseptic loosening, implant material, and glenoid erosion.

The overall revision rate for HSA was found to be significantly higher (7.6%) than that for TSA (1.2%), with a maximum follow-up of 7 years. Subanalysis within the HSA group revealed a notably higher revision rate in cases involving a metal head (cobalt-chrome or titanium) (12.8%) than those with a pyrocarbon head (2.3%).

This study underscores the importance of distinguishing between TSA and HSA when evaluating shoulder arthroplasty outcomes. The significantly higher revision rate in HSA, particularly with metal heads, suggests the need for careful consideration of implant selection to optimize long-term success in shoulder arthroplasty procedures.

Glenohumeral osteoarthritis in the presence of an intact rotator cuff is a debilitating condition that often leads to surgical intervention in the form of joint arthroplasty. Historically, anatomic total shoulder replacement (ATSR) had been considered the treatment of choice. Over the past decade, however, there has been a shift in treatment patterns to the use of reverse shoulder replacement to treat this condition due to concerns of subsequent rotator cuff failure and glenoid component loosening with ATSR. With continued innovation of implants and surgical techniques, it is unclear which procedure provides the best outcomes for patients. The Reverse or Anatomical replacement for Painful Shoulder Osteoarthritis, Differences between Interventions trial aims to definitively answer this question and evaluate the cost effectiveness of both procedures.

The aim of this study is to analyse the most cited articles in shoulder arthroplasty surgery and identify trends in topics by decade.

Journal Citation Index Web of Science (WoS) was searched to find articles using the search terms "shoulder arthroplasty", "shoulder hemiarthroplasty", "shoulder replacement" and "shoulder prosthesis". All articles were ranked according to most cited overall and most cited between 2022 and 2023, and then further analysed to find the most cited articles per decade. Articles were studies for topic, study type, evidence level and number of subjects. A second search was performed using Google Scholar (GS) with the same search terms.

All the most cited articles were published in 4 orthopaedic journals. Citation counts were higher for GS searches than WoS for every article, by an average of 1.92 times. Each decade's most cited articles seemed to fit into a few broad topics, showing trends in that decade. The highest cited papers were generally low-level evidence studies.

Shoulder arthroplasty literature appears to follow trends throughout the decade. High quality evidence is lacking in the highest cited papers, but this study highlights the importance and value of these lower-evidence breakthrough studies, which have shaped shoulder arthroplasty surgery.

The utilization of stemless anatomic total shoulder arthroplasty is on the rise. Epiphyseal fixation leads to radiological bone remodeling, which has been reported to exceed 40% in certain studies series. The aim of this study was to present the clinical and radiological outcomes of a stemless implant with asymmetric central epiphyseal fixation at an average follow-up of 31 months.

This retrospective multicenter study examined prospective data of patients undergoing total anatomic arthroplasty with intuitive shoulder arthroplasty Stemless implant and followed up at least 2 years. Clinical assessment included preoperative and final follow-up measurements of active range of motion, Constant score, and Subjective Shoulder Value. Anatomical epiphyseal reconstruction and bone remodeling at the 2-year follow-up were assessed by standardized computed tomography scanner (CT scan). Statistical analysis employed unpaired Student's t-test or chi-squared test depending on the variable type, conducted using EasyMedStat software (version 3.22; www.easymedstat.com).

Fifty patients (mean age 68 years, 62% females) were enrolled, with an average follow-up of 31 months (24-44). Primary osteoarthritis (68%) with type A glenoid (78%) was the prevailing indication. The mean Constant score and Subjective Shoulder Value improved significantly from 38 ± 11 to 76 ± 11 (P < .001) and from 31% ± 16 to 88% ± 15 (P < .001) respectively at the last follow-up. Forward elevation, external rotation, and internal rotation range of motion increased by 39° ± 42, 28° ± 21 and 3,2 ± 2,5 points respectively, surpassing the Minimally Clinically Important Difference after total shoulder arthroplasty. No revisions were necessary. CT scans identified 30% osteolysis in the posterior-medial calcar region, devoid of clinical repercussions. No risk factors were associated with bone osteolysis.

At an average follow-up of 31 months, intuitive shoulder arthroplasty Stemless implant provided favorable clinical results. CT analysis revealed osteolysis-like remodeling in the posterior-medial zone of the calcar (30%), without decline in clinical outcomes and revisions. Long-term follow-up studies are mandated to evaluate whether osteolysis is associated with negative consequences.

Primary glenohumeral arthritis is typically associated with glenoid retroversion and posterior bone loss. Glenoid component fixation remains a weak link in the survivorship of anatomical total shoulder arthroplasty, particularly in the B2 glenoid. The aim of this study was to compare biomechanical properties of 2 glenoid preparation techniques in a B2 glenoid bone loss model.

This was a biomechanical cyclic loading study. Thirty sawbone shoulder models were generated from a computed tomography scan of a scapula with a B2 glenoid and 15° retroversion. The study consisted of 2 groups with 'low' correction (A groups), 2 groups with 'high' correction (B groups), and a control. Group A1 consisted of a 7° eccentric ream and a standard component; group A2 consisted of a 15° posteriorly augmented glenoid component (7° correction); group B1 consisted of a 12° anterior ream and standard component; group B2 used a 25° posteriorly augmented component (12° correction); group C (control) consisted of a standard component inserted in retroversion with no correction. Mechanical stability testing was performed through cyclic loading and resulting displacement was determined at 1, 10, 1000, 10,000, 50,000, and 100,000 cycles to assess for loosening.

A total of 26 samples were included in the analysis, all reaching 100,000 cycles. Displacement increased significantly from baseline to 100,000 cycles in all groups (P < .05). At 100,000 cycles, the B1 group (1.4 mm ± 0.19) had significantly less displacement then the A2 (2.0 mm ± 0.29) and B2 (2.2 mm ± 0.49) (P = .0.005) groups. There were no significant differences in translational forces between any of the groups at 100,000 cycles.

Our data demonstrated that the use of higher degree posteriorly augmented components resulted in statistically greater translational displacement over time compared with high-side reaming and use of a standard component. Further prospective clinical studies are needed to confirm these findings.

Total shoulder arthroplasty (TSA), encompassing both anatomical and reverse TSA, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level.

The Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data were stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions.

Between 2013 and 2021 TSA utilization increased by 121.8%, nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1108.59; P < .001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1223.44; P < .001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; P < .001). The average comorbidity burden of patients was decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (P < .001).

This study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.

The purpose of this study is to report the minimum 5-year clinical and radiographic outcomes of patients undergoing anatomic total shoulder arthroplasty (aTSA) with a posteriorly augmented glenoid component.

Thirty-five shoulders with minimum 5-year follow-up underwent aTSA using a posteriorly augmented glenoid component for the treatment of glenohumeral osteoarthritis with posterior glenoid bone loss. Clinical outcomes included range of motion, visual analog scale (VAS) for pain, and patient-reported outcomes scores. Radiographs and computed tomography scans were obtained to assess glenoid morphology, retroversion, and central peg osseous integration via Wirth score, Lazarus scores, and Yian scores. Postoperative outcomes were measured at minimum 2- and 5-year follow-up. Kaplan-Meier survival analysis was calculated.

Two patients experienced prosthetic instability requiring revision, leaving 33 shoulders with an average follow-up of 6.6 years. Average preoperative glenoid retroversion was 21.6°. A significant improvement in pain, range of motion, and patient-reported outcomes score was noted at minimum 2- and 5-year follow-up. In addition, VAS pain, American Shoulder and Elbow Surgeons, and Quick Disabilities of the Arm, Shoulder, and Hand scores improved between minimum 2- and 5-year follow-up. The average Lazarus and Yian scores at final follow-up were 0.73 and 2.6, respectively. There was an increase in Lazarus score and a decrease in Wirth score between 2- and 5-year follow-up. A significant correlation was identified between VAS pain scores and both Lazarus and Wirth scores. Survivorship free from revision was 92% at 8.8 years postoperatively.

Midterm results of aTSA with a posteriorly augmented, stepped glenoid component demonstrate sustained improvements in clinical outcomes with low rates of radiographic loosening. Continued improvement in pain and function, as well as a minor progression of radiographic osteolysis, may be expected between 2- and 5-year follow-up. In addition, the severity of radiographic loosening correlates with subjective pain levels.

Glenoid bone loss in shoulder arthroplasty is a difficult problem that is prone to complications because of challenges with achieving glenoid component fixation and stability. The purpose of this study was to evaluate the outcomes of primary shoulder hemiarthroplasty for patients with severe glenoid medialization precluding placement of a glenoid component.

This was a retrospective case series evaluating patients who underwent shoulder hemiarthroplasty for severe glenoid erosion and medialization between 2010 and 2020. Patients were evaluated via chart review and phone survey to determine if there were any reoperations at final follow-up and to obtain Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Simple Shoulder Test (SST) scores. Preoperative and postoperative radiographs were evaluated and compared to determine glenoid morphology, version, medialization, acromiohumeral distance, and humeral offset. Final postoperative films were also evaluated for anterosuperior migration and signs of mechanical failure, including loosening or periprosthetic fracture.

Overall, there were 28 patients during this period who underwent shoulder hemiarthroplasty for severe glenoid medialization. Eight patients were deceased at the time of the study, 2 were unable to complete surveys because of dementia, and 7 were lost to follow-up. The final cohort included 11 shoulders and 11 patients with a mean age of 71 ± 7.1 years and mean follow-up of 6.7 years (range 1.6-13.0 years). Mean postoperative SANE, ASES, and SST scores were 80.6 ± 17.6, 71.5 ± 29.3, and 7.6 ± 2.0, respectively. There were no reoperations or revision surgeries at final follow-up. Radiographic evaluation demonstrated severe glenoid medialization and decreased lateral humeral offset, which was unchanged postoperatively. There were 2 patients with signs of anterosuperior migration at final radiographic follow-up but no signs of implant failure.

Shoulder hemiarthroplasty for severe medial glenoid bone loss provides modest clinical outcomes and low rates of reoperation at mid- to long-term follow-up and is an option worth considering in cases where placement of a glenoid component is challenging because of deficient bone stock and high risk for complications.

Prior studies have demonstrated higher preoperative pain and decreased patient-reported outcomes (PROs) following total shoulder arthroplasty (TSA) in individuals with lower socioeconomic status (SES). The goal of this study was to investigate the rate of clinical improvement following TSA in individuals with differing SES.

Individuals included in this study underwent anatomic or reverse TSA by 2 surgeons between May 2018 and January 2021. Patients were split into 3 SES groups (low, moderate, and high) based on neighborhood SES level as determined by Area Deprivation Index. PROs were collected preoperatively and at 9 weeks, 26 weeks, 1 year, and 2 years postoperatively. Shoulder-specific PROs included the American Shoulder and Elbows Surgeons shoulder score, 10-point visual analog scale for pain, single-assessment numeric evaluation, and Western Ontario Osteoarthritis of the Shoulder Index. The Veterans Rand 12-Item health survey was used to measure overall well-being. We used a mixed-design analysis of variance to determine the interaction of time and improvement in PROs following surgery followed by 1-way mixed-design analysis of variance with post-hoc analysis.

One hundred seventy individuals (low SES n = 34, moderate n = 90, high n = 46) met the inclusion criteria and were included in this study. There were no significant differences between groups for body mass index or age at time of surgery. All groups significantly improved from baseline scores on all PROs (P < .001) with the majority of improvement being achieved within the first year after surgery. There were no significant differences in rate of clinical improvement on PROs among the groups when compared to their respective preoperative scores. Significant differences were discovered when comparing groups independent of time with the low- and moderate-SES groups scoring significantly lower on American Shoulder and Elbows Surgeons shoulder score when compared to the high-SES group (P < .01) and the low-SES group reporting significantly higher visual analog scale pain when compared to the high-SES group (P = .034).

Individuals with lower SES at the neighborhood level report higher pain and decreased shoulder function both preoperatively and postoperatively following TSA; however, the rate of clinical improvement following surgery in this group is comparable to individuals with higher SES when compared to baseline scores. All groups demonstrated significant improvement following surgery, suggesting TSA remains a successful operation regardless of SES.

Revision shoulder arthroplasty (RevSA) is a complex procedure that can result in various postoperative complications. However, the impact of hepatitis C virus (HCV) on postoperative complications after RevSA remains unclear because of limited and inconsistent evidence. This study aims (1) to investigate the incidence of postoperative complications in patients with HCV undergoing RevSA and (2) to evaluate the impact of HCV treatment on complication rates at different time points after the revision procedure, specifically at 90 days, 1 year, and 2 years.

We queried a national, all-payer database to investigate recent trends in the use of RevSA among HCV patients to assess postoperative complication rates, including venous thromboembolism (VTE), wound complication, transfusion, and periprosthetic joint infection (PJI). Statistical analyses involved propensity score matching to create balanced cohorts and logistic regression to determine the relative risk of postoperative complications. Data were analyzed with SPSS software (version 24.0 for Windows). The study included patients who underwent partial or total RevSA procedures between January 1, 2010, and December 31, 2020. Patients were identified based on medical claims that included procedural codes for RevSA and associated diagnosis codes for PJI or insertion/removal of an antibiotic spacer. A Bonferroni correction was used because many tests were performed and statistical significance was set at P = .0125.

The HCV cohort demonstrated higher PJI rates at 1-year (5.5% vs. 3.9%, P = .006) and 2-year follow-ups (6.7% vs. 4.6%, P = .006). However, no significant differences emerged in VTE and wound complication rates between the HCV and non-HCV cohorts. Comparing untreated and treated HCV patients, the former showed significantly higher PJI rates at 2 years (P = .010), whereas the treated group had significantly lower odds ratios for PJI. When comparing treated HCV patients with the non-HCV cohort, minimal differences were found in postoperative outcomes, indicating no significant difference in the risk of complications between the groups.

Our study observed an association between HCV patients who received antiviral treatment prior to RevSA and a reduced incidence of PJI compared to untreated HCV patients. When comparing this group to the non-HCV controls, there was no significant difference in the incidence of PJI, suggesting a potential association between antiviral treatment and the observed risk patterns in HCV patients. Proper management of HCV-positive patients during RevSA is crucial for improving outcomes and reducing complications.

The optimal management of primary glenohumeral arthritis (GHOA) in the elderly is an ongoing topic of debate. The purpose of this study was to compare functional outcomes and complications in patients aged 75 years or older treated with anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) for primary GHOA with an intact rotator cuff.

A retrospective study was performed on a prospectively maintained database which was queried for patients 75 years of age or older who underwent TSA or RSA for primary GHOA with an intact rotator cuff at a single institution between 2012 and 2021 with minimum 2-year follow-up. Patient-reported outcomes (PROs), including Visual Analog Scale for pain, American Shoulder and Elbow Surgeons, and Subjective Shoulder Value, as well as active range of motion including forward flexion, external rotation, internal rotation, were collected preoperatively and postoperatively. Complications, reoperations, and satisfaction were also recorded. The percentage of patients achieving clinically significant improvement was evaluated with the minimally clinical important difference, substantial clinical benefit, and patient acceptable symptomatic state for each PRO.

One-hundred and 4 patients were available for analysis, including 67 TSA patients and 37 RSAs with a mean follow-up of 39.4 months. Preoperative baseline characteristics, PROs, and range of motion were similar between groups. RSA was more commonly performed for eccentric glenoid wear (Walch B2/B3, 62% vs. 22%; P < .001). While clinical outcomes improved comparably in both groups, the TSA cohort showed significantly greater improvement in external rotation (36° vs. 26°; P = .013). Both cohorts had low revision (3% for TSA vs. 0% for RSA) and complication (7% for TSA vs. 5% for RSA; P = .677) rates. Satisfaction was similar in both groups (93% for TSA vs. 92% for RSA; P = .900). Clinically significant improvement was comparable between groups based on the American Shoulder and Elbow Surgeons score (minimally clinical important difference, 93% for TSA vs. 100% for RSA; substantial clinical benefit, 82% vs. 95%; patient acceptable symptomatic state, 67% vs. 78%; P > .05).

In this retrospective small sample size comparison study, TSA and RSA provide similar short-term clinical outcomes for patients 75 years and older with primary GHOA and an intact rotator cuff. Complication and revision rates are comparably low at short-term follow-up. Our data suggests that advanced age alone should not be used as a decision-making tool for TSA vs. RSA in the setting of primary GHOA with an intact rotator cuff.

A total shoulder arthroplasty (TSA) system utilizing an inlay glenoid component has been proposed as a means of reducing glenoid component loosening while still providing patients with desirable functional and clinical outcomes. The purpose of this study was to systematically review current outcomes literature on TSA using an inlay glenoid component.

A literature search was conducted using PubMed/MEDLINE, Cochrane Database of Systematic Reviews, and Web of Science databases. Studies comparing pre- and postoperative functional and clinical outcomes were included.

Five studies with 148 shoulders (133 patients) were included. Patient-reported outcomes improved, including the American Shoulder and Elbow Surgeons score (mean change 34.1 to 80.6), Penn Shoulder Score (mean change 43.3 to 85.5), Single Assessment Numeric Evaluation score (mean change 34.1 to 80.6), and visual analog scale-pain (mean change 6.9 to 1.6). Range of motion improved for forward elevation (mean change 109.6 to 156.2) and external rotation (mean change 21.5 to 50.8). Glenoid component loosening occurred in one shoulder (0.68%). Two revision surgeries (1.35%) were performed.

The use of an inlay glenoid component is associated with improvements in postoperative pain, function, and satisfaction while minimizing rates of glenoid component loosening and the need for revision surgery over short-term follow-up.

systematic review, level IV.

The primary goal of this study was to investigate whether superior humeral head osteophyte (SHO) size is associated with rotator cuff insufficiency, including rotator cuff tear (RCT), supraspinatus tendon thickness, and fatty infiltration of the rotator cuff muscles.

Patients  ≥ 18 years who were diagnosed with glenohumeral osteoarthritis were retrospectively reviewed. SHO size was determined by radiograph. MRI measured SHO and RCT presence, type, and size; supraspinatus tendon thickness; and fatty infiltration of rotator cuff musculature.

A total of 461 patients were included. Mean SHO size was 1.93 mm on radiographs and 2.13 mm on MRI. Risk ratio for a RCT was 1.14. For each 1-mm increase in SHO size on radiograph, supraspinatus tendon thickness decreased by 0.20 mm. SHO presence was associated with moderate-to-severe fatty infiltration of the supraspinatus with a risk ratio of 3.16.

SHOs were not associated with RCT but were associated with higher risk of supraspinatus FI and decreased tendon thickness, which could indicate rotator cuff insufficiency.

IV.

We reviewed the shoulder arthroplasty (SA) literature to correlate citations, methodological characteristics and quality of most-cited articles in this field. We hypothesized that a greater number of citations would be found for high-quality clinical studies.

We searched the Web of Knowledge database for the 50 most-cited articles about SA and collected author name, publication year, country of origin, journal, article type, level of evidence (LoE), subject of paper, type of arthroplasty and metrics (number of citations and citation rate). Coleman Methodology Score (CMS) was computed for clinical articles. Statistical analysis of variance and correlation coefficients were used to investigate the relationship between different variables.

Out of the selected 50 studies on SA, 26% were nonclinical. There were 15,393 citations overall (mean 307.8), with a mean 19.5 citations per year (range 48.3-6.7). Thirty or 60% of all articles were LoE IV. All studies were published between 1984 and 2011 in 8 journals. Reverse SA (RSA) was the most common subject (36% of studies). The United States was the country responsible for most contributions (50% of studies). CMS ranged from 81 to 38 (mean 59.6). RSA received the highest number of citations (P < .001), independently from country of origin (P = .137) and LoE (P = .723). CMS correlated with citation rate (r = 0.397; P = .013) and publication year (tau = 0.397; P = .013), but not with LoE (P = .204).

In SA literature, citation rate positively correlates with methodological quality of a study, independently from publication country and LoE. Among most-cited papers, RSA is the most common standalone subject.

Introduction Reverse polarity shoulder arthroplasty (RSA) is an evolving surgery, and its indications have expanded over time. Apart from cuff tear arthropathy (CTA), it is recommended for complex proximal humerus fractures in the elderly, inflammatory arthritis, primary osteoarthritis in the elderly, and revision for failed hemiarthroplasty. Glenoid base plate placement and fixation are important to prevent complications, especially glenoid base plate loosening, dislocation, and scapular notching, and to improve longevity. Guided personalized surgery (GPS)-navigated RSA was devised to optimize the glenoid base plate position and fixation. Methodology A retrospective study was carried out in a low-volume district general hospital in England. All the patients who underwent GPS-navigated RSA were included. Their preoperative glenoid version, bone stock, glenoid base plate, and glenoid screw lengths were analysed. Preoperative and post-surgery patient-reported outcomes were gathered using the Oxford Shoulder Score (OSS) at six months and annually thereafter. Results Fourteen patients have undergone GPS-navigated RSA in our institute since 2018. Ten patients were female. All of them had a retroverted glenoid with a mean value of 13.6 degrees. Ten out of 14 patients had an augmented glenoid base plate. This included six eight-degree posterior augmentations, three 10-degree superior augmentations, and one extended cage peg. The follow-up period was six months to five years, depending on the date of surgery, and none of the patients dropped out of follow-up. The OSS revealed statistically significant improvement from preoperative values to six months postoperative, an improvement of 21.64±7.175. It also showed progressive improvement over time during postoperative follow-up, and the three-year mean was 47. The commonest complication was fractures, which happened in four cases. There were no infections or dislocations. Discussion Guided personalized surgery-navigated RSA was performed on selected patients at our institution when they were not suitable for conventional RSA due to distorted glenoid anatomy. Glenoid base plate positioning and fixation are important to optimize the outcome of RSA. Guided personalized surgery navigation is helpful in achieving optimum glenoid base placement, especially when the normal glenoid anatomy is distorted. There were no dislocations, glenoid base plate loosening, or scapular notching in the study group. There were four reported fractures, which was comparable with the published literature.

Background: Periprosthetic joint infection (PJI) after shoulder arthroplasty remains a significant complication. This study aimed to explore the epidemiology and risk factors of shoulder PJI in patients aged 60 and younger, analyze treatment options, and evaluate outcomes after 1-year follow-up. Methods: In this retrospective multicentric observational study, data from 1404 shoulders in patients under 60 who underwent primary shoulder arthroplasty were analyzed. Patients with PJI and at least 1-year follow-up after infection treatment were included. Results: The study identified 55 shoulders with PJI, resulting in a 2.35% infection rate after primary shoulder arthroplasty in the young population. Male gender and reverse shoulder arthroplasty were risk factors for infection, while previous surgeries did not significantly contribute. The most common causative agents were Cutibacterium acnes and Staphylococcus epidermidis. Open washout had a 52.9% success rate for acute infections, while one-stage and two-stage revisions achieved infection control rates of 91.3% and 85.7%, respectively. Resection arthroplasty had an 81.8% success rate but poorer functional outcomes. Conclusions: PJI following shoulder arthroplasty in young patients is a significant concern. Preoperative planning should be carefully considered to minimize infection risk. Treatment options such as open washout and one-stage and two-stage revisions offer effective infection control and improved functional outcomes. Resection arthroplasty should be reserved for complex cases where reimplantation is not a viable option.

Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature; however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge vs. inpatient SA in a cohort of patients considered higher risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3.

Data from Kaiser Permanente's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018 to 2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge vs. ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism, and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10.

The cohort included a total of 1814 SA patients, of whom 1005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR] = 0.64, one-sided 95% upper bound [UB] = 0.89) and overall complications (OR = 0.67, 95% UB = 1.00). We lacked evidence in support of noninferiority for 90-day ED visit (OR = 0.96, 95% UB = 1.18), cardiac event (OR = 0.68, 95% UB = 1.11), or venous thromboembolism (OR = 0.91, 95% UB = 2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis.

In a cohort of over 1800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay, and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting.

Smoking is a major public health concern and an important risk factor to consider during preoperative planning. Smoking has previously been reported as the single most important risk factor for developing postoperative complications after elective orthopedic surgery. However, there is limited literature regarding the postoperative complications associated with smoking following outpatient total shoulder arthroplasty (TSA). The purpose of this study was to investigate the association between smoking status and early postoperative complications following outpatient TSA using a large national database.

We queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent TSA between 2015 and 2020. Smoking status in National Surgical Quality Improvement Program is defined as any episode of smoking with 12 months prior to surgery. Bivariate logistic regression was used to identify patient demographics, comorbidities, and complications significantly associated with current or recent smoking status in patients who underwent TSA with a length of stay (LOS) of 0. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between current or recent smokers and 30-day postoperative complications.

22,817 patients were included in the analysis, 2367 (10.4%) were current or recent smokers and 20,450 (89.6%) were nonsmokers. These patients were further stratified based on LOS: 2428 (10.6%) patients had a LOS of 0 days, 15,267 (66.9%) patients had a LOS of 1 day, and 5122 (22.4%) patients had a LOS of 2 days. Within the outpatient cohort (LOS = 0), 202 (8.3%) patients were current or recent smokers and 2226 (91.7%) were nonsmokers. Multivariate logistic regression identified current or recent smoking status to be independently associated with higher rates of myocardial infarction (odds ratio [OR] 9.80, 95% confidence interval [CI] 1.48-64.96; P = .018), deep vein thrombosis (OR 20.05, 95% CI 1.63-247.38; P = .019), and readmission (OR 2.82, 95% CI 1.19-6.67; P = .018) following outpatient TSA. Readmission was most often due to pulmonary complication (n = 10, 22.7%).

Current or recent smoking status is independently associated with higher rates of myocardial infarction, deep vein thrombosis, and readmission following TSA performed in the outpatient setting. Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. As outpatient TSA becomes increasingly popular, refining proper patient selection criteria is imperative to optimizing postoperative outcomes.

We conducted a review of current literature to examine the effects of smoking and smoking cessation on shoulder arthroplasty surgery.

A literature search was performed using the search terms "shoulder arthroplasty AND [smoke OR smoking OR tobacco OR nicotine]." Studies included English-language clinical outcomes studies on anatomic total shoulder arthroplasty (TSA), reverse TSA, and partial shoulder arthroplasty with evidence levels 1 through 4. Descriptive statistics calculated in the included studies were used during the analysis. Categorical variables were reported as proportions, while continuous variables were reported as means with minimum to maximum absolute ranges.

Twenty-four studies were included and analyzed. Following TSA, patients who quit smoking at least 1 month preoperatively had improved outcomes compared to current smokers. Current smokers had statistically significant higher pain scores or opioid use. Five studies found increased rates of revision surgery in smokers. Smokers were significantly (p < 0.05) more likely to have increased rates of surgical, wound, superficial, and deep surgical site complications.

Former smokers had lower complication rates and visual analog scale scores when compared to current users. A period of four weeks or more of preoperative smoking cessation is recommended.

Level III, Systematic Review.

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.

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.

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.

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.

The occurrence of prosthesis-related complications after total shoulder arthroplasty is devastating and costly. The purpose was to determine the incidence and risk of in-hospital prosthesis-related complications after total shoulder arthroplasty utilizing a large-scale sample database.

A retrospective database analysis was performed based on Nationwide Inpatient Sample from 2010 to 2014. Patients who underwent total shoulder arthroplasty were included. Patient demographics, hospital characteristics, length of stay, economic indicators, in-hospital mortality, comorbidities, and peri-operative complications were evaluated.

A total of 34,198 cases were capture from the Nationwide Inpatient Sample database. There were 343 cases of in-hospital prosthesis-related complications after total shoulder arthroplasty and the overall incidence was 1%, with a more than 2.5-fold decrease from 2010 to 2014. Dislocation was the most common category among prosthesis-related complications (0.1%). The occurrence of in-hospital prosthesis-related complications was associated with significantly more total charges and slightly longer length of stay while less usage of Medicare. Risk factors of prosthesis-related complications were identified including younger age (<64 years), female, the native American, hospital in the South, alcohol abuse, depression, uncomplicated diabetes, diabetes with chronic complications, fluid and electrolyte disorders, metastatic cancer, neurological disorders, and renal failure. Interestingly, advanced age (≥65 years) and proprietary hospital were found as protective factors. Furthermore, prosthesis-related complications were associated with aseptic necrosis, rheumatoid arthritis, rotator cuff tear arthropathy, Parkinson's disease, prior shoulder arthroscopy, and blood transfusion.

It is of benefit to study risk factors of prosthesis-related complications following total shoulder arthroplasty to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.

The severity of glenohumeral osteoarthritis (OA) as demonstrated by preoperative radiographs and patient-reported pain plays an important role in the indication for anatomic total shoulder arthroplasty (aTSA). In hip and knee research, data about the effect of the severity of preoperative radiographic OA on the outcome of total joint arthroplasty have been mixed. For shoulder replacement, we are unsure of the effects of radiographic severity on outcomes.

This study investigated whether the preoperative radiographic severity of glenohumeral OA is associated with improvement in pain and function after aTSA. We asked, (1) does the severity of glenohumeral OA correlate with improvement in patient-reported outcomes after TSA (delta American Shoulder and Elbow Surgeons score [postoperative-preoperative], delta Single Assessment Numeric Evaluation, delta Simple Shoulder Test, and delta VAS)? (2) Is having mild osteoarthritis associated with not meeting the minimum clinically important differences in preoperative and postoperative American Shoulder and Elbow Surgeons scores?

An institutional query of patients who underwent aTSA for OA was performed between January 2015 and December 2018. A total of 1035 patients were eligible; however, only patients with adequate preoperative radiographs and patient-reported outcome measures collected preoperatively and at a minimum of 2 years postoperatively were included. Patients with proximal humerus fractures, inflammatory arthropathy, cuff tear arthropathy, prior ipsilateral rotator cuff repair, brachial plexus injury or neuromuscular disorder, workers compensation, periprosthetic joint infection, or revision surgery within 2 years were excluded. Patient characteristics, comorbidities, and prior shoulder surgery were recorded. The severity of OA was classified based on the modified Samilson-Prieto and Walch classification. The association between Samilson-Prieto grade and patient-reported outcome measures (American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and VAS score) was evaluated. Radiographic characteristics, patient demographics, comorbidities, and prior surgery were also evaluated for the potential risk of not achieving improvement in the minimum clinically important difference (16.1) with respect to the American Shoulder and Elbow Surgeons score. The American Shoulder and Elbow Surgeons score is scored 0 to 100, with higher scores representing less pain and better function. A total of 206 patients (20% of those eligible) with a mean follow-up of 2.3 years were included. Twenty-three patients had Samilson-Prieto Grade I, 38 had Grade II, 57 had Grade III, and 88 had Grade IV.

There were no differences in improvements (delta) between the groups and between patient-reported outcome scores (American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and VAS). Compared with patients with more severe osteoarthritis (Samilson-Prieto Grades II, III, and IV), a higher proportion of patients with less severe osteoarthritis (Grade I) did not exceed the minimum clinical important difference for the American Shoulder and Elbow Surgeons score (22% [five of 23] versus 4% [seven of 183]; odds ratio 0.14 [95% confidence interval 0.04 to 0.520]; p = 0.006).

The improvement in patient-reported outcome measure scores was similar regardless of radiographic severity after aTSA. Surgeons should use caution when recommending surgery to patients with less severe OA because a higher percentage did not improve, based on the minimum clinically important difference.

Level III, therapeutic study.

Glenoid baseplate positioning for reverse total shoulder arthroplasty (rTSA) is important for stability and longevity, with techniques such as image-derived instrumentation (IDI) developed for improving implant placement accuracy. We performed a single-blinded randomized controlled trial comparing glenoid baseplate insertion accuracy with 3D preoperative planning and IDI jigs vs. 3D preoperative planning and conventional instrumentation.

All patients had a preoperative 3D computed tomography to create an IDI; then underwent rTSA according to their randomized method. Repeat computed tomography scans performed at six weeks postoperatively were compared to the preoperative plan to assess for accuracy of implantation. Patient-reported outcome measures and plain radiographs were collected with 2-year follow-up.

Forty-seven rTSA patients were included (IDI n = 24, conventional instrumentation n = 23). The IDI group was more likely to have a guidewire placement within 2mm of the preoperative plan in the superior/inferior plane (P = .01); and exhibited a smaller degree of error when the native glenoid retroversion was >10° (P = .047). There was no difference in patient-reported outcome measures or other radiographic parameters between the two groups.

IDI is an accurate method for glenoid guidewire and component placement in rTSA, particularly in the superior/inferior plane and in glenoids with native retroversion >10°, when compared to conventional instrumentation.

Orthopedic surgery is one of the most common subspecialties subject to medical malpractice claims. Although total shoulder arthroplasty (TSA) is associated with favorable patient outcomes and relatively low complication rates, surgeons performing this procedure may be subject to malpractice litigation leading to significant economic and psychological burden on the provider. The purpose of this study is to characterize and describe malpractice claims against orthopedic surgeons performing TSA using the Westlaw legal database.

The Westlaw legal database was queried for all cases related to TSA using the terms "malpractice" AND "shoulder replacement" OR "shoulder arthroplasty." Cases were excluded if the defendant was not an orthopedic surgeon, the procedure involved was not a TSA, or if the patient was a minor. Patient demographics, causes cited for litigation, case outcomes, and indemnity payments were analyzed to determine common factors that lead plaintiffs to pursue legal action.

Thirty-five TSA cases were identified that met inclusion criteria. The mean plaintiff age was 55 years with 63.6% female. The most common category of negligence alleged was intraoperative error, which occurred in 25 claims (71%). The most common types of damages incurred were nerve injury (23%), functional limitation (20%), and infection (17%). Overall, 27 cases (77%) resulted in a defense verdict. Four cases (11%) resulted in settlements and 4 cases (11%) resulted in plaintiff verdicts. The average inflation-adjusted monetary award in these cases was $1,619,919 (standard deviation, $1,689,452).

This study provides a comprehensive summary of malpractice claims and associated outcomes in TSA. Given the rapidly increasing rate of TSA in the United States and the burden of associated malpractice claims, understanding potential legal implications of TSA is of great value to orthopedic surgeons. Intraoperative error was the category of negligence cited most commonly in TSA malpractice claims. Nerve injury, functional limitation, and infection were the most commonly cited specific damages. These findings highlight the need for orthopedic surgeons to educate patients regarding potential postoperative complications while continuing to focus on minimizing their occurrence.

Postoperative delirium (POD) is a common complication after major surgery, resulting in various adverse reactions. However, incidence and risk factors associated with POD after shoulder arthroplasty (SA) have not been well studied using a large-scale national database.

A retrospective database analysis was performed based on the Nationwide Inpatient Sample (NIS) from 2005 to 2014, the largest fully paid hospital care database in the United States. Patients undergoing SA were included. The patient's demographics, comorbidities, length of stay (LOS), total costs, type of insurance, type of hospital, in-hospital mortality, and medical and surgical perioperative complications were assessed.

A total of 115,147 SA patients were obtained from the NIS database. The general incidence of delirium after SA was 0.89%, peaking in 2010. Patients with delirium after SA had more comorbidities, prolonged LOS, increased hospitalization costs, and higher in-hospital mortality (P < 0.0001). These patients were associated with medical complications during hospitalization, including acute renal failure, acute myocardial infarction, pneumonia, pulmonary embolism, stroke, urinary tract infection, sepsis, continuous invasive mechanical ventilation, blood transfusion, and overall perioperative complications. Risk factors associated with POD include advanced age, neurological disease, depression, psychosis, fluid and electrolyte disturbances, and renal failure. Protective factors include elective hospital admissions and private insurance.

The incidence of delirium after SA is relatively low. Delirium after SA was associated with increased comorbidities, LOS, overall costs, Medicare coverage, mortality, and perioperative complications. Studying risk factors for POD can help ensure appropriate management and mitigate its consequences. Meanwhile, we found some limitations of this type of research and the need to establish a country-based POD database, including further clearly defining the diagnostic criteria for POD, investigating risk factors and continuing to collect data after discharge (30 days or more), so as to further improve patient preoperative optimization and management.

Total shoulder arthroplasty (TSA), including anatomic TSA (aTSA) and reverse TSA (rTSA), has increased in popularity due to reliably good patient outcomes. Postoperative physical therapy (PT) is considered essential to the success of this operation and has become standard practice. The authors present general rehabilitation principles as well as preferred postoperative PT protocols for aTSA and rTSA, which are based on evidence-based literature and the different early postoperative concerns for each of these procedures.

The Shoulder Arthroplasty Smart (SAS) score is a new, validated machine learning-derived outcome measure that requires six input parameters. The SAS score has the potential to replace legacy shoulder outcome scores.

We conducted a retrospective review of a multinational shoulder arthroplasty database of one platform shoulder prosthesis (used interchangeably for anatomic and reverse total shoulder arthroplasty). All primary shoulder arthroplasties with a minimum of two-year follow-up and an available SAS score were evaluated. Associations between scoring systems were assessed using Pearson correlations, with 95% confidence intervals stratified by time point (preoperatively and postoperatively at 2- and 5-year follow-ups, respectively) and procedure (anatomic verses reverse total shoulder arthroplasty). Conversion equations were developed using the best-fit line from linear regression analysis. Ceiling effects were assessed based on two definitions: (1) >15% of participants scoring the maximal possible score and (2) a standardized distance less than 1.0, whereby the standardized distance is calculated by subtracting the mean from the maximal score and dividing by the standard deviation.

Two thousand four hundred six shoulders were evaluated at 4,553 clinical encounters. For preoperatively collected data, the SAS score correlated strongly with the Constant (R = 0.83), University of California at Los Angeles (R = 0.85), and Shoulder Pain and Disability Index (R = -0.70) scores and moderately with the American Shoulder and Elbow Surgeons (R = 0.69) and Simple Shoulder Test (R = 0.65) scores. The SAS score strongly correlated (R > 0.7) with all legacy outcome scores collected at 2- and 5-year postoperative visits. Score predictions made using the conversion equations between the SAS score and legacy outcome scores strongly correlated with their actual values. Neither the SAS nor the Constant score were influenced by ceiling effects. All other outcome scores evaluated demonstrated ceiling effects.

The SAS score correlates well with legacy shoulder scores after primary shoulder arthroplasty while mitigating ceiling effects. Surgeons may decrease patient questionnaire burden by using the brief six-question SAS score.

Several techniques have been described for mobilizing the subscapularis tendon in anatomic total shoulder arthroplasty (TSA). The purpose of this study was to compare subscapularis tendon healing rates, as determined by ultrasound, in patients following anatomic TSA with either a subscapularis tenotomy or subscapularis peel.

This study was a secondary analysis of patients from a previous randomized controlled trial in which patients underwent anatomic TSA and were randomized to either a tenotomy or peel approach. The primary outcome was postoperative tendon healing rates determined on ultrasound at >12 months after surgery. Secondary outcomes included postoperative tendon thickness measured on ultrasound; elbow position (neutral alignment in the belly-press position vs. posterior); internal rotation function measured with the third and fourth questions of the American Shoulder and Elbow Surgeons questionnaire; and Western Ontario Osteoarthritis of the Shoulder index. Radiographs were analyzed in patients with torn tendons.

One hundred patients were randomized to a tenotomy (n = 47) or peel (n = 53) approach. Postoperative ultrasound results were available in 88 patients. Tendon healing rates were 95% for tenotomy vs. 75% for peel (P = .011). The mean postoperative tendon thickness was 4 mm (standard deviation, 1.0 mm) and 4 mm (standard deviation, 1 mm) in the tenotomy and peel groups, respectively (P = .37). Internal rotation function was not associated with healing status (P = .77 and P = .22 for questions 3 and 4, respectively, of the American Shoulder and Elbow Surgeons questionnaire), nor was elbow position (P = .2) in the belly-press position.

We observed that subscapularis tenotomy had a higher healing rate than peel as determined by ultrasound in TSA patients. There was no statistically significant difference in postoperative tendon thickness in intact tendons as measured on ultrasound when comparing subscapularis mobilization techniques, nor was there any association between healing status and internal rotation function or elbow position.

The currently recommended time to return to driving following shoulder arthroplasty is controversial. The purpose of this study was to determine patient-specific factors associated with early return to driving after anatomic (aTSA) and reverse total shoulder arthroplasty (RTSA).

All patients aged >18 years undergoing primary aTSA or RTSA at a single institution over a 3-year period were retrospectively identified. Patients were emailed a questionnaire to determine time to postoperative return to driving and frequency of driving prior to and following surgery. Patients who did not drive prior to surgery or did not complete the questionnaire were excluded from analysis. Multivariate analysis was used to determine patient-specific factors associated with early return to driving (within 2 weeks following surgery) and delayed return (>6 weeks following surgery).

Four hundred six patients were included for analysis (aTSA = 214, RTSA = 192). Patients undergoing aTSA were significantly younger (68 vs. 74 years) and drove more frequently both pre- and postoperatively than the RTSA cohort. One hundred percent of patients returned to driving postoperatively. Patients undergoing aTSA more commonly demonstrated earlier return to driving than RTSA patients (34% vs. 20%). Factors associated with increased odds of early return to driving included male sex (aTSA) and compliance with surgeon instruction (aTSA). Decreased odds of early return was associated with waiting to drive until cessation of sling use (RTSA), older age (RTSA), and increased body mass index (RTSA). The presence of surgical complications (aTSA) and prolonged use of narcotics (RTSA) were associated with return to driving >6 weeks following surgery. No difference in the rate of motor vehicle accidents was found between patients returning to driving <2 vs. >2 weeks postoperatively.

Patients undergoing aTSA return to driving sooner than those undergoing RTSA. Early return to driving appears to be influenced by patient sex, age, BMI, narcotic and sling use, and compliance with surgeon instruction, but does not appear to result in a high incidence of postoperative MVA.

The primary purpose of this study was to compare 2-year anatomic total shoulder arthroplasty (TSA) functional and radiographic outcomes between Walch type A and B glenoids treated with an all-polyethylene glenoid designed for hybrid fixation with peripheral cement and central osseous integration. The secondary purpose was to evaluate outcomes based on central peg technique. The hypotheses were that there would be no difference in short-term radiographic or functional outcome scores based on preoperative glenoid morphology or central peg technique.

We performed a multicenter retrospective review of patients who underwent TSA with the same hybrid all-polyethylene glenoid and had minimum 2-year follow-up. Patient-reported outcomes and radiographic outcomes were analyzed based on preoperative Walch morphology and central peg technique. Radiographic analysis included preoperative glenoid morphology; preoperative and postoperative glenoid version, glenoid inclination, and posterior humeral head subluxation; and postoperative glenoid radiolucencies according to the Wirth and Lazarus classifications.

A total of 266 patients with a mean age of 64.9 ± 8.2 years were evaluated at a mean of 28 months postoperatively. Postoperatively, there were significant improvements in all functional outcome measures (P < .001), range-of-motion measures (forward elevation, external rotation at 0°, external rotation at 90°, internal rotation by spinal level, and internal rotation at 90°; P < .001), and strength measures (Constant, external rotation, and modified belly press; P < .001). There were no clinically meaningful differences in functional outcomes or statistically significant differences in radiographic appearance between Walch type A and B glenoids. Subgroup analysis revealed that glenoids with a cemented central peg had the worst radiographic outcomes based on Lazarus scoring.

Patients undergoing TSA with a hybrid in-line pegged glenoid have excellent clinical outcomes at short-term follow-up regardless of preoperative glenoid morphology. Different central peg techniques do not appear to play a significant role in the risk of glenoid component lucencies at 2 years postoperatively.

Glenohumeral arthritis is a degenerative disease of the shoulder joint. There is limited evidence in the literature in superiority of outcomes between total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) for patients when the rotator cuff is intact. The purpose of this systematic review was to compare patient-reported outcome measures (PROMs) and rate of complication between these 2 interventions in patients with primary glenohumeral arthritis and an intact rotator cuff. Previous systematic reviews have focused only on results from randomized controlled trials, demonstrating mixed outcomes in PROMs and no difference in postoperative complications or rate of revision. Our study is the first, to our knowledge, to assess all comparative studies including prospective and retrospective observational studies, assessing a combined 1317 patients. Using the ratio of means, data from different PROMs were pooled to analyze and compare the total combined relative effect change following intervention.

We undertook literature review of the reference databases until March 2021. We included randomized controlled trials in addition to comparative observational studies and case series (more than 10 patients). Study participants were adults who had primary glenohumeral arthritis with an intact rotator cuff. Meta-analysis was performed by the ratio of means for PROMs and risk ratio for revision and complication data.

Comparing clinical outcome of TSA against HA from 10 studies, meta-analyses using ratio of means demonstrated an 8% significantly improved relative increase in the postoperative PROMs in the TSA cohort (ratio of means 1.08, 95% confidence interval [CI] 0.04-1.12, P < .01). The TSA cohort additionally demonstrated a significantly lower revision rate (relative risk 1.84, 95% CI 1.05-3.24, P = .03). Although the risk of complication was nonsignificant, pooling revision and complications data revealed a 2-fold increased risk in the HA group compared with TSA (relative risk 2.09, 95% CI 1.17-3.74, P = .01).

In patients with primary glenohumeral osteoarthritis with an intact rotator cuff, TSA is favored to HA in terms of clinical outcome, risk of revision surgery, and postoperative complications.

The purpose of this study is to evaluate the impact of intravenous tranexamic acid on clinical and hematologic outcomes after total shoulder arthroplasty.

Retrospective review was conducted for 282 consecutive patients undergoing either anatomic shoulder arthroplasty or reverse total shoulder arthroplasty. Univariate analysis and multivariate linear regression were used to compare outcomes for patients receiving intravenous tranexamic acid with those who did not.

Of the 282 patients included in this study, 78 patients received intravenous tranexamic acid and 204 did not. Patients who received intravenous tranexamic acid had significantly lower pre- to postoperative change in hemoglobin and hematocrit, and decreased postoperative drain output. In addition, patients receiving intravenous tranexamic acid were significantly less likely to have a postoperative hematocrit <30. There were no significant differences in length of stay, rate of 30 day hematoma, surgical site infection, deep vein thrombosis, or readmission between groups.

Intravenous tranexamic acid is associated with a significant reduction in change in hematocrit and hemoglobin and postoperative drain output after both anatomic and reverse total shoulder arthroplasty. Despite improving hematologic outcomes for these patients, tranexamic acid appears to have little impact on clinical outcomes such as length of stay and 30-day complication rates.

Osteoarthritis (OA) is a common shoulder disorder that impacts shoulder functions. Shoulder arthroplasty is often required to restore function and quality of life. Reverse total shoulder arthroplasty (RSA), which was originally designed mainly for irreparable rotator cuff damage, has gained popularity in recent years for the treatment of advanced shoulder OA instead of the clinically standard total shoulder arthroplasty (TSA). However, this RSA has some nonnegligible flaws such as higher complications rate and economic cost, not mention the following problems caused by irreversible physical structural damage. Therefore, the employment of RSA needs to be carefully considered. This study aimed to compare TSA and RSA in OA patients with or without rotator cuff damage to better guide clinical decision making. We believe the radical use of RSA in patients without rotator cuff deficiency may cause more harm than good. We queried the Nationwide Inpatient Sample (NIS) database from 2011 to 2014 to collect information on OA patients who received TSA and RSA. Patients were divided into 2 groups of comparison according to the presence of rotator cuff deficiency and matched with propensity score analysis. A total of 57,156 shoulder arthroplasties were identified. RSA patients in the rotator cuff deficiency group had significant higher transfusion rates and longer hospital stays. RSA patients without rotator cuff deficiency had a statistically significantly higher number of implant-related mechanical complications, acute upper respiratory infections and postoperative pain. Overall, RSA incurred higher costs in both groups. For OA patients with rotator cuff deficiencies, RSA has its benefits as complication rates were comparable to TSA. For those patients without rotator cuff deficiencies, the use of RSA should be reconsidered as there were more complications with higher severity.

Although anatomic total shoulder arthroplasty (ATSA) has favorable outcomes, nearly all techniques involve subscapularis tendon release for shoulder joint access. Such takedown of the subscapularis may be associated with decreased function, instability, and pain. Subscapularis-sparing approaches have the theoretical benefits of improved function, decreased failure of the tendon reattachment site, and early range of motion and rehabilitation. The primary purpose of this study was to use ultrasound to assess the postoperative integrity of the subscapularis tendon and surrounding soft tissues after ATSA with a subscapularis-sparing technique through an extensile anterosuperior skin incision. Our hypothesis was that this subscapularis-sparing approach would have low rates of subscapularis disruption.

A consecutive cohort of patients who underwent subscapularis-sparing ATSA between 2014 and 2017 were included. Ultrasound was used to evaluate the rotator cuff tendons and deltoid postoperatively, and these were classified as intact, disrupted, or unable to be adequately visualized. Clinical outcome scores, range of motion, and strength measurements were also collected at 1-3 years postoperatively.

Thirty-seven subscapularis tendons and 40 supraspinatus and infraspinatus muscles were adequately visualized and included for analysis. Of the subscapularis muscles, 32 (86%) were intact; 38 of the visualized supraspinatus muscles (95%) and 39 of the infraspinatus muscles (98%) were intact. No dehiscence or loss of integrity of the deltoid was noted. Clinical comparison between patients with disrupted subscapularis muscles and patients without such disruption demonstrated no difference in clinical outcome scores and postoperative range of motion but showed less strength in forward flexion, abduction, and external rotation.

The rate of subscapularis disruption using a subscapularis-sparing approach for ATSA was low (14%), but the potential for tendon disruption was not eradicated. Favorable clinical outcomes support this surgical approach as a potential technique for ATSA.

Shoulder osteoarthritis (OA) with eccentric (B) glenoids has generally been associated with poor patient-reported outcomes and increased complications. The purpose of this study was to outline all the described treatment options and their outcomes and complications in order to better guide treatment.

This systematic review was performed according to the Preferred Reporting Items for Systematic review and Meta-analysis guidelines. Searches were performed up to December 19, 2019, using Medline, EMBASE, Scopus, and Cochrane databases. Inclusion criteria included studies for glenohumeral OA reporting posterior humeral head subluxation and/or posterior glenoid erosion. Studies were excluded if they were review papers, abstracts, or conference papers; had heterogeneity of included Walch types; or were not written in English.

Twenty-one studies met inclusion criteria. The mean follow-up duration was 47.5 months (range, 14-300), and the mean patient age 62 years (38-88). Six different discernible techniques were identified: asymmetric reaming with onlay glenoid (AROG) in 267 shoulders, posterior glenoid bone grafting (PGBG) with onlay glenoid in 79 shoulders, augmented glenoid (AG) in 160 shoulders, reverse shoulder arthroplasty (RSA) with or without bone grafting in 118 shoulders, hemiarthroplasty with concentric reaming (HACR) in 57 shoulders, and humeral head arthroplasty with inlay glenoid (HAIG) in 36 shoulders. All techniques reported improved patient outcomes and range of motion. Short-term (<5 years) studies reported glenoid loosening leading to revisions in 3% of AROG, 2.7% PGBG, 0.8% AG, 1.4% RSA, and 0% HAIG shoulders. HACR had a high revision rate (12.3%) due to persistent pain and stiffness. Midterm (>5 years) studies demonstrated increased rates of glenoid loosening with AROG (14.5%), PGBG (21% loose, 23.8% "at risk"), and AG (18.9% "at risk"), as well as increased rates of subluxation or revision due to instability. HAIG did not demonstrate loosening, subluxation, or revision at 55.2 months.

Various techniques exist to manage complex primary glenohumeral OA with posterior subluxation and posterior glenoid erosion. Glenoid component survival is a concern with ASOG, PGBG, and AG. HACR has the highest early revision rate. RSA offers promising short-term and midterm results likely due to the advantage of more secure fixation as well as a constrained design to prevent posterior subluxation. HAIG has the lowest complication and revision rates although further long-term studies are needed.

Both clinical outcomes and early rates of failure will not be associated with glenoid retroversion.

All patients who underwent an anatomic total shoulder arthroplasty with minimal, noncorrective reaming between 2006 and 2016 with minimum 2-year follow-up were reviewed. Measurements for retroversion, inclination, and posterior subluxation were obtained from magnetic resonance imaging or computerized tomography. A regression analysis was performed to assess the association between retroversion, inclination and subluxation, and their effect on patient reported outcomes (PROs). Clinical failures and complications were reported.

One hundred fifty-one anatomic total shoulder arthroplasties (90% follow-up) with a mean follow-up of 4.6 years (range, 2-12 years) were assessed. The mean preoperative retroversion was 15.6° (range, 0.2-42.1), the mean posterior subluxation was 15.1% (range, -3.6 to 44.1%), and the mean glenoid inclination was 13.9° (range, -11.3 to 44.3). All median outcome scores improved significantly from pre- to post-operatively (P < .001). The median satisfaction was 10/10 (1st quartile = 7 and 3rd quartile = 10). Linear regression analysis found no significant association between retroversion and any postoperative PRO. A total of 5 (3.3%) failures occurred due to glenoid implant loosening (3 patients) and Cutibacterium acnes infection (2 patients) with no association between failure causation and increased retroversion or inclination. No correlation could be found between the Walch classification and postoperative PROs.

Anatomic total shoulder replacement with minimal and noncorrective glenoid reaming demonstrates reliable increases in patient satisfaction and clinical outcomes at a mean of 4.6-year follow-up in patients with up to 40° of native retroversion. Higher values of retroversion were not associated with early deterioration of clinical outcomes, revisions, or failures. Long-term studies are needed to see if survivorship and outcomes hold up over time.

Massive tears of the rotator cuff can result in severe functional deficits due to loss of the axial force couple and effective fulcrum that the intact cuff normally provides. For massive, irreparable rotator cuff tears, especially in the setting of early to moderate degenerative changes, reverse total shoulder arthroplasty functions to modify the center of joint rotation, allowing the deltoid and intact components of the cuff to carry out shoulder function more effectively. Our preferred technique uses a standard open deltopectoral shoulder approach with a 3-dimensional glenoid baseplate model and a 135° prosthesis in an onlay configuration to reduce the risk of scapular notching and increase lateralization of the humerus.

To summarize factors that are associated with a better treatment outcome after post-operative physical therapy in patients with shoulder arthroplasty.

PubMed, Cochrane, and Web of Science.

Studies examining factors that are associated with a better outcome after post-operative physical therapy interventions in patients with shoulder arthroplasty were included. Two independent reviewers performed screening, extracted data, and assessed the risk of bias and level of evidence, using the Quality In Prognosis Studies tool and Evidence-Based Guideline Development checklist. PRISMA guidelines were followed.

In total, 460 articles were found and 14 studies were included. Two of the included articles had a moderate risk of bias, 12 high. The overall number of patients in the included studies varied from 20 to 2053. Patients had either a reverse (N = 1863), an anatomic total shoulder arthroplasty (N = 1029) or, a hemiarthroplasty (N = 133). Anatomic total shoulder arthroplasty patients with a neutral rotation sling position showed less night pain and greater range of motion, which was awarded moderate evidence. Other modifiable and non-modifiable factors such as telemedicine, immediate range of motion exercises, and pre-operative function were only awarded preliminary or conflicting evidence.

Mainly preliminary and conflicting evidence was found. The possible causes of the conflicting evidence were the different measurement methods, implant types, and follow-up times used. The methodological quality was low and physical therapy protocols differed greatly. More high-quality research with standardized protocols is needed to determine the association of various factors with treatment outcomes after post-operative physical therapy in patients with shoulder arthroplasty.

In cases of severe osteoarthritis, posterior glenoid wear leads to acquired retroversion of the glenoid. Surgical treatment of glenoids with acquired retroversion and posterior humeral subluxation with anatomic total shoulder arthroplasty (aTSA) is controversial. The purpose of this study was to determine mid- to long-term outcomes and reoperation rates of augmented and nonaugmented aTSA for treatment of glenohumeral osteoarthritis with Walch B3 glenoid deformity.

This observational cohort study reviewed patients with a Walch B3 glenoid undergoing aTSA at a single institution between 2007 and 2014. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 6 years postoperatively. Outcome measures collected included the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score and Single Alpha Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgery on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again.

Thirty-nine patients met inclusion criteria, and thirty-five (89.7%) were able to be contacted for final outcomes evaluation. Mean follow-up was 8.7 years (range 6-13) after surgery. Sixteen patients were treated with an augmented glenoid component, and 19 patients were treated with a standard glenoid component. Of those with standard components, all were partially corrected with asymmetric reaming. At final follow-up, there were no statistically significant differences between those with augmented and standard glenoid components for mean ASES score (93.3 vs. 85.7, P = .217), ASES pain score (47.2 vs. 41.6, P = .161), SANE score (87.8 vs. 86.0, P = .692), and percentage patient satisfaction (95.6% vs. 96.8%, P = .735), forward elevation (148° vs. 149°, P = .852), or external rotation (36° vs. 39°, P = .202). No patient in either group had undergone revision surgery of the operative shoulder over the study period and all patients stated that they would undergo the same surgery again.

Both augmented and standard aTSA can provide satisfactory and sustained improvements in patient-reported outcomes in patients with acquired glenoid retroversion due to glenohumeral osteoarthritis. Despite a trend toward alternative treatment options, anatomic shoulder arthroplasty should remain a surgical consideration even in the setting of a Walch B3 glenoid deformity.

Stemless total shoulder arthroplasty (TSA) was approved for use in the United States in 2015, and there remains a paucity of data on its performance in this market. Decreased operative time without compromise of clinical outcomes is a theoretical advantage of stemless TSA, but no studies have evaluated this in a comparative study to date. Herein, the operative times and clinical outcomes of stemless vs. conventional stemmed TSA are investigated.

This is a retrospective cohort study, evaluating all consecutive TSAs performed by a single surgeon between 2015 and 2018. Data were collected from 59 patients who underwent TSA with conventional, stemmed humeral implants and 115 patients in whom a stemless humeral implant was used. Operative times and demographic data were collected retrospectively from the anesthesia record, and prospectively collected patient-reported outcome measures were collected from the Surgical Outcomes System database. For patient-reported outcome measure, visual analog scale, American Shoulder and Elbow Surgeons, and Single Assessment Numerical Evaluation scores were recorded serially until a minimum 2-year follow-up.

The average operative time was 24 minutes less in the stemless cohort compared with the stemmed cohort (104 minutes vs. 128 minutes, P < .001). Cost analysis showed a decreased personnel cost of 15.9% that correlates to a 3.1% overall reduction in operating room-associated cost. Patient-reported outcome scores significantly improved postoperatively in both cohorts across all time points. There was no difference found in visual analog scale, American Shoulder and Elbow Surgeons, and Single Assessment Numerical Evaluation scores between the cohorts at the 2-year follow-up.

Stemless TSA significantly reduces operative time with equivalent functional outcomes at a minimum 2-year follow-up.

Shoulder arthroplasty is increasingly performed for patients with symptoms of glenohumeral arthritis. Advanced imaging may be used to assess the integrity of the rotator cuff preoperatively because a deficient rotator cuff may be an indication for reverse shoulder arthroplasty (RSA) rather than anatomic total shoulder arthroplasty (TSA). However, the cost-effectiveness of advanced imaging in this setting has not been analyzed.

In this cost-effectiveness modeling study of TSA, all patients underwent history and physical examination, radiography, and CT, and we compared (1) no further advanced imaging, (2) selective MRI, (3) MRI for all, (4) selective ultrasound, and (5) ultrasound for all.

A simple chain decision model was constructed with a base-case 65-year-old patient with a 7% probability of a large-to-massive rotator cuff tear and a follow-up of 5 years. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness to pay of both USD 50,000 and 100,000 per quality-adjusted life year (QALY) used, in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. Diagnostic test sensitivity and specificity were extracted from published systematic reviews and meta-analyses, and patient utilities were obtained using the Cost-Effectiveness Analysis Registry from the Center for the Evaluation of Value and Risk in Health. Final patient states were categorized as either inappropriate or appropriate based on the actual rotator cuff integrity and type of arthroplasty performed. Additionally, to evaluate the real-world impact of intraoperative determination of rotator cuff status, a secondary analysis was performed where all patients indicated for TSA underwent intraoperative rotator cuff examination to determine appropriate implant selection.

Selective MRI (ICER of USD 40,964) and MRI for all (ICER of USD 79,182/QALY) were the most cost-effective advanced imaging strategies at a willingness to pay (WTP) of USD 50,000/QALY gained and 100,000/QALY gained, respectively. Overall, quality-adjusted life years gained by advanced soft tissue imaging were minimal: 0.04 quality-adjusted life years gained for MRI for all. Secondary analysis accounting for the ability of the surgeon to alter the treatment plan based on intraoperative rotator cuff evaluation resulted in the no further advanced imaging strategy as the dominant strategy as it was the least costly (USD 23,038 ± 2259) and achieved the greatest health utility (0.99 ± 0.05). The sensitivity analysis found the original model was the most sensitive to the probability of a rotator cuff tear in the population, with the value of advanced imaging increasing as the prevalence increased (rotator cuff tear prevalence greater than 12% makes MRI for all cost-effective at a WTP of USD 50,000/QALY).

In the case of diagnostic ambiguity based on physical exam, radiographs, and CT alone, having both TSA and RSA available in the operating room appears more cost-effective than obtaining advanced soft tissue imaging preoperatively. However, performing selective MRI to assess rotator cuff integrity to indicate RSA or TSA is cost-effective if surgical preparedness, patient expectations, and implant availability preclude the ability to switch implants intraoperatively.

Level III, economic and decision analysis.