Current practices of infection prevention for primary shoulder arthroplasty: A survey of American Shoulder and Elbow Surgeons Society members

Are primary and revision shoulder arthroplasty appropriately reimbursed based on relative value units?

Functional internal rotation after shoulder arthroplasty: a comparison of anatomic and reverse shoulder arthroplasty

Complications after primary and revision shoulder arthroplasty: a matched cohort study

The American Shoulder and Elbow Surgeons (ASES) questionnaire was developed to provide a standardized method for evaluating shoulder function. Previous studies have determined the clinical responsiveness of this outcome measure for heterogenous populations or patients with nonoperatively treated rotator cuff disease. Currently, to our knowledge, no studies exist that establish the clinically relevant change in the ASES score after shoulder arthroplasty. We asked: (1) What are the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the ASES score after primary and reverse shoulder arthroplasties? (2) Are the MCID and SCB for the ASES score different between primary and reverse shoulder arthroplasties? (3) What patient-related factors are associated with achieving the MCID and SCB after total shoulder arthroplasty and reverse shoulder arthroplasty? A longitudinally maintained institutional shoulder arthroplasty registry was retrospectively queried for patients who underwent primary shoulder arthroplasty, including anatomic or reverse total shoulder arthroplasty from 2007 to 2013, with a minimum 2-year followup. Seven hundred ninety-four patients were identified and eligible; 304 of these patients did not have 2 years of followup or complete datasets, resulting in a study cohort of 490 patients (62% of the 794 potentially eligible). The MCID and SCB of the ASES score for these patients was calculated using an anchor-based method, using four different anchors measuring satisfaction with work, activities, overall, and activity from the SF-36. The MCID (anchored to somewhat satisfied) and SCB (very satisfied) of the ASES score were calculated for the entire cohort and stratified by arthroplasty type. Multivariate logistic regression of patient-related factors that influence the MCID and SCB achievement was performed. The MCID for all patients combined ranged from 6.3 to 13.5; for the overall satisfaction anchor, the MCID was 13.5 ± 4.5 (95% CI, 4.8-22.3). The SCB for the overall cohort ranged from 12.0 to 36.6; for the overall satisfaction anchor, the SCB was 36.6 ± 3.8 (95% CI, 29.1-44.1). There were no differences in the MCID of the ASES score between anatomic and reverse shoulder arthroplasty for any of the anchors (p = 0.159-0.992) or the SCB for any of the anchors (p = 0.467-0.977). Combining anatomic and reverse shoulder arthroplasty in one group, higher preoperative ASES score (odds ratio [OR], 0.96; 95% CI, 0.94-0.98; p < 0.001), having a reverse shoulder arthroplasty (OR, 0.36; 95% CI, 0.16-0.85; p = 0.016), and having rheumatoid arthritis were independent predictors of not achieving an MCID for the ASES 2 years after surgery. Higher preoperative ASES score (OR, 0.91; 95% CI, 0.89-0.92; p < 0.001), a diagnosis of rotator cuff tear arthropathy (OR, 0.14; 95% CI, 0.07-0.30; p < 0.001), a diagnosis of back pain (OR, 0.42; 95% CI, 0.24-0.71); p = 0.002), and living alone (OR, 0.36; 95% CI, 0.19-0.69; p = 0.002) were all independent predictors of not achieving SCB after shoulder arthroplasty. Patients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change, whereas those who have at least a 23-point improvement in their ASES score experience a substantial clinical benefit. High preoperative function was associated with a decreased likelihood of achieving clinically important change after total shoulder arthroplasty. Level III, therapeutic study.

Deep infection after shoulder arthroplasty is a diagnostic and therapeutic challenge. The current literature on this topic is from single institutions or Medicare samples, lacking generalizability to the larger shoulder arthroplasty population. We sought to identify (1) patient-specific risk factors for deep infection, and (2) the pathogen profile after primary shoulder arthroplasty in a large integrated healthcare system. A retrospective cohort study was conducted. Of 4528 patients identified, 320 had died and 302 were lost to followup. The remaining 3906 patients had a mean followup of 2.7 years (1 day-7 years). The study endpoint was the diagnosis of deep infection, which was defined as revision surgery for infection supported clinically by more than one of the following criteria: purulent drainage from the deep incision, fever, localized pain or tenderness, a positive deep culture, and/or a diagnosis of deep infection made by the operating surgeon based on intraoperative findings. Risk factors evaluated included age, sex, race, BMI, diabetes status, American Society for Anesthesiologists (ASA) score, traumatic versus elective procedure, and type of surgical implant. For patients with deep infections, we reviewed the surgical notes and microbiology records for the pathogen profile. Multivariable Cox regression models were used to evaluate the association of risk factors and deep infection. Adjusted hazard ratios and 95% CI are presented. With every 1-year increase in age, a 5% (95% CI, 2%-8%) lower risk of infection was observed. Male patients had a risk of infection of 2.59 times (95% CI, 1.27-5.31) greater than female patients. Patients undergoing primary reverse total shoulder arthroplasty had a 6.11 times (95% CI, 2.65-14.07) greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty. Patients having traumatic arthroplasties were 2.98 times (95% CI, 1.15-7.74) more likely to have an infection develop than patients having elective arthroplasties. BMI, race, ASA score, and diabetes status were not associated with infection risk (all p > 0.05). Propionibacterium acnes was the most commonly cultured organism, accounting for 31% of isolates. Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty. Reverse total shoulder arthroplasty and traumatic shoulder arthroplasties also carry a greater risk for infection. Propionibacterium acnes was the most prevalent pathogen causing infection in our primary shoulder arthroplasty population. Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to determine whether the addition of hydrogen peroxide to the preoperative skin preparation for primary total shoulder arthroplasty is associated with a difference in patient-reported outcomes, risk for postoperative infection, and risk for revision surgery at a minimum of 2-year follow-up. This was a prospective, blinded, and controlled trial, which included a consecutive series of patients undergoing primary shoulder arthroplasty. The control group underwent standard sterile skin preparation using ethyl alcohol and ChloraPrep applicators, and the peroxide group had the same preparation with the addition of hydrogen peroxide between the alcohol and ChloraPrep applications. We then compared patient-reported outcome scores (American Shoulder and Elbow Surgeons Shoulder Score [ASES], simple shoulder test [SST], visual analog scale [VAS]), infections, and revision surgeries between the two groups at 2-year follow-up. Of the 61 patients included in the original study, 52 of 58 (85%) living patients agreed to participate in this study. No preoperative differences were observed between groups. No difference was observed in ASES, SST, or VAS scores at 2 years. More revision surgeries were done in the control group (7 versus 2, P = 0.268) and Cutibacterium acnes infections (2 versus 0, P = 0.168). The addition of hydrogen peroxide to the preoperative skin preparation before primary shoulder arthroplasty is safe, and additional research is warranted to investigate whether it may decrease the risk for revision surgery and postoperative C acnes infection. III.

Development and validation of a predictive model for outcomes in shoulder arthroplasty: a multicenter analysis of nearly 2000 patients.

Defining the tipping point for primary shoulder arthroplasty

With the increasing popularity of shoulder arthroplasty, indications and usage has expanded to younger more physically active patients. Limited knowledge exists on return to outdoorsman sports after shoulder arthroplasty. To determine return to outdoorsman sports, including fishing, shooting, archery, and rowing, after primary total shoulder arthroplasty at a minimum 2-year follow-up. Case series; Level of evidence, 4. A retrospective study was performed on patients who underwent primary reverse or anatomic total shoulder arthroplasty between 2012 and 2022 who participated in outdoorsman sports, including fishing, shooting, archery, and rowing, with a minimum 2-year follow-up. Questionnaires were expanded to explore patients' preoperative and postoperative activity with regard to outdoorsman sports. Patient-reported outcomes (PROs), including visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES), and Subjective Shoulder Value, as well as active range of motion including forward flexion, external rotation, internal rotation, were collected pre- and postoperatively. A total of 102 patients met study criteria and responded. Overall, 77% returned to outdoorsman sports, with 80%, 85%, 50%, and 68% returning to fishing, shooting, archery, and rowing, respectively. Of those who returned, 86% reported being mostly or completely satisfied with their performance postoperatively, with 77% reporting a return to at least the same level of activity. Among those who returned, 61% did so within 6 months postoperatively. Patients from all sports showed significant clinical improvement in forward flexion (P≤ .003), external rotation (P≤ .006), and PROs (P≤ .006) at a mean postoperative follow-up of 38 ± 12 months. Between sports, postoperative VAS (P = .04) and ASES (P = .03) values were significantly different, with shooting showing lower ASES (83) and higher VAS (1.5) scores, despite demonstrating the highest return rate (85%). When considering arm dominance, return rates were comparable between patients who had surgery on their dominant arm and those treated on their nondominant arm across each sport. Participants had a 77% return to outdoorsman sports, such as fishing, shooting, archery, and rowing, with >50% doing so within 6 months of primary total shoulder arthroplasty. Respondents who participated in rowing and archery returned at lower rates compared with fishing and shooting, despite shooting's showing higher pain postoperatively. Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty.

What is the clinical impact of positive cultures at the time of primary total shoulder arthroplasty?

American Shoulder and Elbow Surgeons membership and its association with primary and revision shoulder arthroplasty volume

Early aseptic reoperation after shoulder arthroplasty increases risk of subsequent prosthetic joint infection.

Tranexamic acid achieves less blood loss volume of in primary shoulder arthroplasty: a systematic review and meta-analysis of level I randomized controlled trials

What's New in Shoulder and Elbow Surgery.

Defining the younger patient: age as a predictive factor for outcomes in shoulder arthroplasty