Anatomic Total Shoulder Arthroplasty Research Articles

A SPECIALIZED SYSTEM FOR IN VITRO TEST OF ANATOMIC GLENOIDS BASED ON ASTM F2028-14

Glenoid loosening, primarily induced by the “rocking horse” phenomenon from humeral head load on the glenoid rim, is the foremost complication and cause of failure in anatomic total shoulder arthroplasty. The dynamic load exerted by universal fatigue testing machines significantly deviates from the standard ASTM F2028-14 in the rocking test. To accurately conduct the in vitro loosening test on anatomic glenoids, a specialized system and customized test methods are developed to achieve anatomic glenoid rocking and subluxation tests. The horizontal and vertical loading can be achieved synchronously or asynchronously by two self-developed high-performance electromagnetic linear motors. In addition, the subluxation tests on anatomic glenoids are verified by finite element simulation. The results show that the subluxation load and translation of anatomic glenoids in the subluxation tests are consistent with those in numerical simulations. The error of the applied axial force in the rocking tests is only 5[Formula: see text]N, strictly meeting the standard of ASTM F2028-14. During the rocking tests, the system runs smoothly and the software works well, indicating the feasibility of the in vitro shoulder joint test system. This study provides an approach to accurate dynamic evaluation of glenoid loosening or disassociation.

Glucagon-like Peptide-1 Receptor Agonist Use is Associated With Increased Risk of Perioperative Complication and Readmission Following Shoulder Arthroplasty

Glucagon-like peptide-1 (GLP-1) receptor agonists, increasingly used for diabetes management and weight loss, have been linked to lower readmission rates after knee and hip arthroplasty. However, their impact on total shoulder arthroplasty (TSA) outcomes remains unclear. This study investigates the effects of GLP-1 receptor agonists on major complications and revisions following TSA. A retrospective query of the TriNetX database from 2010 to 2023 was performed to identify patients who underwent anatomic or reverse TSA and were prescribed GLP-1 receptor agonists. GLP-1 receptor agonist users were 1:1 propensity score-matched to controls for demographic factors and comorbidities, yielding 1,259 patients in each group. Outcomes included 90-day postoperative medical complications and readmission and revision surgery at 2 years. Odds ratios (ORs), 95% confidence intervals, and P values were calculated. After Bonferroni correction, P < 0.005 was considered significant. GLP-1 receptor agonist users (n = 1,259) experienced significantly higher rates of deep vein thrombosis (1.6% vs. 0.9%; OR 3.0; P = 0.001), myocardial infarction (1.60% vs. 0.9%; OR 2.84; P = 0.003), pneumonia (3.34% vs 1.50%; OR 2.25; P = 0.003), transfusion (7.1% vs. 4.3%; OR 1.7; P = 0.003), and readmission (8.1% vs 5.2%; OR 1.6; P = 0.004) in the 90-day postoperative period compared to patients not taking GLP-1 receptor agonists. There were no differences in the rates of stroke, pulmonary embolism, postoperative anemia, or renal failure. In patients with a minimum 2-year follow-up (n = 776), there was no difference in revision rate (3.2% vs 1.8%; OR 1.8; P = 0.07). GLP-1 receptor agonist use during TSA was associated with an increased risk of deep vein thrombosis, myocardial infarction, pneumonia, need for transfusion, and readmission. Further investigation into the perioperative risk assessment and medical optimization of patients utilizing GLP-1 receptor agonists may be warranted.

Anatomic Total Shoulder Arthroplasty Revised to Reverse Total Shoulder Arthroplasty: Clinical and Radiographic Outcomes Compared to Primary Reverse Total Shoulder Arthroplasty

Reverse total shoulder arthroplasty (rTSA) has become the procedure of choice for a failed aTSA. Little data exists regarding outcomes; the few studies published to date have small numbers, short follow-up, and most do not have a control group or use first generation implants. The purpose of this study is to compare the clinical and radiographic outcomes of failed aTSA revised to rTSA to primary rTSA. A prospective multicenter shoulder registry was used to conduct a retrospective review of patients that received a primary rTSA for osteoarthritis and rotator cuff disease and compare them to those that had an aTSA revised to a rTSA using the same implant between 2007 and 2021 with a minimum follow-up of two years. Cohorts were matched 3:1 (primary:revision) by age, gender, body mass index and length of follow-up. Those that underwent revision for humeral fracture, infection, or an unknown reason were excluded. Preoperative and postoperative range of motion (ROM) and patient reported outcome measures (PROMs) were compared. Outcomes included rates of scapular notching, complications, revision, and patient satisfaction. There were 88 aTSA revised to rTSA compared to 264 matched primary rTSA. In both cohorts, the mean age was 68 years, 59% were female, and the mean follow-up was 56 months. The most common reason for revision was rotator cuff tearing (53%), followed by aseptic glenoid loosening (34%), instability (9%), aseptic humeral loosening (6%) and glenoid component dissociation (3%). At latest follow-up, patients in both groups had statistically significant improvements in all outcome scores, exceeding the minimal clinically important difference (MCID) and the substantial clinical benefit (SCB). The revision cohort had significantly less postoperative abduction (P<0.001) and forward elevation (P=0.001) compared to the primary rTSA cohort. All PROMs in the revision cohort were significantly worse than those in the primary rTSA cohort. Patient satisfaction rate in the revision cohort was significantly lower than the primary cohort (P<0.001). Complication (P=0.005) and revision rates (P=0.013) were significantly higher in the revision cohort, while scapular notching was similar. Patients undergoing revision of a failed aTSA to rTSA have worse clinical outcomes compared to those undergoing primary rTSA, including all PROMs, abduction, elevation, pain relief and patient satisfaction, with higher complication and revision rates. While patients in the revision group had significant improvements that exceeded the MCID and SCB, they do not achieve the same outcomes as patients who undergo primary rTSA.

Revision Anatomic Total Shoulder Arthroplasty Surgical Technique/Tips and Tricks

In the United States, the use of total shoulder arthroplasty has grown significantly over the past decade, leading to an increased need for revision total shoulder arthroplasty. The most common causes for revision include instability, rotator cuff deficiency, infection, fractures, and component loosening. Although revisions are sometimes unavoidable, thoughtful preoperative planning and proper implant positioning, among other mitigation strategies, can help reduce this risk. A comprehensive evaluation is essential for determining the appropriate treatment modality, with computed tomography arthrography and metal suppression magnetic resonance imaging being particularly helpful depending on the etiology. Initial treatments may include conservative approaches, such as analgesic medications and physical therapy, but more commonly, surgical intervention is required. This typically involves revision total shoulder arthroplasty or conversion to reverse total shoulder arthroplasty, and in rare cases diagnostic arthroscopy or arthroscopic rotator cuff repair. Surgeons should be prepared for all potential treatments and complications, and a thorough work-up ensures that all possible scenarios are accounted for.

Tranexamic Acid Use in Total Shoulder Arthroplasty Continues to Increase and is Safe in High-Risk Patients

IntroductionTranexamic acid (TXA) is increasingly utilized in total shoulder arthroplasty (TSA) to minimize blood loss. Despite its benefits, concerns persist regarding its use in patients at elevated risk of postoperative venous thromboembolism (VTE). This study evaluates trends in TXA use and assesses its safety in both general and high-risk patient populations. MethodsPatients who underwent primary, elective anatomic TSA and reverse TSA from January 1st, 2016, to December 31st, 2020, were identified using the Premier database. TXA use trends and the proportion of patients requiring blood transfusions were reported. Patients were divided on the basis of having received TXA on the day of surgery or not. To account for confounding variables, a propensity score was generated for the probability of treatment with TXA. A sub analysis of high-risk patients, defined as those with a history of VTE, was performed using multivariable regression analyses. Endpoints included the 90-day risk of pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion. ResultsIn total, 86,356 patients underwent TSA from 2016 to 2020. Of these, 41,380 (47.9%) received TXA, and 44,976 (52.1%) did not. After matching, 28,232 received TXA, and 28,232 did not. The use of TXA increased from 33.4% in 2016 to 60.3% in 2020. The rates of transfusion decreased from 1.05% to 0.47%. Following matching, the risk of all thromboembolic complications (odds ratio [OR]: 0.98, 95%-Confidence Interval [CI]: 0.72-1.33, p=0.874), DVT (OR: 1.11, 95%-CI: 0.71-1.71, p=0.655), and PE (OR: 0.87, 95%-CI: 0.56-1.33, p=0.513) were similar between cohorts. The high-risk cohort comprised 4,757 patients with a history of VTE, of which 1,850 (38.9%) received TXA, and 2,907 (61.1%) did not. The use of TXA for high-risk patients increased from 27.4% to 52.0% while rates of transfusion decreased from 1.76% to 0.70%. Following multivariable regression, there was similar risk of all thromboembolic complications (adjusted OR [aOR]: 0.77, 95%-CI: 0.47-1.28, p=0.316), DVT (aOR: 0.96, 95%-CI: 0.39-2.36, p=0.92), and PE (aOR: 0.54, 95%-CI: 0.23-1.28, p=0.163) between high-risk cohorts. DiscussionTXA in shoulder arthroplasty usage has nearly doubled from 2016 to 2020 and is now administered to 60% of all patients. This rise in TXA use has been coupled with a significant decrease in the risk of blood transfusion. Patients receiving TXA were not at increased risk of thromboembolic, infectious, epileptogenic, surgical, and medical complications even if they had a history of VTE.

The Relationship Between Surgeon Volume and Major Surgical Complications After Total Shoulder Arthroplasty: An Evaluation of 3177 US Orthopedic Surgeons.

Total shoulder arthroplasty (TSA), which includes anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), is a technically demanding procedure and limited data exist on the relationship between case volume and complications. We sought to identify volume thresholds for TSA, aTSA, and rTSA at which risk of a major surgical complication decreased and to compare complications of patients treated by high-volume surgeons with those of patients treated by low-volume surgeons. Primary, elective TSAs (aTSA and rTSA) from January 1, 2016, to December 31, 2019, were identified in the Premier Healthcare Database. Multivariable logistic regression with restricted cubic splines modeled the relationship between annual TSA, aTSA, and rTSA surgeon volume and 90-day risk of major surgical complications. The 90-day complications of patients treated by high- and low-volume surgeons were compared. From 2016 to 2019, 3177 surgeons performed 78,639 TSAs. Increasing annual volume was associated with decreasing major surgical complication risk (thresholds: 50 TSAs, 25 aTSAs, and 36 rTSAs). High- and low-volume surgeons performed 24,595 and 54,044 TSAs, respectively. Patients of high-volume surgeons had lower risk of major surgical complications (adjusted odds ratio [aOR], 0.69; 95% CI, 0.56-0.84), myocardial infarction (aOR, 0.59; 95% CI, 0.36-0.97), and readmission (aOR, 0.71; 95% CI, 0.62-0.81). Importantly, 74.9% of high-volume and 93.0% of low-volume surgeon-year units had major surgical complication rates below the mean of all recorded surgeons. While most high- and low-volume surgeons had major surgical complication rates below the cohort average, increasing TSA volume was associated with a decreased risk of complications. [Orthopedics. 202x;4x(x):xx-xx.].

Trend shift in proximal humeral fracture treatment: a detailed review of national shoulder arthroplasty data.

This study aimed to scrutinize nationwide utilization trends of shoulder arthroplasty for proximal humerus fractures (PHFs) using a comprehensive national surgical database. A retrospective study was conducted with 4181 patients who underwent shoulder arthroplasty due to PHF between 2016 and 2022 using national health records. They are grouped as hemiarthroplasty (HA), anatomical total shoulder arthroplasty (TSA), and reverse shoulder arthroplasty (RSA). The patients' demographic data, length of hospital stay, revision histories, transfusion rates, mortality data, trends in arthroplasty methods over the years, the distribution of cases by hospital characteristics and geographical regions were analyzed. Treatment with HA was administered to 22.1% of patients, TSA to 30.2%, and RSA to 47.7%. The lowest revision rate was observed after HA (4.3%), while higher rates were recorded after TSA (7.9%) and RSA (7.4%) (p = 0.019). It was observed that there was a significant increasing trend in RSA rates and a decreasing trend in HA and TSA rates over time (p < 0.001). From 2016 to 2022, there appears to have been a significant increase in the utilization of RSA for the arthroplasty treatment of proximal humeral fractures in Türkiye, and it is used more frequently than HA. However, revision rates after RSA are still higher than those after HA. Level III, retrospective cohort study.

Differences in Primary Total Shoulder Arthroplasty Volume, Reimbursement, Practice Styles, and Patient Populations Based on Surgeon Gender: A Temporal Analysis

BackgroundOrthopedic surgery has previously been shown to have a shortage of female physicians and a gender pay gap. However, this has not been thoroughly evaluated in the setting of shoulder surgery. The primary purpose of this study was to evaluate differences in total shoulder arthroplasty (TSA) volume, reimbursement, surgeon billing practices, and patient populations between male and female surgeons from 2013 to 2021. MethodsThe Medicare Physician and Other Practitioners database, a publicly available dataset that includes 100% of services billed to Medicare Part B was utilized. The database was queried for all billing episodes of Current Procedural Terminology (CPT) code 23472, which encompasses both anatomic and reverse primary TSA. Procedural volume, average inflation-adjusted reimbursement per TSA, physician billing information, and the patient demographics of each surgeon who performed TSAs were collected. Welch’s t-test and Kruskal-Wallis were utilized to compare male and female surgeons each year between 2013 and 2021. ResultsBetween 2013 and 2021, the proportion of TSAs performed by female surgeons nationally increased from 1.8% to 2.9% (+1.1%). This increase was greatest in the Northeast (2.0% to 6.1%), while a decrease was seen in the Midwest (1.9% to 1.6%). In 2021, there was no significant difference between male and female surgeons in the average inflation-adjusted reimbursement per TSA ($1,144.00 vs $1,143.00, p=0.792) and the average number of TSAs performed per surgeon (26.6 vs 23.1, p=0.105). Female TSA surgeons, on average, had less Medicare beneficiaries (348 vs 462, p<0.001), performed fewer annual services (1,817 vs 3,630, p<0.001), and performed fewer unique services (60 vs 76, p<0.001) compared to male surgeons. A higher proportion of female surgeon’s patient populations were non-White (24% vs 22%, p=0.028), female (61% vs 59%, p=0.001), and dual enrolled Medicare-Medicaid patients (13% vs 10%, p<0.001). However, there was no difference in the average patient complexity between male and female TSA surgeons based on hierarchical condition category (HCC) score (1.0783 vs 1.0732, p=0.228). ConclusionFemale representation within TSA surgery is increasing nationally, with the greatest representation in the Northeast and West and the lowest representation in the South and Midwest. Although female TSA surgeons perform a similar number of TSAs, receive comparable reimbursement per TSA, and have a similarly complex patient population as their male counterparts, they perform significantly fewer total and unique billable services annually. Additionally, female TSA surgeons tend to see more non-White, women, and dual Medicare-Medicaid enrolled patients.

Convertible glenoid replacement in the anatomical total shoulder arthroplasty: medium-term results.

The older generation of high thickness metal-backed glenoid prostheses had a high failure rate. The goal of our study was to analyze the medium-term clinical and radiological results of a technically modified generation of metal backed glenoids with 35% decrease in thickness. Thirty-nine patients (43 shoulders) with a mean age of 66.5 years at surgery were examined from two to ten years (mean 71.2 months) using the Constant-Score, Subjective Shoulder Value and X-ray in a.p. and axial view. Indication for surgery included patients with glenoid types B1, B2, or B3 and/or posterior subluxation but intact rotator cuff, or patients who did not want a reverse prosthesis and had high functional demands. Inclusion criteria comprised participation in a clinical and radiological follow-up examination, along with a minimum follow-up duration of 24 months. Additionally, in all cases, the Constant Score and the Subjective Shoulder Value (PROM) had to be determined. Exclusion criteria were an incomplete dataset, implantation of a different prosthesis type, and failure to meet the minimum follow-up time. The absolute Constant Score (CS) improved significantly (p < 0.0001) from 43 ± 13 (range: 20-69) points before to 80 ± 13 (range: 46-98) points after surgery. The only preoperative negative influencing factor on the result was the glenoid protrusion according to Lévigne (p = 0.0150). No significant differences in functional outcomes were found between glenoid types A2,B1,B2 and B3. Radiolucent lines at the interface were observed in a total of four patients (13%). Radiological signs of glenoid osteolysis were seen in six patients (20%).Humeral upward migration was observed in four patients (13%) and posterior shoulder joint decentering occurred in one patient (3%). Implant-specific complications occurred in three cases (7%). Due to a massive rotator cuff tear, two cases (4.7%) had to be converted to a reversed implant, with the primary metal component remaining in place. If the implant-specific and rotator cuff-associated complications are summarized, the rate is 11.7%. All components that required conversion to an reverse implant have so far remained free of complications. Favorable clinical results can be achieved, especially in patients with an eccentric glenoid type. Severe preoperative glenoid erosion (Walch A2, B2, B3) does not appear to have any influence on postoperative functional results. The complication and revision rates are significantly better than in previous studies with conventional metal-backed glenoid components. Conversion of the anatomical glenoid component to a reverse system was always possible and good clinical results were achieved.

Predictive factors of intraoperative conversion to reverse total shoulder arthroplasty in patients with anatomic total shoulder arthroplasty

BackgroundMany factors play a role in decision-making for arthroplasty type in patients with glenohumeral osteoarthritis (GHOA). The purpose of this study was to evaluate preoperative and intraoperative factors that might predict the need for Reverse Total Shoulder Arthroplasty (rTSA) versus Anatomic Total Shoulder Arthroplasty (aTSA) for patients with primary GHOA. Secondarily, American Shoulder and Elbow Surgeons (ASES) were compared. MethodsPatients with primary GHOA indicated for aTSA versus rTSA were identified. Preoperative records were reviewed for demographics, range of motion, rotator cuff strength, and glenoid morphology. Operative reports were assessed to identify intraoperatively rotator cuff pathology and glenoid deficiency. ASES scores at 2-years postoperative were collected. Results111 patients were included from 2018-2021. 94 patients underwent aTSA, while 17 were intraoperatively converted to rTSA. There were no significant differences in age, BMI, or preoperative Walch classification between cohorts. rTSA patients had significantly decreased preoperative external rotation (p=0.006). External rotation ≤30 degrees was the only preoperative predictive factor for performing rTSA versus aTSA (p=0.0004). The most common reason for intraoperative transition to rTSA was rotator cuff deficiency. At 2-year follow-up, median ASES scores were 94.2 (IQR 85-96.7) and 88.3 (IQR 73.3-94.5) for aTSA and rTSA, respectively (p=0.097). ConclusionMany patients with primary GHOA are well-served with aTSA. However, there are patients with primary GHOA in which rTSA may be ideal given rotator cuff deficiency or glenoid defects felt to limit aTSA glenoid component placement. This study highlights the need for preoperative external rotation and intraoperative evaluation of rotator cuff integrity and glenoid bone stock.

Correlation of Preoperatively Planned Humeral Component Size and Actual Implanted Size: A Retrospective and Prospective Evaluation of Anatomic and Reverse Shoulder Arthroplasty

BackgroundThe aims of the study were to (1) evaluate the correlation of planned humeral component diameter with implanted humeral component diameter for reverse total shoulder arthroplasty (rTSA) and (2) to evaluate the correlation of planned humeral components with executed humeral components for stemless anatomic total shoulder arthroplasty (aTSA). MethodsFour shoulder surgeons participated in two phases of the study. In the retrospective arm, 3 months of TSA and rTSA cases which were completed with preoperative CT-based planning, but without any humeral planning, were re-planned using humeral planning, and the components from the virtual planning compared to the implanted components. In the prospective arm, 3 months of TSA and rTSA cases were prospectively planned by each surgeon. The planned and implanted components were similarly compared. Results97 rTSAs were included (50 retrospective, 48 prospective). In the retrospective analysis, in 60% of cases, the rTSA stem diameter was within one size of the plan; in 84%, it was within two sizes; in 90%, it was within 3 sizes. In the prospective analysis, the rTSA stem diameter was within one size in 73% of cases; in 90% within 2 sizes, and in 94% within 3 sizes (p > 0.05 all comparisons). The cup diameter was always within one size of the plan; it matched in 84% of the retrospective cases and 90% of the prospective cases (p > 0.05). 77 TSA were included (33 retrospective, 44 prospective). For prosthetic head diameter, in the retrospective analysis, it was an exact match in 52% of patients, within one size in 85% and within two sizes in 100%. In the prospective analysis, the diameter was an exact match in 57%, within one size in 86% and within two sizes in 100% (p > 0.05 all comparisons). The thickness of the prosthetic component was a match to the plan in 88% of the retrospective cases and 86% of prospective cases (p > 0.05). ConclusionsFor the utilized planning software and implants, humeral planning for rTSA affords some predictability for stem diameter regardless of whether assessed retrospectively or prospectively, with 84-90% of cases within two diameters of the plan. The inlay humeral cup diameter was an exact match to the plan in 84-90% of cases. For stemless aTSA, the humeral component diameter was an exact match to the plan in 52-57%, but within one size in 85-86% of cases. There were no significant differences if the planning was performed retrospectively or prospectively.

After Primary Total Shoulder Arthroplasty, Factors Associated with Returning to the Same Surgeon for Subsequent Total Shoulder Arthroplasty.

Total shoulder arthroplasty (TSA) is commonly done for degenerative conditions. Patients may need additional contralateral TSA or ipsilateral revision TSA. As a marker of patient satisfaction and practice integrity, factors associated with return to the same or different surgeon are of interest. Patients undergoing TSA were abstracted from the PearlDiver data set. Subsequent TSA within 2 years was identified. Factors analyzed included age, sex, comorbidity burden, prior depression diagnosis, insurance type, reverse versus anatomic TSA, ipsilateral versus contralateral surgery, and postoperative adverse events. Patients returning to the same surgeon versus different surgeon were compared with multivariable analysis. 98,048 TSA patients were identified, with 8483 patients (8.7%) undergoing subsequent TSA within 2 years. Of those, 1,237 (14.6%) chose a different surgeon. Factors associated with changing surgeons were revision surgery on the ipsilateral shoulder (OR:2.47), Medicaid insurance (OR:1.46), female sex (OR:1.36), any adverse events (OR:1.23), and higher Elixhauser Comorbidity Index (OR:1.07 per point), while prior depression diagnosis was associated with decreased odds (OR:0.74) of changing surgeon (P < 0.05 for all). When pursuing a subsequent TSA, only a minority of patients changed to a different surgeon. Factors identified associated with changing to a different surgeon may help guide measures to improve patient satisfaction and practice integrity.

An in vitro study of glenoid implant peripheral peg interface mechanics during eccentric loading and lift-off.

Glenoid implants used in anatomic total shoulder arthroplasties typically incorporate peripheral pegs as a design feature to support eccentric loads. These peripheral pegs and the implant-cement-bone interface undergo substantial cyclic tensile-compressive loads during normal activity. Therefore, these pegs are of interest in translating the micromechanics of local implant fixation failure to the biomechanics of gross anatomic failure of the glenoid implant after total shoulder arthroplasty. This study used an in vitro peg-cement-bone construct which incorporated bone tissue acquired from osteoarthritic patients undergoing total shoulder arthroplasty. Strain distributions in the peripheral peg-cement-bone interfaces were analyzed under loading conditions emulating glenoid implant edge displacements. It was found that tensile strains in the interfaces were highest near the backside-peg junction and were greater in magnitude than compressive strains. Notably, strains near the peg's fixation channels were relatively low. These results suggest that cracks may initiate around the peg near the backside and travel downward to cause broader fixation failure.

Is revision to anatomic shoulder arthroplasty still an option? A systematic review.

With the historical complications when using total shoulder arthroplasty (TSA) to revise failed arthroplasties, and the success of the reverse prosthesis in the revision setting, the question arises whether revision to TSA is still a reasonable option? This systematic review examines revision to TSA and the factors associated with outcomes. A systematic review was performed for studies of TSA used to revise a failed hemiarthroplasty or TSA. The primary outcome was implant failure leading to a repeat revision arthroplasty. Secondary outcomes included visual analog scale (VAS) pain scores, shoulder motion and other clinical outcomes of shoulder function. Data were pooled to generate representative frequency-weighted means. Thirteen studies were included, totaling 312 shoulders. Etiologies for revision included glenoid arthrosis (62%), glenoid component failure (36%), and other (2%). Of which, 39% of cases experienced complications and 12% required another arthroplasty revision. Secondary outcomes such as VAS pain, Constant, ASES and UCLA score improved, but none were statistically significant. Unsatisfactory outcomes were higher among patients with glenoid bone loss, instability, and soft tissue deficiencies. Revision to anatomic TSA can be an acceptable option in certain patients. However, the high rate of complications and glenoid loosening, makes this a limited approach for a revision to anatomic TSA procedure.

Preoperative Mental Health Disorders Affect Opioid Consumption and Perioperative Complications After Total Shoulder Arthroplasty.

Limited evidence exists regarding the influence of mental health disorders (MHDs) on opioid use and complications after total shoulder arthroplasty (TSA). We aimed to identify the prevalence of common MHDs among patients undergoing anatomic TSA (aTSA) and reverse TSA (rTSA). The Premier Healthcare Database was queried for patients undergoing primary aTSA and rTSA from 2016 to 2020. International Classification of Diseases, Tenth Revision, diagnosis codes were used to identify MHDs. Primary outcomes included the prevalence of MHDs, perioperative opioid consumption, and 90-day risk of postoperative complications, revision, and readmission. Bivariate and multivariate regression analyses were performed to assess 90-day risk of primary endpoints while controlling for potential confounders. Statistical significance was defined as P<.05. From 2016 to 2020, 49,997 of 144,725 (34.55%) patients undergoing primary TSA had at least one diagnosed MHD. The most prevalent were depression (17.03%), anxiety (16.75%), and substance use disorder (10.20%). Patients with a MHD had higher mean hospital costs ($75,984±$43,129 vs $73,316±$39,046, P<.0001), longer mean length of stay (1.95±2.25 days vs 1.61±1.51 days, P<.0001), and higher mean total postoperative opioid use (72.00±231.55 morphine milligram equivalents [MMEs] vs 59.32±127.31 MMEs, P<.0001). Periprosthetic fractures (odds ratio, 1.20; P=.041), dislocation (odds ratio, 1.12; P=.042), and 90-day readmission rates (odds ratio, 1.26; P<.001) were significantly higher among patients with a MHD. This study found that MHDs are associated with significantly increased perioperative opioid consumption, medical and surgical complication rates, and risk of readmission after TSA. Recognition and optimization of MHDs is critical to minimizing complications and opioid consumption after TSA. [Orthopedics. 202x;4x(x):xx-xx.].

Association of neighborhood level socioeconomic status and patient reported clinical improvement following total shoulder arthroplasty

BackgroundPrior 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. MethodsIndividuals included in this study underwent anatomic (a)TSA or reverse (r)TSA by two surgeons between May 2018 and January 2021. Patients were split into three SES groups (low, moderate, and high) based on neighborhood SES level as determined by Area Deprivation Index (ADI). 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 Surgeon’s shoulder score (ASES), 10-point visual analog scale (VAS) for pain, single assessment numeric evaluation (SANE), and Western Ontario Osteoarthritis of the Shoulder Index (WOOS). The Veterans Rand 12 item health survey (VR-12) was utilized to measure overall well-being. We utilized a mixed design analysis of variance (ANOVA) to determine the interaction of time and improvement in PROs following surgery followed by one-way ANOVA with post-hoc analysis. Results/Discussion170 individuals (low SES n=34, moderate n=90, high n=46) met inclusion criteria and were included in this study. There were no significant differences between groups for BMI 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 ASES when compared to the high SES group (p<.01) and the low SES group reporting significantly higher VAS pain when compared to the high SES group (p=.034). ConclusionIndividuals 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.

Instability and the Anatomic Total Shoulder Arthroplasty.

Instability of the anatomic total shoulder arthroplasty is a challenging problem. With an incidence of 1% to 5% reported in the literature, it is critical for shoulder surgeons to understand and be capable of addressing this complication. Etiology is multifactorial and related to soft-tissue imbalance, osseous pathology, implant malposition, or more commonly, a combination of these various causes. Historically, high rates of failure have been reported after revision procedures, prompting a movement toward the more inherently stable reverse shoulder arthroplasty as a reliable form of management. However, this may not be the ideal solution for all patients, particularly the young and active population. Consequently, the purpose of this article was to provide a review of the literature on the management of postoperative instability and intraoperative strategies to prevent this complication during the index procedure.

Total Shoulder Arthroplasty in Patients With Hemophilia A: Greater Odds of Postoperative Bleeding and Thromboembolic Events but No Difference in 5-year Implant Survival.

Patients with hemophilia A can develop joint hemarthroses, degenerative changes, and eventually undergo total shoulder arthroplasty (TSA). Few data exist concerning complications and prosthesis survival after TSA in this population. (1) Is hemophilia A associated with more bleeding and thromboembolic adverse events after TSA relative to matched controls? (2) Is 5-year TSA prosthesis survival reduced in patients with hemophilia A compared with matched controls? The 2010 to 2022 PearlDiver M161 database was used to identify patients who underwent primary anatomic or reverse TSA. Given that the X-linked recessive condition hemophilia A presents nearly exclusively in males, male patients with hemophilia A who underwent TSA were matched 1:10 with male patients without hemophilia who underwent TSA based on age and Elixhauser comorbidity index (ECI). This yielded 73 patients with hemophilia A who underwent TSA who were matched 1:10 with 729 patients without hemophilia. Ninety-day adverse events were compared with multivariable analysis. Revision within 5 years was assessed using Kaplan-Meier analysis. Compared with the control cohort, patients with hemophilia had greater odds of bleeding issues (hematoma, OR 6.8 [95% CI 3.0 to 15.3]; p < 0.001; anemia, OR 2.5 [95% CI 1.5 to 4.2]; p < 0.001, transfusion, OR 5.0 [95% CI 2.4 to 10.3]; p < 0.001), venous thromboembolic events (VTE) (OR 1.9 [95% CI 1.1 to 3.1]; p = 0.01), and prosthetic loosening (OR 3.5 [95% CI 1.4 to 8.0]; p = 0.004). Based on available data, 5-year implant survival was not different in patients with hemophilia (97.3% [95% CI 93.6% to 100.0%]) relative to matched controls (95.2% [95% CI 93.4% to 97.2%]; p = 0.60). The elevated risks of both 90-day bleeding complications (hematoma, anemia, and transfusion) and VTE (DVT and PE) in patients with hemophilia emphasize the special challenges of carefully balancing factor replacement and VTE prophylaxis pre-, intra-, and postoperatively on an individual patient basis with careful hematologist coordination. Further study on Factor VIII levels and targets as well as tranexamic acid and VTE prophylaxis in this population is necessary to provide further guidance. Furthermore, 5-year implant survival was not different between patients with hemophilia and matched controls (patients without hemophilia) based on available data, suggesting that TSA survivorship remains durable and may be offered to patients in this population as indicated. Level III, therapeutic study.

Accessing information provided via artificial intelligence regarding reverse and anatomic total shoulder arthroplasty

BackgroundThe purpose of this study is to analyze the quality, accuracy, and readability of information provided by an artificial intelligence (AI) interface ChatGPT (OpenAI, San Francisco). We searched ChatGPT for commonly asked questions by patients regarding anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA). MethodsChatGPT was used to answer 30 commonly asked questions by patients regarding aTSA and rTSA, inputted as “total shoulder replacement” and “reverse shoulder replacement”. These questions were categorized based on the Rothwell criteria into Fact, Policy, and Value. The answers generated were analyzed for quality, accuracy, and readability using the DISCERN scale, JAMA benchmark criteria, Flesch-Kincaid Reading Ease Score (FRES) and Grade Level (FKGL). ResultsFor both rTSA and aTSA the DISCERN score for Fact questions was 57, Policy questions was 61, and for Value questions was 58 (all were all considered “good”). The JAMA benchmark criteria was 0, representing the lowest score for Fact, Policy, and Value questions for both rTSA and aTSA questions. The FRES score for the aTSA answers for Fact was 15.15, for Policy was 11.14, and for Value questions was 10.95. The FRES score for rTSA questions for Fact is 48.02, Policy is 12.51, and Value is 17.22. The FKGL for aTSA answer for Fact was 17.48, Policy was 17.72 and Value was 17.96. The FKGL for rTSA questions for Fact are 8.10, Policy is 17.27, and Value is 16.56. ConclusionOverall, the quality of answers provided by AI open model, ChatGPT was considered “good.” The information provided had lower reliability, and lack of information regarding funding and disclosures. Most of the information generated by ChatGPT was also found to have the readability of “academic level text”, while Fact related information on reverse shoulder arthroplasty was found to have the readability of 9th grade level, which may be too complex for most patients. Overall, these results indicate that ChatGPT can provide correct answers to questions about aTSA and rTSA, although we would caution patients from utilizing this resource due to the lack of citations and complexity of the output that ChatGPT provides. Importantly, all answers provided by AI suggested reaching out to physicians to get more accurate and personalized advise, to factor into the shared decisions making model.

Preoperative rotator cuff fatty infiltration and muscle atrophy do not negatively influence outcomes following anatomic total shoulder arthroplasty

BackgroundAnatomic total shoulder arthroplasty (TSA) is an effective surgical option for the treatment of primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. While an intact rotator cuff is essential to the success of TSA, little is known about how preoperative rotator cuff muscle quality may impact clinical outcomes. In this study, we sought to determine the effects of rotator cuff fatty infiltration (FI) and muscle atrophy (MA) on clinical outcomes following TSA. MethodsA retrospective review of a prospectively maintained, single-surgeon registry was used to identify patients undergoing TSA for GHOA between April 2015 and March 2020. Patients were included if they had preoperative magnetic resonance imaging available, an intact rotator cuff, and complete preoperative and minimum 2-year postoperative patient-reported outcome measures (PROMs) and active range of motion (ROM) measurements. Preoperative MA and FI of the rotator cuff were assessed on magnetic resonance imaging by measuring muscle cross-sectional area and using the Goutallier classification system, respectively. Pearson’s correlation was used to determine any relationship between MA and clinical outcomes. Univariate analysis was used to compare clinical outcomes of patients with moderate-to-severe FI to those with minimal-to-mild FI. ResultsThere were 163 shoulders from 154 patients with a mean age of 62.5 (standard deviation = 7.4) and a mean follow-up of 2.9 years (standard deviation 1.2) that met inclusion criteria. Rotator cuff muscle area was not correlated with any preoperative or postoperative ROM or PROMs (P > .05). However, the ratio of infraspinatus and teres minor (posterior cuff) to subscapularis muscle area was minimally negatively correlated with change in Single Assessment Numerical Evaluation (r = −0.171, P = .029) and change in internal rotation (r = −0.207, P = .008), although the clinical relevance is unclear. No significant differences in preoperative ROM or PROMs were found between patients with minimal-to-mild and moderate-to-severe FI (P > .05). ConclusionPreoperative rotator cuff muscle volume and FI do not impact clinical outcomes following TSA in patients with GHOA and intact rotator cuffs. TSA remains a viable surgical treatment for individuals with GHOA and an intact rotator cuff, provided the MA and FI are not so severe that a patient may be indicated for another type of treatment.