Primary Shoulder Arthroplasty Research Articles

Determining the validity of the Outpatient Arthroplasty Risk Assessment (OARA) tool for identifying patients for safe same-day discharge after primary shoulder arthroplasty.

Early discharge has been a target of cost-control efforts given the growing demand for joint replacement surgery. The Outpatient Arthroplasty Risk Assessment (OARA) score, a medically based risk-assessment score, has shown high predictive ability in achieving safe early discharge following outpatient lower-extremity arthroplasty using a score threshold initially set at ≤59 points but more recently adapted to ≤79 points. However, no study has been performed using the OARA tool for shoulder replacement, which has been shown to have lower associated medical risks than lower-extremity arthroplasty. The purpose of this study was to determine the OARA score threshold for same-day discharge (SDD) following shoulder arthroplasty and evaluate its effectiveness in selecting patients for SDD. We hypothesized that the OARA score threshold for shoulder arthroplasty would be higher than that for lower-extremity arthroplasty. We performed a retrospective review of 422 patients who underwent primary anatomic or reverse shoulder arthroplasty between April 2018 and October 2019 performed by a single surgeon. As standard practice, all patients were counseled preoperatively regarding SDD and given the choice to stay overnight. Medical history, length of stay, and 90-day readmissions were obtained from medical records. Analysis of variance testing and screening test characteristics compared the performance of the OARA score vs. the American Society of Anesthesiologists Physical Status (ASA-PS) class and a previously published OARA score threshold used to define a low risk of outpatient lower-extremity arthroplasty. A preoperative OARA score cutoff of ≤110 points demonstrated a sensitivity of 98.0% for identifying patients with SDD after shoulder arthroplasty, compared with 66.7% using the hip and knee OARA score threshold of ≤59 points (P < .0001) and 80.4% using ASA-PS class ≤ 2 (P = .008). OARA scores ≤ 110 points also showed a negative predictive value of 98.9% and a false-negative rate of 2.0% but remained incomprehensive with a specificity of 24.0% (P < .0001). Analysis of variance demonstrated that mean OARA scores increased significantly with length of stay (P = .001) compared with ASA-PS classes (P = .82). Patients with OARA scores ≤ 110 points were also 2.5 times less likely to have 90-day emergency department visits (P = .04) than those with OARA scores > 110 points. There was no difference in 30- and 90-day readmission rates for patients with OARA scores ≤ 59 points, OARA scores ≤ 110 points, and ASA-PS classes ≤2. Our study suggests that a preoperative OARA score threshold of ≤110 points is effective and conservative in screening patients for SDD following shoulder arthroplasty, with low rates of 90-day emergency department visits and readmissions. This threshold is a useful screening tool to identify patients who are not good candidates for SDD.

Establishing thresholds for achievement of clinically significant satisfaction at two years following shoulder arthroplasty: the patient acceptable symptomatic state

BackgroundThe patient acceptable symptomatic state (PASS) represents clinical improvement following surgery that patients deem as satisfactory; however, thresholds for achieving this clinical benchmark have not yet been established beyond 1 year following primary and reverse shoulder arthroplasty. MethodsA prospectively maintained registry was retrospectively queried for patients undergoing either a primary TSA or RTSA at a single institution between November, 2015 and October, 2017. All patients completed the ASES, SANE, and Constant patient-reported outcome (PRO) scores at the 2-year time point. PASS threshold scores were calculated using anchor-based methodology with subsequent calculation of achievement rates. Multivariate logistic regression was used to identify demographic and clinical variables associated with the likelihood of PASS achievement. ResultsA total of 93 TSA (mean age 61.4 ± 8.5 years, 32.3% female) and 111 RTSA (mean age 70.0 ± 8.1 years, 51.4% female) patients met final inclusion criteria. One-hundred sixty-five patients (80.8%) responded to the binary anchor question as “satisfied” regarding their surgical outcome. The PASS cutoffs for ASES, SANE, and Constant were 81.7, 85.7, and 24.0, respectively (AUC > 80%), with PASS achievement rates ranging from 50.7% to 59.9% for the entire study population and 66.7% to 83.3% for a risk-stratified subgroup. Patients undergoing TSA had a significantly higher PASS achievement rate relative to RTSA (P = .010) for ASES. Independent risk factors for decreased PASS achievement included lower preoperative PRO score, prior shoulder surgery, sedentary lifestyle, smoking, workers’ compensation status, and diabetes mellitus (DM). ConclusionThe majority of patients reach the PASS benchmark by 2 years after shoulder arthroplasty, with an optimal subgroup of risk-stratified patients achieving PASS at a rate greater than 80% for ASES. Patients undergoing TSA have a higher likelihood of reaching the PASS than patients undergoing RTSA, independent of other variables. Lower baseline outcome scores, prior shoulder surgery, smoking, and sedentary lifestyle are associated with lower PASS rates after TSA. Worker's compensation status and comorbid DM are predictive of reduced PASS rates after RTSA. Primary diagnosis and glenoid morphology did not have a significant impact on the rate of achieving the PASS. This information is valuable for patient selection and counseling prior to shoulder arthroplasty. Level of EvidenceLevel III; Prognostic Study; Retrospective Case Series.

Postoperative Trends of Serum C-Reactive Protein Levels after Primary Shoulder Arthroplasty-Normal Trajectory and Influencing Factors.

Background—Postoperative serum C-reactive protein (CRP) is an important diagnostic parameter for systemic inflammation and reflects surgical trauma. While trends and normal trajectories after total knee (TKA) or hip arthroplasty (THA) are established, there is no reference standard for shoulder arthroplasty (SA). Therefore, the aim of this study was to research CRP trends and influencing factors following SA. Methods—This retrospective study analyzed postoperative serum CRP levels and trajectories in 280 patients following SA. Influence of prosthesis design, sex, operating time, BMI, and humeral augmentation with bone cement were analyzed using descriptive statistics and (non-) parametric testing. Results—There is a CRP trend with a peak on day two or three, with a subsequent decrease until day seven. Reverse and stemmed prostheses show a statistically higher CRP peak than stemless prostheses or hemiarthroplasties (HA). There was no influence of gender, body mass index (BMI), operating time, or bone cement. Conclusion—The presented findings may contribute to a better understanding of the postoperative CRP course after SA. The results of this retrospective study should be validated by a prospective study design in the future.

Operating room efficiency and cost reduction in shoulder arthroplasty: is there an advantage of a dedicated operating room team?

Operating room (OR) efficiency is a crucial component in the delivery of high quality, cost-efficient healthcare in orthopedic shoulder arthroplasty, and generally in surgery. Utilizing a dedicated OR team may lead to higher clinical efficiency by potentially reducing total OR time and cost while avoiding operational redundancies or errors. The purpose of this study is to identify specific parameters influencing OR efficiency with a 2-roomed system with dedicated OR staff and evaluate its influence on operational cost of the OR per min. From 2017 to 2018, 348 patients underwent primary shoulder arthroplasty at one institution, that had 2 established OR systems: A traditional “1-room” system (TS) with general OR staff, and a “2-room” shoulder service (SS) with a dedicated OR team. Medical health records were accessed to obtain pertinent study data, which included demographics, surgical indication, and time-points per surgical case. Anesthesia preparatory time (APT) was time from patient OR entry to skin incision; surgery time (ST) – from skin incision to skin closure; conclusion time (CT) – from skin closure to patient exiting OR; and turnover time (TT) – time from 1 patient's exiting to the next patient's admittance into the OR. Nonoperative time was a summation of APT, CT, and TT, while Total OR time comprised of nonoperative time and ST. Cost equivalent per minute OR operation was then used to calculate differences between the 2 interest groups. The SS treated 270 patients (77.6%) and TS treated 78 patients (22.4%). The SS demonstrated a 74 minutes decrease in total OR time (116 vs. 190 minutes) when compared to the TS ( P < .0001). When surgeon factor (“surgery time”) was removed, the SS consistently demonstrated a 23-minute decrease in nonoperative time (76 vs. 99 minutes, P < .0001) and a 26-minute decrease in turnover time (14 vs. 40 minutes, P < .0001) – about a 3-fold reduction. When analyzing cost, the SS demonstrated a $291 decrease in nonoperative cost per case ($1090 vs. $1381, P < .0001) despite the staffing cost of 3 floating staff members. The TT reduction translated to $360 savings in OR cost per case ($198 vs. $558, P < .0001). A dedicated OR team using 2 ORs improves both clinical efficiency (decreases total OR time) and reduces cost (decreases total OR cost) - despite having more staff members and associated staffing costs - compared to a traditional 1-room system. When surgeon-specific factors were removed, the largest reduction in OR cost was associated with decrease in turnover time. Level III.

Radiographic changes around the glenoid component in primary reverse shoulder arthroplasty at mid-term follow-up

Some local events after reverse shoulder arthroplasty (RSA) occur without the patient experiencing symptoms and yet may be detected on diagnostic imaging, thereby serving as indicators of future complications that may require revision. Most of these events involve the glenoid component, but radiographic studies evaluating this component are scarce, especially medium- and long-term studies. This study aimed to analyze the radiographic changes around the glenoid component and determine the risk factors associated with the presence of these radiographic changes. A retrospective review of 105 primary Grammont-style RSAs implanted between 2003 and 2014 was conducted. Radiographic outcomes were evaluated in patients with ≥5 years of radiographic follow-up. Standardized digital radiographs obtained immediately postoperatively and at a minimum follow-up time of 5 years were analyzed to determine (1) glenoid component position (inclination and height) and (2) minor radiographic changes (Sirveaux grade 1 or 2 scapular notching; nondisplaced acromial fracture; radiolucent lines around 1 or 2 screws; Brooker grade 1a, 1b, or 2 heterotopic calcifications; or single screw rupture), as well as major radiographic changes (Sirveaux grade 3 or 4 scapular notching; radiolucent lines around ≥3 screws or central peg; Brooker grade 1c or 3 heterotopic calcifications; prosthetic dislocation; loosening or migration; or disassembly). Major radiologic changes were identified in 14.3% of the cases. Bivariate analysis showed that more changes were associated with the arthroplasties implanted in the first years of the study (odds ratio [OR] = 0.81, P = .012). This time-related variable was also associated with inclination (OR = 0.88, P = .045) and height (OR = 0.75, P = .001), improving in arthroplasties implanted in the last years of the study. Multivariate analysis revealed an increased risk of severe scapular notching mainly associated with superior tilt (OR = 2.52, P = .036) and a high (OR = 2.68, P = .019) or excessively high (OR = 7.55, P = .013) position and an increased risk of loosening signs associated with superior tilt (OR = 8.92, P = 9.1 × 10-6). The percentage of radiologic changes of the glenoid component in RSA is considerable, despite the detection of a decrease in their presence among the arthroplasties implanted outside the initial period. Superior tilt and an excessively high position appear to be associated with a severe degree of scapular notching development and increased risk of radiographic loosening signs. Knowledge of the factors associated with major radiologic changes in the medium-term follow-up will help to optimize the primary surgical technique for each patient and indication, improving implant survival in primary RSA surgery.

Early postoperative pain relief after total shoulder arthroplasty

BackgroundPatients undergoing elective shoulder arthroplasty have highly variable pain experiences. We sought to characterize preoperative patient characteristics associated with fast and slow pain relief after elective total shoulder arthroplasty and evaluated whether differences in early pain recovery predicted longer term pain relief. MethodsWe identified 324 patients undergoing elective primary shoulder arthroplasty, reverse and anatomic, between 2015 and 2018 from our prospective registry. Postoperative pain relief was defined as the difference in preoperative and 2-week postoperative pain intensity. Three groups were then created: fast responders (top decile), slow responders (bottom decile), and normal responders. Multinomial regression was used to identify preoperative patient factors associated with either slow or fast pain responses. ResultsFactors associated with a fast pain response included older age and being married. A slow pain response was associated with being unmarried. Pain intensity was lower in the fast responders at 6 weeks (0.60 ± 0.80 vs. 3.4 ± 2.50, P < .05) and 3 months (0.60 ± 0.90 vs. 2.60 ± 2.30, P < .05), but there was no difference at 1 year (0.30 ± 0.60 vs. 1.00 ± 1.10, P = .068) and 2 years (0.50 ± 1.30 vs. 1.40 ± 2.10, P = .183) postoperatively. ConclusionThe postoperative pain experience after shoulder arthroplasty seems to be influenced by patient age and marital status. Patients with marginal improvement in pain relief should be counseled that their recovery may be more prolonged, but by the 1-year mark they are likely to achieve comparably low pain levels to other patients. Level of evidenceLevel III; Retrospective Design; Prognosis Study

The relationship between glenoid inclination and instability following primary reverse shoulder arthroplasty

Despite advances in implant design and surgical technique, instability remains the most common early complication and reason for early revision after reverse shoulder arthroplasty (RSA). The purpose of this study is to evaluate the glenoid implant inclination, as measured by the β-angle, as an independent risk factor for instability after primary RSA. A retrospective case-control study was conducted matching cases with instability after primary RSA using a single implant to controls without instability. Controls were matched to age, sex, body mass index, and baseplate type (1:3 ratio of cases to controls). The preoperative, postoperative, and the change in pre- to postoperative glenoid inclination (β-angle) were compared between groups. Thirty-four cases (mean age, 66.2 years) were matched to 102 controls (mean age, 67.0 years). There was a wide range of postoperative (63° to 100°) and pre- to postoperative change (-16.5° to +30.5°) in β-angles collectively. There was no significant difference in the postoperative β-angle (mean, 80.8° vs. 82.7°, P = .19) or the change in β-angle (mean, +1.7° vs. +3.4°, P = .35) between cases and controls, respectively. Regression analysis demonstrated no increased odds of instability with the postoperative β-angle, odds ratio 0.965 (confidence interval [CI] = 0.916-1.02, P = .19). Likewise, for the preoperative to postoperative change in β-angle, there was no significantly increased odds of instability, odds ratio 0.978 (CI = 0.934-1.03, P = .35). Finally, there was no difference in risk of instability in patients whose implant positioning resulted in a net superior increase in inclination, relative risk 0.85 (95% CI = 0.46-1.56, P = .28). Neither the final prosthetic glenoid inclination nor the change in glenoid inclination, as measured by the β-angle, significantly influences the risk of prosthetic instability after primary RSA.

The base of coracoid process as a reference for glenoid reconstruction in primary or revision reverse shoulder arthroplasty: CT-based anatomical study.

Joint replacement surgery as a treatment for glenohumeral arthritis with glenoid bone loss is challenging. The aim of this study is to offer an anatomical orientation for glenoid reconstruction. In this study, we measured size, inclination and version of the glenoid surface, as well as the distance between the articular line of the glenoid, base of the coracoid process, and acromion using computer tomographic (CT) imaging of 131 study participants aged 19-88years in the period of 2010-2013. We measured a mean distance of 6.5 ± 0.2mm from the glenoid articular line to the base of the coracoid process in the transverse CT plane. Body height has shown no significant impact on the glenoid morphology. We observed significant differences between males and females: The glenoid appeared to be located 5.2 ± 0.9mm higher and the humeral head was 4.5 ± 0.7mm larger in male subjects compared with females (r = .699; p < .01). In our study, the base of the coracoid offers an anatomical reference during reconstruction of the glenoid in primary and revision shoulder arthroplasty. As only 2D-CT imaging allows for accurate assessment of glenoid bone defects, we consider conventional X-ray imaging insufficient for proper preoperative planning before shoulder arthroplasty. III.

Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty

Venous thromboembolism (VTE) events are infrequent but potentially catastrophic complications following orthopedic surgery. There is currently a paucity of evidence regarding the role of chemoprophylaxis with low-dose aspirin (acetylsalicylic acid [ASA]) after shoulder arthroplasty. We conducted a retrospective review of prospectively collected complications occurring within 90 days of 2394 primary shoulder arthroplasties performed over a 3-year period at a single institution. Patients preoperatively underwent risk stratification into medically high risk, moderate risk, or low risk as part of a standardized navigated-care pathway. For chemoprophylaxis, 81 mg of ASA (low dose) was routinely used once daily for 6 weeks unless alternative medications were deemed necessary by the medical team. Baseline demographic information, medical comorbidities, and postoperative VTE prophylaxis, as well as rates of clinically symptomatic VTE, were assessed. Symptomatic VTE occurred after 0.63% of primary shoulder arthroplasties (15 of 2394). There were 9 patients with deep vein thromboses and 6 with pulmonary embolisms. Eighty-one milligrams of ASA was used in 2141 patients (89.4%), resulting in an overall VTE rate of 0.56%. Medically high-risk patients were significantly more likely to have a VTE (P = .018). Patients with a history of deep vein thrombosis, asthma, and cardiac arrhythmia were significantly more likely to have a VTE (P < .05). Complications occurred in 4 patients (0.19%) associated with low-dose ASA and 1 patient (0.63%) associated with a novel oral anticoagulant medication. Routine use of low-dose ASA results in a very low risk of VTE and medication-associated complications following primary shoulder arthroplasty. Preoperative medical risk stratification can potentially identify patients at high risk of postoperative VTE.

Predictors of Long-term Opioid Use After Elective Primary Total Shoulder Arthroplasty

Opioids are prescribed routinely for pain after total shoulder arthroplasty (TSA). This study was designed to characterize opioid use after elective primary TSA and identify predictors of long-term postoperative opioid use. The authors used the MarketScan administrative claims database to identify 5676 adults who underwent elective primary TSA between 2010 and 2015 and had 1 year or more of continuous insurance enrollment, including prescription drug coverage, postoperatively. Long-term postoperative opioid use was defined as filling prescriptions totaling a 120-day or greater supply during the 3- to 12-month postoperative period. The authors performed univariate regression analysis with age, sex, US region, anatomic or reverse TSA, anxiety, chronic obstructive pulmonary disease, congestive heart failure, depression, diabetes, history of drug abuse, hypertension, obesity, osteoporosis, history of myocardial infarction, and current tobacco use. Variables that were significant at P<.05 were included in multivariate logistic regression. Overall, 16% of patients had long-term postoperative opioid use, which was strongly predicted by the multivariate model (area under the curve, 0.77; P<.001). The strongest predictors in the multivariate analysis were preoperative opioid use (odds ratio [OR], 4.7; 95% CI, 4.0-5.5), history of drug abuse (OR, 2.5; 95% CI, 1.3-4.9), depression (OR, 1.9; 95% CI, 1.6-2.3), anxiety (OR, 1.4; 95% CI, 1.2-1.7), surgery performed in the Western United States (OR, 1.8; 95% CI, 1.3-2.4), and reverse TSA (OR, 1.5; 95% CI, 1.2-1.8). Most patients do not have long-term opioid use after elective primary TSA. Strong predictors of long-term postoperative opioid use are preoperative opioid use, history of drug abuse, depression, anxiety, reverse TSA, and surgery performed in the Western United States. [Orthopedics. 2021;44(1):58-63.].

Prevalence and predictors of persistent pain 2 years after total shoulder arthroplasty

BackgroundElective total shoulder arthroplasty is highly successful, but there is a subset of patients who continue to experience pain after this procedure. The purposes of this study were to elucidate the prevalence and patient characteristics predictive of persistent pain after shoulder arthroplasty. MethodsWe identified patients who had received an elective primary shoulder arthroplasty (anatomic or reverse) between 2016 and 2017 from our prospectively maintained, single-surgeon registry. Patients were stratified by the presence or absence of persistent pain at 2 years postoperatively, as defined by a Visual Analog Pain score of ≥2. This value was chosen in accordance with previously reported values for minimal clinically important differences. Multivariable logistic regression was used to identify factors associated with persistent pain. ResultsOf the 244 patients included for analysis, 46(18.9%) had persistent pain at 2 years postoperatively. The average pain score in this group was found to be significantly greater than the patients without pain (3.6 ± 1.6 vs 0.14 ± 0.35, P< .001). Patients with persistent pain had a higher incidence of preoperative opioid use (26.1% vs 13.6%, P= .038), diabetes (28.3% vs 11.6%, P= .004), number of self-reported allergies (3 ± 4.8 vs 1.9 ± 2.3,P= .03), peak postoperative inpatient pain (8.1 ± 1.9 vs 6.9 ± 2.1,P< .001), incidence of prior ipsilateral shoulder surgery (50% vs 30%, P= .011), and a higher percentage received a reverse shoulder arthroplasty (87% vs 70.7%, P= .024). The patient characteristics that were independently predictive of persistent pain were history of prior ipsilateral shoulder surgery (odds ratio 2.44; 95% confidence interval 1.21-4.91; P = .013) and greater postoperative inpatient pain intensity (odds ratio, 1.26 per 1 unit increase; 95% confidence interval 1.03-1.55; P = .024). ConclusionAbout 1 in 5 patients report persistent pain after elective primary shoulder arthroplasty. Prompt identification of at-risk patients (eg, those with severe postoperative inpatient pain and a history of prior shoulder surgery) may prove effective in optimizing the pain experience after shoulder arthroplasty. Level of evidenceLevel III; Cohort Study with Prospective Data and Retrospective Study Design.

Early complications of reverse total shoulder arthroplasty

Background. The frequency of early complications after reverse shoulder arthroplasty remains high enough, and the overall complication rate is reported from 4.7% to 38%.&#x0D; Methods. We did 23 primary reverse shoulder arthroplasty and used clinical information after these operations in our study. As a comparative material, we used date from registers of foreign countries, as well as information from special literature.&#x0D; Results. Early complications were found in five cases (21.7%) in our study: two cases (8.7%) of a periprosthetic fracture; three patients (13.2%) had dislocation components. We studied these complications and formulated rules preventive measures.&#x0D; Conclusions. (1) The most common early complications after revers total shoulder arthroplasty were instability components, periprosthetic fracture. (2) These types of complications arise due to unbalanced soft tissues, inadequate selection of the size of the glenosphere, interposition of soft tissues, and inadequate term of loads on the operated limb. (3) The number of these complications can be reduced by observing preventive measures at all stages of treatment.

Higher primary stability of tuberosity fixation in reverse fracture arthroplasty with 135° than with 155° humeral inclination

Proximal humeral fractures in elderly patients are frequently treated with reverse total shoulder arthroplasty, and tuberosity healing improves clinical outcome and patient satisfaction. So far reverse prostheses with different humeral inclination (HI) angles have been used. However, it has not been investigated yet if the HI angle affects the primary stability of the tuberosity fixation in primary reverse total shoulder arthroplasty for proximal humeral fractures in a biomechanical setting. A 4-part fracture was created in 7-paired human cadaver proximal humeri after preceding power analysis. After randomization in a pairwise fashion, reverse prostheses with either 135° (n = 7) or 155° (n = 7) were implanted. The tuberosities were reduced anatomically to the metaphysis of the prostheses and were fixed with 3 suture cerclages in a standardized technique. Tightening was performed with a cerclage tension device with 50 Newton meter (N m). Before biomechanical testing, the initial vertical and horizontal gap formation was measured. The humeri were placed in a custom-made test setup enabling internal and external rotation. Cyclic loading with a gradually increasing load magnitude was applied with a material testing machine starting with 20 N m and increasing by 5 N m after each 100th cycle until failure (>15° rotation of the tuberosities). Any motion of the tuberosities was measured with a 3-dimensional camera system. Overall, the 155° group reached an average of 1460 ± 270 cycles and the 135° group of 1900 ± 271 cycles (P = .048). In contrast to the 135° group, in the 155° group, a mean initial vertical (0.3 ± 0.7 mm) and horizontal (2.7 ± 3.3 mm) gap formation could be observed before cyclic loading. After 1100 cycles, the 155° group showed increased rotation of both lesser and greater tuberosities in all 3 axes around the humeral shaft compared with the 135° group. Primary stability of the reattached tuberosities is significantly increased, whereas rotational movements are decreased in prostheses with an anatomic HI of 135° compared with a 155° HI according to the original Grammont design. In addition, a 135° HI allows an exact anatomic reposition of the tuberosities, whereas this was not possible for the 155° design. However, transferability and clinical relevance of these biomechanical results have to be verified with clinical studies.

An analysis of the Oxford Shoulder Score and its relationship to early joint revision in the New Zealand Joint Registry

Primary shoulder arthroplasties significantly improve shoulder function and have acceptable prosthesis survival for various indications. Currently, no validated shoulder questionnaire exists that can anticipate the early failure of primary shoulder arthroplasties. This study hypothesized that the Oxford Shoulder Score (OSS) after primary shoulder arthroplasty at 6 months would be significantly associated with early revision procedures. Data on all primary and revision shoulder arthroplasties covering the period of January 1, 1999, to December 31, 2019, were obtained from the New Zealand Joint Registry. The OSS questionnaires at 6 months were analyzed with regardto their relationship to revision within 2 years from the questionnaire date. Confounding risk factors were adjusted for in multivariate logistic regression analysis. Statistical analysis revealed that the 6-month OSS had a significant association with revision in the following 2 years for anatomic total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), and shoulder hemiarthroplasty (HA) (P < .001). An OSS of ≤44 for TSAs, ≤40 for RSAs, and ≤33 for HAs accounted for 68.9%, 63.1%, and 50.7%, respectively, while capturing at least 85% of revisions for all prostheses within the following 2 years. This study confirms that a poor OSS at 6 months is an independent risk factor for early revision after TSA, RSA, and HA. We recommend discharging patients with a 6-month OSS greater than the identified threshold values for each prosthesis to improve resource efficiency.

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

Cultures taken at the time of primary shoulder arthroplasty are commonly positive for Cutibacterium acnes. Despite our limited understanding of the clinical implication of deep tissue inoculation from dermal colonization, significant efforts have been made to decolonize the shoulder prior to surgery. The purpose of this study is to determine differences in clinical outcomes based on culture positivity at the time of primary shoulder arthroplasty. A series of 134 patients who underwent primary anatomic or reverse total shoulder arthroplasty and had intraoperative cultures obtained via a standard protocol were included. In each case, 5 tissue samples were collected and processed in a single laboratory for culture on aerobic and anaerobic media for 13 days. Minimum 2-year functional outcomes scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Single Assessment Numeric Evaluation [SANE]) and reoperation data were analyzed. Forty-two (31.3%) patients had positive cultures (30 C acnes and 21 with at least 2 positive cultures) at the time of surgery. There was no statistically significant difference in postoperative functional outcome scores (ASES: 82.5 vs. 81.9; P = .89, SANE: 79.5 vs. 82.1; P = .54) between culture-positive and culture-negative cohorts. There were no cases of infection. Two patients (4.8%; 2/42) with positive cultures required reoperation compared with 4 patients (5.6%; 4/71) without positive cultures. The apparent colonization by nonvirulent organisms in patients undergoing primary shoulder arthroplasty does not appear to have a clinically significant effect on functional outcomes or need for repeat surgery in the short term.

Responsiveness of patient-reported outcomes in shoulder arthroplasty: what are we actually measuring?

The purpose of this study was to determine the prevalence and responsiveness of common patient-reported outcome (PRO) tools in patients undergoing primary total shoulder arthroplasty (TSA) for glenohumeral arthritis. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of anatomic and reverse TSA studies from PubMed, SportDiscus, Cochrane, and CINAHL was performed. Studies on primary TSA for glenohumeral arthritis that reported at least 1 PRO tool were included in the final analysis. A subgroup analysis of studies that reported preoperative and postoperative PRO scores with at least 2-year follow-up data was evaluated to compare the responsiveness between the different PRO instruments. After full-text review of 490 articles, 74 articles metall inclusion criteria and were included in the final analysis. Anatomic TSA was evaluated in 35 studies, reverse TSA in 32 studies, and both anatomic and reverse in 7 studies. There were a total of 7624 patients, and 25 different PRO tools were used. The most commonly reported PRO tools were the American Shoulder and Elbow Surgeons (44 studies), Constant (42 studies), the visual analog scale for pain (23 studies), and the Simple Shoulder Test (17 studies). A median of 3.0 PRO instruments were used in each study. All instruments had large effect sizes. The University of California at Los Angeles (UCLA) score was found to be the most responsive instrument, and the Single Assessment Numeric Evaluationscore was least responsive. The American Shoulder and Elbow Surgeons score was the most responsive instrument that required only patient-reported data. Overall, the UCLA score was found to be the most responsive followed by the Adjusted Constant. However, both the UCLA and Adjusted Constant scores require strength and range of motion assessment that may limit their widespread clinical use. The increased responsiveness of these measures, which include objective clinical testing, speaks to the predicted increases in strength and range of motion after shoulder arthroplasty. Of the measures that can be administered without in-person clinical evaluation, the American Shoulder and Elbow Surgeons score and Western Ontario Osteoarthritis of the Shoulder index were the most responsive.

Postoperative opioid utilization associated with revision risk following primary shoulder arthroplasty

With a substantial increase in utilization of primary shoulder arthroplasty, it is important to understand risk factors that may signal early failure and need for revision. Recent studies have reported that sustained postoperative opioid use is associated with a higher revision risk after total hip or knee arthroplasty. In this study, we evaluated postoperative opioid utilization as a risk factor for revision after primary shoulder arthroplasty. We conducted a cohort study using data from a United States integrated health care system's Shoulder Arthroplasty Registry. Patients who had a primary elective shoulder arthroplasty were identified (2009-2017); those with cancer or who underwent other arthroplasty procedures (either shoulder, hip, or knee) within the preceding year were excluded. Cumulative daily opioid utilization during the first year postoperative, calculated as oral morphine equivalents (OME), was categorized into 3 exposure groups: high user (≥15 mg OME daily), moderate user (<15 mg OME daily), and no opioid use (reference group). The exposure window was stratified into 2 time periods: postoperative days 1-90 and postoperative days 91-360. Multivariable Cox proportional-hazards regression was used to evaluate the association between postoperative opioid use and aseptic revision risk. The final study sample included 8325 shoulder arthroplasty procedures. Of these individuals, 3707 (45%) received some opioid within the 1 year before the index procedure. We failed to observe a difference in aseptic revision risk between opioid utilization in the first 90 days postoperatively, regardless of dose. After the first 90 days, a higher revision risk was observed for high opioid users compared with nonusers (hazard ratio = 1.62, 95% confidence interval = 1.10-2.41), and no association was observed for moderate users (hazard ratio = 1.25, 95% confidence interval = 0.82-1.91). We found a positive association between opioid consumption and aseptic revision risk after primary shoulder arthroplasty. This study cannot determine if opioids have a direct physiological cause that increases the risk of revision; rather it is likely that opioid consumption is a marker of chronic pain, poor function, and/or poor coping mechanisms. Further study is needed to determine if programs designed to decrease opioid use may impact revision risk after shoulder arthroplasty.

Tensioning device increases biomechanical stability of tuberosity fixation technique with cerclage sutures in reverse shoulder arthroplasty for fracture

Complex proximal humeral fractures in elderly patients are increasingly treated with primary reverse total shoulder arthroplasty. Many surgeons use cerclage sutures for tuberosity fixation in reverse total shoulder arthroplasty for proximal humeral fractures. In this study, we hypothesized that sutures fixated with a tensioning device would achieve higher initial fixation stability of the tuberosities compared with manually knotted cerclage sutures in a biomechanical model. A 4-part fracture was created in 7-paired human cadaver proximal humeri. The tuberosities were reduced anatomically and fixed with 3 cerclage sutures in a standardized technique. Tightening was performed either manually (n = 7) or with a cerclage tensioning device with 50 Newton meter (N m) (n = 7). The humeri were placed in a custom-made test setup enabling internal and external rotation. Cyclic loading with gradually increasing load was applied with a material testing machine starting with 20 N m and increasing by 5 N m after each 100th cycle until failure (>15° rotation of the tuberosities). Motion of the tuberosities was measured with a 3-dimensional camera system. Overall, the knot group reached 1040 ± 152 cycles, and the device group reached 1820 ± 719 cycles (P = .035). Major fragment motion was detected in the humeral shaft axis and in the distal divergence of the tuberosities. After 900 cycles, the knot group showed increased rotation of both lesser and greater tuberosities in all 3 axes around the humeral shaft compared with the device group. Biomechanical stability of the reattached tuberosities is significantly increased, and rotational movement of the tuberosities is decreased after tightening of the applied cerclage sutures with a tensioning device compared with manual knotting. However, transferability of these promising biomechanical results and their clinical relevance have to be verified with clinical studies.

Progression and projection for shoulder surgery in France, 2012–2070: Epidemiologic study with trend and projection analysis

IntroductionShoulder surgery has been rapidly expanding over the past 20 years and now makes up a large share of orthopedic surgery practice. Data on how this activity has changed is not available in France due to a lack of registries. The study objectives were to: (1) quantify the number of shoulder surgeries in France, (2) predict how this activity will change over the next 50 years based on extreme scenarios. MethodsThis study involved an analysis of shoulder surgery data taken from the French hospital discharge database (PMSI). Two mathematical scenarios were applied to define the change over time: the first only considered the evolution in the population and changes in the age brackets over time; the second extrapolated the trends observed over the past few years (2012 to 2018). ResultsIn 2018, there were 234,612 procedures coded as primary shoulder surgery procedures in France. This activity increased 24.5% between 2012 and 2018 and is projected to increase 18% to 161% from now to 2050, depending on the scenario (p<0.0001). Rotator cuff surgery procedures were done 173,799 times – of which 61,055 were tendon repair – representing 74% of all shoulder procedures. The scenarios point to an increase of 13.6% to more than 300% (p<0.0001). Primary shoulder arthroplasty corresponded to 17,043 procedures in 2018 (7.3% of all procedures), with a 47% increase between 2012 and 2018. Between 2018 and 2050, the number of total shoulder arthroplasty procedures is expected to increase 31% to 322% (p<0.0001). The total number of revision arthroplasty procedures was 1508, increasing by 39% from 2012 to 2018. There were 14,229 procedures done for anterior or posterior instability in 2018 (6% of total). Bone block procedures made up 53% of these cases. This increased 17% between 2012 and 2018, with a projected increase of 5% to 82% up to 2050 (p<0.01). DiscussionShoulder surgery is the third largest activity in the orthopedic realm after hip and knee surgery, although it has seen the largest increases in recent years. This growth in shoulder procedures should continue over the next decades. Level of evidenceIV, descriptive epidemiology study.

Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States

The purpose of this study was to determine the incidence of primary reverse total shoulder arthroplasty (RTSA) and anatomic total shoulder arthroplasty (TSA) in the United States and examine changes in age- and sex-based procedure rates. A secondary goal was to determine the incidence of hemiarthroplasty. Using nationally representative data along with US Census data, we identified >508,000 cases of primary RTSA, anatomic TSA, and shoulder hemiarthroplasty from 2012 to 2017. Trends in the incidence of each procedure were analyzed, and sex- and age-adjusted procedure rates were calculated. From 2012 to 2017, the population-adjusted incidence of primary RTSA increased from 7.3 cases per 100,000 persons (22,835 procedures) to 19.3 cases per 100,000 (62,705 procedures); anatomic TSA increased from 9.5 cases per 100,000 (29,685 procedures) to 12.5 cases per 100,000 (40,665 procedures); and hemiarthroplasty decreased from 3.7 cases per 100,000 (11,695 procedures) to 1.5 cases per 100,000 (4930 procedures). These trends were observed among maleand female patients, as well as all age groups. The greatest increase in incidence was seen in male patients as well as patients aged 50-64 years undergoing RTSA. The incidence of primary RTSA and incidence of anatomic TSA have increased substantially in the United States from 2012 to 2017 whereas the incidence of hemiarthroplasty has decreased.