Shoulder Arthroplasty Cases Research Articles

Artificial Intelligence Machine Learning Algorithms Versus Standard Linear Demographic Analysis in Predicting Implant Size of Anatomic and Reverse Total Shoulder Arthroplasty.

Accurate and precise templating is paramount for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) to enhance preoperative planning, streamline surgery, and improve implant positioning. We aimed to evaluate the predictive potential of readily available patient demographic data in TSA and RSA implant sizing, independent of implant design. A total of 578 consecutive, primary, noncemented shoulder arthroplasty cases were retrospectively reviewed. Demographic variables and implant characteristics were recorded. Multivariate linear regressions were conducted to predict implant sizes using patient demographic variables. Linear models accurately predict TSA implant sizes within 2 millimeters of humerus stem sizes 75.3% of the time, head diameter 82.1%, head height 82.1%, and RSA glenosphere diameter 77.6% of the time. Linear models predict glenoid implant sizes accurately 68.2% and polyethylene thickness 76.6% of the time and within one size 100% and 95.7% of the time, respectively. Linear models accurately predict shoulder arthroplasty implant sizes from demographic data. No significant statistical differences were observed between linear models and machine learning algorithms, although the analysis was underpowered. Future sufficiently powered studies are required for more robust assessment of machine learning models in predicting primary shoulder arthroplasty implant sizes based on patient demographics.

Anatomic or Reverse Total Shoulder Arthroplasty? How Fellowship Training Affects Selection of Arthroplasty Type

While both anatomic (ATSA) and reverse total shoulder arthroplasty (RTSA) have been popularized as a means of treating individuals with degenerative shoulder conditions, the indications for each can vary widely amongst providers. While surgeons with differing fellowship training commonly perform these procedures, it is not understood how fellowship training influences choice of implant. A national database was queried to identify surgeons performing anatomic and reverse total shoulder arthroplasty. For all surgeons who performed more than 10 cases between 2010-2022, fellowship data was individually collected via online search. For each fellowship group, rates of anatomic and reverse total shoulder arthroplasty were identified using International Classification of Diseases (ICD) procedural codes. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Primary outcome measures included the proportion of primary and revision ATSA and RTSA by fellowship in addition to the rate of RTSA performed for a primary diagnosis of glenohumeral osteoarthritis. A total of 131,974 patients met the inclusion criteria and were retained for this study. RTSA increased from 50.1% of all primary shoulder arthroplasty cases in 2011 to 72.0% in 2022. After adjusting for age and comorbidities, Sports Medicine fellowship-trained (Sports) surgeons opted for primary RTSA over ATSA at a significantly higher rate than Shoulder and Elbow fellowship-trained (Shoulder) surgeons and surgeons who completed another type of fellowship or no fellowship (Other). Sports surgeons also chose RTSA more frequently for the diagnosis of glenohumeral osteoarthritis compared to Shoulder surgeons. Surgeons in the Other cohort were more likely to perform primary ATSA rather than RTSA in comparison to surgeons in the Shoulder and Sports cohorts. Sports surgeons were responsible for the greatest increase in percentage of all shoulder arthroplasty procedures from 2010-2022 (28.4% to 40.4%) while the Other group decreased by a comparable amount (45.9% to 32.4%) over the same period. Surgeons who have completed a Sports Medicine fellowship choose RTSA over ATSA at a higher rate than Shoulder and Elbow surgeons, both for all indications and also for a primary diagnosis of glenohumeral osteoarthritis. Those who have no fellowship training or fellowship training outside of Sports Medicine and Shoulder and Elbow surgery have the highest percentage of ATSA in their arthroplasty practice. Revision anatomic and revision reverse total shoulder arthroplasty represents a larger percentage of overall case volume for Shoulder and Elbow surgeons.

Use of pre-operative 3D planning software for revision shoulder arthroplasty: clinical experience data from a survey in a real-world setting

BackgroundPreoperative 3D planning is routinely used in primary shoulder arthroplasty, while specific challenges in the revision setting make such approaches more cumbersome and less accessible. Recently, an established preoperative planning software (Blueprint; Stryker, Tornier SA, Montbonnot-Saint-Martin, France) was expanded to offer a capability for planning of revision and complex primary shoulder arthroplasty cases. The aim of this study was to survey experienced surgeons on their perception of the new software feature for preoperative 3D planning in the setting of revision shoulder arthroplasty. MethodsAn observational survey was conducted from January 2022 to October 2022 among orthopedic surgeons performing revision shoulder arthroplasty cases. The survey was part of the Early Product Surveillance program, with the primary goal of obtaining observational data from surgical experience in a real-world setting. A two-staged survey process was applied with separate questionnaires to seek voluntary feedback on the preoperative planning phase as well as on the intra-operative evaluation of the software planning features in revision shoulder arthroplasty. ResultsTwenty-five fellowship-trained orthopedic surgeons from the USA and Canada participated in the survey and reported their feedback on 34 revision shoulder arthroplasty cases that were preoperatively planned with use of Blueprint revision planning software. The surgeons were largely in favor of the revision software planning features and confirmed perceived benefits of its use in the preoperative planning stage of revision shoulder arthroplasty cases. Reported benefits in the preoperative planning phase included increased efficiency and improved ease of creating an appropriate surgical plan, as well as increased confidence to execute revision shoulder arthroplasty cases. Surgeons also noted improvements in translation of preoperative planning to intra-operative execution of revision cases, including more appropriate implant selection and improved accuracy of implant placement. ConclusionThe feedback from fellowship-trained shoulder arthroplasty surgeons on the use of the new software feature for preoperative 3D planning of revision shoulder arthroplasty is largely favorable. Further research should be conducted to investigate whether these surgeon-perceived benefits can lead to improved clinical outcomes for patients.

Effects of Surgeon-Preferred Staff and Staff Turnover on Operating Time and Complication Rates in Reverse and Anatomic Total Shoulder Arthroplasty.

This study focuses on investigating the risk factors of increased operating room time and patient complication rates after total shoulder arthroplasty cases (both reverse and anatomic). We hypothesize that the use of surgeon-preferred staff will improve operating room efficiency and reduce complication rates while increased staff turnover will decrease efficiency and increase complications. This is a single-center, retrospective study focused on determining the effects of staffing on operating room time and efficiency in total shoulder arthroplasty. The study included patients who underwent total shoulder arthroplasty by a single fellowship-trained orthopaedic surgeon from 2018 to 2023. Four hundred twenty-three patients were included in the study from August 2018 to April 2023, 264 of which were reverse total shoulder arthroplasty (rTSA) and 159 were anatomic total shoulder arthroplasty (aTSA). In both rTSA and aTSA, the presence of surgeon-preferred staff markedly decreased operating room time. In rTSA, staff turnover increased risk of 90-day complications. Because the presence of surgeon-preferred staff affects operating room time and efficiency, orthopaedic surgeons should train multiple surgical teams so that efficiency is not affected by the loss of personnel during a case. To reduce 90-day complication rates in rTSA, staff breaks and turnover should be minimized as much as possible because this has a direct effect on patient outcomes. Effort from hospital administration and management should be put toward reducing turnover to improve patient outcomes.

Five-Year Mortality Rates Following Elective Shoulder Arthroplasty and Shoulder Arthroplasty for Fracture in Patients Over Age 65.

To effectively counsel patients prior to shoulder arthroplasty, surgeons should understand the overall life trajectory and life expectancy of patients in the context of the patient's shoulder pathology and medical comorbidities. Such an understanding can influence both operative and nonoperative decision-making and implant choices. This study evaluated 5-year mortality following shoulder arthroplasty in patients ≥65 years old and identified associated risk factors. We utilized Centers for Medicare & Medicaid Services Fee-for-Service inpatient and outpatient claims data to investigate the 5-year mortality rate following shoulder arthroplasty procedures performed from 2014 to 2016. The impact of patient demographics, including fracture diagnosis, year fixed effects, and state fixed effects; patient comorbidities; and hospital-level characteristics on 5-year mortality rates were assessed with use of a Cox proportional hazards regression model. A p value of <0.05 was considered significant. A total of 108,667 shoulder arthroplasty cases (96,104 nonfracture and 12,563 fracture) were examined. The cohort was 62.7% female and 5.8% non-White and had a mean age at surgery of 74.3 years. The mean 5-year mortality rate was 16.6% across all shoulder arthroplasty cases, 14.9% for nonfracture cases, and 29.9% for fracture cases. The trend toward higher mortality in the fracture group compared with the nonfracture group was sustained throughout the 5-year postoperative period, with a fracture diagnosis being associated with a hazard ratio of 1.63 for mortality (p < 0.001). Medical comorbidities were associated with an increased risk of mortality, with liver disease bearing the highest hazard ratio (3.07; p < 0.001), followed by chronic kidney disease (2.59; p < 0.001), chronic obstructive pulmonary disease (1.92; p < 0.001), and congestive heart failure (1.90; p < 0.001). The mean 5-year mortality following shoulder arthroplasty was 16.6%. Patients with a fracture diagnosis had a significantly higher 5-year mortality risk (29.9%) than those with a nonfracture diagnosis (14.9%). Medical comorbidities had the greatest impact on mortality risk, with chronic liver and kidney disease being the most noteworthy. This novel longer-term data can help with patient education and risk stratification prior to undergoing shoulder replacement. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparing comorbidity burden between patients undergoing ambulatory rotator cuff repair vs. inpatient anatomic total shoulder arthroplasty

BackgroundRotator cuff repair (RCR) patients routinely undergo same-day discharge in an ambulatory setting, while anatomic total shoulder arthroplasty (TSA) cases have historically been performed in an inpatient hospital setting. For healthier patients, however, TSA has increasingly transitioned to same-day discharge. Understanding whether a true difference in comorbidity burden exists between these patient groups would inform the appropriateness of outpatient TSA in an ambulatory setting. MethodsA retrospective review was performed of patients undergoing primary TSA and same-day, ambulatory RCR performed between September 2017 and May 2021 at a single institution by 3 fellowship-trained orthopedic surgeons. Selected sociodemographic factors and the Elixhauser Comorbidity Index (30 variables) were used to summarize and compare comorbidity burden. Only patients >50 year old were included. Chi-square and Kruskal-Wallis testing was used to compare the prevalence or severity for categorical and continuous variables, respectively. Results1433 cases met inclusion criteria, including 146 (34%) primary inpatient TSAs and 287 (66%) ambulatory RCRs. There were few differences in comorbidity burden between TSA and RCR, with TSA having a significantly higher prevalence for only 4 Elixhauser comorbidities and RCR having a higher prevalence of 1 comorbidity, although none survive a Bonferroni correction. TSA patients had a significantly higher prevalence of uncomplicated (P = .04192) and complicated hypertension (P = .0336), chronic pulmonary disease (P = .0045), and cardiac arrhythmia (P = .0031). The prevalence of diabetes (P = .029758) was significantly higher among RCR patients. Additionally, age (P = .011) was significantly higher among TSA patients. Of the TSA cohort, there were 10 incidences (1%) of 90-day readmission whereas there were 14 incidences (5%) of 90-day readmissions after RCR. ConclusionOverall, few differences in the prevalence of individual comorbidities (and sociodemographic parameters) existed between patients undergoing outpatient RCR and inpatient primary anatomic TSA. Comorbidities with larger differences can be either optimized preoperatively or managed chronically, and given these similarities, TSA may be similarly appropriate for ambulatory settings, particularly as efficiencies in operative time and improvements in regional anesthesia continue to evolve.

Three-dimensional scapular orientation: a comparison of glenohumeral osteoarthritis and cuff tear arthropathy to the unaffected shoulder

BackgroundScapular orientation may play an important role in preoperative planning for shoulder arthroplasty; however, there is currently no defined method for producing standardized three-dimensional measurements. The purpose of this study is to develop a reproducible measurement system of scapular orientation and to evaluate differences between unaffected shoulders and those with diagnoses of primary glenohumeral osteoarthritis (GHOA) and rotator cuff tear arthropathy (CTA). MethodsPatients receiving computed tomography scans for preoperative shoulder arthroplasty planning were enrolled prospectively. Thin sliced axial images that included bilateral shoulders and the thorax were reformatted. The pathology of the bilateral glenohumeral joints was defined as GHOA, CTA, or unaffected. Scapular orientation was defined relative to the thorax using three-dimensional models to define the protraction, rotation, and tilt angles in the supine position. Univariate analysis was performed to compare demographics and scapular measurements between patients with GHOA, CTA, and unaffected shoulder pathology. Multivariate linear regression analysis was performed to identify independent predictors of scapular orientation. ResultsOne hundred fifty-eight shoulders, comprising 79 patients were included. Twenty-seven percent (n = 21/79) of patients had an unaffected contralateral shoulder. Shoulders with GHOA had significantly greater downward scapular rotation (-14 ± 7 degrees) than both unaffected shoulders (-8 ± 7 degrees; P < .001) and those with CTA (-7 ± 8 degrees; P < .001). Increased downward scapular rotation was predicted by a shoulder pathology of GHOA in multivariate analysis (beta -7.09; P < .001). The magnitude of side-to-side difference was greatest in scapular rotation for patients with GHOA compared to CTA, with no significant differences in tilt or protraction. ConclusionScapular rotation in the supine position varies by shoulder pathology, with greater downward rotation seen in patients with primary GHOA. These findings underscore the need for awareness of scapular orientation in addition to glenoid morphology when evaluating and planning shoulder arthroplasty cases.

Humeral stem loosening is not always prosthetic joint infection

BackgroundAseptic humeral stem loosening is an uncommon complication of shoulder arthroplasty, and its presence has been considered a highly specific predictor of prosthetic joint infection (PJI). Literature on aseptic humeral stem loosening is sparse. The primary purpose of this study was to determine the rate of aseptic humeral loosening in revision shoulder arthroplasty. Secondarily, we sought to identify predictors of septic and aseptic humeral loosening. MethodsOur institutional revision shoulder arthroplasty database was reviewed. Inclusion criteria were patients with humeral stem loosening as indicated in the operative report. Patient demographics, index surgery and indication, revision surgery and indication, and operative data were recorded. Charts were manually reviewed, and PJI scores were calculated using the International Consensus Meeting (ICM) scoring criteria. ICM classifications of PJI “unlikely” and “possible” were considered aseptic, and PJI “probable” and “definite” were considered septic. Statistical analysis was performed to determine associations between the abovementioned variables and aseptic humeral loosening. ResultsForty-six patients with forty-eight shoulders were included in our analysis. Ten cases (21%) were classified as definite PJI, thirteen cases (27%) were classified as probable PJI, four cases (8%) were classified as possible PJI, and twenty-one cases (44%) were classified as PJI unlikely. On analysis of stem design, there were no statistically significant associations with aseptic loosening; although, a lack of proximal porous ingrowth surface trended toward higher rates of aseptic loosening in all patients and in ATSA and RTSA subgroup analyses. In the index RTSA subgroup, aseptic loosening was associated with female sex (p=0.005). Seventeen of 39 shoulders (44%) that underwent either index ATSA or RTSA demonstrated concomitant glenoid loosening. The absence of glenoid loosening was associated with aseptic humeral loosening in index ATSA and RTSA (p<0.001). Conclusion52% of revision shoulder arthroplasty cases with humeral loosening performed at our institution were aseptic. There appear to be distinct demographic and radiographic factors that are more commonly associated with aseptic as opposed to septic humeral loosening. Our data demonstrate that demographic predictors of aseptic loosening of RTSA include female sex. The absence of glenoid component loosening is associated with aseptic humeral loosening and concomitant glenoid loosening is associated with septic humeral loosening. Understanding of these factors can guide the preoperative index of suspicion for PJI in the setting of humeral stem loosening.

Predictors of Return to Emergency Department and Readmission Following Primary Elective Total Shoulder Arthroplasty.

Returns to the Emergency Department (ED) and unplanned readmissions within 90 days of shoulder arthroplasty represent a significant financial burden to healthcare systems. Identifying the reasons and risk factors could potentially reduce their prevalence. A retrospective review of primary anatomic (aTSA) and reverse shoulder arthroplasty (rTSA) cases from January 2016 through August 2023 was performed. Demographic patient and surgical data, including age, diagnosis of anxiety or depression, body mass index (BMI), smoking status, age-adjusted Charlson Comorbidity Index (ACCI), modified 5-item fragility index (mFI-5), and hospital length of stay (LOS) was collected. Patient visits to the ED within 12 months prior to surgery were recorded. Predictors for return to the ED within 90 days postoperatively and any readmissions were determined. There were 338 cases (167 aTSA and 171 rTSA), of which 225 (67%) were women. Patients with anxiety (OR=2.44, 95% CI 1.11-5.33; P=0.026), surgical postoperative complications (OR=3.22, 95% CI 1.36-7.58; P=0.008), ED visit within 3 months prior to surgery (OR=3.80, 95% CI 1.71-8.45; P=0.001), ED visit 3 to 6 months prior to surgery (OR=2.60, 95% CI 1.12-6.05; P=0.027), and ED visit 6 to 12 months prior to surgery (OR=2.12, 95% CI 1.02-4.41; P=0.045) were more likely to have ED visit within 90 days postoperatively. Patients with prior ipsilateral shoulder surgery (OR=3.32, 95% CI 1.21-9.09; P=0.02), surgical postoperative complications (OR=13.92, 95% CI 5.04-38.42; P<0.001), an ED visit within 3 to 6 months preoperatively (OR=8.47, 95% CI 2.84-25.27; P<0.001), and an mFI-5 ≥2 (OR=3.66, 95% CI 1.35-9.91; P=0.011) were more likely to be readmitted within 90 days. Patients who present to the ED within 12 months prior to shoulder arthroplasty, those with anxiety, those with surgical complications and those with higher fragility should be monitored closely during the early postoperative period to minimize returns to the ED and/or unplanned readmissions.

Survivorship of the Stryker Ascend Flex uncemented metaphyseal bearing stem at a minimum 2- and 5-year follow-up.

The Ascend Flex short stem implant has been reported to have good early clinical outcomes and low revision rates. This retrospective study aimed to evaluate the early to mid-term radiographic and clinical outcomes of patients who underwent primary shoulder arthroplasty with this implant. All consecutive patients who underwent primary shoulder arthroplasty with short uncemented Ascend Flex stems with a minimum of 24-month follow-up were included. The primary outcomes were revision and reoperation rate. The secondary outcomes included stress shielding and Oxford Shoulder Score (OSS). Totally, 151 shoulders were eligible for inclusion. Out of which 73 were anatomic total shoulder arthroplasty, 77 were reverse geometry, and 1 was a hemiarthroplasty. Mean follow-up duration was 52 ± 17.2 months. The revision and reoperation rates were 0.6% and 2.6%, respectively. 1.3% anatomic total shoulder arthroplasty (aTSA) cases and 6.5% RSA cases demonstrated stress shielding. OSS improved from 16.1 ± 8.5 to 34.1 ± 12.3 in aTSA cases (Z = -3.98, p < 0.001) and from 15.6 ± 8.4 to 30.0 ± 13.5 in RSA cases (Z = -3.41, p < 0.001). These findings demonstrate reassuring outcomes for this implant at a mean of 52 months. Further reports are required to document the long-term outcomes for this component.

Preoperative Prophylactic Antibiotics Administration Does Not Influence Culture Yield in Revision Shoulder Arthroplasty.

The importance of administrating prophylactic antibiotics prior to a surgical procedure is well established. Given the difficulty in diagnosing shoulder periprosthetic infections, which are more indolent in nature, some advocate holding prophylactic antibiotics prior to obtaining cultures as there is a concern antibiotics may lead to a false negative culture result. The purpose of this study is to determine whether administration of antibiotics prior to obtaining cultures in revision shoulder arthroplasty influences culture yield. This was a retrospective analysis of revision shoulder arthroplasty cases performed at a single institution between 2015 and 2021. During the study period, each surgeon had a standardized protocol that dictated whether antibiotics were given or held prior to each revision surgery. Each case was categorized into either a Pre-culture antibiotic group, if antibiotics were administered prior to incision, or a Post-culture antibiotic group if antibiotics were administered after incision and obtaining cultures. Basic demographics and the International Consensus Meeting (ICM) scoring criteria provided by the Musculoskeletal Infection Society was used to categorize the probability of periprosthetic joint infection for each case. Culture positivity was calculated as the ratio of positive cultures and total number of cultures obtained. One hundred and twenty-four patients met inclusion criteria. There were 48 patients in the Pre-culture group and 76 patients in the Post-culture group. No significant difference in patient demographics or ICM criteria (p=0.09) was observed between the two groups. With regards to culture positivity, there was no difference between the Pre-culture antibiotic group and the Post-culture antibiotic group (16% vs 15%, p=0.82, confidence interval= 8-25% vs. 10-20%, respectively). In the setting of revision shoulder arthroplasty, timing of antibiotic administration did not significantly influence culture yield. This study supports the use of prophylactic antibiotics prior to obtaining cultures in revision shoulder arthroplasty.

Clinical outcomes of revision to anatomic total shoulder arthroplasty

BackgroundAnatomic total shoulder arthroplasty (aTSA) remains the gold-standard for management of end-stage glenohumeral arthritis. However, in the setting of failed hemiarthroplasty or aTSA, the appropriate utilization of revision to an anatomic vs. reverse TSA remains unknown. This study aims to assess the outcomes of revision to aTSA. MethodsAll revision shoulder arthroplasty cases at a single institution by one of five fellowship-trained surgeons were reviewed. All aseptic revision cases where the revision construct was an aTSA were included. Attempts were made to contact each case for enrollment in the institution’s shoulder registry and ascertain any cases requiring revision surgery. Patient-reported outcome measures: American Shoulder and Elbow Surgeons score, single assessment numeric evaluation, visual analog scale for pain, patient satisfaction, and a validated scale of patient-reported shoulder range-of-motion were collected. ResultsTwenty eight cases underwent revision aTSA between 2004 and 2019. The average age was 53.4 years (range: 23-66), 16 (57%) were male, and 14 (50%) were revised from a hemiarthroplasty while the remainder were revised from an aTSA. Seven (25%) cases required revision surgery at a mean 1.8 years. Three of these cases had been revised from hemiarthroplasty. Reasons for revision included: glenoid loosening (1), infection (1), rotator cuff failure (3), and persistent pain of nonspecific etiology (2). Ultimately, 6 (21%; 6/28) were revised to reverse TSA at a mean of 2 years (range: 1 month-5.7 years) postoperatively. Patients requiring further revision surgery were older (58.8 vs. 51.4 years; P = .06) than those not requiring further revision. Of the patients managed with lesser tuberosity osteotomy, the revision rate was 7.1% (1/14) compared to 42.9% (6/14) for the remainder of the cohort (P = .08). Of the 21 patients with retained aTSA, 15 (71%) provided clinical follow-up at an average of 4 years (range: 1-8). These patients had a mean American Shoulder and Elbow Surgeons score of 70.2 (range: 41-94), visual analog scale pain score of 2.8 (range: 0-6), single assessment numeric evaluation score of 52.1% (range: 14-92), and satisfaction of 73% (range: 1-100). DiscussionThe outcomes of revision shoulder arthroplasty to an aTSA construct are varied. While in the appropriately indicated young patient high-quality results can be achieved, there is a high revision rate and highly variable patient-reported outcomes. Surgeons should be selective when recommending revision to an aTSA. Further study is needed to better predict successful outcomes in this patient population.

How have the Volume and Backlog of Total Shoulder Arthroplasty Cases Changed during the COVID-19 Pandemic?

BACKGROUND As COVID-19 rapidly propagated, many institutions were forced to respond with suspension in all elective surgical procedures, including primary and revision Total Shoulder Arthroplasty (TSA). In 2021, the Centers of Medicare &amp; Medicaid Services (CMS) removed primary and revision TSA from the Inpatient-Only-List (IPO). These rapid changes created uncertainty surrounding the potential backlog of patients that healthcare systems could face. The purpose of this study is to observe the change in volume as well as proportion of TSA performed in the outpatient setting. METHODS Patients who underwent primary and revision elective TSA from January 2018 to April 2021 were identified using the Pearldiver database. Descriptive analysis was utilized to report the monthly changes in elective TSA volume and the proportion of the volume performed in the outpatient setting. A linear forecast analysis using historical data was utilized to determine the expected volume and proportion of TSA cases performed on an outpatient basis during the pandemic period. This was compared to the observed case volume and setting. RESULTS Within 3 months following suspension, the total volume had returned to expected for both primary and revision TSA. Those performed in the outpatient setting significantly increased throughout the pandemic, with the largest peak following January 2020. By April 2021, four months after the CMS removal of TSA from the IPO list, the backlog of primary TSA volume had decreased by 30.8% with respect that in December 2020. For revision TSA, the backlog was entirely overcome by April 2021 as there was an observed decrease of 131% with respect that in December 2020. CONCLUSION The backlog for both primary and revision TSA from the beginning of the pandemic has decreased. The observed decrease did not seem to start until January 2021 following CMS’ removal of TSA from the IPO list. Therefore, the reduction in the backlog may be associated with the increased utilization of outpatient primary and revision TSA.

Prevalence and Risk Factors for Missed Short-term Follow-up After Primary Total Shoulder Arthroplasty.

The importance of consistent postoperative follow-up has been established for collecting patient-reported outcomes and surveilling for potential complications. Despite this, the prevalence of and risk factors for missed short-term follow-up after elective shoulder arthroplasty remain limited. A retrospective review of consecutive primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty cases with a minimum of 12-month follow-up performed by a single, fellowship-trained shoulder surgeon was undertaken from January 2015 to December 2021. Demographic patient and surgical data, including age, sex, marital status, self-identified race, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson Comorbidity Index, prior ipsilateral shoulder surgery and/or contralateral arthroplasty, distance from home to clinic, smoking status, and hospital length of stay, were collected. The follow-up at 1 week, 6 weeks, 6 months, 12 months, and 24 months and beyond was determined. Patient-related and surgical predictors for missing the 12-month and 24-month follow-up were identified. There were 295 cases included (168 aTSA and 127 reverse total shoulder arthroplasty), of whom 199 (67%) were women. Of the total cases, 261 (86%) were eligible for 24-month follow-up. Patients undergoing aTSA, those of younger age, those of male sex, and those who missed their 6-week and 6-month follow-up were significantly more likely to miss the 12-month follow-up visit. Following multivariable analysis, a missed 6-month follow-up (OR 10.10, 95% CI 5.32 to 19.16, P < 0.001) was associated with 12-month visit nonattendance, and increasing age (per year) (OR 0.96, 95% CI 0.93 to 0.99, P = 0.011) was associated with improved 12-month follow-up. Not having a surgical complication within 6 months postoperatively, not undergoing ipsilateral revision arthroplasty, and missing the 1-week and 12-month follow-up were significantly associated with missing the 24-month follow-up. After multivariable analysis, missing the 1-week (OR 3.07, 95% CI 1.12 to 8.41, P = 0.029) and 12-month (OR 3.84, 95% CI 2.11 to 6.99, P < 0.001) follow-ups was associated with missing the 24-month visit, whereas having a postoperative complication was associated with increased attendance at 24 months (OR 0.38, 95% CI 0.14 to 0.99, P = 0.047). Strategies for preventing missed short-term follow-up should be focused on ensuring that patients undergoing TSA attend the 6-month and 12-month visit, particularly among younger patients and those with an uneventful postoperative course.

Revision of failed reverse total shoulder arthroplasty with reverse: short-term clinical outcomes

The prevalence of failed reverse total shoulder arthroplasty (rTSA) is increasing. This can often present a challenging clinical situation with substantial bone loss and limited reconstruction options. This study reports a single tertiary referral center's experience with revision of failed rTSA managed with revision rTSA of bone-interfacing components. Following institutional review board approval, all revision shoulder arthroplasty cases performed at a single institution between 2012 and 2020 were reviewed. Cases in which rTSA was revised to a new rTSA construct with revision of at least one bone-interfacing implant (humeral stem and/or baseplate) with a minimum two-year follow-up were identified. Characteristics of revision cases-including indications, bony stock, revised components, and use of bone graft-were collected. All patients were contacted for patient-reported outcome measures at a minimum of two-years following surgery. In addition, the incidence and indication for any reoperation following revision were determined. Thirty-three patients with an average age of 66 years (range: 46-82) 19 (58%; 19/33) being female met inclusion criteria and had a mean follow-up of 4.2 years (range: 2-8). The most common indication for revision rTSA included humeral component loosening (33%; 11/33), baseplate loosening (27%; 9/33), and instability (21%; 7/33). Pre-revision infectious workup demonstrated no cases of periprosthetic shoulder infection. Thirteen cases had massive bone loss-five treated with humeral allograft prosthetic composite, five with glenoid bone grafting, and three with custom glenoid implant. In total, 10 cases (30%; 10/33) required re-operation at mean of 13 months (range: 1-44) for instability (4), humeral loosening (2), infection (1), baseplate loosening (1), or periprosthetic fracture (1). The re-operation rate for patients with revised baseplates only, humerus only, or combined was 23% (3/13), 28% (5/18), and 27% (3/11), respectively. Overall, VAS pain improved from 6.5 preoperatively to 2.0 (p<0.001) and the ASES score improved from 30.7 to 67.5 (p<0.001). However, postoperative SANE score averaged only 51.2% (range: 2-100). This study demonstrates that failed rTSA can be salvaged with a revision rTSA. However, patient expectations for functional improvements should be tempered and a high re-operation rate should be expected.

Bariatric surgery prior to elective shoulder arthroplasty: a Nationwide Inpatient Sample analysis

BackgroundObesity has been linked to adverse outcomes after various orthopedic procedures, and bariatric surgery is an effective surgical treatment for morbid obesity. This study assesses whether prior bariatric surgery is associated with differences in hospital length of stay (LOS), discharge destination, and inpatient complication rate for elective shoulder arthroplasty. MethodsThe Nationwide Inpatient Sample database was queried from years 2003 to 2014 for all elective anatomic and reverse total shoulder arthroplasty cases. Two groups were defined: morbidly obese without prior bariatric surgery (MO cohort) and prior bariatric surgery without morbid obesity (BS cohort). Outcome measures were LOS (extended if greater than the 75th percentile), discharge destination (home or non-home), and any inpatient complication. Patients under age of 18 years and those with missing information were excluded. National estimates were calculated using weights provided by the Nationwide Inpatient Sample database. Chi-squared tests were performed for demographics and comorbidities. Binomial multivariate logistic regression was performed using significant demographics and comorbidities. ResultsA weighted-total of 19,877 patients were included in the study, of which 2783 were in the BS cohort and 17,094 were in the MO cohort. The BS group was younger (62.9 years vs. 66.0 years), had more females (73% vs. 69%), and was more likely to be anemic (15% vs. 10%). The MO group was more likely to have diabetes (40% vs. 22%), hypertension (83% vs. 65%), and peripheral vascular disease (3% vs. 1%). Multivariate analysis showed that the BS cohort had decreased odds of extended LOS (odds ratio [OR], 0.68), non-home discharge destination (OR, 0.67), and developing any inpatient complication (OR, 0.42). ConclusionIn the setting of anatomic and reverse total shoulder arthroplasties, patients with prior bariatric surgery and without morbid obesity had more favorable hospital LOS, discharge destination, and inpatient complication rate than morbidly obese patients with no prior bariatric surgery. Further studies are warranted to better elucidate the relationship between bariatric surgery and shoulder arthroplasty.

Volume, indications, and number of surgeons performing reverse total shoulder arthroplasty continue to expand: a nationwide cohort analysis from 2016-2020

Since its approval, reverse total shoulder arthroplasty (rTSA) has continued to increase in usage, with expanding indications beyond rotator cuff arthropathy. Existing literature has captured further increased utilization over the last decade through 2017. However, this data has not been updated to include a contemporary cohort of patients. This study sought to determine the trends of anatomic total shoulder arthroplasty (aTSA), rTSA, and hemiarthroplasty (HA) usage based on primary diagnosis and total number of surgeons performing each procedure annually from 2016-2020. Patients who underwent primary rTSA, aTSA, and HA from 2016-2020 were identified in the Premier Healthcare Database. Primary indication diagnoses for procedures were identified using International Classification of Diseases 10th edition codes. Temporal trends in patient and hospital demographics, primary indication, and procedure utilization were captured on an annualized basis. The number of surgeons performing each procedure annually was noted. Descriptive statistics were employed with significance set at P<.05. From 2016 to 2020, 154,499 patients undergoing primary shoulder arthroplasty were identified: 48,890 aTSA, 95,808 rTSA, and 9801 HA. In 2016, rTSA comprised a slight majority (55%) of all arthroplasty cases but increased to nearly 70% of all arthroplasty cases in 2020. The absolute numbers of aTSA and HA cases decreased over time, while rTSA volume increased from 14,781 in 2016 to a high of 23,644 cases in 2019. There was a corresponding 12% increase in the number of surgeons performing rTSA across the same time period, contrasted with a 42.1% decrease in surgeons performing HA and a 14.3% decrease for aTSA. Glenohumeral osteoarthritis remains the most common indication for rTSA and aTSA, while HA is used primarily for proximal humerus fractures or hardware complications. The volume of primary rTSA in the United States has continued to increase from 2016 to 2020 with concurrent decreases in the number of primary aTSA and HA cases performed. Primary rTSA accounts for nearly 70% of all primary shoulder arthroplasty cases. The number of surgeons performing rTSA continues to increase, while there has been a decrease in the number of surgeons performing aTSA and HA.

Rate of occurrence of respiratory complications in patients who undergo shoulder arthroplasty with a continuous interscalene brachial plexus block and associated risk factors

IntroductionContinuous interscalene nerve block techniques are an effective form of targeted non-opioid postoperative analgesia for shoulder arthroplasty patients. One of the limiting risks, however, is potential phrenic nerve blockade with...

Trends in outcomes following aseptic revision shoulder arthroplasty.

As the incidence of anatomic and reverse total shoulder arthroplasty (TSA, RSA) increases, revision procedures will also increase with a corresponding need for counseling patients regarding outcomes. We hypothesized that different revision categories would have different complication profiles depending on both the indication as well as the nature of the prior hardware. A retrospective review of 1773 cases performed at a single tertiary health system utilized case postings and diagnoses to identify revision shoulder arthroplasty cases. Revisions were classified based on the prior hardware present, with basic demographics and other perioperative and postoperative outcomes recorded within the limits of available follow-up. 166 surgical cases involving revision of prior shoulder arthroplasty metal hardware were identified with an average follow-up of 1.0years. Immediate perioperative outcomes of revision cases were similar relative to the companion cohort of 1607 primary cases. 137 cases (83%) required no further revision surgery, while 19 cases (11%) underwent aseptic revision, and 10 cases (6%) were revised for periprosthetic infection. RSA hardware revised to another RSA had the highest repeat revision rate relative to the other revision categories (32% vs < 14%). Revision of reverse shoulder arthroplasty to a repeat reverse has the highest rate of subsequent all-cause revision, and these repeat revisions often occurred for periprosthetic infection. Despite a relatively high long-term complication rate following revision shoulder arthroplasty, immediate perioperative outcomes remain similar to primary cases, providing some preliminary evidence for policymakers considering inclusion in future value-based care models. Level III Treatment Study.

Hematoma Following Shoulder Arthroplasty: Incidence, Management, and Outcomes.

A paucity of data regarding the implications of postoperative hematoma formation on outcomes after shoulder arthroplasty exists. Previous studies on major joint arthroplasty have associated postoperative hematoma formation with high rates of prosthetic joint infection (PJI) and reoperation. A total of 6,421 shoulder arthroplasty cases were retrospectively reviewed from an institutional database (5,941 primary cases, 480 revision) between December 2008 and July 2017. Patients who developed a postoperative hematoma were identified through direct chart review. Cases with a history of shoulder infection treated with explant and antibiotic spacer placement were excluded. Demographics, surgical characteristics, treatment course, and outcomes were collected. Hematoma occurred in 105 (1.6%; 105/6421) cases within the first three postoperative weeks and was more common following revision (3.3%; 16/480) compared to primary cases (1.5 %; 89/5941; P=0.002). Overall, postoperative shoulder hematoma was successfully managed with nonoperative treatment in 87% of cases via observation (62%, 62/105) and aspiration (25%, 26/105). A total of 14 patients (0.22%, 14/6421) underwent reoperation for hematoma. Eight patients (7.6%, 8/105) that required reoperation for hematoma were diagnosed with PJI. Postoperative hematoma is a complication of shoulder arthroplasty. While many postoperative hematomas can be managed without operative intervention, this analysis reiterates the association between hematoma formation and the development of PJI.