Total Shoulder Arthroplasty Research Articles

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.

Increased Risk of 90-Day Complications in Patients With Fibromyalgia Undergoing Total Shoulder Arthroplasty

Introduction: Anatomic and reverse total shoulder arthroplasties (TSAs) are effective treatment options for end-stage glenohumeral osteoarthritis. Those undergoing TSA may also have fibromyalgia, a musculoskeletal condition. However, the association of fibromyalgia with shorter and longer term outcomes after TSA has not been well characterized. Methods: Patients undergoing TSA for osteoarthritis indications were identified in the PearlDiver M165 database from January 2016 to October 2022. Exclusion criteria included age younger than 18 years, shoulder infection, neoplasm, or trauma within 90 days before surgery, and inactivity in the database within 90 days of surgery. Patients with fibromyalgia were matched in a 1:4 ratio to patients without based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events were compared using univariable and multivariable analyses. Five-year revision-free survival was compared using the log-rank test. Results: Of 163,565 TSA patients, fibromyalgia was identified for 9,035 (5.52%). After matching, cohorts of 30,770 non-fibromyalgia patients and 7,738 patients with fibromyalgia were identified. Multivariable analyses demonstrated patients with fibromyalgia were at independently increased odds ratios (ORs) for the following 90-day complications (decreasing OR order): urinary tract infection (OR = 4.49), wound dehiscence (OR = 3.63), pneumonia (OR = 3.46), emergency department visit (OR = 3.45), sepsis (OR = 3.15), surgical site infection (OR = 2.82), cardiac events (OR = 2.72), acute kidney injury (OR = 2.65), deep vein thrombosis (OR = 2.48), hematoma (OR = 2.03), and pulmonary embolism (OR = 2.01) (P < 0.05 for each). These individual complications contributed to the increased odds of aggregated minor adverse events (OR = 3.68), all adverse events (OR = 3.48), and severe adverse events (OR = 2.68) (P < 0.05 for each). No statistically significant difference was observed in 5-year revision-free survival between groups. Discussion: This study found TSA patients with fibromyalgia to be at increased risk of adverse events within 90 days of surgery. Proper surgical planning and patient counseling are crucial to this population. Nonetheless, it was reassuring that those with fibromyalgia had similar 5-year revision-free survival compared with those without.

Staged bilateral total shoulder arthroplasty: a single institutional experience with mid-term follow-up

BackgroundThe preferred surgical approach for surgical treatment of advanced glenohumeral arthritis is shoulder arthroplasty (SA). Considering the growing volume and success of SA, patients with bilateral shoulder disease are likely to undergo surgery on both shoulders. There are numerous studies evaluating the outcomes of bilateral hip and knee arthroplasty, but a paucity of information examining bilateral SA. This study intends to evaluate the clinical outcomes of patients undergoing staged bilateral anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA). MethodsInstitutional records were queried for patients who underwent staged bilateral aTSA or rTSA from 2009 to 2020. Patient records were retrospectively reviewed to assess preoperative and postoperative range of motion (ROM) and strength measurements, demographic information, and complications. Mean ± standard deviation was reported for all continuous variables. Mean functional measurements were compared using a 2-Sample t-Test, ordinal variables via Wilcoxon-Mann Whitney test, and categorical variables via Chi-squared test. Patients were included in the outcome analysis if they had a bilateral TSA with the same procedure (i.e. aTSA on both sides, or rTSA on both sides). Results43 patients (15 male, 28 female) were included. There was an average time of 1.8 years between surgeries. Of the 43 patients, 26 patients had staged bilateral aTSAs and 14 had staged bilateral rTSAs with three patients who had different surgeries on each shoulder. The three patients with different surgeries on each shoulder were excluded from outcome analysis. Patients who had staged aTSA operations demonstrated significant improvement in external rotation (P = .0191, P < .001), forward elevation (FE) (P = .0004, P < .001), and internal rotation (IR) (P = .0183, P = .0166) after the first and second surgeries. Staged rTSA patients showed significant improvement in FE after the first (P = .0043) and second surgeries (P = .016). Patients demonstrated significant increase in strength of external rotation (P = .0136), FE (P = .0088), and IR (P = .0206) after the first rTSA. There was no corresponding increase in strength testing after the second bilateral rTSA surgery. The average Single Assessment Numeric Evaluation, Contralateral Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Simple Shoulder Test scores for all surgeries were 84 ± 10, 83 ± 13, 75 ± 20, and 9 ± 2, respectively for the first surgery and 82 ± 13, 83 ± 13, 71 ± 21, and 8 ± 3 for the second surgery. ConclusionIndividuals that undergo staged aTSA procedures gain a better ROM and IR strength after both operations. However, individuals that undergo staged rTSA procedures have an improved ROM and strength after the first surgery but limited improvement after the second.

Operative time and relative value units for total shoulder arthroplasty based on pathology in the United States

BackgroundDespite total shoulder arthroplasty (TSA) and reverse TSA (rTSA) being fundamentally different procedures, and indicated in different pathologies (rTSA for rotator cuff deficiency [RCD] and proximal humeral fractures [PHFx] and anatomic TSA [aTSA] for glenohumeral osteoarthritis [GHOA]), they have the same Current Procedural Terminology (CPT) code (23472). This paper’s aim is to investigate differences in operative time and work-related value units (wRVUs) per hour among these pathologies, and ultimately determine if there is a need to assign separate CPTs for aTSA and rTSA. MethodsA retrospective cohort of data from the American College of Surgeons–National Surgical Quality Improvement Program was collected, all patients who underwent aTSA or rTSA (CPT: 23472) between the years of 2006 and 2019 for diagnoses of GHOA, RCD, and PHFx were included. Data collected included patient age, body mass index, operative time, and wRVUs per hour. ResultsCompared to GHOA (reference group), the average operative time for the RCD cohort was 12.242 minutes shorter (P < .001), while the wRVUs were higher by 1.627 (P < .001). The average operative time for rTSAs in the PHFx cohort were 17.615 minutes longer (P < .001), while the wRVUs were lower by 2.205 (P < .001). ConclusionThe average operative time for rTSAs for both RCDs and PHFx were longer than that for aTSAs for GHOA. Additionally, wRVUs were lower for rTSAs for RCD and PHFx compared to aTSAs for GHOA. This elucidates inconsistency in reimbursement structure for the procedures, which should be revisited.

Reverse shoulder arthroplasty with an inverted-bearing prosthesis as revision procedure for failed anatomic and reverse shoulder arthroplasty: a long-term multicenter study

BackgroundDespite the increasing popularity of revision total shoulder arthroplasty (RTSA), studies directly comparing revision RTSA performed for different failed index procedures are limited. We therefore compared the results of revision RTSA between patients with a failed primary anatomic arthroplasty (total shoulder arthroplasty and hemiarthroplasty) and those with a failed primary RTSA to explore revision of which index procedure resulted in better long-term clinical outcomes. MethodsIn this prospective, multicenter, observational study, patients underwent revision RTSA using an inverted-bearing prosthesis. We recorded clinical scores, active range of motion, pain, satisfaction, and the rate of scapular notching. Complications and prosthesis survival were also noted. ResultsWe included 45 patients (45 shoulders) with revision RTSA for failed primary anatomic shoulder arthroplasty (30 patients) and RTSA (15 patients). Clinical and radiographic outcomes were recorded from 36 patients at a median follow-up of 101.6 months, and prosthesis survival was assessed from all 45 patients. At final follow-up, clinical scores (P < 0.05), abduction (P = 0.032), re-revision rate (P = 0.018), and prosthesis survival (P = 0.015) were significantly better in patients revised from failed primary anatomic shoulder arthroplasty than those from RTSA. However, pain, satisfaction, and overall complication rates were similar in both groups (P > 0.05). ConclusionsWe found better long-term clinical scores, abduction, and prosthesis survival rates after failed primary anatomic shoulder arthroplasty than after RTSA. Pain reduction and complication rates were comparable in both groups. Thus, anatomic shoulder arthroplasty remains an attractive option for primary arthroplasty in selected cases.

Prediction of premorbid three-dimensional anatomy of the glenoid based on statistical shape modeling

BackgroundRestoration of an anatomic joint line after anatomic total shoulder arthroplasty and of the optimal lateral offset after reverse total shoulder arthroplasty may be relatively straightforward when the glenoid does not present with severe erosion. However, in cases of severe glenoid bone loss, the surgeon is left with no preoperative landmark to restore these parameters. The objective of this study was to use statistical shape modeling, to predict the premorbid morphology of the glenoid. We hypothesized that this would allow us to accurately determine premorbid glenoid version and inclination, in addition to accurately quantifying bone loss and medialization. MethodsFifty-six bilateral computed tomography scans of the shoulders of patients scheduled for shoulder arthroplasty and determined to have unilateral osteoarthritis (primary osteoarthritis or cuff tear arthropathy with a healthy contralateral side) were obtained. A statistical shape model was automatically applied on the pathologic arthritic side to predict its premorbid anatomy. Glenoid version, inclination, height, width, and glenoid and scapula lateral offset were measured automatically. These measurements were obtained on the pathological arthritic cases, on the contralateral control healthy cases, and on the premorbid predictions of the pathological arthritic cases and were compared pair by pair. ResultsThe mean difference between the pathological arthritic side and the contralateral healthy side was 9.1° ± 7.3° for version, 4.8° ± 4.8° for inclination, 4.9 ± 4.5 mm for height, 4.7 ± 5.3 mm for width, 2.4 ± 1.9 mm for scapula lateral offset, and the glenoid lateral offset was 1.5 ± 1.5 mm. The mean difference between the premorbid prediction of the pathological side and the contralateral healthy side was reduced to 3.3° ± 2.4° for version, 3.4° ± 2.6° for inclination, 3.0 ± 1.9 mm for height, 2.3 ± 1.4 mm for width, 2.2 ± 1.7 mm for scapula lateral offset, and the glenoid lateral offset was 0.9 ± 0.8 mm. ConclusionThis study shows that statistical shape modeling can allow accurate prediction of the premorbid morphology of the glenoid. This could help optimize implant selection and positioning after anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty to restore optimal soft-tissue tension.

Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050.

Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States. Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index. Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932). The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.

Effect of body mass index on complications following total shoulder arthroplasty: a population-wide analysis

BackgroundEvidence regarding the effect of body mass index (BMI) on complications following anatomic shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) remains controversial. This high-powered study examines the effect of BMI on surgical and medical complications following anatomic shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA). MethodsThis retrospective cohort study was conducted using the Premier Healthcare Database (PHD) to query all adult patients who underwent primary, elective TSA (aTSA, rTSA) from 2016 to 2020. Patients eligible for inclusion were identified using ICD-10 and CPT codes for primary TSA. Patients were stratified into three subgroups based on BMI (BMI <30 kg/m2, BMI 30-35 kg/m2, BMI > 35 kg/m2). The primary endpoints assessed were 90-day risks of postoperative complications, revisions, and readmissions among the three BMI groups undergoing primary TSA. ResultsA total of 32,645 patients were analyzed; 10,951 patients underwent aTSA and 21,694 patients underwent rTSA. Patient populations for aTSA and rTSA differed significantly across all BMI categories in terms of age, sex, cost of care, and insurance status. After multivariate regression analysis, there was no increased risk of surgical complications in the aTSA and rTSA cohorts with BMI 30-35 kg/m2 and BMI > 35 kg/m2. In the aTSA cohort, rates of acute respiratory failure (adjusted Odds Ratio (aOR) 2.65) was all significantly higher in the BMI > 35 kg/m2 group. As for rTSA cohort, acute respiratory failure (aOR 1.67) and acute renal failure (aOR 1.53) were significantly higher in the BMI > 35 kg/m2 group. ConclusionWhile we found no increased risk of immediate postoperative surgical risks, patients with a BMI > 35 kg/m2 demonstrated greater risk of medical complications after rTSA. Given this trend, providers should exercise caution in patient selection for TSA and counsel obese patients as to these increased risks. Future studies should aim to provide a more comprehensive picture of the effect of BMI on functional outcomes after TSA.

Use of a Krackow suture technique with PEEK barrel augmentation for subscapularis repair is stronger than use of a Mason-Allen suture technique

BackgroundIn total shoulder arthroplasty, the subscapularis tendon is routinely mobilized, by tenotomy, peel, or lesser tuberosity osteotomy, to visualize the joint and allow proper implant positioning. Careful mobilization of the subscapularis is undertaken to achieve an anatomic tension-free repair. This cadaveric study tests the biomechanical differences of 2 repair techniques of the subscapularis peel (SP) compared to the classically described technique. We hypothesize that adaptation of this SP technique using a custom-designed polyether-ether-ketone (PEEK) barrel in the bicipital groove may further stabilize suture repair of the subscapularis. MethodsTwenty paired cadaveric shoulder specimens underwent SP and repair via transosseous suture fixation. The PEEK barrel used was a laboratory prototype designed for the study (Catalyst OrthoScience, Naples, FL, USA). Five specimens were repaired using a traditional Mason-Allen suture; their paired shoulders were repaired using the PEEK barrel and a Mason-Allen suture. Five specimens were repaired using the Krackow suture; their paired shoulders were repaired using the PEEK barrel and a Krackow suture. Mechanical testing was performed using a uni-axial materials testing system with primary outcome of gap displacement and secondary outcomes of maximum load to failure and method of failure. ResultsThe Krackow repair method with and without PEEK augmentation was significantly stiffer than the Mason-Allen repair method with and without PEEK augmentation (P < .001 across all groups). Adding augmentation changed the strength of the Mason-Allen repair without achieving statistical significance (P = .0925). Intergroup differences in cyclic displacement were not statistically significant. The Krackow repair methods had higher mean maximal load at failure than the Mason-Allen repairs of 534 ± 108 N and 266 ± 98 N, respectively (P < .001). Maximum load at 5 mm displacement was significantly different across groups (P = .004). Methods of failure in the Mason-Allen technique groups included knot and tendon failure, and in the Krackow technique groups included suture failure and lesser tuberosity fracture. ConclusionRepairing the subscapularis with a Krackow suture is significantly stronger than a Mason-Allen repair in stiffness as well as load to failure. The results reported here compare a Krackow suture with a more common Mason-Allen suture configuration, and demonstrate the application of PEEK augmentation to subscapularis repair techniques. This study can guide surgeon selection of an ideal subscapularis repair technique for stemmed or stemless total shoulder arthroplasty.

Regional variation from 2013 to 2021 in primary total shoulder arthroplasty utilization, reimbursement, and patient populations

BackgroundTotal shoulder arthroplasty (TSA), encompassing both anatomical and reverse total shoulder arthroplasty, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level. MethodsThe Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data was stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions. ResultsBetween 2013 and 2021, TSA utilization increased by 121.8% nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1,108.59; p<0.001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1,223.44; p<0.001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; p<0.001). The average comorbidity burden of patients decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (p<0.001). ConclusionThis study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.

Total shoulder arthroplasty for glenohumeral arthritis associated with posterior glenoid bone loss: midterm results of an all-polyethylene, posteriorly augmented, stepped glenoid component

BackgroundThe purpose of this study is to report the minimum 5-year clinical and radiographic outcomes of patients undergoing anatomic total shoulder arthroplasty (aTSA) with a posteriorly augmented glenoid component. MethodsThirty-five shoulders with minimum 5-year follow-up underwent aTSA using a posteriorly augmented glenoid component for the treatment of glenohumeral osteoarthritis with posterior glenoid bone loss. Clinical outcomes included range of motion (ROM), Visual Analog Scale (VAS) for pain, and patient reported outcomes scores (PROS). Radiographs (XR) and computed tomography (CT) scans were obtained to assess glenoid morphology, retroversion, central peg osseous integration (CPOI) via Wirth score, Lazarus scores, and Yian scores. Postoperative outcomes were measured at minimum 2- and 5-year follow-up. Kaplan-Meier survival analysis was calculated. ResultsTwo patients experienced prosthetic instability requiring revision, leaving 33 shoulders with an average follow-up of 6.6 years. Average preoperative glenoid retroversion was 21.6˚. A significant improvement in pain, ROM, and PROS was noted at minimum 2-year and 5-year follow-up. Additionally, VAS pain, American Shoulder and Elbow Surgeons (ASES), and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) scores improved between minimum 2-year and 5-year follow-up. The average Lazarus and Yian scores at final follow-up were 0.73 and 2.6, respectively. There was an increase in Lazarus score and decrease in Wirth score between 2- and 5-year follow-up. A significant correlation was identified between VAS pain scores and both Lazarus and Wirth scores. Survivorship free from revision was 92% at 8.8 years postoperatively. ConclusionsMidterm results of aTSA with a posteriorly augmented, stepped glenoid component demonstrate sustained improvements in clinical outcomes with low rates of radiographic loosening. Continued improvement in pain and function, as well as a minor progression of radiographic osteolysis, may be expected between 2- and 5-year follow-up. Additionally, the severity of radiographic loosening correlates with subjective pain levels.

Seasonal timing of surgery does not affect clinical outcomes in total shoulder arthroplasty

BackgroundTotal shoulder arthroplasty (TSA) is an effective treatment option for glenohumeral arthritis. It is unclear if seasonal timing of surgery affects outcomes. MethodsPatients who underwent TSA between 2015 and 2021 and were enrolled in a multicenter registry were eligible for inclusion. Date of surgery was recorded and was divided up into winter, spring, summer, and fall. Demographic data and Walch classification were recorded. Baseline strength, range of motion (ROM), and patient-reported outcomes were recorded. Patient-reported outcomes and ROM at 2 years of follow-up were assessed and compared between TSA groups for each season. ResultsOverall, 506 patients were included in the analysis. Breakdown by season was winter (N = 124), spring (N = 118), summer (N = 120), and fall (N = 144). There were no differences in baseline demographics between patients based on season of surgery or Walch classification. No difference existed in baseline ROM, clinical outcomes, or strength between seasonal groups. There were no differences in 2-year clinical outcomes, ROM, or strength between groups. ConclusionThere is no difference in clinical outcomes based on seasonal timing for patients who undergo TSA. Patients should feel confident that their outcomes will not vary based on the season in which they undergo TSA.

Lateralization of the humerus in reverse total shoulder arthroplasty: can preoperative planning software predict postoperative lateralization and does lateralization influence outcomes?

IntroductionReverse total shoulder arthroplasty (RTSA) can result in varying amounts of humeral medialization or lateralization. The amount of medial or lateral change-in-arm-position can be predicted using 3D CT planning software. It is not clear if the preoperatively-predicted change-in-arm-position correlates with the actual, radiographically-measured change-in-arm-position or if predicted or actual change-in-arm-position correlates with patient-reported outcomes or complications. MethodsPatients undergoing RTSA underwent preoperative 3D CT planning to predict the postoperative medial-to-lateral change-in-arm-position (PCAP). Preoperative and postoperative radiographs were used to calculate the actual medial-to-lateral change-in-arm-position using the measurement of the lateral edge of the greater tuberosity to the lateral edge of the acromion (RCAP-LHO). The Western Ontario Osteoarthritis Score (WOOS), American Shoulder and Elbow Surgeons score (ASES) and Single Assessment Numeric Evaluation (SANE) were recorded at baseline, 1-year, and 2-years. Rates of complications were recorded. ResultsTwo-hundred-and-fifty patients were eligible for this study including 189 patients reaching the one-year clinical follow-up point and 144 patients reaching the two-year clinical follow-up point. One-year and two-year follow-up rates were 89 percent and 91 percent, respectively. The mean PCAP was 3+5 mm and RCAP-LHO was 1+8 mm. There was moderate correlation between PCAP and RCAP-LHO. There was weak correlation between increased PCAP lateralization and higher WOOS and ASES at two years and improvement from baseline to 2 years in WOOS. There was very weak correlation between increased PCAP lateralization and improvement compared to baseline in 1 year SANE and improvement compared to baseline in 2 year SANE. There was weak correlation between lateralized RCAP-LHO and 2 year postoperative SANE. There was superior 2-year WOOS, ASES, and SANE, and improvement in SANE at 1-year compared to baseline in patients with a lateralized PCAP compared to a medialized or neutral PCAP. There was superior 2-year WOOS, improvement in WOOS from baseline to 2-year follow-up, and SANE at 2-years in patients with a lateralized RCAP-LHO compared to a medialized or neutral RCAP-LHO. Overall complication rates were similar between groups although the dislocation rate in shoulders with a lateralized change-in-arm-position was significantly less compared to shoulders with a medial or neutral change-in-arm-position. ConclusionsPCAP correlated with actual RCAP-LHO. Correlations exist with increased humeral lateralization and improved patient-determined outcomes. Patient-determined outcomes were the same or better in patients with a lateralized change-in-arm-position compared to those that were medialized or remained neutral. A lateralized change-in-arm-position did not result in increased overall complications and was protective against postoperative instability.

Shoulder arthroplasty outcomes in a series of patients diagnosed with Parkinson’s disease: a retrospective analysis

BackgroundParkinson’s disease (PD) is a neurodegenerative disorder that causes resting tremor and rigidity. Total shoulder arthroplasty (TSA) in patients with PD has proven to be a challenging clinical scenario and is associated with a high risk of complications. The purpose of this study is to explore the relationship between patients diagnosed with PD and outcomes following shoulder arthroplasty (SA). MethodsInstitutional records were queried for patients with PD who underwent SA from 2009 to 2020. Patient medical documentation was retrospectively reviewed to assess demographic information, comorbidity status, preoperative and postoperative range of motion measurements, and complications. Mean ± standard deviation was reported for continuous variables. ResultsA total of 17 patients were identified that met the inclusion criteria. The mean age of the cohort was 57.6 ± 10.6 years at the time of PD diagnosis and 68.1 ± 6.9 years at the time of surgery. The mean follow-up was 1.6 ± 1.2 years. The most common indications for surgery were degenerative joint disease, osteoarthritis, rotator cuff arthropathy, proximal humerus fracture, and rotator cuff tear (1). Mean forward elevation improved from 126.6 ± 24.8° to 131.2 ± 27.8°; mean external rotation improved from 29.4 ± 17.3° to 38.8 ± 10.5°. DiscussionSA is an effective method of improving pain and function in PD patients. Patients undergoing anatomic TSA exhibited the most robust functional improvement in this cohort; however, anatomic TSA was associated with postoperative complications and similar functional measurements were achieved at final follow-up in patients who underwent reverse TSA. Thus, significant care must be taken to ensure the correct implant is chosen on an individual basis to maximize the potential for functional improvement.

The role of smoking status on survivorship and clinical outcomes following total shoulder arthroplasty

BackgroundSmoking has been strongly associated with poor healing and worse outcomes following various joint arthroplasties, including worse functional measurements and increased complication rates. While smoking is associated with adverse events and complications in shoulder arthroplasty, the role of smoking in functional measurements and patient-reported outcomes (PROs) remains to be fully characterized. MethodsInstitutional electronic medical records were used to study patients who underwent primary anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA) between 2009 and 2020 with at least 2 years of follow-up. Patients were called to obtain PROs. Patients were stratified into 3 cohorts, by tobacco smoking status: current, former, and never smokers. ResultsAmong 498 patients who underwent TSA, 280 were aTSAs and 218 were rTSAs. Within aTSAs, 28 patients were classified as current, 99 as former, and 153 as never smokers. In rTSAs, 20 were current, 68 were former, and 130 were never smokers. Current smokers were younger at the time of surgery than former and never smokers in both aTSA (current: 58.8 ± 8.5; former: 63.9 ± 9.2; never: 62.8 ± 9.0 years; P = .031) and rTSA (current: 59.0 ± 6.8; former: 68.5 ± 7.2; never: 69.0 ± 9.0 years; P < .001). Furthermore, current smokers experienced lower 5-year implant survival in aTSA (current: 84.3%; former: 98.8%; never: 95.0%; P = .015) and rTSA (current: 82.4%; former: 94.5%; never: 94.1%; P = .004). No differences were found among the 3 cohorts for preoperative range of motion (ROM) and strength, or postoperative ROM and strength in the aTSA cohort. rTSA preoperative measurements demonstrated no differences in ROM and strength, and only postoperative forward elevation strength and external rotation strength were found to be different. PROs were found to be of similar magnitude for all patients in the aTSA and rTSA groups. ConclusionThe findings of this study indicate that current smokers exhibited a higher likelihood of necessitating TSA at a younger age and had higher implant failure rates. However, functional measurements were only marginally affected by smoking status.

Shoulder arthroplasty in the upper extremity weight-bearing patient: a systematic review of clinical outcomes and complications

Patients who rely on their upper extremities for ambulation, or upper extremity ambulators (UEAs), place considerable stress on their shoulders through the use of assistive devices like walkers, crutches, canes, and wheelchairs. It has been postulated that UEAs may be at increased risk for complications following shoulder arthroplasty. This study aimed to systematically review the literature related to (1) patient-reported outcomes measures (PROMs), (2) functional outcomes, and (3) complications in UEAs who undergo shoulder arthroplasty. A systematic review of the PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify studies reporting clinical outcomes of shoulder arthroplasty in UEAs. Patient demographics, clinical characteristics, patient-reported outcomes measures, radiographic outcomes, and postoperative range of motion were collected and compared to control patients (ie bipedal ambulators) from the constituent studies. A total of eight studies evaluating 248 UEA cases and 206 control cases were included for review. Ambulatory assistive devices utilized by UEAs included walkers (39%), wheelchairs (38%), canes (22%), and a crutch (<1%). Among UEA cases, 197 (79%) reverse total shoulder arthroplasty (TSA), 37 (15%) anatomic TSA, and 14 (6%) hemiarthroplasty were performed. Overall, patients exhibited significant improvements in mean American Shoulder and Elbow Surgeons scores, Constant-Murley scores, Simple Shoulder Test scores, and Visual Analog Scale scores postoperatively. Among 3 studies that included comparison with control groups of bipedal ambulators, no significant differences in outcomes were identified. The overall clinical complication rate was 17% for UEAs compared to 9.1% for controls. The rate of revision surgery was 7.7% for UEAs and 4.9% for bipedal ambulators. UEAs experience satisfactory pain relief, functional improvements, and good subjective outcomes following shoulder arthroplasty. However, complication and revision rates are higher compared to those for bipedal ambulators, and the majority of UEAs undergo reverse shoulder arthroplasty compared to anatomic TSA.

Trabecular metal backed glenoids in anatomic total shoulder arthroplasty: outcomes after a decade on average

BackgroundFirst-generation trabecular metal (TM) backed glenoids reported poor implant survival and were recalled from the market. Second generation TM glenoids have demonstrated promising findings at short- and mid-term follow-up. In our study, we report on clinical and radiographic outcomes of TM glenoids with an average of 10 years of clinical and radiographic follow-up. MethodsThe charts of 14 TM glenoid patients with minimum 5 years follow-up were retrospectively analyzed. The primary end points included implant survival, range of motion, and patient-reported outcomes. Additionally, radiographic data (metal debris, lateral humeral offset (LHO), acromiohumeral interval (AHI)) were studied. ResultsThe mean age at surgery was 52 ± 11 years and the mean follow-up time was 10 ± 3 years. Implant survivorship was 100%. Range of motion improved significantly following surgery. Forward elevation changed from 120 ± 22º preoperatively to 155 ± 13º postoperatively (P < .01). The mean external rotation showed a statistically significant increase from 19 ± 30º preoperatively to 54 ± 13º postoperatively (P < .01). Internal rotation improved six vertebral levels on average (P < .01). Pain levels decreased significantly from 7 ± 1 to 2 ± 2 (P < .01) while American Shoulder and Elbow Surgeons Shoulder scores increased from 35 ± 10 to 83 ± 21 (P < .01). Simple Shoulder Test scores demonstrated an improvement from 5 ± 3 to 10 ± 3 (P < .01). No patients had glenoid loosening, metal debris, or radioluency on radiographic imaging. The immediate LHO was 18 (standard deviation [SD] ± 9) and final LHO of 16 (SD ± 8) (P value = .01). The immediate AHI was 12 (SD ± 3) and final AHI was 11 (SD ± 3) (P value = .01). ConclusionTM backed glenoids should remain in the modern orthopedic surgeon’s armamentarium of procedures. This particular glenoid design showed 100% implant survival at a decade following surgery, and provided sustained improvements in range of motion and shoulder function in osteoarthritic patients.

The effect of lateralization and distalization after Grammont-style reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to evaluate the relationship between multiple radiographic measures of lateralization and distalization and clinical outcome scores after reverse total shoulder arthroplasty (RTSA). MethodsWe retrospectively evaluated all RTSAs performed by the senior author between January 1, 2007, and November 1, 2017. We then evaluated the visual analog scale for pain (VAS pain), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) scores and complication and reoperation rates at a minimum of 2-year follow-up. We measured preoperative and postoperative (2-week) radiographs for the lateralization shoulder angle (LSA), the distalization shoulder angle (DSA), lateral humeral offset (LHO), and distance from glenoid to lateral aspect of the greater tuberosity (GLAGT). A multivariable analysis was performed evaluating the effect of the postoperative radiographic measurements on final patient reported outcomes (ASES scores, SST, VAS pain). ResultsThe cohort included 216 shoulders from unique patients who had patient reported outcome scores available at a minimum of 2-year follow-up (average, 4.0±1.9 years) for a total follow-up rate of 70%. In the multivariable models, more lateralization (LSA) was associated with worse final ASES scores -0.52 (95% CI: -0.88 to -0.17; p=0.004), and more distalization (DSA) was associated with better final ASES scores 0.40 (95% CI: 0.11, 0.69; p=0.007). More lateralization (LSA) was associated with worse final SST scores -0.06 (95% CI: -0.11, -0.003; p=0.039). Finally, greater distalization (DSA) was associated with lower final VAS pain scores, Ratio = 0.98 (95% CI: 0.96, 1.00; p=0.021). ConclusionGreater distalization and less lateralization are associated with better function and less pain after Grammont-style RTSA. If utilizing a Grammont-style implant, remaining consistent with Grammont’s principles of implant placement will afford better final clinical outcomes.

After primary shoulder arthroplasty appropriate vancomycin antibiotic prophylaxis does not lead to increased infectious complications when compared to cefazolin

INTRODUCTIONIn primary shoulder arthroplasty (SA), intravenous (IV) cefazolin has demonstrated lower rates of infectious complications when compared to IV vancomycin. However, previous analyses included SA cohorts with both complete and incomplete vancomycin administration. Therefore, it is currently unclear whether cefazolin still maintains a prophylactic advantage to vancomycin when it is appropriately indicated and sufficiently administered at the time of surgical incision. This study evaluated the comparative efficacy of cefazolin and complete vancomycin administration for surgical prophylaxis in primary shoulder arthroplasty with respect to infectious complications. METHODSA retrospective cohort study was conducted utilizing a single institution total joint registry database, where all primary SA types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed between 2000 to 2019 for elective and trauma indications using IV cefazolin or complete vancomycin administration as the primary antibiotic prophylaxis were identified. Vancomycin was primarily indicated for patients with a severe self-reported penicillin or cephalosporin allergy and/or MRSA colonization. Complete administration was defined as at least 30 minutes of antibiotic infusion prior to incision. All included SA had at least 2 years of clinical follow-up. Multivariable Cox proportional hazard regression was used to evaluate all-cause infectious complications including survival free of prosthetic joint infection (PJI). RESULTSThe final cohort included 7,177 primary SA, 6,879 (95.8%) received IV cefazolin and 298 (4.2%) received complete vancomycin administration. Infectious complications occurred in 120 (1.7%) SA leading to 81 (1.1%) infectious reoperations. Of the infectious complications 41 (0.6%) were superficial infections and 79 were (1.1%) PJIs. When categorized by administered antibiotics, there were no differences in rates of all infectious complications (1.6% vs. 2.3%; P = .352), superficial complications (0.5% vs. 1.3%; P = .071), PJI (1.1% vs. 1.0%; P = .874), or infectious reoperations (1.1% vs. 1.0%; P = .839). On multivariable analyses, complete vancomycin infusion demonstrated no difference in rates of infectious complications compared to cefazolin administration (hazard ratio [HR], 1.50 [95% confidence interval (CI), 0.70 to 3.25]; P = .297), even when other independent predictors of PJI (male sex, prior surgery, and Methicillin-resistant Staphylococcus aureus colonization) were considered. CONCLUSIONSIn comparison to cefazolin, complete administration of vancomycin (infusion to incision time greater than 30 minutes) as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should promote appropriate indications for the use of cefazolin or vancomycin, and when necessary, ensure complete administration of vancomycin to mitigate additional infectious risks after primary SA.

Finite element analysis of acromial fracture after reverse total shoulder arthroplasty

BackgroundThe prevalence of acromial fracture after reverse total shoulder arthroplasty (RSA) is reportedly 2.6%-8.4%, and clinical outcomes differ among fracture sites. However, few studies have investigated the factors affecting fracture sites. This study aimed to reproduce acromial fractures after RSA by replicating the postoperative displacement of the humerus using finite element models (FEMs), and to investigate the effect of humeral displacement on the fracture site. MethodsSix patients (mean age, 76.3 ± 7.9 years; 5 women and 1 man) with acromial fractures after RSA treated at our institution were included. Among them, 3 had Levy Type 1 fractures, whereas the other 3 had Levy Type 2 fractures. Preoperative computed tomography data were used to create a 3-dimensional FEM. All elements within the proximal 2 cm of the clavicle and the scapular body were completely constrained. The entire humerus was forcibly displaced following its displacement after RSA, as measured by preoperative and postoperative computed tomography. The fracture sites, total displacement, external constraint of the humerus at the initial fracture, and bone density from the acromion to the scapular spine were investigated. Values of P < .05 were considered statistically significant in tests of statistical inference but were interpreted as reference values due to the small number of cases. ResultsThere were no major differences in humeral displacement between Type 1 and Type 2 fractures. Although the fracture sites in the FEM were slightly more medial than the actual fracture sites, they were similar. The total displacement and external constraint of the humerus at the initial fracture were similar in Type 1 and Type 2 fractures. The distribution of bone density from the acromion to the scapular spine differed between fracture types. ConclusionWe were able to reproduce acromial fractures after RSA by replicating humeral displacement using FEM. The extent and direction of humeral displacement may not significantly affect the acromial fracture site, whereas the bone density distribution from the acromion to the scapular spine may affect it.