Minimal Clinically Important Differences for Oxford, Constant, and University of California Los Angeles Shoulder Scores After Reverse Shoulder Arthroplasty to Allow Interpretation of Patient-Reported Outcome Measures and Future Statistical Power Analyses

Non-operative versus reverse shoulder arthroplasty for the treatment of 3- or 4-part proximal humeral fractures: A systematic review and meta-analysis

Background

Proximal humerus fractures (PHFs) are a common injury experienced by elderly patients, however there is no consensus regarding the best treatment option. Recently, the use of reverse shoulder arthroplasty (RSA) in elderly patients with complex fractures is increasing. This systematic review and meta-analysis will compare the outcomes between RSA and non-operative treatment in 3- or 4-part PHFs in the elderly.

Methods

This study was conducted according to the PRISMA statement protocol and registered in PROSPERO (CRD42023439647). Searches on four databases (Medline, Embase, Web of Science, and Cochrane Library) were performed, and comparative studies which compared the outcomes of using RSA with conservative management were included. Demographic data, patient related outcome measures (PROMs), and complications rates were collected. Data were pooled using a random-effects model. Heterogeneity was determined using the I2 statistic and Cochran's Q test.

Results

Six studies involving 439 patients (mean age 79.0 years old; 12.1 % male) were analysed. The average Charlson co-morbidity index (CCI) was 3.74 and follow-up time was 26.0 months. Compared to the non-operative cohort, the RSA cohort had better VAS scores (1.0 versus 0.575; p = 0.047), Constant-Murley scores (66.3 versus 71; p = 0.114), active forward flexion (121.5° versus 100°; p = 0.023; I2 = 35 %), external rotation (34.8° vs 23.1°; p = 0.020), and internal rotation (Constant score 5.44 versus 4.28; p = 0.169). There is no difference in the overall risk of complications (8.2 % versus 6.0 %; RR = 1.00; p = 0.993), but those treated by RSA have a higher risk of needing subsequent revision surgery (3.7 % versus 2.8 %; p = 0.640; I2 = 25 %).

Conclusion

In the short-term, elderly patients with complex PHFs treated with RSA may have decreased pain, increased Constant-Murley scores, and increased ROM compared with patients treated non-operatively, at the expense of a higher risk of needing subsequent surgery. However, moderate between-study heterogeneity in effect sizes and the retrospective nature of included studies may limit the clinical applications of conclusions obtained in this review.

Level of evidence

III.

Long-term clinical and radiographic outcomes after inverted-bearing reverse total shoulder arthroplasty: a multicenter study with the Affinis Inverse prosthesis

BACKGROUND

Inverted-bearing reverse total shoulder arthroplasty (IB-rTSA) prostheses feature a polyethylene glenosphere and a metallic or ceramic humeral liner. Although midterm clinical results are promising, long-term clinical data with IB-rTSA are limited. Therefore, we evaluated the long-term clinical and radiographic outcomes of IB-rTSA in a variety of shoulder pathologies. Additionally, we reported the type and rate of scapular notching and assessed its effect on clinical results. Finally, we recorded implant survival and complication rates.

METHODS

In this prospective, multicenter, observational study, patients with different shoulder pathologies underwent IB-rTSA with the Affinis Inverse prosthesis. We recorded clinical and functional scores, active range of motion, pain, radiolucent lines, and the type and rate of scapular notching. All complications were documented, and prosthesis survival rates were calculated.

RESULTS

We included 318 patients (335 shoulders) with IB-rTSA. The final clinical and radiographic analysis involved 175 patients (183 shoulders), examined at a median of 120.7 months (range, 84.1-172.4 months). At final follow-up, clinical and functional scores, active range of motion, and pain improved significantly from preoperative values (P < .001). Additionally, improvements at the final follow-up in clinical scores and pain substantially exceeded the corresponding minimal clinically important difference determined for rTSA. The type of scapular notching was strikingly different from that observed with conventional rTSA prostheses, and no grade 4 scapular notching was seen. We found scapular notching in 63 (35.8%) shoulders, and the presence of scapular notching did not affect long-term clinical outcomes as well as complication and prosthesis survival rates. The overall prosthesis survival for any revision was 95.7% at 14 years.

CONCLUSIONS

IB-rTSA with the Affinis Inverse prosthesis resulted in excellent long-term clinical scores and radiographic outcomes, low scapular notching rates, and high prosthesis survival rates in patients with a range of shoulder pathologies. Overall, patients undergoing IB-rTSA can expect good and stable long-term clinical outcomes with low complication and revision rates, making it a viable choice for different shoulder pathologies.

The impact of the underlying pathology and previous surgery on the long-term functional outcomes of the Delta Xtend reverse total shoulder arthroplasty: a prospective cohort study with a minimum follow-up of 11 years

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) is a successful treatment option for rotator cuff tear arthropathy (CTA). Since its introduction, the range of indications has been expanded while implant designs have been enhanced. The purpose of this study is to evaluate the long-term clinical, radiographic, and patient-reported outcomes of the Delta Xtend rTSA.

MATERIALS AND METHODS

In this prospective cohort study, 108 consecutive patients who underwent implantation of rTSA using the DePuy Delta Xtend in 2008 were included. Patients were divided into 4 indication groups: CTA (60%), revision shoulder arthroplasty (15%), fracture sequelae (19%), and postinfectious arthropathy (6%). Clinical examination and radiographic follow-up were performed after 5 years and at long term with a minimum follow-up of 11 years.

RESULTS

Forty three patients were eligible for follow-up with a median follow-up period of 12.5 years (range: 11.5-12.6 years, response rate 79%). The preoperative Constant score (CS) was 19 (9-24), and the CS at follow-up was 56 (41-64) with a significant increase between implantation and latest follow-up (P < .001). No significant difference of the CS at follow-up was reported between the 4 groups. Between the mid-term follow-up and the latest follow-up, a significant decrease of the CS of 10 (2-14) was observed (P = .004); however, no significant difference in the age-correlated and sex-correlated CS was reported (P = .13). Patients who underwent previous surgery before the index arthroplasty (51 [35-62]) had a significantly lower CS than patients without previous surgery (63 [58-66], P = .032). Patients with revision arthroplasty had a significantly lower range of motion at long-term follow-up than patients with CTA (P = .013). Implant survival was 95.3% after 11 years. Patients with fracture sequelae had a significantly higher risk for revision than patients with CTA (P = .04). Implant survival without revision for any complication was 89.7%; the overall complication rate was 12.5%.

CONCLUSION

This study demonstrated favorable long-term outcomes of rTSA and a satisfactory survival rate using the Delta Xtend system. However, a significant decline of the functional outcome was observed since the mid-term follow-up. For indications other than CTA, the functional results are inferior, and the risk for revision is higher. Previous shoulder surgery prior to the index arthroplasty leads to a worse functional outcome and a higher risk of reoperation due to any complication.

A novel methodology for establishing minimum clinically important difference and substantial clinical benefit thresholds for patient-reported outcome measures following reverse total shoulder arthroplasty

BACKGROUND

Increasing reliance on patient-reported outcome measures (PROMs) following reverse total shoulder arthroplasty (rTSA) has resulted in variability in the thresholds for minimum clinically important difference (MCID) and substantial clinical benefit (SCB) reported in the literature. In this study, we aimed to identify the best threshold values for MCID and SCB for common rTSA PROMs.

METHODS

The PubMed, Embase, MEDLINE, Cochrane Library, and Google Scholar databases were queried for studies published from January 1, 2000 to March 1, 2024 that identified clinically significant thresholds for PROMs following rTSA. The threshold calculation method, anchor questions/response options, follow-up duration, and confidence intervals were extracted. A novel hierarchical methodology evaluated various threshold calculation characteristics to identify the best MCID and SCB values following rTSA.

RESULTS

We included 37 studies for analysis comprising 11,960 patients. Using our methodology, the MCID values from the literature we recommend for American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), Constant-Murley Shoulder Outcome Score (Constant), University of California at Los Angeles Shoulder Score (UCLA), Shoulder Pain and Disability Index (SPADI) score, and Visual Analog Scale (VAS) following rTSA are 8.9, 3.7, 9.3, 2.9, 20, and 1.4, respectively. The recommended MCID threshold values for ASES and SST were from Werner and McLaughlin, respectively. The recommended thresholds for Constant and UCLA were from Zhou, while the thresholds for SPADI and VAS were from Simovitch. Using our methodology, the SCB threshold values from the literature we recommend for ASES following rTSA are 28.3 for glenohumeral osteoarthritis and 23.1 for rotator cuff arthropathy from Puzzitiello. For SST, Constant, UCLA, SPADI, and VAS, the SCB values we recommend are 3.2, 13.6, 10.4, 42.7, and 2.6, respectively. The recommended SCB thresholds for SST, Constant, UCLA, SPADI, and VAS were all from Simovitch.

CONCLUSION

We present recommended MCID and SCB values identified through our comprehensive methodology and recommend how these thresholds should be calculated for common rTSA PROMs moving forward. With increasing use and dependence on MCID and SCB values for PROMs, these recommended threshold values for MCID and SCB will help standardize assessment of clinically significant improvement for patients undergoing rTSA.

Effectiveness over time of the reverse shoulder prosthesis for acute proximal humeral fracture

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) has proven to be an effective surgical procedure for irreparable rotator cuff tears, comminuted fractures of the proximal humerus, and shoulder arthroplasty revision surgeries. We know from the literature that the functional results are good in the short term, but not whether these results remain stable in the long term or, on the contrary, show deterioration in functionality.

OBJECTIVE

This study aims to analyze the functionality, degree of satisfaction, complications, and prosthesis survival at different cut-off points in patients with complex proximal humerus fractures treated with rTSA, with a minimum postoperative follow-up of 7 years.

MATERIAL AND METHODS

Analytical, longitudinal, and prospective observational study of a cohort of patients treated for a fracture of the proximal humerus with Prótesis Inversa de Hombro. Functional outcome was assessed using the Constant Score and the Constant adjusted for age and gender of the patients. Quality of life was measured using the University of California at Los Angeles Shoulder Assessment scale and the Disability of the Arm, Shoulder and Hand score scale. In addition, range of motion, pain, and radiologic variables of loosening, scapular notching, and tuberosity consolidation were assessed.

RESULTS

Thirty-three patients were included with a mean postoperative follow-up of 8.3 years (range 7-12 years). There was a progressive and significant decrease in Constant Score at 5 and 7 years follow-up compared to the baseline assessment 2 years after surgery, although the effect size was not significant. The age- and sex-adjusted Constant as well as the University of California at Los Angeles Shoulder Assessment scale did not show statistically significant variations at follow-up. Both shoulder abduction and anterior shoulder flexion correlated well with the final Disability of the Arm, Shoulder and Hand score scale score. Radiologic variables did not influence any of the study outcome variables.

CONCLUSION

The functionality and quality of life of patients with complex proximal humerus fractures treated with rTSA decreased significantly compared to the 2-year evaluation, although this change was not clinically relevant. Survival of rTSA was satisfactory in the medium to long term with a low complication rate.

Baseline characteristics and 2-year functional outcome data of patients undergoing an arthroscopic rotator cuff repair in Switzerland, results of the ARCR_Pred study

The ARCR_Pred study was initiated to document and predict the safety and effectiveness of arthroscopic rotator cuff repair (ARCR) in a representative Swiss patient cohort. In the present manuscript, we aimed to describe the overall and baseline characteristics of the study, report on functional outcome data and explore case-mix adjustment and differences between public and private hospitals. Between June 2020 and November 2021, primary ARCR patients were prospectively enrolled in a multicenter cohort across 18 Swiss and one German orthopedic center. Baseline characteristics, including sociodemographic and diagnostic variables, were reported. Clinical scores and patient-reported outcome measures were assessed up to 24-month follow-up. After screening 2350 individuals, 973 patients with ARCR were included. Follow-up rates reached 99%, 95%, 89% and 88% at 6 weeks, 6, 12, and 24 months, respectively. While the proportion of massive tears was higher in the study population (44% vs. 20%, Std. Diff. = 0.56), there were no other major differences in key characteristics between enrolled and non-enrolled patients or in patients lost to follow-up. Functional scores improved over time, with positive changes rates ranging from 83% to 92% at 6-month, reaching 91% to 97% at 12- and 24-month follow-up. In linear mixed models, used to estimate the associations between baseline factors, hospital type and standardized 0-100 scores, marginal effects for time ranged from 20 to 30, 28 to 39 and 34 to 41 points at the 6-, 12- and 24-month follow-up, respectively. Except at the 12-month follow-up, where marginal effects for the interaction terms ranged from -5 to -4 points in the standardized scores, there were no consistent outcome differences between public and private hospitals. Increasing number of years of education was consistently associated with better scores, greater feelings of depression and anxiety, smoking and ASA group III-IV were consistently associated with worse scores. Tear severity showed a consistent negative association solely for the Constant-Score. The ARCR_Pred study shows high potential for generalizability to the population of patients undergoing an ARCR in Switzerland. Further analyses are needed to establish relevant clinimetrics for the Swiss population and to compare outcomes for surgical techniques, surgeon experiences profiles and post-operative management.

Survivorship and outcomes of arthroscopic bankart repair for anterior shoulder dislocations: A minimum of 2 year follow-up

Background

This study aims to evaluate long-term survivorship of arthroscopic Bankart repair (ABR).

Methods

About 101 patients under a single surgeon were followed up for ≥2 years post-ABR. Primary outcome was survivorship, defined as re-dislocation post-surgery. Secondary outcomes included a range of motion, strength, pain, University of California-Los-Angeles shoulder score, Oxford shoulder score (OSS), Oxford Shoulder Instability Score (OSIS), Constant Murley Score, and satisfaction. Clinical factors were correlated.

Results

Eight patients experienced postoperative dislocation (5 high-energy trauma, 2 low-energy trauma, 1 atraumatic), with 2 patients requiring revision. The mean time to post-operative dislocation was 1.5 years (range 0.3-3.8). Competitive athletes demonstrated worse survivorship (p = 0.027) but greater isometric strength at 6 months (p = 0.041) compared to recreational players. Patients ≥25 years old experienced slower recovery of internal rotation at 3 months (p = 0.006). Patients with surgery >1 year after injury had slower recovery of external rotation (p = 0.006), worse Constant scores at 3 months (p = 0.036) and lesser improvements in isometric strength at 3 months (p = 0.032). Patients with single pre-operative dislocations (p = 0.036 OSS; p = 0.039 OSIS) and patients ≥25 years old (p = 0.044 OSS) had worse Oxford scores at 3 months.

Discussion

ABR demonstrates good outcomes with low recurrence. This study prognosticates long-term outcomes across various subgroups.

Outcomes following revision of a failed primary reverse shoulder arthroplasty

Aims

Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA.

Methods

MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews were searched. Studies involving adult patients who underwent revision of a primary RSA for any indication were included. Those who underwent a RSA for failure of a total shoulder arthroplasty or hemiarthroplasty were excluded. Pre- and postoperative shoulder scores were evaluated in a random effects meta-analysis to determine the mean difference. The rates of re-revision and complications were also calculated.

Results

The initial search elicited 3,166 results and, following removal of duplicates and screening, 13 studies with a total of 1,042 RSAs were identified. An increase in shoulder scores pre- to postoperatively was reported in all the studies. Following revision of a RSA to a further RSA, there was a significant increase in the American Shoulder and Elbow Surgeons Score (mean difference 20.78 (95% CI 8.16 to 33.40); p = 0.001). A re-revision rate at final follow-up ranging from 9% to 32%, a one-year re-revision rate of 14%, and a five-year re-revision rate of 23% were reported. The complication rate in all the studies was between 18.5% and 36%, with a total incidence of 29%.

Conclusion

This is the largest systematic review of the outcomes following revision of a RSA. We found an improvement in functional outcomes after revision surgery, but the rates of re-revision and complications are high and warrant consideration when planning a revision procedure.

Outcomes following revision reverse shoulder arthroplasty for infection

BACKGROUND

In comparison to primary reverse shoulder arthroplasty (RSA) procedures, revision arthroplasty can be a longer and more complex procedure leading to an increased risk of complications. The reported rates of infection in primary RSA range from 1% to 19% and the cost impact on patients and health care systems is significant, leading to multiple revision surgeries. The purpose of this study was to evaluate the postoperative outcomes, complications, and revision rates for revision reverse shoulder arthroplasty (rRSA) due to infection compared with rRSA for noninfectious causes.

METHODS

Patients who underwent rRSA between 2009 and 2020 by a single fellowship-trained orthopedic surgeon at a single institution were retrospectively identified through a prospectively collected database. Patients were separated into 2 cohorts based on revision diagnosis: (1) rRSA due to infection (rRSAi) and (2) rRSA due to noninfectious causes (rRSAn). Patient-reported outcome scores (PROs), including the Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, University of California-Los Angeles shoulder score, Shoulder Arthroplasty Smart score, and active range of motion (ROM) were collected preoperatively and at a minimum 1-year follow-up. Postoperative complications and revision rates were also collected.

RESULTS

A total of 93 patients (n = 19 rRSAi group, n = 74 rRSAn group) with a mean age of 68 years were included in this analysis. All baseline demographics were comparable between groups. No significant differences were found in preoperative or postoperative PROs and ROM between the 2 groups. Postoperative complication rates and revision rates were comparable between the groups.

CONCLUSION

RSA due to infection results in similar patient-reported outcome scores, range of motion, and revision rates when compared to rRSA for noninfectious causes. Our results suggest that despite the unique challenges associated with rRSA for infection, patient outcomes do not differ from cases attributed to noninfectious causes. More efforts are warranted to further validate and contextualize these findings, considering the protentional influence of patient-specific and implant-specific factors.

The variability of MCID, SCB, PASS, and MOI thresholds for PROMs in the reverse total shoulder arthroplasty literature: a systematic review

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is a common procedure utilized to address degenerative pathologies of the glenohumeral joint and rotator cuff. Increased reliance on patient-reported outcome measures (PROMs) have placed emphasis on the utilization of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), patient acceptable symptom state (PASS), and maximal outcome improvement (MOI) thresholds to assess the clinical efficacy of RTSA. In this study, we systematically reviewed the MCID, SCB, PASS, and MOI thresholds reported for PROMs following RTSA.

METHODS

PubMed, Embase, MEDLINE, Cochrane Library, and Google Scholar were queried for articles from January 1, 2000 to August 31, 2023 reporting MCID, SCB, PASS, or MOI values for PROMs following RTSA. Patient demographic data, study characteristics, MCID/SCB/PASS/MOI thresholds, and threshold calculation methods were extracted.

RESULTS

One hundred and forty-one articles were screened with 39 ultimately included, comprising 11,984 total patients that underwent RTSA. 34 (87%) studies reported MCID thresholds, 20 (51%) reported SCB, 5 (13%) reported PASS, and 2 (5%) reported MOI. 25/39 (64%) studies referenced a previous study when reporting MCID, SCB, PASS, or MOI values, 11 (28%) used an anchor-based method to calculate threshold values, 1 (3%) used a distribution-based method, and 2 (5%) used both anchor and distribution methods. There were 19 newly calculated MCID (11), SCB (5), PASS (1), and MOI (2) thresholds. For 5 of the 6 most utilized PROMs (ASES, SST, Constant, UCLA, and SPADI), the range of reported MCID values exceeded 50% of the most common threshold. For 3 of 6, the range of SCB values exceeded 25% of the most common threshold.

CONCLUSION

There is substantial variability in the MCID and SCB threshold values reported in the RTSA literature. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for RTSA may allow for improved assessment of PROMs.

Single-stage revision for total shoulder arthroplasty infection. Results at a minimum 2 years follow-up

INTRODUCTION

Similar to the management of periprosthetic joint infections of the lower limb, one-stage revision in total shoulder arthroplasty (TSA) infections is an option that has been highlighted in scientific publications since the early 2010s. However, there are only a few studies which validate this treatment and determine its scope of application in relation to two-stage treatment.

HYPOTHESIS

Single-stage revision for infected TSA is a reliable treatment allowing good infection control and satisfactory functional results.

METHODS

This single-center retrospective series of 34 consecutive patients operated on between 2014 and 2020 for a one-stage prosthetic revision was evaluated at a minimum of 2 years of follow-up. All of the patients included underwent revision shoulder arthroplasty during this period with the diagnosis of infection confirmed by microbiological analysis of surgical samples. Patients who did not benefit from a bipolar revision were excluded. All patients were followed at least 2 years after the intervention. Clinically suspected recurrence of infection was confirmed by a periprosthetic sample under radiographic guidance. Functional clinical outcomes as well as mechanical complications were also reported.

RESULTS

The average follow-up was 40.4 months (24-102±21.6). A septic recurrence was observed in three patients (8.8%). A mechanical complication was present in four patients (14.7%), and three (11.8%) required at least one surgical revision. The mean Constant-Murley score at the last follow-up was 49 (42-57±21.83).

DISCUSSION

Single-stage revision for shoulder periprosthetic joint infection results in a success rate of 91.2% with satisfactory functional results after more than 2 years of follow-up.

LEVEL OF EVIDENCE

IV; retrospective study.

Experiences and outcomes in shoulder replacements in a district general hospital over 19 years

BACKGROUND

This study aimed to evaluate the changing experiences of shoulder surgeons working in a district general hospital.

METHODS

A consecutive series of 395 shoulders (225 male, 170 female) over a 19-year period (2000-2019) with a minimum follow-up of 2 years were analyzed. Outcome measures were length of stay, operating time, satisfaction visual analog score (VAS), pain VAS, Oxford Shoulder Score (OSS), Constant-Murley score, range of movement, complications, and implant survival.

RESULTS

The incidence of a diagnosis of osteoarthritis as the surgical indication increased over time. The number of cases by surgeon per year increased from three cases in 2,000 to a peak of 33 in 2011. Up to seven implant manufacturers were used. The incidence of hemiarthroplasties decreased, and more numerous reverse polarity and anatomic arthroplasties were performed (P<0.001). More glenoid and humeral components were cemented and more short-stem implants were used in later years (P<0.001). Length of stay was a median of 1 day with a trend towards daytime surgery in recent years. Patients were satisfied (VAS 8/10) and OSS improved by 8 points on average throughout the observation period.

CONCLUSIONS

Despite frequent introductions of new implants, patient outcome, satisfaction, and complication rates remained good. There appears to be a need for large-scale, generalizable studies to understand why technological advancements leading to changes in implants do not influence clinical outcomes. Level of evidence: III.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review

PURPOSE

To examine reported minimal clinically important difference (MCID) and patient-acceptable satisfactory state (PASS) values for patient-reported outcome measures (PROMs) after shoulder instability surgery and assess variability in published values depending on the surgery performed. Our secondary aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS use in studies on shoulder instability surgery.

METHODS

A systematic review of MCID and PASS values after Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English and studies reporting use of MCID or PASS for patient-reported outcome measures (PROMS) after Latarjet, Bankart, and Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using medians and ranges. Categorical variables, including PROMs and MCID/PASS methods, were described using percentages. Because MCID is a patient-level rather than a group-level metric, the authors confirmed that all included studies reported proportions (%) of subjects who met or exceeded the MCID.

RESULTS

A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely used outcome threshold and was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit or maximal outcome improvement.

CONCLUSIONS

Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. Although MCID has been the most frequently reported metric, there is considerable interstudy variability observed in their values.

CLINICAL RELEVANCE

Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental because they allow us to know what is a clinically significant improvement for the patient.

Postoperative recreational sports and subjective shoulder function: a comprehensive analysis following intramedullary stabilization of displaced midshaft clavicular fractures

Introduction Sports-related outcomes and the role of recreational sports activities for shoulder function after intramedullary stabilization (IMS) of displaced midshaft clavicular fractures (DMCFs) in the general population are not well known. In this study, we aimed to determine the sport-related outcomes (return-to-sports [RTS] rate, type of sports, time until RTS, and intensity) and to explore the role of sports after IMS of DMCFs. Materials and Methods This single-center, retrospective, cohort study included patients who underwent IMS of DMCFs between 2009 and 2022 at a Level II trauma center in Germany, experienced no major complications, and had completed at least 1 year of follow-up. Propensity score matching was conducted to obtain a balanced sample of patients who did not engage (cases) and engaged (controls) in postoperative sports activities by adjusting for age and fracture complexity. Groups were compared to assess the impact of regular sports activities on subjective shoulder functioning at follow-up, as evaluated using the Disabilities of the Arm, Shoulder, and Hand and Oxford Shoulder Score (OSS) questionnaires, after controlling for the patient- (i.e., sex and smoking) and treatment- (i.e., surgery duration and physical therapy) factors. Results Among the 199 patients included, the RTS rate was 97.5%, and 160 patients practiced regular postoperative activity, mostly in the same sport and intensity. In the matched cohort (39 cases and 39 controls), practicing regular sports activities postoperatively was the only independent factor associated with a higher OSS in the multiple regression analysis (unstandardized regression coefficient = 2.40; Bias-corrected and accelerated 95% confidence interval [0.28, 4.69]). Conclusions The sport-related outcomes after IMS of DMCFs in our cohort were comparable to those achieved after plate osteosynthesis, and IMS reported in the literature. Recreational sports activities benefitted subjective shoulder function, thereby encouraging further research and potentially influencing management policies. Level of evidence Grade IV - a retrospective observational cohort study.

Radiologic, clinical, and patient-reported outcomes in stemless reverse shoulder arthroplasty at a mean of 46 months

BACKGROUND

The humeral stem can be a cause of problems in shoulder arthroplasty, for example, loss of bone stock, intraoperative and postoperative periprosthetic fractures, or postoperative infections involving the medullary canal. Therefore, stemless reverse shoulder arthroplasty (slRSA) has gained popularity, particularly in terms of preserving bone stock. However, there are limited data available on the midterm outcomes of slRSA. The objective of this study was to evaluate the clinical, radiologic, and patient-reported outcomes of slRSA at a minimum follow-up period of 2 years.

METHODS

Data on all stemless reverse shoulder prostheses implanted between January 2016 and October 2020 were collected. Patients were followed up at 6 weeks and 6, 12, and 24 months postoperatively. Clinical and radiologic data as well as patient-reported outcome measures were assessed with validated questionnaires (University of California at Los Angeles Shoulder Score [UCLA], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Quick Disabilities of the Arm, Shoulder, and Hand questionnaire [Quick-DASH], visual analog scale [VAS] for pain, Subjective Shoulder Value [SSV], and Constant-Murley score [CS]). All patients had a minimum follow-up of 2 years.

RESULTS

During the observation period, 26 shoulders in 25 patients fulfilled the inclusion criteria. The mean follow-up was 46.8 months (range 25-66). The mean age was 70.1 years (range 59.9-86.4). At the most recent follow-up, a significant improvement was noted in the ASES score (55.9 ± 19.9 vs. 85.6 ± 10.7, P < .001), SSV (44.3 ± 18.7 vs. 85.3 ± 10.4, P < .001), Quick-DASH score (40.6 ± 22.0 vs. 17.8 ± 13.9, P < .001), VAS pain score (4.6 ± 3.2 vs. 0.9 ± 1.2, P < .001), and range of motion in flexion (66 ± 53 vs. 154 ± 22, P < .001) as well as in the absolute (44.1 ± 18.7 vs. 83.1 ± 10.1, P < .001) and relative CS (62.1 ± 27.8 vs. 111.9 ± 13.3, P < .001). Scapular notching was observed in 16% of cases, and radiolucent lines were detected in 28% of cases without symptoms of implant loosening. No revision was necessitated by any causes related to the stemless humeral component. Hence, implant survivorship was 100%.

CONCLUSIONS

With an ASES score showing a 30-point improvement and thus exceeding the minimal clinically important difference of 21 points and no revisions due to the stemless component, these results indicate that slRSA is a viable option, providing good to excellent midterm outcomes that are comparable to those of stemmed reverse shoulder prostheses, with the added advantage of bone stock preservation.

Midterm outcomes of primary reverse shoulder arthroplasty: a systematic review of studies with minimum 5-year follow-up

Background

Excellent short-term outcomes after reverse shoulder arthroplasty (RSA) have been reported, but longer term outcomes in the existing literature are sparse and vary widely. The purpose of this study is to systematically assess the existing literature to quantify functional outcomes and complication rates after RSA at a minimum of five years of follow-up.

Methods

A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant systematic literature search of the PubMed and Embase databases was undertaken. Studies reporting outcomes after primary RSA for nontrauma-related indications with a minimum of 5-year follow-up were included.

Results

Overall, 20 studies satisfied all inclusion criteria. This represented 1591 shoulders in 1556 patients (32.1% males), with a mean age of 70.2 ± 5.0 years and mean follow-up of 8.8 years, or 106.2 ± 30.1 months (60-243). At final follow-up, the mean reported Constant Murley score was 62.1 ± 5.0 (49.0-83.0). The mean adjusted Constant Murley score was 83.5 ± 12.5 (58-111.9). The mean American Shoulder and Elbow Surgeons score was 81.8 ± 4.6, while the mean subjective shoulder value was 74.6 ± 6.4. Overall, 88% of patients rated their satisfaction as either good or very good. The range of active forward flexion, abduction, external, and internal rotation were respectively, 126° ± 13°, 106° ± 11°, 22° ± 11°, and 6° ± 2°. The overall rate of revision surgery was 4.9% (0%-45.5%). Regarding complications, the rate of prosthetic joint infection was 4.3% (0%-26.7%), shoulder dislocation was 3.7% (0%-20.4%), and acromial fracture was 2.0% (0%-8.8%). At final follow-up, 30.9% of shoulders had some degree of scapular notching.

Conclusion

This systematic review shows that RSA results in high satisfaction rates, good clinical outcomes, as well as modest complication and revision rates at minimum 5-year follow-up.

Editorial Commentary: Utility of Patient-Reported Outcome Threshold Scores to Estimate Patient Satisfaction: 'Let's Ask the Patient!'

The reporting and analysis of patient-reported outcome measures have come a long way. Since the concept of the minimally clinically important difference was first introduced in 1989, threshold scores have grown to include substantial clinical benefit and patient acceptable symptomatic state (PASS). The initial motivation for developing these thresholds was rooted in separating clinical significance from statistical. These thresholds provide insight into the relationship between scores on patient-reported outcome measures (PROM) and patient-reported improvement and satisfaction. It follows that in order to evaluate PROM scores, the best method for deriving the threshold typically uses an anchor-based methodology, i.e., "ask the patient." Specifically, patients are asked how much change they've experienced and whether they consider their current state to be satisfactory. The responses to these questions are compared with the scores on PROMs to find outcome thresholds that best separate patients who reported no improvement from those who reported minimal improvement, substantial improvement, and satisfaction with their current state of health (PASS). The PASS is of particular importance as it speaks to what arguably matters most to patients-a satisfactory state of health. Finally, viewing the PASS from the perspective of variation from study to study rather than as a uniform classifier is needed to make use of the growing number of papers reporting these thresholds. Examining differences in PASS values across papers can provide insight into how well PROM scores reflect patient satisfaction in different settings.

Medium-term results of inlay vs. onlay humeral components for reverse shoulder arthroplasty: a New Zealand Joint Registry study

BACKGROUND

The purpose of this study was to compare medium-term results of inlay and onlay humeral components in reverse shoulder arthroplasty (RSA). Specifically, we report differences in revision rate and functional outcomes between the 2 designs.

METHODS

The 3 most used inlay (in-RSA) and onlay (on-RSA) implants by volume from the New Zealand Joint Registry were included in the study. In-RSA was defined as having a humeral tray that recessed within the metaphyseal bone, whereas on-RSA was defined as having a humeral tray that rested on the epiphyseal osteotomy surface. The primary outcome was revision up to 8 years postsurgery. Secondary outcomes included the Oxford Shoulder Score (OSS), implant survival, and revision cause for in-RSA and on-RSA as well as individual prostheses.

RESULTS

There were 6707 patients (5736 in-RSA; 971 on-RSA) included in the study. For all causes, in-RSA demonstrated a lower revision rate compared to on-RSA (revision rate/100 component years: in-RSA 0.665, 95% confidence interval [CI] 0.569-0.768; on-RSA 1.010, 95% CI 0.673-1.415). However, the mean 6-month OSS was higher for the on-RSA group (mean difference 2.20, 95% CI 1.37-3.03; P < .001). However, this was not clinically significant. At 5 years, there were no statistically or clinically significant differences between the 2 groups with respect to the OSS.

CONCLUSION

The medium-term survival of in-RSA was higher than that of on-RSA. However, functional outcomes at 6 months were better for on-RSA compared to in-RSA. Further follow-up is required to understand the long-term survivorship and functional outcomes between these designs.