Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015

Predictors of operating room time in shoulder arthroplasty for glenohumeral osteoarthritis

Background

The aim of this study is to identify risk factors for prolonged operative duration in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) for patients with glenohumeral osteoarthritis (GHOA).

Methods

A retrospective chart review of electronic medical records was conducted to identify patients who underwent shoulder arthroplasty for GHOA by one of six surgeons across two academic institutions between 2017 and 2023. Multivariate linear regression was used to identify factors associated with operative duration.

Results

In total, 513 patients underwent primary ATSA, and 528 underwent primary RTSA. The mean operating room (OR) time was significantly longer in patients undergoing ATSA (183.5 ± 39.5 minutes) compared to those undergoing RTSA (150.5 ± 33.4 minutes). For ATSA, older patient age, male sex, increased body mass index, lower Charlson comorbidity index (CCI), increased preoperative retroversion, increased preoperative inclination, and a glenoid Walch classification of B2 or B3 were significant predictors of OR time. For RTSA, younger patient age, lower CCI, and increased preoperative retroversion were significant predictors of OR time.

Conclusion

ATSA has a significantly longer mean OR time than RTSA for the treatment of isolated GHOA. Preoperative demographic and radiographic data can be used to predict operative duration.

Improving outcomes in shoulder arthroplasty: A case series on the GPS-navigated bulk humeral autograft technique

Background

The purpose of this case series is to evaluate the efficacy and safety of the GPS-navigated humeral head (HH) autograft technique in the setting of primary reverse total shoulder arthroplasty (rTSA) for severe glenoid bone loss.

Methods

A database of prospectively enrolled patients was reviewed to identify patients who underwent GPS navigated primary rTSA with HH autograft (N = 8). Variables collected pre-operatively and at last follow up included demographics, active range of motion (ROM), patient reported outcome measures radiographic measures, complications, and revisions.

Results

Mean age was 59.5 (range: 45-80), mean BMI was 26.8 (range: 18-37) and 5 patients were male. At final follow up (median: 24 months), patients had a mean increase in forward flexion of 44 (p = 0.003), external rotation of 27 (p = 0.039), internal rotation score of 1.1 (p = 0.048), global function score of 4.8 (p < 0.001), American Shoulder and Elbow Surgeons score of 44 (p < 0.001), and decrease in visual analog scale pain of 5 (p < 0.001). Two patients had evidence of glenoid component loosening at 3 years post-operatively, however only one was symptomatic requiring a revision operation.

Discussion

Our findings demonstrate significant improvement in ROM, pain relief, and shoulder function following GPS-navigated primary rTSA with bulk HH autograft.

Level of Evidence

IV.

Multimodal pain management and postoperative outcomes in inpatient and outpatient shoulder arthroplasties: a population-based study

INTRODUCTION

Multimodal analgesia has been associated with reduced opioid utilization, opioid-related complications, and improved recovery in various orthopedic surgeries; however, large sample size data is lacking for shoulder surgery.

METHODS

A retrospective review using the Premier Healthcare Database of patients who underwent inpatient or outpatient (reverse, total, partial) shoulder arthroplasty from 2010 to 2019. Opioid-only analgesia was compared with multimodal analgesia, categorized into 1, 2, or >2 additional analgesic modes, with/without a nerve block. Multivariable regression models measured associations between multimodal analgesia and opioid charges (in oral morphine equivalents (OME)), cost and length of stay, and opioid-related adverse effects (approximated by naloxone use). We report % change and 95% CIs.

RESULTS

Among 176 225 procedures, 169 679 (75.7% multimodal analgesia use) and 6546 (37.8% multimodal analgesia use) were inpatient and outpatient shoulder arthroplasties, respectively. Among inpatients, multimodal analgesia (>2 modes) without a nerve block (vs opioid-only analgesia) was associated with adjusted reductions in OMEs on postoperative day 1: -19.4% (95% CI -21.2% to -17.6%/representing unadjusted median OME reductions from 45 to 30 mg). For total hospitalization, this was -6.0% (95% CI -7.2% to -4.9%/representing unadjusted median OME reductions from 173 to 135 mg). Conversely, for outpatients, this was +13.7% change in OMEs (95% CI +4.4% to +23.0%/representing unadjusted median OME increases from 110 to 131 mg). In both settings, addition of a nerve block to multimodal analgesia attenuated effects in terms of opioid charges.

CONCLUSIONS

Multimodal analgesia is associated with reductions in opioid charges-specifically inpatient setting-but not various other outcomes.

Differences in primary total shoulder arthroplasty volume, reimbursement, practice styles, and patient populations based on surgeon gender: a temporal analysis

BACKGROUND

Orthopedic surgery has previously been shown to have a shortage of female physicians and a gender pay gap. However, this has not been thoroughly evaluated in the setting of shoulder surgery. The primary purpose of this study was to evaluate differences in total shoulder arthroplasty (TSA) volume, reimbursement, surgeon billing practices, and patient populations between male and female surgeons from 2013 to 2021.

METHODS

The Medicare Physician and Other Practitioners database, a publicly available dataset that includes 100% of services billed to Medicare Part B, was utilized. The database was queried for all billing episodes of Current Procedural Terminology code 23472, which encompasses both anatomic and reverse primary TSA. Procedural volume, average inflation-adjusted reimbursement per TSA, physician billing information, and the patient demographics of each surgeon who performed TSAs were collected. Welch's t-test and Kruskal-Wallis were utilized to compare male and female surgeons each year between 2013 and 2021.

RESULTS

Between 2013 and 2021, the proportion of TSAs performed by female surgeons nationally increased from 1.8% to 2.9% (+1.1%). This increase was greatest in the Northeast (2.0%-6.1%), while a decrease was seen in the Midwest (1.9%-1.6%). In 2021, there was no significant difference between male and female surgeons in the average inflation-adjusted reimbursement per TSA ($1144.00 vs. $1143.00, P = .792) and the average number of TSAs performed per surgeon (26.6 vs. 23.1, P = .105). Female TSA surgeons, on average, had less Medicare beneficiaries (348 vs. 462, P < .001), performed fewer annual services (1817 vs. 3630, P < .001), and performed fewer unique services (60 vs. 76, P < .001) compared to male surgeons. A higher proportion of female surgeon's patient populations were non-White (24% vs. 22%, P = .028), female (61% vs. 59%, P = .001), and dual enrolled Medicare-Medicaid patients (13% vs. 10%, P < .001). However, there was no difference in the average patient complexity between male and female TSA surgeons based on hierarchical condition category score (1.0783 vs. 1.0732, P = .228).

CONCLUSION

Female representation within TSA surgery is increasing nationally, with the greatest representation in the Northeast and West and the lowest representation in the South and Midwest. Although female TSA surgeons perform a similar number of TSAs, receive comparable reimbursement per TSA, and have a similarly complex patient population as their male counterparts, they perform significantly fewer total and unique billable services annually. Additionally, female TSA surgeons tend to see more non-White, women, and dual Medicare-Medicaid enrolled patients.

Fatigue test evaluation of a customised humeral component for an instrumented total elbow prosthesis and strain validation study

The survival rate of total elbow arthroplasty (TEA) is negatively impacted by the lack of available data on elbow biomechanics. This study developed a modified humeral component for TEA that is purposed to be instrumented to generate real-time 6 degrees of freedom (d.o.f) force and moment data during activities of daily living (ADL). The objectives are twofold: (1) to assess the safety of the modified humeral component under peak anticipated loads in fatigue, and (2) verify the strains measured under physiological loads with strains modelled using finite element analysis (FEA). Four modified titanium alloy humeral components were welded, and fatigue tested at 5 Hz for 5 million cycles under a compressive load of 700 N corresponding to moderate ADL. The strains were measured using triaxial 350 Ω rectangular rosette (45°) strain gauges bonded to three specific locations on the humeral component confirmed through an FE study. The four welded humeral components successfully withstood fatigue conditions and did not deform. The measured and modelled principal strains were confirmed to be highest at the external wall of the lateral cavity, with a percentage difference of <10 %.

The effect of surgeon volume on complications after total shoulder arthroplasty: a nationwide assessment

BACKGROUND

Increased surgeon volume has been demonstrated to correlate with improved outcomes after orthopedic surgery. However, there is a lack of data demonstrating the effect of surgeon volume on outcomes after total shoulder arthroplasty.

METHODS

The PearlDiver Mariner database was retrospectively queried from the years 2010 to 2022. Patients who underwent shoulder arthroplasty were selected using the Current Procedural Terminology code 23472 (total shoulder arthroplasty). Patients younger than 40 years, those who underwent revision arthroplasty, and cases of bilateral arthroplasty were excluded. In addition, cases with a history of fracture, infection, or malignancy before surgery were excluded. Only surgeons who performed a minimum of 10 cases were selected, and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90-day, 1-year, and 2-year rates of complication and reoperation. A Bonferroni correction was used in which the significance threshold was set at P ≤ .00082.

RESULTS

A total of 155,560 patients met inclusion criteria and were retained for analysis. The 90th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90th percentile (n = 340) operated on 68,531 patients, whereas surgeons below the 90th percentile (n = 3038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship (P < .001) and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine (P < .001). Low-volume surgeons operated on patients with higher baseline comorbidities (Charlson Comorbidity Index [CCI]: 2.01 vs. 1.85, P < .001). After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure (P < .001), anemia (P < .001), and urinary tract infection (P < .001). All-cause readmission (0.90, P < .001), reoperation at 90 days (odds ratio: 0.75, P < .001), and reoperation at 1 year (odds ratio: 0.86, P < .001) were significantly lower among high-volume surgeons. High-volume surgeons exhibited lower rates of various complications including prosthetic joint infection (90 days: P < .001, 1 year: P < .001, and 2 years: P < .001), periprosthetic fracture (90 days: P < .001, 1 year: P < .001, and 2 years: P < .001), and all complications (90 days: P < .001 and 1 year: P < .001).

CONCLUSIONS

Surgeons who perform a high volume of total shoulder arthroplasty are more likely to operate on healthier patients than surgeons who perform a lower volume of cases. When compared with low-volume surgeons, and after adjusting for age, gender, and CCI, high-volume surgeons have a significantly lower overall complication rate. Despite this lower complication rate, high-volume surgeons are responsible for a decreasing portion of shoulder arthroplasty since 2016.

Humeral shaft periprosthetic fractures: Fracture patterns differ between short and standard-length arthroplasty stems

INTRODUCTION

There have been no published studies evaluating the impact of humeral stem length on humeral shaft periprosthetic fractures. We sought evaluate the differences in fracture patterns between periprosthetic fractures around a short stem and standard stem humeral implants.

MATERIALS AND METHODS

This is a retrospective cohort study. Patients sustaining a humeral shaft periprosthetic fracture around shoulder arthroplasty implants from December 2011 to January 2021 were identified using ICD-9/10 codes. Three upper extremity trained surgeons evaluated all radiographs assessing fracture location and configuration, as well as signs of stem stability before and after the fracture. They classified the fractures based on two classification schemes: Wright & Cofield, and the Unified Classification System (UCS), and they recorded their recommended treatment for each case based on fracture pattens and implant stability.

RESULTS

76 patients with periprosthetic humeral shaft fractures were identified and divided into two groups: short stem (n=18) and standard stem (n=58). Patients with a short stem were more likely to be classified as having an unstable prosthesis after fracture (67% versus 33%, p=0.01). Additionally, the proposed plan for treatment was different between the two groups (p=0.004): more patients in the standard stem group were recommended open reduction internal fixation (50% vs. 33%) or non-operative treatment (17% vs. 0%), and more patients in the short stem group were recommended revision arthroplasty (50% vs. 29%).

CONCLUSION

Patients sustaining a periprosthetic fracture around a short implant may be more likely to have an unstable prosthesis compared to a standard stem, which may have an impact on treatment options.

LEVEL OF EVIDENCE

Prognosis Study, Level III.

Shoulder Arthroplasty Patients Are Underscreened for Osteoporosis

INTRODUCTION

Osteoporosis screening and subsequent treatment has been shown to be efficacious in decreasing the rates of fragility fractures and periprosthetic fractures (PPF). However, current screening and treatment rates are low. This study aims to determine (1) the prevalence of total shoulder arthroplasty (TSA) patients who meet criteria for osteoporosis screening, (2) the prevalence of those screened, and (3) the 5-year cumulative incidence of fragility fracture (FF) and periprosthetic fractures (PPF).

METHODS

The PearlDiver database was used to identify all patients older than 50 years who underwent TSA. Guidelines from the American Association of Clinical Endocrinologists were used to stratify patients into "high risk" and "low risk" of osteoporosis cohorts using International Classification of Disease codes for various risk factors. The prevalence of osteoporosis screening using dual-energy x-ray absorptiometry (DXA) scan was analyzed, and the 5-year cumulative incidence of FF and PPF was calculated between the "low-risk" and "high-risk" groups using Kaplan-Meier analysis.

RESULTS

In total, 66,140 (65.5%) who underwent TSA were considered "high risk" for osteoporosis. Of the "high-risk" patients, 11.7% patients received routine osteoporosis screening preoperatively. Within 5 years, "high-risk" TSA patients had markedly higher cumulative incidence for PPF (HR: 1.4; 95% CI: 1.0-1.9; P = 0.037) and FF (HR: 2.42; 95% CI: 2.1-2.8; P < 0.001) when compared with those at "low risk".

DISCUSSION

There is a high prevalence of osteoporosis among patients undergoing TSA but a low rate of routine osteoporosis screening in this cohort. Patients with osteoporosis who are categorized as "high risk" have an increased rate of fragility fractures and PPF. Therefore, there is an opportunity to increase appropriate osteoporosis screening and management in this cohort, which may affect future risk of FF and periprosthetic fracture.

LEVEL OF EVIDENCE

III.

Outcomes of ambulatory versus outpatient hospital-based surgical center shoulder arthroplasty: complications, readmissions, and charges

PURPOSE

The rising demand for primary total shoulder arthroplasty (TSA) has spurred interest in comparing the safety and cost-effectiveness of outpatient TSA in ambulatory surgical centers (ASCs) versus hospital-based centers (HSCs). This study evaluates ASCs and HSCs for medical complications, readmission rates, implant complications, and costs.

METHODS

This retrospective cohort study used the PearlDiver Mariner Database to identify patients undergoing primary TSA in ASCs or HSCs, assessing medical complications, readmissions, implant issues, and costs. ASC patients were matched in a 1:5 ratio to HSC patients by age, sex, region, and Elixhauser Comorbidity Index (ECI). Logistic regression analyzed the impact of ASC versus HSC settings on complications and readmissions, while Welch's t-tests compared costs. Statistical significance was determined by a P value less than or equal to 0.05.

RESULTS

ASCs showed lower odds of pulmonary embolism (OR = 0.69; P = 0.04), total medical complications (OR = 0.89; P = 0.01), prosthetic joint dislocation (OR = 0.43; P = 0.05), and total implant-related complications (OR = 0.85; P = 0.03), but a higher 90-day readmission rate (OR = 1.22; P < 0.01). ASCs also offered significant cost savings on the day of surgery ($4600 vs. $11,100; P < 0.01) and for 90-day total costs ($6600 vs. $13,500; P < 0.01) compared to HSCs.

CONCLUSION

Outpatient primary TSA in ASCs offers comparable safety with substantially lower costs than HSCs. Despite higher readmission rates, ASCs represent a viable, cost-effective alternative.

Projections of utilization of primary and revision shoulder arthroplasty in the United States in the next 40 years

Background

In the past 20 years, the incidence of total shoulder arthroplasty (TSA) has increased greatly, and it is expected to continue growing. Current literature lacks future projections for the utilization of TSA. These projections can help predict demand quantities and anticipate the future burden on the healthcare system. The aim of this study is to determine the predictions of utilization for TSA, primary and revision, through 2060.

Methods

This analysis used the publicly available 2000-2019 data from the Center for Medicare and Medicaid Services Medicare Part-B National Summary. Procedure volumes, including TSA and revision TSA, were determined using Current Procedural Terminology codes and were uplifted to account for the growing number of Medicare eligible patients covered under Medicare Advantage. Log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average models were applied to the procedural volumes to generate projections from 2020-2060. The Poisson model was chosen to display the data based on error analysis and prior literature.

Results

The projected annual growth from 2020 to 2060 rates for primary and revision TSA are 11.65% growth (95% confidence interval 11.60%-11.69%) and 13.89% growth (95% confidence interval 13.35%-14.42%), respectively. By 2060, the demand for primary TSA and revision TSA is projected to be 10,029,260 and 1,690,634, respectively.

Conclusion

The results of this study concluded that both primary and revision TSA procedures are projected to exponentially increase from 2020 to 2060. Additionally, revision procedures are projected to increase at greater rates than their respective primary counterparts.

Current trends in shoulder arthroplasty - Are the trends backed by evidence?

Shoulder arthroplasty is the third most common joint replacement performed worldwide and remains a rapidly innovative area for improvement in patient care. This article explores the evidence surrounding current trends aiming to improve patient outcome in all forms of shoulder arthroplasty.

Diagnostic and Invasive Colonoscopies Do Not Increase the Risk of Prosthetic Joint Infection After Reverse Shoulder Arthroplasty

Introduction Reverse shoulder arthroplasty (RSA) is increasingly used to manage various degenerative and traumatic shoulder conditions. Prosthetic joint infection (PJI) remains a rare but serious complication, occurring in approximately 1-4% of cases. Given that colonoscopy can cause transient bacteremia - a potential risk factor for PJI - the current study aimed to determine whether undergoing diagnostic or invasive colonoscopy within one year after RSA is associated with an increased risk of PJI or all-cause revision surgery. Methods A retrospective cohort study was conducted using the PearlDiver All Payer Claims Database (MARINER). Patients who underwent RSA with at least three years of follow-up were identified and stratified into three groups: a control group (no colonoscopy), a diagnostic colonoscopy group, and an invasive colonoscopy group. The colonoscopy occurred within one year after undergoing the index procedure. Demographics, including age and sex, along with comorbidity data (using the Elixhauser Comorbidity Index), were collected. The primary outcomes assessed were the incidence of PJI and the rate of all-cause revision at 3 years postoperatively. Results A total of 1,244 patients in the diagnostic colonoscopy group, 2,973 in the invasive colonoscopy group, and 74,309 in the control group were identified. At three years postoperatively, the incidence of PJI was not significantly different between the diagnostic (3.94% vs. 3.29%, p = 0.20) or invasive (3.8% vs. 3.29%, p = 0.13) groups compared to controls. However, while the rate of all-cause revision in the diagnostic group (7.32% vs. 7.53%, p = 0.78) did not differ significantly from controls, the invasive colonoscopy group approached statistical significance (8.48% vs. 7.53%, p = 0.05) in univariate analysis and was statistically significant in multivariate analysis (OR = 1.63, p ≤ 0.01).  Conclusion This study found that undergoing a diagnostic or invasive colonoscopy within one year after RSA does not increase the risk of PJI at three years postoperatively. However, patients who underwent invasive colonoscopy exhibited a higher rate of all-cause revision, which was statistically significant in multivariate analysis. These findings suggest that routine colonoscopy screening should not be deferred in RSA patients due to infection concerns, but the increased risk of revision following invasive colonoscopy highlights the need for further research to determine potential underlying factors.

Anatomic or reverse total shoulder arthroplasty? How fellowship training affects selection of arthroplasty type

BACKGROUND

Although 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 among providers. Although surgeons with differing fellowship training commonly perform these procedures, it is not understood how fellowship training influences choice of implant.

METHODS

A national database was queried to identify surgeons performing ATSA and rTSA. For all surgeons who performed more than 10 cases between 2010 and 2022, fellowship data were individually collected via an online search. For each fellowship group, rates of ATSA and rTSA were identified using International Classification of Diseases procedural codes. Those who underwent revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Primary outcome measures included the proportion of primary and revision ATSAs and rTSAs by fellowship in addition to the rate of rTSA performed for a primary diagnosis of glenohumeral osteoarthritis.

RESULTS

A total of 131,974 patients met the inclusion criteria and were retained for this study. The proportion of rTSAs 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 than Shoulder surgeons. Surgeons in the Other cohort were more likely to perform primary ATSA rather than rTSA in comparison with surgeons in the Shoulder and Sports cohorts. Sports surgeons were responsible for the greatest increase in the percentage of all shoulder arthroplasty procedures from 2010 to 2022 (28.4%-40.4%), whereas the Other group decreased by a comparable amount (45.9%-32.4%) over the same period.

CONCLUSIONS

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 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 ATSAs in their arthroplasty practice. Revision ATSA and revision rTSA represent a larger percentage of overall case volume for Shoulder and Elbow surgeons.

Impact of a Recently Accredited Orthopedic Surgery Residency on Patient Outcome Scores in Total Shoulder Arthroplasty: A Retrospective Study

BACKGROUND

Patient-reported outcome measures are a valuable tool to evaluate an intervention from a patient's perspective. Previous evidence shows that, while resident involvement may increase operative times, it does not affect complications or patient-reported outcomes. This study sought to assess the impact of a new residency program on patient-reported outcome measures, operative time, and complication rates in total shoulder arthroplasty.

MATERIALS AND METHODS

A retrospective cohort study was performed of patients who underwent total shoulder arthroplasty at a single health care system. Demographic data, resident presence during shoulder arthroplasty, arthroplasty type, procedure duration, complications, and American Shoulder and Elbow Surgeons (ASES) score change were collected. Patients 18 years or older who underwent primary anatomic or reverse total shoulder arthroplasty were included. Patients who did not meet the inclusion criteria, had a preoperative diagnosis other than primary osteoarthritis, lacked preoperative and postoperative ASES scores, and canceled procedures were excluded.

RESULTS

A total of 139 patients were identified and included in our analysis. Ninety-seven total shoulder arthroplasties were performed with a resident not present, and 42 with a resident present. This study showed no significant effects of the presence or absence of a resident on ASES scores, complication rates, or surgery times.

CONCLUSION

This study adds to previous evidence indicating that attending orthopedic surgeons can support resident learning and surgical skill development while maintaining patient-reported outcome measures, surgical time, and complication rates similar to those without resident involvement when performing shoulder arthroplasty. [Orthopedics. 2025;48(2):104-110.].

Patients posture affects clinical outcomes and range of motion after reverse total shoulder arthroplasty: A clinical study

Background

Movement limitations following implantation of reverse total shoulder arthroplasty (rTSA) have been observed in some patients postoperatively, with implant design and positioning recognized as important influential factors. Recent analyses have identified patient's posture, measured as scapula internal rotation on computed tomography (CT), as an additional factor influencing the functional outcome after rTSA. However, no clinical study has correlated the preoperatively photo-documented posture to functional outcome. It was the aim of this study to correlate preoperatively photo-documented posture to scapula orientation using CT and analyze the influence on functional outcome following rTSA implantation.

Methods

A prospectively enrolled rTSA database was retrospectively reviewed to include a total of 360 patients with a minimum follow-up of 2 years. Patient's posture was analyzed using standardized preoperative photo and video documentation. The posture was defined following the classification system of Moroder et al as type A (upright posture, retracted scapulae), type B (intermediate), and type C (kyphotic posture with protracted scapulae). In addition, CT data were used to measure scapula position (internal rotation). Correlation analyses between them were conducted. Postoperative range of motion (ROM) and clinical outcomes (absolute Constant-Murley Score and relative Constant-Murley Score) were compared between the different posture types.

Results

According to the photo-documented posture types, the patients were divided into posture types A (n = 59), B (n = 253) and C (n = 48). Average absolute Constant-Murley Score differed significantly among the groups (69 ± 16 vs. 69 ± 14 vs. 64 ± 16, P < .05) favoring patients with posture types A and B over type C. In terms of ROM, flexion, abduction, and internal rotation significantly differed among the groups. Types A and B exhibited better flexion and abduction (flexion 124 ± 26° and 123 ± 23° vs. 113 ± 25°, abduction 140 ± 34° and 137 ± 30° vs. 128 ± 34°). Patients with posture type A demonstrated superior internal rotation (CS points: 5.9 ± 2.9 vs. 5.0 ± 2.7 vs. 4.4 ± 2.8, P < .05). External rotation was better for type A compared to type C (A: 33 ± 17° vs. B: 30 ± 16° vs. C: 28 ± 18°). Correlation analysis of posture classification using photo documentation and CT scan showed poor reliability (r = 0.35).

Conclusion

Patients with clinical posture types A and B exhibited improved ROM values compared to type C postures. Clinical outcome scores were also notably superior in types A and B. However, the measurement of scapula internal rotation on supine CT does not reliably correlate with photo documentation of patient's posture. Preoperatively, patient's posture should be considered in rTSA planning because of the potential influence on ROM and clinical outcomes.

Trends in shoulder arthroplasty research over the decades

Introduction

The aim of this study is to analyse the most cited articles in shoulder arthroplasty surgery and identify trends in topics by decade.

Methods

Journal Citation Index Web of Science (WoS) was searched to find articles using the search terms "shoulder arthroplasty", "shoulder hemiarthroplasty", "shoulder replacement" and "shoulder prosthesis". All articles were ranked according to most cited overall and most cited between 2022 and 2023, and then further analysed to find the most cited articles per decade. Articles were studies for topic, study type, evidence level and number of subjects. A second search was performed using Google Scholar (GS) with the same search terms.

Results

All the most cited articles were published in 4 orthopaedic journals. Citation counts were higher for GS searches than WoS for every article, by an average of 1.92 times. Each decade's most cited articles seemed to fit into a few broad topics, showing trends in that decade. The highest cited papers were generally low-level evidence studies.

Conclusion

Shoulder arthroplasty literature appears to follow trends throughout the decade. High quality evidence is lacking in the highest cited papers, but this study highlights the importance and value of these lower-evidence breakthrough studies, which have shaped shoulder arthroplasty surgery.

Analyzing Declining Trends, Patient Demographics, and Complications in Total Elbow Arthroplasty: Nationwide Retrospective Data Analysis

Background: Total elbow arthroplasty (TEA) was initially introduced for end-stage rheumatoid arthritis but has since expanded to include osteoarthritis and complex distal humerus fractures, particularly in elderly patients. Over the past two decades, TEA utilization trends have fluctuated, with a recent decline attributed to advancements in disease-modifying antirheumatic drugs. Despite its benefits, TEA presents a high complication rate, necessitating further investigation into clinical outcomes, costs, and postoperative management. Methods: This retrospective cohort study analyzed TEA procedures from 2016 to 2019 using the National Inpatient Sample (NIS) database. Patients were identified via ICD-10 codes, with elective procedures included to ensure homogeneity. This study examined temporal trends, patient demographics, comorbidities, complication rates, length of stay (LOS), and hospitalization costs. Statistical analyses included chi-square tests, t-tests, and multivariate regression to assess associations between patient characteristics and outcomes. Results: A total of 4110 TEA procedures were analyzed, revealing a 16% decline in annual volume from 2016 to 2019 (p = 0.012). The cohort had a mean age of 65.99 years, with a predominance of female (75.3%) and White (72.6%) patients. The median LOS was two days, and median hospitalization costs were USD 78,473 (IQR: 56,935-115,671 USD). The most prevalent complications included mechanical loosening (12.5%), blood loss anemia (10.6%), cardiac complications (5.7%), and prosthetic-related pain (3.3%). Multivariate analysis identified hypertension, anemia, and respiratory disease as significant predictors of adverse outcomes. Conclusions: TEA utilization has declined, likely due to medical advancements in rheumatoid arthritis management. The procedure remains associated with substantial complication rates, particularly in trauma-related cases. Findings highlight the importance of patient optimization, surgical expertise, and postoperative monitoring to improve outcomes.

Comparative clinical outcomes and patient satisfaction in primary vs. revision total elbow arthroplasty

BACKGROUND

Total elbow arthroplasty has become a common surgical procedure. However, a certain percentage of patients may require revision due to unsatisfactory outcomes or complications. This study aimed to compare the clinical outcomes and patient satisfaction between primary and revision total elbow arthroplasty (TEA), considering factors such as etiology and causes for revision.

METHODS

The study utilized a retrospective analysis of medical records from a cohort of 33 and 18 cases of primary and revision TEA, respectively, with a minimum follow-up of 2 years from the primary procedure. Clinical outcomes were assessed by measuring the Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score, range of motion, numeric rating scale, the Single Assessment Numeric Evaluation questionnaire, and patient satisfaction.

RESULTS

Significant differences were observed between primary and revision groups in the Mayo Elbow Performance Score (79.5 vs. 65.0), Disabilities of the Arm, Shoulder and Hand scores (32.6 vs. 53.7), and elbow range of motion (107.6° vs. 85.8°). The patients' subjective assessment via the numeric rating scale score, Single Assessment Numeric Evaluation score, and satisfaction did not show significant differences. The average numeric rating scale score was 1.6 for both groups; however, the Single Assessment Numeric Evaluation score (63 vs. 54) and patient satisfaction (4.0 vs. 4.1) were not significantly different between groups.

CONCLUSION

The clinical outcomes of primary vs. revision TEA were significantly worse in the revision group. Patient satisfaction scores were not different between the primary and revision groups despite differences in outcome scores, suggesting that revision patients may be satisfied with their outcomes despite lower clinical scores. These findings underscore the importance of considering both patient-reported outcomes and satisfaction levels in addition to objective clinical measures when evaluating the success of primary vs. revision TEA procedures.

Utilization trends of the ExactechGPS® computer-assisted navigation system in total shoulder arthroplasty

BACKGROUND

Guidance technology in total joint arthroplasty has gained popularity over the last few decades. Computer-assisted navigation (CAN) was recently introduced for glenoid implantation in total shoulder arthroplasty (TSA). However, utilization trends of CAN TSA are not currently known. This study aims to determine the prevalence and trends of CAN usage in TSA from its introduction in 2017 until 2023.

METHODS

A retrospective review was performed of all TSAs (anatomic TSA [aTSA] or reverse TSA [rTSA]) implanted using a single computer navigation shoulder system (ExactechGPS®; Gainesville, FL). Intraoperative navigation was performed for the glenoid component only. Use of CAN was reported per year to determine trends in the prevalence of CAN cases, number of users, new users, dropped users, high-volume users (>50 CAN cases/year), and the number of cases completed by high-volume users. The data were also stratified by type of TSA (aTSA vs. rTSA) and type of glenoid component used (augmented or nonaugmented).

RESULTS

From 2017 to 2023, navigated TSAs increased from 654 to 9777 cases per year, with a greater increase in navigated rTSA than aTSA volume. The number of CAN cases using augmented implants grew 1435% whereas nonaugmented implants grew 1352%. By 2023, the overall number of CAN users increased from 79 to 667 users. High-volume CAN surgeons increased to 50 users by 2023. Over this period, the number of CAN TSA performed by high-volume surgeons increased more rapidly than the actual number of high-volume surgeons per year.

CONCLUSIONS

This study demonstrates an exponential increase in the use of CAN for TSA in the last 8 years. This increase is driven by progressive growth in both the volume of new users and CAN TSAs performed by existing users by several hundred folds. These upward trends in use of guidance technology for TSA are likely to continue in future.

How fellowship training affects complication rate after shoulder arthroplasty: a nationwide assessment

BACKGROUND

Total shoulder arthroplasty is performed by orthopedic surgeons with various fellowship training backgrounds. Whether surgeons performing shoulder arthroplasty with different types of fellowship training have differing rates of complications and reoperation remains unknown.

METHODS

The PearlDiver Mariner database was retrospectively queried from the years 2010 to 2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Fellowship was determined and verified via online search. Only surgeons who performed a minimum of 10 cases were selected; and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90-day, 1-year, and 5-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at P ≤ .00023.

RESULTS

In total, 150,385 patients met the inclusion criteria and were included in the study. Analysis of surgical trends revealed that Sports Medicine and Shoulder and Elbow fellowship-trained surgeons are performing an increasing percentage of all shoulder arthroplasty over time, with each cohort exhibiting an 11.3% and 4.2% increase from 2010 to 2022, respectively. The geographic region with the highest proportion of cases performed by Sports Medicine surgeons was the West, while the Northeast has the highest proportion of cases performed by Shoulder and Elbow surgeons. Shoulder and Elbow surgeons operated on patients that were significantly younger and had fewer comorbidities. Both Shoulder and Elbow and Sports Medicine surgeons had lower rates of postoperative complications at 90 days, 1 year, and 5 years in comparison to surgeons who completed another type of fellowship or no fellowship. Across each time point, the rates of individual complications between Sports Medicine and Shoulder and Elbow were comparable, but the pooled complication rate was lowest in the Shoulder and Elbow cohort.

CONCLUSION

Surgeons who have completed either a Sports Medicine or Shoulder and Elbow fellowship are performing an increasing proportion of shoulder arthroplasty over time. Sports Medicine and Shoulder and Elbow-trained surgeons have significantly lower complication rates at 90 days, 1 year, and 5 years postoperatively. The individual complication rates between Sports Medicine and Shoulder and Elbow are comparable, but Shoulder and Elbow have the lowest pooled complication rates overall.

Effect of Antifibrotic Medications on Development of Postoperative Adhesive Capsulitis and Need for Manipulation Under Anesthesia Following Total Shoulder Arthroplasty

BACKGROUND

The local inflammatory response after total shoulder arthroplasty leads to increased scar formation and, potentially, adhesive capsulitis. Recent research has evaluated the use of antifibrotic medications to decrease rates of postoperative adhesive capsulitis (AC).

METHODS

PearlDiver database was used to analyze patients from 2010 to 2022 who underwent total shoulder arthroplasty, identified by Common Procedural Terminology codes. Medication usage was determined using National Drug Codes. Patients who developed ipsilateral AC within 6 months after surgery or underwent a manipulation under anesthesia (MUA) within 12 months of diagnosis of AC were identified. Logistic regression analysis was used to evaluate patient characteristics and drug class usage that increased odds for postoperative AC within 12 months and for MUA within 6 months of diagnosis of AC.

RESULTS

Overall, 1.3% (993/79,010) of patients developed postoperative AC within 6 months of surgery. Of those who developed AC, 7.2% (71/993) underwent MUA within 12 months of diagnosis. Medication use with any of the drug classes had no markedly decreased odds for the development of AC or subsequent MUA. Male sex, increasing age, and diagnosis of depression all markedly decreased the odds of developing AC ((odds ratio) OR = 0.42, P = 0.001; OR = 0.95, P < 0.001; OR = 0.59, P = 0.04, respectively) and subsequent need for MUA (OR = 0.68, P ≤ 0.001; OR = 0.96, P < 0.001; OR = 0.87, P = 0.04, respectively).

CONCLUSION

Patients on an antifibrotic medication had no difference in the odds of being diagnosed with AC within 6 months of surgery and for MUA within 12 months of diagnosis of AC. Male sex, increasing age, and presence of depression markedly decreased the odds.

Retrospective analysis of the occurrence, potential risk factors and medical significance of pulmonary complications after total shoulder arthroplasty from the National Inpatient Sample database (2010-2019)

BACKGROUND

In USA, total shoulder arthroplasty (TSA) ranks amongst the top five surgeries that require hospitalization. As a result, the healthcare system in USA could face a considerable financial strain due to the emergence of subsequent pulmonary problems. This study aimed to conduct a thorough examination of the prevalence, influential factors and medical importance of pulmonary complications, with emphasis on pneumonia, respiratory failure and pulmonary embolism (PE) following total shoulder arthroplasty (TSA) procedures in USA.

METHODS

The National Inpatient Sample (NIS) was utilized to survey all patients who underwent primary elective TSA from 2010 to 2019. Pneumonia, respiratory failure and PE following TSA were considered to be pulmonary consequences. The inpatient expenses, length of hospitalization, death rates and patient characteristics of those with and without reported perioperative pulmonary problems were compared. The utilization of trend weights was necessary to obtain incidence estimates across USA, considering the stratified framework of the NIS database and the dependence on observed frequencies within the database. Two assessments were utilized to assess the projected annual rates of complications.

RESULTS

Between 2010 and 2019, a total of 189,695 patients were estimated to underwent primary elective TSA. Infections, such as pneumonia, respiratory failure or PE, complicated 1.4% (95% CI, 1.52%-1.64%) of TSA operations. The ailments at this period that were most likely to result in pulmonary problems were ulcer (adjusted odds ratio [AOR] = 9.43; 95% CI, 4.99-46.91), pulmonary circulation disorders (AOR = 9.01; 95% CI, 4.56- 31.92), weight loss (AOR = 4.84; 95% CI, 2.15-10.88), fluid and electrolyte disorders (AOR = 3.55; 95% CI, 2.55-4.95), alcohol abuse (AOR = 1.56; 95% CI, 1.08-2.26), congestive heart failure (AOR = 3.09; 95% CI, 1.83-5.24), chronic pulmonary disease (AOR = 2.45; 95% CI, 1.60-3.75), deficiency anaemia (AOR = 1.56; 95% CI, 1.08-2.26), depression (AOR = 1.47; 95% CI, 1.03-2.11) and obesity (AOR = 1.46; 95% CI, 1.01-2.11). A correlation was found between perioperative pulmonary problems and extended LOS (+ 3 days; 95% CI, 2-6) and increased hospitalization costs (= + 20,514 US dollars; 95% CI, 14,109-35,281).

CONCLUSIONS

This investigation primarily aimed to ascertain potential risk factors linked to pulmonary issues that may occur after TSA. The analysis revealed that the pneumonia rates decreased each year, whereas the PE rates remained relatively stable. A noticeable and consistent increase was found in respiratory failure from 2010 to 2019. The findings suggests that individuals who are older (primarily between the ages of 60 and 80 years) and female exhibit increased rates. These factors could help stratify patients and reduce the risk of potential complications. This claim is especially applicable in PE because it is associated with more significant improvements in resource utilization.

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

BACKGROUND

Total shoulder arthroplasty (TSA), encompassing both anatomical and reverse TSA, 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.

METHODS

The 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 were stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions.

RESULTS

Between 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 ($1108.59; P < .001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1223.44; P < .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 < .001). The average comorbidity burden of patients was 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 < .001).

CONCLUSION

This 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.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Impact of insurance payer type (medicare vs. private) on the patient reported outcomes after shoulder arthroplasty

Background

This study's purpose is to determine if there is a difference in patient-reported outcome measures (PROMs) following shoulder arthroplasty (SA) based upon payer insurance type, with a secondary outcome of determining if any appreciable difference surpasses the minimal clinically important difference (MCID).

Methods

Subjects undergoing anatomic and reverse total shoulder arthroplasty were prospectively enrolled between March 2019 and March 2021. Subjects completed patient reported outcomes measurement information system upper extremity (P-UE), the American Shoulder and Elbow Surgeons score (ASES), and the simple shoulder test (SST) preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months, postoperatively. Descriptive statistics of baseline patient characteristics and preoperative PROMs (ASES, SST, and P-UE) were compared between insurance types.

Results

143 patients were identified who met the inclusion criteria for this study. There were 98 patients within the Medicare cohort and 45 patients with private insurance. Patients in the Medicare cohort were older (mean age 70.5 vs. 61.3 years), with high proportion of smokers, diabetics, and reverse total shoulder arthroplasty compared to the private payor cohort. There were no significant differences between the two cohorts with respect to outcomes scores except for significantly better SST in the private insurance cohort (69.3 vs. 79.4, P = .02). No significant differences were noted for the achievement of MCID between cohorts [P-UE (P = 1.0), ASES (P = .25), and SST (0.52)] and pre-to-postoperative improvements for P-UE (P = .62), ASES (P = .4), or SST (0.66).

Conclusion

Our study demonstrates that, at a tertiary-level academic institution in a metropolitan city, payor type does not have significant impact on achieving MCID or pre-to-postoperative improvements in PROMs after SA.

Description of a new surgical approach for elbow arthroplasty: Selective Triceps-On Medial Paraolecranon (STOMP) approach

Background

Surgical approaches for total elbow arthroplasty (TEA) are broadly divided into two groups; "triceps-off" and "triceps-on" approaches. Traditional "triceps-off" approaches provide excellent visualization for TEA; however, they carry a risk of triceps failure and require triceps protecting rehabilitation protocols. Triceps-on approaches have the advantage of preservation of triceps function yet present technical challenges for access to and preparation of the bony surfaces of the proximal ulna and radius. We present here the operative technique, indications, and initial outcomes of a novel Selective Triceps-On Medial Paraolecranon (STOMP) approach for TEA, which allows both preservation of the triceps function and excellent exposure to the proximal ulna with minimal risk to the ulnar nerve.

Methods

A two center, retrospective cohort study of all patients undergoing primary TEA, hemiarthroplasty, or revision elbow arthroplasties using the STOMP approach in the practice of the senior authors between 2010 and 2020 were reviewed. Patient data, including admission demographics and diagnoses were collated. Outcome measures were collected from patient charts.

Results

A total of 37 elbow arthroplasties in 35 patients were performed with the STOMP approach during the reviewed period, of which 27 patients (77%) were female. Thirty-two arthroplasties were primary cases (86%), and 5 (14%) were revision cases. The main indications leading to elbow arthroplasty was rheumatoid arthritis (n = 18, 49%) followed by primary or secondary elbow osteoarthritis (n = 9, 24%) and distal humeral fracture (n = 7, 19%). There were 7 postoperative complications (19%). Five patients (14%) developed elbow stiffness, one patient a postoperative olecranon fracture (n = 1, 3%) and one patient had an ulnar nerve injury with incomplete resolution but that did not warrant surgical treatment (n = 1, 3%). A reoperation was required in 3 patients (9%).

Conclusion

The STOMP approach is a safe approach for elbow arthroplasty surgery. It does not detach the triceps and we believe it offers improved exposure and safety compared to other triceps-on techniques. Furthermore, this approach allows excellent surgical access to the coronoid, olecranon, and ulnar canal with low midterm complications.

Elbow arthroplasty utilization in 2060: projections of primary and revision elbow arthroplasty in the United States in the next 40 years

BACKGROUND

In the past decade, the prevalence of end-stage inflammatory elbow arthritis has declined with consequential changes in indications and utilization of total elbow arthroplasty (TEA). Current literature lacks future projections for the utilization of TEA. The aim of this study is to review the trends in the utilization of TEA in the last 2 decades and determine the projections of utilization for TEA (primary and revision) through 2060.

METHODS

This analysis used the publicly available 2000-2019 data from the CMS Medicare Part-B National Summary. Procedure volumes including TEA, and revision TEA, were determined using Current Procedural Terminology codes and were uplifted to account for the growing number of Medicare eligible patients covered under Medicare Advantage. Using these volumes, log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average models were applied to generate projections from 2020 to 2060. The Poisson model was chosen to display the data based on error analysis and prior literature.

RESULTS

The projected annual growth rates from 2020 to 2060 for primary and revision TEAs are 1.03% (95% confidence interval: 0.82%-1.25%) and 5.17% (95% confidence interval: 3.02%-6.97%), respectively. By 2060, the demand for primary TEA and revision TEA is projected to be 2084 procedures (95% forecast interval: 1995-2174) and 3161 procedures (95% forecast interval: 3052-3272), respectively. The procedure volume for revision TEA is estimated to outnumber primary TEA by year 2050.

CONCLUSION

The overall procedural volume of primary TEA and revision TEA continues to be low. Although it is estimated that the incidence of primary and revision TEAs will continue to increase in the next 40 years, the utilization trends only show a mild increase, which is 5 times higher for revision TEA than primary TEA.

Preoperative corticosteroid injections are associated with a higher periprosthetic infection rate following primary total shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

Corticosteroid injections (CSIs) are commonly used for the treatment of shoulder pain in patients with osteoarthritis and rotator cuff arthropathy. These injections may increase the risk of infection following eventual shoulder arthroplasty. The purpose of this study was to perform a systematic review and meta-analysis of existing data to explore the relationship between preoperative CSI's and postoperative periprosthetic joint infection (PJI) following shoulder arthroplasty.

METHODS

A literature search was performed on PubMed, Embase, and Web of Science databases through September 29, 2023. Of the 4221 retrieved, 7 studies including 136,233 patients were included for qualitative analysis. Studies describing patients receiving CSI prior to shoulder arthroplasty and the effect on postoperative infection risk were included in the systematic review and subsequent meta-analysis. Assessment of risk of bias was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Receiving a CSI prior to shoulder arthroplasty was found to have a statistically significant association with increased risk for PJI (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.06-1.19; P < .0001). The rate of PJI increased when injections were given closer to the time of surgery. Patients who received an injection at any time point before surgery had a 5.4% risk of PJI compared to 7.9% and 9.0% in patients receiving an injection within 3 months and 1 month of surgery, respectively. This time dependent association however did not reach statistical significance: 1 month OR 1.48; 95% Cl: 0.86-2.53; P = .16, 3 months OR 1.95; 95% Cl: 0.95-4.00; P = .07.

CONCLUSION

The results of this systematic review and meta-analysis demonstrate that patients receiving corticosteroid shoulder injections prior to shoulder arthroplasty may be at an increased risk for PJI postoperatively. While time dependent stratification did not reach statistical significance, our findings indicate a clear trend of increased risk for patients receiving injections closer to surgery.

Racial and gender disparities in utilization of outpatient total shoulder arthroplasties

BACKGROUND

Utilization in outpatient total shoulder arthroplasties (TSAs) has increased significantly in recent years. It remains largely unknown whether utilization of outpatient TSA differs across gender and racial groups. This study aimed to quantify racial and gender disparities both nationally and by geographic regions.

METHODS

168,504 TSAs were identified using Medicare fee-for-service inpatient and outpatient claims data and beneficiary enrollment data from 2020 to 2022Q4. The percentage of outpatient cases, defined as cases discharged on the same day of surgery, was evaluated by racial and gender groups and by different census divisions. A multivariate logistics regression model controlling for patient sociodemographic information (White vs. non-White race, age, gender, and dual eligibility for both Medicare and Medicaid), hierarchical condition category (HCC) score, hospital characteristics, year fixed effects, and patient residency state fixed effects was performed.

RESULTS

The TSA volume per 1000 beneficiaries was 2.3 for the White population compared with 0.8, 0.6, and 0.3 for the Black, Hispanic, and Asian population, respectively. A higher percentage of outpatient TSAs were in White patients (25.6%) compared with Black patients (20.4%) (P < .001). The Black TSA patients were also younger, more likely to be female, more likely to be dually eligible for Medicaid, and had higher HCC risk scores. After controlling for patient sociodemographic characteristics and hospital characteristics, the odds of receiving outpatient TSAs were 30% less for Black than the White group (odds ratio 0.70). Variations were observed across different census divisions, with South Atlantic (0.67, P < .01), East North Central (0.56, P < .001), and Middle Atlantic (0.36, P < .01) being the 4 regions observed with significant racial disparities. Statistically significant gender disparities were also found nationally and across regions, with an overall odds ratio of 0.75 (P < .001).

DISCUSSION

Statistically significant racial and gender disparities were found nationally in outpatient TSAs, with Black patients having 30% (P < .001) fewer odds of receiving outpatient TSAs than White patients, and female patients with 25% (P < .001) fewer odds than male patients. Racial and gender disparities continue to be an issue for shoulder arthroplasties after the adoption of outpatient TSAs.

Same-day discharge vs. inpatient total shoulder arthroplasty: an age stratified comparison of postoperative outcomes and hospital charges

BACKGROUND

As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly.

METHODS

This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and IP settings. The outcome measures included length of stay (LOS), complications, hospital charges, emergency department (ED utilization), readmissions, and reoperations within 90 days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P < .05 was considered statistically significant.

RESULTS

There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (American Society of Anesthesiologists score P = .12, Elixhauser Comorbidity Index P = .067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P < .001), and the SDD group higher rate of intraoperative tranexamic acid use (P = .015) and lower estimated blood loss (P = .009). There were no differences in 90-day overall minor (P = .20) and major complications (P = 1.00), ED utilization (P = .63), readmission (P = .25), or reoperation (P = .51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P = .80) and minor (P = .36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS = 8.4 hours in ≥65 to <75-year cohort vs. LOS = 25.9 hours in ≥80-year cohort; P < .001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P = .82).

CONCLUSION

SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting.

Sex Disparities Affecting Postoperative Outcomes After Total Elbow Arthroplasty

Purpose

To investigate sex disparities in 30-day postoperative outcomes of total elbow arthroplasty.

Methods

The American College of Surgeons-National Surgical Quality Improvement Program files were queried for all patients who underwent a total elbow arthroplasty (TEA) between 2006 and 2020. Sex disparities in preoperative variables were studied using Fisher exact tests. Multivariate logistic regression models were used to determine the adjusted odds ratios (aOR) of postoperative outcomes for women in comparison with men.

Results

A total of 788 patients underwent a TEA in the period of 2006-2020. Of those, 180 were men, and 608 were women. We found an increase in TEAs performed each year with a predominance in females compared to males. Additionally, our work demonstrated increased statistically significant odds of a major adverse cardiac event (P < .0001), transfusions required (P < .0001), and return to the operating room (P < .0001) as postoperative outcomes in females compared to males following TEA. Finally, we found no statistically significant difference in mortality between the groups (P = 1).

Conclusions

Following a TEA, women had higher adjusted postoperative odds of experiencing a major adverse cardiac event, requiring transfusion, and return to the operating room. No significant differences were found in wound outcomes, pulmonary outcomes, venous thromboembolic outcomes, sepsis, and length of stay. Overall mortality rates were similar between the two groups. Our study warrants further evaluation of the root cause of sex disparities in TEA outcomes and methods to improve care delivery to reduce those disparities.

Type of study/level of evidence

Prognostic 2b.

Cortical windows for implant and cement removal during revision total elbow arthroplasty

Background

Revision total elbow arthroplasty (rTEA) remains a technically challenging procedure with potential for substantial morbidity. Cases involving excessively long cement mantles, removal of well-fixed implants or infected revisions requiring complete cement removal introduce additional technical challenges. Our purpose was to describe the outcomes, results, and complications associated with the use of cortical windows in rTEA. In addition, we provide a technical description of the procedure.

Methods

rTEA cases utilizing a cortical window performed by two surgeons between 2019 and 2023 were reviewed. Baseline demographics and case characteristics were recorded. Preoperative and postoperative outcomes were compared, including range of motion, radiographic outcomes, surgical complications and patient-reported outcome measures.

Results

Seven rTEA cases involving either a humeral or ulnar cortical window were included with an average follow-up of 15 months. Indications for cortical windows included infection, periprosthetic humerus fracture and presumed aseptic loosening. Improvements were noted postoperatively for pain scores, Quick Disabilities of the Arm, Shoulder and Hand and Single Assessment Numeric Evaluation elbow scores. Final flexion-extension and pronation-supination were 100° and 156°. One patient (14%) had a postoperative complication (failure of fixation of a periprosthetic humerus fracture). There were no cases of intraoperative iatrogenic fracture or nerve injury.

Conclusion

For rTEA cases during which a cortical window was performed, complications occurred infrequently in the short term. In these challenging procedures, cortical windows appear to provide a relatively safe and efficient means of removing excessively long cement mantles or well-fixed components.

How to Run a Cost-Effective Operating Room: Opportunities for Efficiency and Cost-Savings

US health care spending is growing at an unsustainable rate. Since physicians control or influence the majority of spending, it is our responsibility to try and control costs. As surgeons we need to learn and consider the cost of implants and supplies and factor them into our treatment decisions to ensure we are providing value for our patients. Although the burden is on us to become more cost conscious, we should never do it at the expense of quality of patient care.

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

Background

With the historical complications when using total shoulder arthroplasty (TSA) to revise failed arthroplasties, and the success of the reverse prosthesis in the revision setting, the question arises whether revision to TSA is still a reasonable option? This systematic review examines revision to TSA and the factors associated with outcomes.

Methods

A systematic review was performed for studies of TSA used to revise a failed hemiarthroplasty or TSA. The primary outcome was implant failure leading to a repeat revision arthroplasty. Secondary outcomes included visual analog scale (VAS) pain scores, shoulder motion and other clinical outcomes of shoulder function. Data were pooled to generate representative frequency-weighted means.

Results

Thirteen studies were included, totaling 312 shoulders. Etiologies for revision included glenoid arthrosis (62%), glenoid component failure (36%), and other (2%). Of which, 39% of cases experienced complications and 12% required another arthroplasty revision. Secondary outcomes such as VAS pain, Constant, ASES and UCLA score improved, but none were statistically significant. Unsatisfactory outcomes were higher among patients with glenoid bone loss, instability, and soft tissue deficiencies.

Discussion

Revision to anatomic TSA can be an acceptable option in certain patients. However, the high rate of complications and glenoid loosening, makes this a limited approach for a revision to anatomic TSA procedure.

Evaluation of interleukin-6 in synovial fluid in periprosthetic joint infection of the elbow

PURPOSE

Searching for quick determinable biomarkers with high sensitivity and specificity is necessary to improve and optimise the early diagnosis of periprosthetic elbow infection (PEI). Therefore, this study's objective was to evaluate the diagnostic value of synovial fluid interleukin-6 (IL-6) levels for diagnosing PEI in total elbow arthroplasty.

METHOD

Twelve prospective enrolled patients underwent total elbow arthroplasty revision surgery, during which synovial fluid was obtained. Between the initial implantation and the revision procedure were 33.5 ± 41 months (range, 2-144 months). Synovial fluid was collected for immediate IL-6 analysis parallel to the revision surgery. Furthermore, microbiological samples were obtained and analysed. Two groups were defined based on the microbiological results: non-infection and infection group. The ability of synovial fluid IL-6 analysis to predict infection status was explored using receiver operating characteristic curves and further statistical analysis.

RESULTS

Synovial fluid IL-6 analysis had a good diagnostic accuracy of 83% for PEI with an area under the curve of 0,79 and an ideal cutoff value (determined using Youden's criterion) of 15244 pg/mL.

DISCUSSION

This is the first study to clinically evaluate IL-6 as a diagnostical marker for periprosthetic joint infection (PJI) in total elbow arthroplasty. Our results suggest a good accuracy and high sensitivity for IL-6 to identify a PEI. The analysis of IL-6 can improve surgical decision-making regarding managing total elbow arthroplasty in terms of one- or two-staged revision.

CONCLUSION

IL-6 can play an important role in the perioperative differentiation of infected and non-infected situations.

The role of body mass index in survivorship and clinical outcomes in total shoulder arthroplasty

BACKGROUND

Increased body mass index (BMI) is a potential risk factor for poorer outcomes and complications. However, the influence of BMI on the long-term outcomes of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) remains to be fully elucidated.

METHODS

Institutional records were queried to identify patients who underwent primary total shoulder arthroplasty (TSA) between 2009 and 2020 with a minimum of 2 years of clinical follow-up. Retrospective review was performed to collect demographic characteristics; comorbidity status; and range-of-motion and strength measurements in forward elevation, external rotation, and internal rotation. Patients were contacted by telephone to provide patient-reported outcomes (PROs). Patients were stratified into 3 cohorts by BMI: underweight or normal weight (U/NW, BMI ≤25 kg/m2), overweight (OW, BMI >25 to ≤30 kg/m2), and obese (BMI >30 kg/m2).

RESULTS

Among 466 TSA patients, 245 underwent aTSA whereas 221 underwent rTSA. In the aTSA cohort, 40 patients were classified as U/NW; 72, as OW; and 133, as obese. Comparatively, the rTSA cohort was composed of 33 U/NW, 79 OW, and 209 obese patients. Patients in the aTSA and rTSA cohorts had an average follow-up period of 5.8 ± 3.2 years and 4.5 ± 2.3 years, respectively. No differences in age at surgery were found in the aTSA group (U/NW vs. obese, 65.2 ± 7.9 years vs. 61.9 ± 8.9 years; P = .133); however, in the rTSA cohort, BMI was found to be inversely related to age at surgery (U/NW vs. obese, 72.4 ± 8.8 years vs. 65.7 ± 8.3 years; P < .001). Across all BMI cohorts, patients saw great improvements in range of motion and strength. Postoperative PROs after TSA did not vary by BMI in terms of Single Assessment Numeric Evaluation, Simple Shoulder Test, visual analog scale pain, and American Shoulder and Elbow Surgeons scores. There was no significant difference in survival rates at 10-year follow-up in the aTSA cohort (U/NW vs. obese, 95.8% vs. 93.2%; P = .753) or rTSA cohort (U/NW vs. obese, 94.7% vs. 94.5%; P = .791).

CONCLUSION

With dramatic improvements in range of motion, minimal differences in PROs, and high rates of implant survival, TSA is a safe and effective treatment option for all patients, including overweight and obese patients.

Is the impact of previous rotator cuff repair on the outcome of reverse shoulder arthroplasty clinically relevant? A systematic review of 2879 shoulders

Background

Outcomes of reverse shoulder arthroplasty (RSA) in patients with prior rotator cuff repair (RCR) remain inconsistent. The purpose of this study, therefore, was to systematically review the current outcomes literature on RSA in patients with prior RCR and to compare the results with controls without prior RCR.

Methods

A systematic review of the literature was performed, and outcome studies reporting on functional and clinical outcomes were included.

Results

A total of 11 studies encompassing 2879 shoulders were included. Improvements in postoperative patient-reported outcomes (PROs) from the baseline were higher in controls including the American Shoulder and Elbow Surgeons score (47.0 vs 39.5), Simple Shoulder Test (6.0 vs 4.9), Constant score (32.6 vs 26.4), and Visual Analog Scale for pain (-5.6 vs -4.9). Improvement in range of motion was greater in the control group, including external rotation (17° vs 11°), anterior elevation (56° vs 43°), and abduction (52° vs 43°). The overall complication rate (8% vs 5%) and revision rate (3% vs 1%) were higher in the RCR group.

Discussion

Differences in postoperative PROs and improvement from the baseline demonstrate a trend toward lower outcomes in patients with prior RCR but may be below the minimal clinically import difference.

Level of evidence

IV; systematic review.

Incidence of and Risk Factors for Reoperation and Revision Following Total Elbow Arthroplasty with an Anatomic Convertible Prosthesis

BACKGROUND

Total elbow arthroplasty (TEA) remains a valuable tool for treating inflammatory, degenerative, and traumatic elbow conditions. This study aimed to understand the incidence of and risk factors for reoperation following TEA at a high-volume center utilizing an implant with a convertible linkage and the potential for anatomic lateral column reconstruction.

METHODS

All patients undergoing primary TEA with the Latitude prosthesis (Stryker) from July 2001 to May 2020 were identified. Patient characteristics, the surgical indication, and implant characteristics were obtained. Additionally, the indications and timing were identified for reoperations. Postoperative radiographs were analyzed to assess cement quality, implant position, lateral column reconstruction, and distal humeral bone loss.

RESULTS

Two hundred and nineteen TEAs were performed in 206 patients; 162 (74.0%) were in female patients, the mean patient age was 61 years (range, 23 to 95 years), and the mean follow-up was 11.8 years (range, 2 to 21 years). The most common indication for surgery was sequelae of trauma (36%). Ninety elbows (41.1%) required 200 reoperations at a mean of 19.6 months. Forty TEAs (18.3%) required revision of nonmodular implants, with 14 (6.4%) undergoing definitive explantation. The 5 and 10-year survivorship was 86.1% and 79.7%, respectively. The most common of the reasons for revision was aseptic loosening (53.8%), and the most common cause for non-revision reoperation was infection (23%). Younger age and greater follow-up duration were associated with greater revision and reoperation risks. Aseptic ulnar loosening was associated with a short ulnar stem length and component linkage (30% of short linked ulnar stems loosened; p < 0.001). Aseptic humeral loosening was associated with less-than-adequate cement-mantle quality (p = 0.04).

CONCLUSIONS

Extended follow-up of the Latitude prosthesis at a high-volume center demonstrates that TEA continues to be hampered by a high reoperation rate, primarily due to infection and aseptic loosening. Technical factors such as good cement-mantle quality, longer stem length, and unlinked implants may play a role in preventing aseptic loosening. Further work is required to optimize long-term outcomes following TEA through improved understanding of appropriate surgical indications, techniques, and implant utilization.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Convertible-platform shoulder arthroplasty

Background

Shoulder arthroplasty has become an increasingly common procedure used to treat degenerative, inflammatory, and traumatic conditions of the glenohumeral joint. With a significant increase in primary anatomic and reverse total shoulder arthroplasty, revision procedures have likewise increased. Updates in shoulder arthroplasty have allowed for the convertibility of implants, which allows for the retention of both glenoid and humeral components during revision surgery. This review aims to highlight the epidemiology, indications, and outcomes of convertible-platform total shoulder arthroplasty procedures.

Methods

A review of the current literature surrounding convertible-platform shoulder arthroplasty was completed to highlight the advantages and disadvantages of commercially available instrumentation and implant systems as well as their outcomes.

Discussion

Leading causes of shoulder arthroplasty revision surgery include glenoid failure, implant instability, and rotator cuff dysfunction. Variations in implant design between inlay and onlay humeral components and metal-backed glenoid components are important considerations at the time of revision surgery. Advantages of convertible-platform systems include increased efficiency and decreased complications during revision procedures as well as shorter recovery, lower cost, and better functional outcomes. Limitations of convertible systems include poorly positioned components during the index procedure, excessive soft-tissue tensioning, and problems associated with metal-backed glenoid implants. Changes in arm length have also been documented. These findings indicate the benefit of additional research and design to improve the effectiveness and utility of convertible-platform shoulder arthroplasty systems.

Mixed-reality improves execution of templated glenoid component positioning in shoulder arthroplasty: a CT imaging analysis

INTRODUCTION

Glenoid placement is critical for successful outcomes in total shoulder arthroplasty (TSA). Preoperative templating with three-dimensional imaging has improved implant positioning, but deviations from the planned inclination and version still occur. Mixed-Reality (MR) is a novel technology that allows surgeons intra-operative access to three-dimensional imaging and templates, capable of overlaying the surgical field to help guide component positioning. The purpose of this study was to compare the execution of preoperative templates using MR vs.standard instruments (SIs).

METHODS

Retrospective review of 97 total shoulder arthroplasties (18 anatomic, 79 reverse) from a single high-volume shoulder surgeon between January 2021 and February 2023, including only primary diagnoses of osteoarthritis, rotator cuff arthropathy, or a massive irreparable rotator cuff tear. To be included, patients needed a templated preoperative plan and then a postoperative computed tomography scan. Allocation to MR vs. SI was based on availability of the MR headset, industry technical personnel, and the templated preoperative plan loaded into the software, but preoperative or intraoperative patient factors did not contribute to the allocation decision. Postoperative inclination and version were measured by two independent, blinded physicians and compared to the preoperative template. From these measurements, we calculated the mean difference, standard deviation (SD), and variance to compare MR and SI.

RESULTS

Comparing 25 MR to 72 SI cases, MR significantly improved both inclination (P < .001) and version (P < .001). Specifically, MR improved the mean difference from preoperative templates (by 1.9° inclination, 2.4° version), narrowed the SD (by 1.7° inclination, 1.8° version), and decreased the variance (11.7-3.0 inclination, 14.9-4.3 version). A scatterplot of the data demonstrates a concentration of MR cases within 5° of plan relative to SI cases typically within 10° of plan. There was no difference in operative time.

CONCLUSION

MR improved the accuracy and precision of glenoid positioning. Although it is unlikely that 2° makes a detectable clinical difference, our results demonstrate the potential ability for technology like MR to narrow the bell curve and decrease the outliers in glenoid placement. This will be particularly relevant as MR and other similar technologies continue to evolve into more effective methods in guiding surgical execution.

Structural bone grafting for glenoid bone loss in primary anatomic total shoulder arthroplasty: a case series and technique report

Background

Posterior glenoid bone loss in glenohumeral osteoarthritis poses significant challenges in shoulder arthroplasty. Anatomic total shoulder arthroplasty (TSA) with a humeral head autograft to address the glenoid bone deficiency is an option for these difficult cases. Variable results with this procedure are reported in the literature. This article describes the surgical technique of posterior glenoid bone grafting in TSA using a glenoid implant with hybrid fixation and a series of reported patient functional and radiographic outcomes.

Methods

A retrospective chart review of cases from 2015 to 2020 by a single surgeon revealed 10 patients who underwent primary TSA with hybrid glenoid component and posterior glenoid bone grafting. Preoperative and postoperative radiographs were assessed for glenoid inclination, glenoid version, acromiohumeral distance, humeral stem status, and glenoid implant status. Functional outcomes were evaluated by range of motion, strength, and patient-reported clinical outcomes (pain and function on a visual analog scale, Disabilities of the Arm, Shoulder, and Hand score, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons score). Complications and reoperations were also evaluated.

Results

Average follow-up was 31.4 months, active forward flexion and external rotation improved on average from 105° to 150° and 20° to 60°, respectively (P < .001) and average abduction improved from 100° to 140° (P < .002). At an average of 26.7 months, patients reported assessments (visual analog scale pain and function, Disabilities of the Arm, Shoulder, and Hand score, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons scores) reveal significant (P < .05) improvement in pain and functional outcomes. Radiographically, at 23.0 ± 20.1 months, all patients demonstrated a well-fixed humeral and glenoid component without evidence of lucent lines. The bone graft used in each patient was well unionized and no radiographic complications were reported. No patients underwent revision surgery, and there was one clinical complication reported, which consisted of a suspected rotator cuff injury at follow-up.

Conclusion

Hybrid fixation with structural glenoid bone grafting in TSA resulted in excellent outcomes with no evidence of graft or component failure on follow-up radiographs and significantly reduced pain, improved functional scores, and improved active range of motion.

Midterm follow-up of the Nexel total elbow arthroplasty

BACKGROUND

Aseptic loosening is one of the most common complications of total elbow arthroplasty (TEA). Modern implants, such as the Nexel, have been designed in an attempt to decrease loosening. The present study aims to report implant survivorship, radiographic assessment of loosening and lucency, and patient-reported outcome measures (PROMs) in patients treated with the Nexel TEA at midterm follow-up.

METHODS

Consecutive series of adult patients underwent TEA using the Nexel by a single surgeon via standardized technique. Patients with minimum 3-year follow-up with radiographic and PROM data were included. Survivorship was defined by the absence of revision. Loosening was assessed via the Wrightington method by 3 independent fellowship-trained shoulder and elbow surgeons. Lucency was analyzed across individual radiographic zones on orthogonal radiographs. PROMs included the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Patient-Rated Elbow Evaluation (PREE), and EuroQoL-5 Dimensions (EQ-5D).

RESULTS

Thirty-eight consecutive patients (22 female, 16 male) with a mean age of 67 years underwent TEA via a triceps-sparing isolated medial window approach. Mean follow-up was 5.5 years (range 3-9). Primary diagnoses were as follows: 19 osteoarthritis (OA), 9 rheumatoid arthritis (RA), 9 post-traumatic arthritis (PA), and 1 conversion of elbow arthrodesis. Overall survivorship was 97.4%, with 1 patient undergoing revision for infection. Loosening was found in 5.3% of elbows, averaged across 3 observers. Lucency was most pronounced at the level of the humeral condyles. PROMs demonstrated significant and clinically meaningful improvements in 76%, 92%, and 73% of patients for QuickDASH, PREE, and EQ-5D, respectively. No significant correlations were found between patient age, gender, loosening, lucency, and PROMs.

CONCLUSION

At midterm follow-up, the Nexel TEA demonstrated excellent overall survivorship and low rate of implant loosening. The single failure requiring revision for infection was conversion of a prior elbow arthrodesis. PROMs overall exhibited marked and consistent improvement from preoperative to final postoperative follow-up. Although promising, these results should be interpreted with some caution as long-term data regarding this prosthesis are still lacking.

Recent Advances in the Design and Application of Shoulder Arthroplasty Implant Systems and Their Impact on Clinical Outcomes: A Comprehensive Review

Purpose of Review

This narrative review comprehensively aims to analyze recent advancements in shoulder arthroplasty, focusing on implant systems and their impact on patient outcomes. The purpose is to provide a nuanced understanding of the evolving landscape in shoulder arthroplasty, incorporating scientific, regulatory, and ethical dimensions.

Recent Findings

The review synthesizes recent literature on stemless implants, augmented glenoid components, inlay vs onlay configurations, convertible stems, and associated complications. Notable findings include improved patient-reported outcomes with stemless implants, variations in outcomes between inlay and onlay configurations, and the potential advantages of convertible stems. Additionally, the regulatory landscape, particularly the FDA's 510(k) pathway, is explored alongside ethical considerations, emphasizing the need for standardized international regulations.

Summary

Recent innovations in shoulder arthroplasty showcase promising advancements, with stemless implants demonstrating improved patient outcomes. The review underscores the necessity for ongoing research to address unresolved aspects and highlights the importance of a standardized regulatory framework to ensure patient safety globally. The synthesis of recent findings contributes to a comprehensive understanding of the current state of shoulder arthroplasty, guiding future research and clinical practices.

The Future of Total Elbow Arthroplasty: A Statistical Forecast Model for Germany

This study provides a statistical forecast for the development of total elbow arthroplasties (TEAs) in Germany until 2045. The authors used an autoregressive integrated moving average (ARIMA), Error-Trend-Seasonality (ETS), and Poisson model to forecast trends in total elbow arthroplasty based on demographic information and official procedure statistics. They predict a significant increase in total elbow joint replacements, with a higher prevalence among women than men. Comprehensive national data provided by the Federal Statistical Office of Germany (Statistisches Bundesamt) were used to quantify TEA's total number and incidence rates. Poisson regression, exponential smoothing with Error-Trend-Seasonality, and autoregressive integrated moving average models (ARIMA) were used to predict developments in the total number of surgeries until 2045. Overall, the number of TEAs is projected to increase continuously from 2021 to 2045. This will result in a total number of 982 (TEAs) in 2045 of mostly elderly patients above 80 years. Notably, female patients will receive TEAs 7.5 times more often than men. This is likely influenced by demographic and societal factors such as an ageing population, changes in healthcare access and utilization, and advancements in medical technology. Our projection emphasises the necessity for continuous improvements in surgical training, implant development, and rehabilitation protocols.

Delayed elective total shoulder arthroplasty: causes and eventual outcomes

PURPOSE

The purpose of this study is to identify risk factors for delays in planned total shoulder arthroplasty (TSA) and determine the perioperative outcomes of TSAs that experienced a delay.

METHODS

The American College of Surgeons National Quality Improvement Program (NSQIP) database was queried from 2006 to 2019 for primary TSA. Delayed TSA was defined as surgery that occurred greater than one day after hospital admission. Patient demographics, comorbidities, and post-operative complications were collected and compared; the incidence of delayed TSA was analyzed.

RESULTS

The delayed patients were older, had a higher BMI, a higher rate of recent prior major surgery, and more comorbidities. Delayed patients had higher rates of postoperative complications, return to the OR, and 30-day readmission. Between 2006 and 2019, the rate of delayed TSA decreased.

CONCLUSION

Surgeons should take care to ensure that patients with comorbidities undergo thorough preoperative clearance to prevent same-day cancellations and postoperative complications.

The association of alcohol use disorder with revision rates and post-operative complications in total shoulder arthroplasty

Background

Alcohol use disorder (AUD) is the most prevalent substance use disorder in the United States. However, the current literature on AUD as a preoperative risk factor for Total Shoulder Arthroplasty (TSA) outcomes is limited. The purpose of this study was to identify the association of AUD with revision rates and 90-day postoperative complications in TSA.

Methods

A retrospective study was conducted using the PearlDiver database. Patients diagnosed with AUD were identified. Patients in remission or with underlying cirrhosis were excluded. Outcomes included 2-year revision, 90-day readmission, 90-day emergency, and 90-day post-operative medical complications. Analysis was performed with univariate chi-squared tests followed by multivariable logistic regression.

Results

A total of 59,261 patients who underwent TSA for osteoarthritis were identified, with 1522 patients having a diagnosis of AUD. Multivariable logistic regression showed that patients with AUD were more likely to undergo 2-year all-cause revision (OR = 1.49, p  =  0.007), 2-year aseptic revision (OR = 1.47, p  =  0.014), 90-day hospital readmission (OR = 1.57, p  =  0.015), and 90-day transient mental disorder (OR = 2.13, p  =  0.026).

Conclusions

AUD is associated with increased rates of 2-year revision surgery, as well as 90-day readmission and 90-day transient mental disorder following primary TSA for osteoarthritis. These findings may assist orthopedic surgeons in counseling patients with AUD during the pre-operative course.

Clinical Outcomes Do Not Deteriorate Over Time Following Primary Reverse Total Shoulder Arthroplasty: Minimum 10-Year Follow-up of 135 Shoulders

Background

Reverse total shoulder arthroplasty (RTSA) offers satisfactory mid-term outcomes for a variety of pathologies, but long-term follow-up data are limited. This study demonstrates the long-term clinical and radiographic outcomes as well as the predictive factors for an inferior outcome following RTSA.

Methods

Using the prospective database of a single, tertiary referral center, we included all primary RTSAs that were performed during the study period and had a minimum 10-year follow-up. Clinical outcomes included the absolute Constant-Murley score (CS), relative CS, Subjective Shoulder Value (SSV), range of motion, pain, complication rate, and reintervention rate. Radiographic measurements included the critical shoulder angle (CSA), lateralization shoulder angle (LSA), distalization shoulder angle (DSA), reverse shoulder angle (RSA), acromiohumeral distance (ACHD), center of rotation, glenoid component height, notching, radiolucent lines, heterotopic ossification, and tuberosity resorption.

Results

A total of 135 shoulders (133 patients) were available for analysis at a mean follow-up of 10.9 ± 1.6 years. The mean age was 69 ± 8 years, and 76 shoulders (76 patients; 56%) were female. For most of the clinical outcomes, initial improvements were observed in the short term and were sustained in the long term without notable deterioration, with >10-year follow-up values of 64 ± 16 for the absolute CS, 79% ± 18% for the relative CS, 79% ± 21% for the SSV, and 14 ± 3 for the CS for pain. However, after initial improvement, deterioration was seen for flexion and external rotation, with values of 117° ± 26° and 25° ± 18°, respectively, at the final follow-up. Scapular notching, heterotopic ossification, and radiolucent lines of <2 mm progressed during the study period. Younger age (p = 0.040), grade-II notching (p = 0.048), tuberosity resorption (p = 0.015), and radiolucent lines of <2 mm around the glenoid (p = 0.015) were predictive of an inferior outcome. The complication rate was 28%, with a reintervention rate of 11%.

Conclusions

RTSA provided improved long-term results that did not significantly deteriorate over time for most of the clinical parameters. Negative clinical outcome predictors were younger age, grade-II notching, tuberosity resorption, and radiolucent lines of <2 mm around the glenoid.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Beyond the joint: Exploring the interplay between mental health and shoulder arthroplasty outcomes

Considering the fact that mental health illnesses increase with age, and that shoulder arthroplasty procedures are often indicated in the older population, exploring the relationship between mental health and shoulder arthroplasty outcomes can have pivotal implications for shoulder surgeons and patients worldwide. The literature has shown that patients with poor mental health report lower patient-reported outcomes, higher peri-operative complications (such as anemia, infection, delirium, and others), lengthier hospital stays, and higher readmission rates than the normal patient. Employing a holistic approach when managing shoulder arthroplasty patients is necessary for optimizing outcomes and setting up recovery expectations.

Tranexamic Acid in Total Shoulder Arthroplasty: A Scoping Review of Current Practices and Future Directions

BACKGROUND

The effectiveness of tranexamic acid (TXA) as an antifibrinolytic agent in total shoulder arthroplasty (TSA) is well documented; however, there remains considerable practice variability concerning the optimal route of administration and dosing protocols concerning the medication's use. Our aim was to conduct a scoping review of the literature regarding the efficacy of various methods of TXA administration in TSA and to identify knowledge gaps that may be addressed.

METHODS

A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The PubMed and MEDLINE electronic databases were searched to identify all articles published before March 2023 investigating the administration of TXA in TSA. Randomized controlled trials and cohort studies were included, and data were extracted to capture information regarding intervention details and related outcomes such as blood loss, transfusion needs, and complication rates.

RESULTS

A total of 15 studies were included in this review. All selected studies used either intravenous (IV) or topical TXA, with 1 study also including a combined approach of both topical and IV TXA. Of the studies that used an IV approach, the most commonly reported favorable outcomes were a reduction in blood volume loss, reduction in hemoglobin or hematocrit change, and decreased drain output. Dosing varied significantly between all identified studies because some used a standard dosing amount in grams or milligrams for all treatment group participants, whereas others used weight-based dosing amounts. All studies that used a weight-based dosing regimen as well as studies using a standard dosing amount between 1,000 and 5,000 mg reported favorable outcomes for postoperative blood loss.

CONCLUSION

Both IV and topical TXA clearly demonstrate favorable perioperative hematologic profiles in TSA. Although both approaches have demonstrated a successful association with decreased blood loss and transfusion requirements, there is no definitive benefit to choosing one over the other. Furthermore, the use of oral TXA either in combination or isolation warrants further study in TSA because of its comparable efficacy profiles and significantly lower associated costs of application.

Rate of incidental findings on routine preoperative computed tomography for shoulder arthroplasty

BACKGROUND

Incidental findings are commonly noted in advanced imaging studies. Few data exist regarding the rate of incidental findings on computed tomography (CT) for preoperative shoulder arthroplasty planning. This study aims to identify the incidence of these findings and the rate at which they warrant further work-up to help guide orthopedic surgeons in counseling patients.

METHODS

A retrospective review was performed to identify patients with available preoperative shoulder CT who subsequently underwent shoulder arthroplasty procedures at a single institution between 2015 and 2021. Data including age, sex, and smoking status were obtained. Radiology reports for CTs were reviewed for incidental findings and categorized based on location, tissue type, and/or body system. The rate of incidental findings and the rate at which further follow-up was recommended by the radiologist were determined.

RESULTS

A total of 617 patients was identified. There were 173 incidental findings noted in 146 of these patients (23.7%). Findings ranged from pulmonary (59%), skin/soft tissue (16%), thyroid (13%), vascular (9%), spinal (2%), and abdominal (1%) areas. Of the pulmonary findings, 50% were pulmonary nodules and 47% were granulomatous disease. Overall, the final radiology report recommended further follow-up for 50% of the patients with incidental findings.

CONCLUSIONS

Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients. Most of these findings are pulmonary in nature. Overall, half of the patients with incidental findings were recommended for further follow-up. These results establish population data to guide orthopedic surgeons in patient counseling. Level of evidence: III.