Outcomes after débridement, antibiotics, and implant retention for prosthetic joint infection in shoulder arthroplasty

BACKGROUND

Patients who undergo total shoulder arthroplasty usually have excellent long-term outcomes. However, a subset of patients is diagnosed with a prosthetic joint infection (PJI) requiring revision procedures and prolonged recovery. The purpose of this study was to evaluate rates of recurrent shoulder PJI in patients undergoing débridement, antibiotics, and implant retention (DAIR), single-stage revision, and 2-stage revision. We also sought to compare outcomes and complications across procedures.

METHODS

Retrospective chart review was conducted for patients diagnosed with PJI after primary shoulder arthroplasty between January 2010 and August 2021. Patients were included if they underwent treatment with DAIR, single-stage revision, or 2-stage revision. Demographic information, surgical details, complications, laboratory data, postoperative antibiotic regimen, and infectious pathogen were collected. Postoperative patient-reported outcomes were collected: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation, Shoulder Activity Scale, and PROMIS Upper Extremity. Chi-square, t test, and 1-way analysis of variance were used as appropriate to evaluate each factor.

RESULTS

Sixty-five patients were included in the study, 26% treated with DAIR, 9% treated with single-stage revision, and 65% treated with 2-stage revision. There were no significant differences in patient comorbidities. Patients undergoing DAIR were diagnosed significantly earlier than those undergoing single- and 2-stage revision procedures (12.6 ± 22.9 months vs. 49.6 ± 48.4 vs. 25.0 ± 26.6, P = .010). Recurrent PJI was noted in 23.1% of patients: 29.4% of DAIR patients, no single-stage patients, and 23.8% of 2-stage patients (P = .330). Patients undergoing 2-stage revision with treatment failure had a significantly higher Elixhauser Comorbidity Index (0.2 ± 3.7 vs. 3.7 ± 3.9, P = .027). There was no significant difference in patient-reported outcomes across groups.

CONCLUSION

Patients undergoing treatment of shoulder PJI with DAIR did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures. Patients treated with DAIR were diagnosed with PJI significantly earlier than those undergoing single-stage and 2-stage revision procedures. There was no difference in complication rates between groups. This information adds to the body of work detailing outcomes after DAIR for shoulder PJI and provides encouraging data for use in this patient population. Future studies with a larger sample size may be conducted to further investigate specific pathogens, infection timelines, and antibiotic regimens that reduce the risk of treatment failure.

High Rate of Clinically Meaningful Achievement in Outcomes After Subacromial Balloon Spacer Implantation for Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-analysis

BACKGROUND

Subacromial balloon spacers have been introduced as a potential treatment option for patients with massive irreparable rotator cuff tears. However, it is important to comprehensively assess the clinical efficacy of this procedure in the context of an increasing amount of contemporary literature.

PURPOSE

To perform a systematic review of the contemporary literature to understand the propensity for clinically meaningful improvements after subacromial balloon spacer implantation for massive irreparable rotator cuff tears.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

The PubMed, Ovid/MEDLINE, and Cochrane databases were queried in July 2022 for data pertaining to studies reporting clinically significant outcomes after subacromial balloon spacer implantation. Freeman-Tukey double arcsine transformation was used to quantify the pooled rate of clinically meaningful improvements in outcomes as evaluated using the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB). Qualitative analysis was performed when data were variably presented to avoid misleading reporting.

RESULTS

There were 10 studies included, all of which reported MCID achievement. The overall pooled rate of MCID achievement for the Constant-Murley score was 83% (95% CI, 71%-93%; range, 40%-98%), with 6 of 8 studies reporting rates equal to or exceeding 85%. One study reported a 98% rate of PASS achievement for the Constant-Murley score at 3-year follow-up. The rate of MCID achievement for the American Shoulder and Elbow Surgeons (ASES) score ranged between 83% and 87.5%. The rate of PASS achievement for the ASES score was 56% at 2-year follow-up, while the rate of SCB achievement for the ASES score was 83% and 82% at 1- and 2-year follow-up, respectively. At 1-year follow-up, 74% and 78% of patients achieved the MCID for the Numeric Rating Scale and Oxford Shoulder Score, respectively. At 3 years, 69% of patients achieved the MCID for the Numeric Rating Scale and 87% achieved it for the Oxford Shoulder Score.

CONCLUSION

Patients who underwent isolated subacromial balloon spacer implantation for massive irreparable rotator cuff tears demonstrated a high rate of clinically significant improvement in outcomes at short- to mid-term follow-up. A paucity of literature exists to appropriately define and evaluate the rates of achieving the PASS and SCB after subacromial balloon spacer implantation, necessitating further study.

Subacromial Balloon Spacer Implantation for Massive Irreparable Rotator Cuff Tears Is Associated With Restoration of the Acromiohumeral Interval and Glenohumeral Center of Pressure: A Systematic Review and Meta-Analysis of Controlled Laboratory Studies

BACKGROUND

Biodegradable subacromial balloon spacers (SBSs) have become increasingly used for the treatment of massive irreparable rotator cuff tears given their theorized clinical benefits; however, the relationship between biomechanical functions of the balloon spacer and clinical benefits remains unclear.

PURPOSE

To perform a systematic review and meta-analysis of controlled laboratory studies investigating the use of SBSs for massive irreparable rotator cuff tears.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

PubMed, OVID/Medline, and Cochrane databases were queried in July 2022 for biomechanical data pertaining to SBS implantation in cadaveric models of irreparable rotator cuff tears. Random-effects meta-analysis of continuous outcomes using the DerSimonian-Laird method was performed to estimate pooled-treatment effect sizes between the irreparable rotator cuff tear state and the state in which an SBS was implanted. Data reported variably or in formats not amenable to analysis were presented descriptively.

RESULTS

Five studies involving 44 cadaveric specimens were included. At 0° of shoulder abduction, SBS implantation resulted in a mean inferior humeral head translation of 4.80 mm (95% CI, 3.20-6.40; P < .001) relative to the irreparable rotator cuff tear state. This decreased to 4.39 mm and 4.35 mm at 30° and 60° of abduction, respectively. At 0° of abduction, implantation of an SBS was associated with a 5.01-mm (95% CI, 3.56-6.46, P < .001) anterior translation of the glenohumeral center of contact pressure relative to the irreparable tear state. This translation changed to 5.11 mm and 5.49 mm at 30° and 60° of abduction. In 2 studies, SBS implantation restored the glenohumeral contact pressure to that of the intact state and significantly reduced subacromial pressure distribution over a rotator cuff repair state. In 1 study, a high balloon fill volume (40 mL) resulted in a significant 10.3 ± 1.4-mm more anterior humeral head position relative to the intact cuff state.

CONCLUSION

SBS implantation in cadaveric models of irreparable rotator cuff tears results in significant improvements in humeral head position at 0°, 30°, and 60° of shoulder abduction. Balloon spacers may also improve glenohumeral and subacromial contact pressures, although insufficient evidence currently exists to corroborate these findings. High balloon fill volumes (40 mL) may confer supraphysiologic anteroinferior translation of the humeral head.

Artificial intelligence for automated identification of total shoulder arthroplasty implants

BACKGROUND

Accurate and rapid identification of implant manufacturer and model is critical in the evaluation and management of patients requiring revision total shoulder arthroplasty (TSA). Failure to correctly identify implant designs in these circumstances may lead to delay in care, unexpected intraoperative challenges, increased morbidity, and excess health care costs. Deep learning (DL) permits automated image processing and holds the potential to mitigate such challenges while improving the value of care rendered. The purpose of this study was to develop an automated DL algorithm to identify shoulder arthroplasty implants from plain radiographs.

METHODS

A total of 3060 postoperative images from patients who underwent TSA between 2011 and 2021 performed by 26 fellowship-trained surgeons at 2 independent tertiary academic hospitals in the Pacific Northwest and Mid-Atlantic Northeast were included. A DL algorithm was trained using transfer learning and data augmentation to classify 22 different reverse TSA and anatomic TSA prostheses from 8 implant manufacturers. Images were split into training and testing cohorts (2448 training and 612 testing images). Optimized model performance was assessed using standardized metrics including the multiclass area under the receiver operating characteristic curve (AUROC) and compared with a reference standard of implant data from operative reports.

RESULTS

The algorithm classified implants at a mean speed of 0.079 seconds (±0.002 seconds) per image. The optimized model discriminated between 8 manufacturers (22 unique implants) with AUROCs of 0.994-1.000, accuracy of 97.1%, and sensitivities between 0.80 and 1.00 on the independent testing set. In the subset of single-institution implant predictions, a DL model identified 6 specific implants with AUROCs of 0.999-1.000, accuracy of 99.4%, and sensitivity >0.97 for all implants. Saliency maps revealed key differentiating features across implant manufacturers and designs recognized by the algorithm for classification.

CONCLUSION

A DL model demonstrated excellent accuracy in identifying 22 unique TSA implants from 8 manufacturers. This algorithm may provide a clinically meaningful adjunct in assisting with preoperative planning for the failed TSA and allows for scalable expansion with additional radiographic data and validation efforts.

Factors associated with humeral stem revision in anatomic to reverse total shoulder arthroplasty revision

BACKGROUND

Recent advances in implant technology have allowed for modular or platform humeral stem insertion during initial anatomic total shoulder arthroplasty (TSA). These systems allow for humeral stem retention during conversion to reverse TSA (RTSA). However, some patients still require humeral stem revision when undergoing revision to RTSA. The purpose of this study was to evaluate the association between patient-specific factors and radiographic parameters with humeral stem revision vs. retention during conversion from TSA to RTSA.

METHODS

Retrospective chart review was conducted for patients who underwent a revision TSA to RTSA between January 2010 and May 2022 at a single institution. Patients were included if their prosthesis included a convertible humeral stem. Patient demographic information, surgical details, and postoperative outcomes and complications were collected. Radiographic parameters were measured by 2 graders on radiographs taken prior to the revision procedure. The need for humeral stem revision and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores (preoperative and 2 years) were also noted. Statistical analysis was performed using chi-square test for categorical variables and t test for continuous variables.

RESULTS

One hundred seven patients were included, with 52 undergoing humeral stem revision. Patients were revised an average of 51.0 ± 54 months after primary TSA. Younger patient age (63.6 vs. 68.5 years, P = .017) and use of a lateralized glenosphere (1.6 mm vs. 0.4 mm, P < .001) were significantly associated with need for humeral stem revision. Glenoid to humeral head cut distance (28.3 mm vs. 26.3 mm, P = .076) approached significant association with the need for humeral stem revision. All other measurements were not associated with the need for humeral stem revision. Improvement of ASES scores at 2 years' follow-up was higher in the nonrevised group (increase of 33.4 points) than the revision group (23.3), but this did not reach significance (P = .149). Estimated blood loss and surgical time were significantly higher in the stem revision group than the non-revised group (P = .048 and P < .001, respectively).

CONCLUSION

Younger patients and those receiving a lateralized glenosphere were more likely to undergo humeral stem revision during conversion from TSA to RTSA. Glenoid to the humeral head cut distance should be studied further as a potential indication for humeral stem revision, as it correlates with the space available for a revision implant. This information can guide surgeons with preoperative planning for a revision arthroplasty.

Complete Restoration of Native Glenoid Width Improves Glenohumeral Biomechanics After Simulated Latarjet

BACKGROUND

The amount of glenoid width that must be restored with a Latarjet procedure in order to reestablish glenohumeral stability has not been determined.

PURPOSE/HYPOTHESIS

The purpose of this article was to determine the percentage of glenoid width restoration necessary for glenohumeral stability after Latarjet by measuring anterior humeral head translation and force distribution on the coracoid graft. The hypothesis was that at least 100% of glenoid width restoration with Latarjet would be required to maintain glenohumeral stability.

STUDY DESIGN

Controlled laboratory study.

METHODS

Nine cadaveric shoulders were prepared and mounted on an established shoulder simulator. A lesser tuberosity osteotomy (LTO) was performed to allow accurate removal of glenoid bone. Coracoid osteotomy was performed, and the coracoid graft was sized to a depth of 10 mm. Glenoid bone was sequentially removed, and Latarjet was performed using 2 screws to reestablish 110%, 100%, 90%, and 80% of native glenoid width. The graft was passed through a subscapularis muscle split, and the LTO was repaired. A motion tracking system recorded glenohumeral translations, and force distribution was recorded using a TekScan pressure sensor secured to the glenoid face and coracoid graft. Testing conditions included native; LTO; Bankart tear; and 110%, 100%, 90%, and 80% of glenoid width restoration with Latarjet. Glenohumeral translations were recorded while applying an anteroinferior load of 44 N at 90° of humerothoracic abduction and 0° or 45° of glenohumeral external rotation. Force distribution was recorded without an anteroinferior load.

RESULTS

Anterior humeral head translation progressively increased as the proportion of glenoid width restored decreased. A marked increase in anterior humeral head translation was found with 90% versus 100% glenoid width restoration (10.8 ± 3.0 vs 4.1 ± 2.6 mm, respectively; P < .001). Greater glenoid bone loss also led to increased force on the coracoid graft relative to the native glenoid bone after Latarjet. A pronounced increase in force on the coracoid graft was seen with 90% versus 100% glenoid width restoration (P < .001).

CONCLUSION

Anterior humeral head translation and force distribution on the coracoid graft dramatically increased when <100% of the native glenoid width was restored with a Latarjet procedure.

CLINICAL RELEVANCE

If a Latarjet is unable to fully restore the native glenoid width, surgeons should consider alternative graft sources to minimize the risk of recurrent instability or coracoid overload.

Epidemiology of Common Injuries in the Volleyball Athlete

PURPOSE OF REVIEW

To review the recent literature regarding the epidemiology of injuries in the volleyball athlete across all levels of play and to discuss areas where further studies are needed.

RECENT FINDINGS

Injury epidemiology for volleyball at the collegiate and high school level has been supported by a longitudinal injury surveillance program through the NCAA Injury Surveillance System (NCAA ISS) and High School Reporting Information Online (HS RIO) for the past 30 years. The creation of the FIVB Injury Surveillance System (FIVB ISS) in 2010 shows promise in advancing the literature on the injury at the professional level, and further studies on beach volleyball injuries are needed. Overall, injury patterns in volleyball in the past decade showed similar distribution to prior studies, but the rate of injury may be decreasing. Common injuries in volleyball include ankle sprains, patellar tendinopathy, finger and thumb sprains, overuse injuries of the shoulder, and concussions. Injury surveillance from the NCAA has demonstrated injury trends at the collegiate level, but further longitudinal studies are needed to evaluate injury at the professional level and for beach volleyball to help develop injury prevention strategy.

Association Between Limited English Language Proficiency and Disparities in Length of Stay and Discharge Disposition After Total Shoulder Arthroplasty: A Retrospective Cohort Study

Background: Limited English language proficiency in patients undergoing total shoulder arthroplasty (TSA) may make treatment more challenging. Purpose: We sought to investigate the potential association between TSA patients' use of a language interpreter and 2 outcomes: hospital length of stay (LOS) and discharge disposition. Methods: We conducted a retrospective cohort study comparing LOS and discharge disposition after TSA for patients who required interpreter services and patients who did not at a single institution in an urban setting between 2016 and 2020. Consecutive patients requiring interpreter services who underwent TSA were matched 1:1 to patients who did not require an interpreter by age, body mass index (BMI), sex, and procedure. Multivariate regression models controlling for age, BMI, sex, smoking, opioid use, white or non-white race, procedure, and diagnosis were constructed to determine associations between interpreter use, LOS, and discharge disposition. Results: Forty-one patients were included in each cohort, exceeding the minimum number required per an a priori power analysis. Mean hospital LOS was longer in the interpreter cohort than in the non-interpreter cohort (2.8 ± 2.4 vs 1.8 ± 1.0 days, respectively). Multivariate linear regression demonstrated interpreter use was the strongest predictor of LOS, with the effect estimate indicating an additional 0.88-day LOS per patient. A greater proportion of patients from the interpreter cohort were discharged to an acute/subacute rehabilitation facility than patients from the non-interpreter cohort (n = 8 [19.5%] vs n = 2 [4.9%], respectively). Patients from the interpreter cohort were 454% more likely to be discharged to acute/subacute rehabilitation facilities. Conclusions: Our retrospective analysis of patients undergoing TSA suggests that the need for interpreter services may be associated with increased LOS and discharge to a facility. More rigorous study is needed to identify the factors that influence these outcomes and to avoid disparities in hospital stay and discharge.

Biomechanical analysis of anterior stability after 15% glenoid bone loss: comparison of Bankart repair, dynamic anterior stabilization, dynamic anterior stabilization with Bankart repair, and Latarjet

BACKGROUND

Dynamic anterior shoulder stabilization (DAS) with Bankart repair is a recently described stabilization technique thought to be more robust than an isolated Bankart repair while avoiding many coracoid transfer-related complications and technical demands. DAS involves transfer of the long head biceps through a subscapularis split to the anterior glenoid to create a sling effect. We hypothesize that DAS with Bankart repair will restore anterior stability in a human-cadaveric model with subcritical (15%) glenoid bone loss.

METHODS

Eight cadaveric shoulders were tested using an established shoulder simulator to record glenohumeral translations with an accuracy of ±0.2 mm. Shoulders were tested in 5 states-intact soft tissues, Bankart defect with 15% bone loss, isolated Bankart repair, DAS with Bankart repair, isolated DAS, and Latarjet. A 45 N anterior force was applied through the pectoralis major tendon, and translation of the humeral head was recorded and compared with repeated measures analysis of variance.

RESULTS

The anterior translation in the intact (native) glenoid was 4.7 mm at neutral position and 4.6 mm at 45° external rotation. Anterior translation significantly increased after introducing a Bankart defect with 15% glenoid bone loss to 9.1 mm (neutral, P = .002) and 9.5 mm (45° external rotation, P < .001). All repair conditions showed a significant decrease in anterior translation relative to Bankart defect. DAS with Bankart repair decreased anterior translation compared with the Bankart defect: 2.7 mm (neutral, P < .001) and 2.1 mm (45° external rotation, P < .001). DAS with Bankart repair significantly decreased anterior translation compared with the isolated Bankart repair (2.7 mm vs. 4.7 mm, P = .023) and the isolated DAS (2.7 mm vs. 4.3 mm, P = .041) in neutral position. The Latarjet procedure resulted in the greatest reduction in anterior translation compared with the Bankart defect: 1.2 mm (neutral, P < .001) and 1.9 mm (45° external rotation, P < .001).

CONCLUSIONS

DAS with Bankart repair is a viable alternative to restore anterior glenohumeral stability with a 15% glenoid defect at a greater degree than either DAS or Bankart repair alone. The Latarjet procedure was the most effective in reducing anterior translation but restrained the anterior translation significantly more than the native glenoid.

Minimum 15-year follow-up for clinical outcomes of arthroscopic rotator cuff repair

BACKGROUND AND HYPOTHESIS

Arthroscopic rotator cuff repair surgery is one of the most common shoulder procedures performed in the United States. Although several studies have shown considerable symptomatic relief in the short term following surgery, a relatively high rate of recurrent defects has led surgeons to question the long-term durability of this operation. We hypothesized that outcomes at a minimum of 15 years of follow-up in patients who underwent all-arthroscopic rotator cuff repair would be maintained and would remain significantly improved compared with the preoperative status.

METHODS

All-arthroscopic rotator cuff repairs were performed in 193 patients from 2003 to 2005. Patient-reported outcomes were collected preoperatively and at 1, 2, 5, and ≥15 years postoperatively. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score. Secondary outcomes included Single Assessment Numeric Evaluation (SANE), Shoulder Activity Scale (SAS), visual analog scale, and Patient-Reported Outcomes Measurement Information System (PROMIS)-Upper Extremity (UE) scores. Patient demographic characteristics, revision surgical procedures, and complications were recorded. Generalized estimating equations were used to model scores over time, and multiple comparisons between time points were performed using Tukey adjustment.

RESULTS

This study included 60 patients with a mean follow-up period of 16.5 years (range, 15.8-17.7 years). The mean ASES score improved from 60.2 ± 18.8 preoperatively to 93.0 ± 9.4 at ≥15 years (P < .0001). The mean visual analog scale pain score decreased from 4.1 ± 0.7 preoperatively to 0.7 ± 0.3 at ≥15 years (P < .0001). The average SANE, SAS, and PROMIS-UE scores at ≥15 years were 87.8 ± 14.8, 8.8 ± 4.3, and 49.6 ± 10.2, respectively. Of 60 patients, 7 underwent revision surgery. Older age and female sex were associated with lower SAS scores at 15 years, whereas female sex was associated with lower PROMIS-UE scores. There were no factors predictive of ASES or SANE scores.

CONCLUSION

At long-term follow-up (≥15 years), the patient-reported outcomes of all-arthroscopic rotator cuff repair show significant improvement from baseline preoperative function and remain durable over a period of 15 years. This information is useful in counseling patients regarding the long-term results of this procedure.

Biomechanical comparison of 3 latissimus dorsi transfer sites for reverse total shoulder arthroplasty in the absence of teres minor

BACKGROUND

Reverse total shoulder arthroplasty is often performed to treat rotator cuff tear arthropathy with irreparable rotator cuff tears. Patients with full-thickness tears involving the posterior cuff and teres minor specifically lose active external rotation of the humerus, limiting activities of daily living. A latissimus dorsi transfer has been described as one potential solution, but few studies have compared different latissimus dorsi transfer sites. This study assesses the biomechanics of 3 latissimus dorsi transfer sites, examining external rotation, deltoid muscle forces, and force across the glenoid for specific activities.

METHODS

The Newcastle Shoulder Model was modified to include a Delta III reverse shoulder arthroplasty and was used to model the effects of 3 latissimus dorsi transfer sites-anterior, posterolateral, and posterodistal-in the setting of teres minor deficiency. The latissimus dorsi was represented by 5 muscle elements approximating anatomic fascicle divisions. Kinematic data sets representing common activities were input into the model, allowing calculation of muscle forces and glenoid loads.

RESULTS

Each of the 3 latissimus dorsi transfer sites demonstrated a change of moment arm from internal to external rotation with increased magnitude. Average maximum deltoid muscle forces and glenoid loading across all motions decreased for each of the 3 transfer sites, with the greatest decreased force noted for the posterior deltoid. This decrease in deltoid force and glenoid loading was significantly greater with the anterior and posterolateral transfer sites, relative to the posterodistal site.

DISCUSSION

Latissimus dorsi transfer to all 3 sites in the setting of reverse total shoulder arthroplasty and posterior rotator cuff deficiency resulted in large external rotation moment arms. The transferred latissimus dorsi shared the external rotation load and resulted in decreased deltoid forces and glenoid loading with very small differences between the 3 transfer sites. The posterodistal location reduced deltoid force and glenoid loading to a lower degree compared with other sites, but it also showed that it did not alter the tendon length compared with the native shoulder.

The role of the long head of the biceps tendon in posterior shoulder stabilization during forward flexion

BACKGROUND

The role of the long head of the biceps tendon (LHBT) in glenohumeral stability is not fully understood. Most objects are lifted in the sagittal plane with forward flexion, which stresses the posterior aspect of the unconstrained glenohumeral joint. Determining the mechanism by which the shoulder maintains stability with functional motions is important to understanding the pathoanatomy of degenerative shoulders. Our hypothesis was that the LHBT resists posterior translation of the humeral head (HH) during forward flexion by tensioning the posterior capsuloligamentous complex.

METHODS

Ten fresh-frozen cadaveric shoulders were tested using an established shoulder simulator that loads the LHBT, rotator cuff, and deltoid tendons through a system of pulleys. A motion tracking system recorded glenohumeral translations with an accuracy of ±0.2 mm. In each subject, the scapula was fixed and the humerus was tested in 6 positions: 30° and 60° of glenohumeral forward flexion at (1) maximum internal rotation (IR), (2) neutral rotation, and (3) maximum external rotation (ER). The deltoid was loaded with 100 N, and the infraspinatus and subscapularis were loaded with 22 N each. The difference in glenohumeral translation was calculated at each position comparing the LHBT loaded with 45 N or unloaded.

RESULTS

At 30° of glenohumeral forward flexion, unloading the LHBT increased HH posterior translation by 2.5 mm (±0.9 mm; P < .001), 1.7 mm (±1.0 mm; P < .001), and 1.0 mm (±0.9 mm; P = .01) at maximum ER, neutral rotation, and maximum IR, respectively. At 60° of glenohumeral forward flexion, unloading the LHBT increased HH posterior translation by 2.8 mm (±1.2 mm; P < .001), 2.4 mm (±1.6 mm; P < .001), and 1.7 mm (±1.4 mm; P < .001) at maximum ER, neutral rotation, and maximum IR, respectively.

CONCLUSION

LHBT loading resists posterior translation of the HH during forward flexion. These data support the role of the LHBT as a posterior stabilizer of the shoulder, specifically when a person is carrying objects in front of them. Further work is needed to determine if unloading the LHBT, as is done with biceps tenotomy or tenodesis, may eventually lead to posterior labral pathology, or to the posterior glenoid wear commonly seen with osteoarthritis.

Backside polyethylene wear in reverse shoulder arthroplasty

BACKGROUND

Aseptic loosening from implant-associated osteolysis in reverse shoulder arthroplasty (RSA) may contribute to premature implant failure. Although articular side polyethylene (PE) damage has been well documented in the literature, no studies to date have investigated backside wear in RSA. The aims of this investigation were to (1) document and compare the damage between the backside and articular surface in explanted RSA components, (2) assess whether certain quadrants have a greater propensity for damage, and (3) report the most common mode(s) of backside PE damage.

METHODS

Twenty-one RSA humeral liners retrieved during revision procedures between 2005 and 2014 were included for analysis. The mean time between implantation and extraction was 16 months (10 days-88 months). Diagnoses at the time of revision included dislocation (10), infection (4), mechanical failure (3), loosening (2), and unknown (2). Liners were examined under light microscopy (×10-30 magnification) and damage on the articular and backside of the liner surface was graded using the modified Hood score. The location and damage modality were compared between the articular side and backside of the implant.

RESULTS

Damage was noted on the articular surfaces of all 21 liners and on the backside surface of 20 liners. The total damage in all the quadrants was higher on the articular surface than on the backside of the component, with a mean difference in total quadrant damage scores of 11.74 ± 3.53 (P < .001). There was no difference in damage among the quadrants on the backside (P = .44) or the articular surface (P = .08). The articular side exhibited greater scratching, abrasion, and surface deformation than the backside (P < .001).

CONCLUSIONS

This short-term retrieval study demonstrated that backside PE damage occurs on the humeral component of RSA implants. There was greater damage to the articular side of the liner but wear to the backside was present in almost all liners. The clinical importance of backside wear in RSA and its overall contribution to PE particulate disease and osteolysis needs further investigation.

Outcomes of shoulder arthroplasty by year of index procedure: are we getting better?

BACKGROUND

The purpose of this study was to determine whether postoperative patient-reported outcomes improved over time following anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

We performed a retrospective analysis of prospectively collected patient-reported outcomes from our institution's registry between 2008 and 2018 (N = 1899). American Shoulder and Elbow Surgeons (ASES) scores at a minimum of 2 years postoperatively were required. Univariable linear models were used to test the association between year of surgery and improvement in ASES scores at 2- and 5-year follow-up, as well as any association with age, sex, primary or revision surgery, hand dominance, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, and Walch classification. Multivariable models were created to analyze ASES score improvement by index year while controlling for significant factors.

RESULTS

In the univariable analysis, 5-year ASES difference scores increased each year by a mean of 1.65 (P < .001; 95% confidence interval [CI], 0.75-2.55) for TSA, 2.50 (P = .014; 95% CI, 0.52-4.49) for RTSA, and 1.64 (P < .001; 95% CI, 0.81-2.47) for the overall population. Patient sex, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, Walch classification, and revision procedures were also significant factors affecting ASES scores. On multivariable analysis controlling for these factors, 5-year ASES difference scores were still significantly associated with year of surgery, increasing each year by a mean of 2.20 (P < .001; 95% CI, 0.91-3.50) for TSA, 4.83 (P < .001; 95% CI, 1.17-8.49) for RTSA, and 1.66 (P < .001; 95% CI, 0.81-2.51) for the entire population.

CONCLUSION

Both anatomic TSA and RTSA patients reported increasing ASES difference scores at 5-year follow-up as time passed. These findings may indicate that advances in shoulder arthroplasty have resulted in better patient outcomes over time. Further research is needed to clarify which factors influence improvements in outcomes, particularly for revision procedures.

Tribocorrosion is Common, but Mild in Modular Humeral Components in Shoulder Arthroplasty: An Implant Retrieval Analysis

Background

Wear and corrosion at the junctions of modular implants are increasingly recognized issues in the design of hip and knee arthroplasty prostheses, yet less is known about their significance in shoulder arthroplasty.

Methods

A query of paired total shoulder implant specimens (eg, humeral head and stem components from the same patient) was performed using an institutional implant retrieval registry. Implants were examined under a stereomicroscope and evaluated for evidence of fretting and corrosion using the modified Goldberg scoring system. Available electronic medical records of included specimens were reviewed to report relevant clinical characteristics and identify potential associations with the presence of tribocorrosion.

Results

Eighty-three paired total shoulder implant specimens, explanted at a single institution between 2013 and 2020, were analyzed. Corrosion was identified in 52% (43/83) of humeral head components and 40% (33/83) of humeral stem components. Fretting was identified in 29% (24/83) of humeral head components and 28% (23/83) of humeral stem components. Of the 56 paired implants for which clinical data were available, the duration of implantation (DOI) was less than 2 years in 29% of paired implants and greater than 5 years in 36% of implants. The presence of corrosion or fretting was not associated with DOI, a male humeral head taper, or periprosthetic infection as the indication for revision.

Conclusion

Mild tribocorrosion was present in more than half of the retrieved humeral implant specimens. However, trunnionosis did not manifest as a clinical cause of revision surgery in our study.

The Comparative Effect of Age on Clinical Outcomes Following Anatomic Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty

At many institutions, the pendulum has swung toward reverse total shoulder arthroplasty (RTSA). Good results have been reported for patients older than 65 years with glenohumeral osteoarthritis with an intact rotator cuff, leading to questioning of the role of anatomic total shoulder arthroplasty (TSA) in the elderly. The purpose of this study was to compare outcome measures between TSA and RTSA patients using minimal clinically important difference (MCID) and substantial clinical benefit (SCB) as a function of age. Primary TSA or RTSA patients with American Shoulder and Elbow Surgeons (ASES) scores at 2-year follow-up were retrospectively identified from a prospective database. Patients with a diagnosis of inflammatory arthritis, infection, proximal humerus fracture, or revision TSA were excluded. Patients were stratified by age as younger than 65 years, 65 to 74 years, and 75 years or older. A total of 659 TSA and 172 RTSA patients were included. Total shoulder arthroplasty had a larger improvement in ASES scores compared with RTSA in patients aged 65 to 74 years and 75 years and older (P=.04 and P<.01, respectively). In patients aged 75 years or older, the percentages of patients achieving MCID were similar (93.1% TSA and 92.3% RTSA; P=.53); however, a higher percentage of TSA patients achieved SCB vs RTSA patients (90.5% vs 76.9%; P=.01). This study highlights the importance of indications and a shared decision-making model to ensure patient satisfaction. The results support a trend that primary RTSA is a viable option for low-demand patients aged 75 years or older; however, appropriately indicated TSA offers a potential for greater improvement in ASES scores and is more successful at achieving SCB compared with RTSA at 2-year follow-up. [Orthopedics. 2021;44(4):e600-e606.].

Superior capsule reconstruction using a single 6-mm-thick acellular dermal allograft for massive rotator cuff tears: a biomechanical cadaveric comparison to fascia lata allograft

BACKGROUND

Success of superior capsule reconstruction (SCR) using both fascia lata (FL) and human acellular dermal (ACD) allografts have been reported. One possible explanation for a discrepancy in outcomes may be attributed to graft thickness. SCR with commercially available 3-mm-thick ACD allograft is not biomechanically equivalent to FL. Our hypothesis was that SCR with a single 6-mm-thick ACD allograft will restore the subacromial space distance (SubDist) and peak subacromial contact pressures (PSCPs) to intact shoulder and will be comparable to SCR with an 8-mm FL allograft.

METHODS

Eight cadaveric shoulders were tested in 4 conditions: intact, irreparable supraspinatus tear (SST), SCR FL allograft (8-mm-thick), and SCR single ACD allograft (6-mm-thick). SubDist and PSCP were measured at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane. Parameters were compared using a repeated measures analysis of variance with Tukey post hoc test, and graft dimensions were compared using a Student t test.

RESULTS

SST had decreased SubDist (P < .05) and increased PSCP (P < .05) compared with the intact state. At all angles, the SCR ACD allograft demonstrated increased SubDist compared with the tear condition (P < .001), with no difference between grafts. Furthermore, there was decreased PSCP after both ACD and FL SCR compared with the intact condition, with no difference between grafts at 0° (P = .006, P = .028) and 60° abduction (P = .026, P = .013). Both ACD and FL grafts elongated during testing.

CONCLUSIONS

Our results suggest SCR with a single 6-mm-thick ACD allograft is noninferior to FL regarding SubDist and PSCP while completely restoring the superior stability of the glenohumeral joint compared with the intact state.

Consensus statement on the treatment of massive irreparable rotator cuff tears: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons

BACKGROUND

Management of massive irreparable rotator cuff tears (MIRCTs) remains controversial owing to variability in patient features and outcomes contributing to a lack of unanimity in treatment recommendations. The purpose of this study was to implement the Delphi process using experts from the Neer Circle of the American Shoulder and Elbow Surgeons to determine areas of consensus regarding treatment options for a variety of MIRCTs.

METHODS

A panel of 120 shoulder surgeons were sent a survey regarding MIRCT treatments including arthroscopic débridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer. An iterative Delphi process was then conducted with a first-round questionnaire consisting of 13 patient factors with the option for open-ended responses to identify important features influencing the treatment of MIRCTs. The second-round survey sought to determine the importance of patient factors related to the 6 included treatment options. A third-round survey asked participants to classify treatment options for 60 MIRCT patient scenarios as either preferred treatment, acceptable treatment, not acceptable/contraindicated, or unsure/no opinion. Patient scenarios were declared to achieve consensus for the preferred and not acceptable/contraindicated categories when at least 80% of the survey respondents agreed on a response, and a 90% threshold was required for the acceptable treatment category, defined by an acceptable treatment or preferred treatment response.

RESULTS

Seventy-two members agreed to participate and were deemed to have the requisite expertise to contribute based on their survey responses regarding clinical practice and patient volume. There were 20 clinical scenarios that reached 90% consensus as an acceptable treatment, with RSA selected for 18 scenarios and arthroscopic débridement and/or partial repair selected for 2. RSA was selected as the singular preferred treatment option in 8 scenarios. Not acceptable/contraindicated treatment options reached consensus in 8 scenarios, of which, 4 related to SCR, 3 related to RSA, and 1 related to partial repair with graft augmentation.

CONCLUSION

This Delphi process exhibited significant consensus regarding RSA as a preferred treatment strategy in older patients with pseudoparesis, an irreparable subscapularis, and dynamic instability. In addition, the process identified certain unacceptable treatments for MIRCTs such as SCR in older patients with pseudoparesis and an irreparable subscapularis or RSA in young patients with an intact or reparable subscapularis without pseudoparesis or dynamic instability. The publication of these scenarios and areas of consensus may serve as a useful guide for practitioners in the management of MIRCTs.

A Comprehensive Enhanced Recovery Pathway for Rotator Cuff Surgery Reduces Pain, Opioid Use, and Side Effects

BACKGROUND

Patients often have moderate to severe pain after rotator cuff surgery, despite receiving analgesics and nerve blocks. There are many suggested ways to improve pain after rotator cuff surgery, but the effects of adopting a pathway that includes formal patient education, a long-acting nerve block, and extensive multimodal analgesia are unclear.

QUESTIONS/PURPOSES

(1) Does adoption of a clinical pathway incorporating patient education, a long-acting nerve block, and preemptive multimodal analgesia reduce the worst pain during the first 48 hours after surgery compared with current standard institutional practices? (2) Does adoption of the pathway reduce opioid use? (3) Does adoption of the pathway reduce side effects and improve patient-oriented outcomes?

METHODS

From September 2018 to January 2020, 281 patients scheduled for arthroscopic ambulatory rotator cuff surgery were identified for this paired sequential prospective cohort study. Among patients in the control group, 177 were identified, 33% (58) were not eligible, for 11% (20) staff was not available, 56% (99) were approached, 16% (29) declined, 40% (70) enrolled, and 40% (70) were analyzed (2% [4] lost to follow-up for secondary outcomes after postoperative day 2). For patients in the pathway cohort, 104 were identified, 17% (18) were not eligible, for 11% (11) staff was not available, 72% (75) were approached, 5% (5) declined, 67% (70) enrolled, and 67% (70) were analyzed (3% [3] lost to follow-up for secondary outcomes after postoperative day 2). No patients were lost to follow-up for primary outcome; for secondary outcomes, four were lost in the control group and three in the pathway group after postoperative day 2 (p = 0.70). The initial 70 patients enrolled received routine care (control group), and in a subsequent cohort, 70 patients received care guided by a pathway (pathway group). Of the 205 eligible patients, 68% (140) were included in the analysis. This was not a study comparing two tightly defined protocols but rather a study to determine whether adoption of a pathway would alter patient outcomes. For this reason, we used a pragmatic (real-world) study design that did not specify how control patients would be treated, and it did not require that all pathway patients receive all components of the pathway. We developed the pathway in coordination with a group of surgeons and anesthesiologists who agreed to apply the pathway as much as was viewed practical for each individual patient. Patients in both groups received a brachial plexus nerve block with sedation. Major differences between the pathway and control groups were: detailed patient education regarding reasonable pain expectations with a goal of reducing opioid use (no formal educational presentation was given to the control), a long-acting nerve block using bupivacaine with dexamethasone (control patients often received shorter-acting local anesthetic without perineural dexamethasone), and preemptive multimodal analgesia including intraoperative ketamine, postoperative acetaminophen, NSAIDs, and gabapentin at bedtime, with opioids as needed (control patients received postoperative opioids but most did not get postoperative NSAIDS and no controls received gabapentin or separate prescriptions for acetaminophen). The primary outcome was the numerical rating scale (NRS) worst pain with movement 0 to 48 hours after block placement. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). The minimum clinically important difference (MCID) [12] for NRS that was used for calculation of the study sample size was 1.3 [18], although some authors suggest 1 [13] or 2 [5] are appropriate; if we had used an MCID of 2, the sample size would have been smaller. Secondary outcomes included NRS pain scores at rest, daily opioid use (postoperative day 1, 2, 7, 14), block duration, patient-oriented pain questions (postoperative day 1, 2, 7, 14), and patient and physician adherence to pathway.

RESULTS

On postoperative day 1, pathway patients had lower worst pain with movement (3.3 ± 3.1) compared with control patients (5.6 ± 3.0, mean difference -2.7 [95% CI -3.7 to -1.7]; p < 0.001); lower scores were also seen for pain at rest (1.9 ± 2.3 versus 4.0 ± 2.9, mean difference -2.0 [95% CI -2.8 to -1.3]; p < 0.001). Cumulative postoperative opioid use (0-48 hours) was reduced (pathway oral morphine equivalent use was 23 ± 28 mg versus 44 ± 35 mg, mean difference 21 [95% CI 10 to 32]; p < 0.01). The greatest difference in opioid use was in the first 24 hours after surgery (pathway 7 ± 12 mg versus control 21 ± 21 mg, mean difference -14 [95% CI -19 to -10]; p < 0.01). On postoperative day 1, pathway patients had less interference with staying asleep compared with control patients (0.5 ± 1.6 versus 2.6 ± 3.3, mean difference -2.2 [95% CI -3.3 to -1.1]; p < 0.001); lower scores were also seen for interference with activities (0.9 ± 2.3 versus 1.9 ± 2.9, mean difference -1.1 [95% CI -2 to -0.1]; p = 0.03). Satisfaction with pain treatment on postoperative day 1 was higher among pathway patients compared with control patients (9.2 ± 1.7 versus 8.2 ± 2.5, mean difference 1.0 [95% CI 0.3 to 1.8]; p < 0.001). On postoperative day 2, pathway patients had lower nausea scores compared with control patients (0.3 ± 1.1 versus 1 ± 2.1, mean difference -0.7 [95% CI -1.2 to -0.1]; p = 0.02); lower scores were also seen for drowsiness on postoperative day 1 (1.7 ± 2.7 versus 2.6 ± 2.6, mean difference -0.9 [95% CI - 1.7 to -0.1]; p = 0.03).

CONCLUSION

Adoption of the pathway was associated with improvement in the primary outcome (pain with movement) that exceeded the MCID. Patients in the pathway group had improved patient-oriented outcomes and fewer side effects. This pathway uses multiple analgesic drugs, which may pose risks to elderly patients, in particular. Therefore, in evaluating whether to use this pathway, clinicians should weigh the effect sizes against the potential risks that may emerge with large scale use, consider the difficulties involved in adapting a pathway to local practice so that pathway will persist, and recognize that this study only enrolled patients among surgeons and the anesthesiologists that advocated for the pathway; results may have been different with less enthusiastic clinicians. This pathway, based on a long-lasting nerve block, multimodal analgesia, and patient education can be considered for adoption.

LEVEL OF EVIDENCE

Level II, therapeutic study.

The Feasibility of Outpatient Shoulder Arthroplasty: Risk Stratification and Predictive Probability Modeling

Whether shoulder arthroplasty can be performed on an outpatient basis depends on appropriate patient selection. The purpose of this study was to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection. This was a retrospective review of prospectively collected data using a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria for this study. Younger age, higher body mass index (BMI), male sex, and prior steroid injection were all significantly associated with suitability for discharge, whereas preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2 were associated with AEs that might prevent same-day discharge. Compared with TSA, reverse TSA was associated with less suitability for discharge (P=.01). On querying the ACS-NSQIP database, 15,254 patients were identified. Female sex, BMI less than 35 kg/m², American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low pre-operative albumin, and hemiarthroplasty were associated with unsuitability for discharge. Males 55 to 59 years old with no comorbidities nor history of narcotic use formed the lowest risk subgroup. Transfusion is the primary driver of AEs. Strategies to avoid this complication should be explored. Risk stratification will improve the ability to identify patients who can safely undergo outpatient shoulder arthroplasty. [Orthopedics. 2021;44(2):e215-e222.].

The impact of prior ipsilateral arthroscopy on infection rates after shoulder arthroplasty

BACKGROUND

Patients frequently undergo interventions before shoulder arthroplasty, including injections and arthroscopy. Although the potential impact of injections on postoperative outcomes such as infection has been well studied, it is less clear whether prior arthroscopy has an impact on infection rates after shoulder arthroplasty. The purpose of this study was to determine whether prior ipsilateral shoulder arthroscopy is associated with an increased risk of postoperative infection after shoulder arthroplasty.

METHODS

Patients who underwent shoulder arthroplasty, including hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty with a minimum of 1-year preoperative database exposure, were queried using Current Procedural Terminology codes from 2 large insurance databases, including both private-payer (Humana, 2008-2017) and Medicare (2006-2014) data. Patients with procedures for infection, fractures, or without laterality data were excluded. Those who underwent ipsilateral shoulder arthroscopy within 2 years before their arthroplasty were identified and compared with controls who did not undergo prior arthroscopy. Each database was analyzed separately. Periprosthetic infection within 1 year after arthroplasty was queried for each group and compared using a logistic regression analysis with control for demographic and comorbidity confounders.

RESULTS

A total of 9362 Medicare patients and 17,716 private-payer patients were included in the study. Of these, 486 (5.2%) Medicare patients and 685 (3.9%) private-payer patients underwent prior arthroscopy. In the Medicare database, prior arthroscopy was also associated with a postarthroplasty infection rate of 3.9% as compared with 1.9% in the control group (odds ratio: 1.96, 95% confidence interval: 1.20-3.22, P = .003). Similarly, in the private insurance cohort, prior shoulder arthroscopy was associated with a postarthroplasty infection rate of 2.9% as compared with 1.4% in the control group (odds ratio: 1.85, 95% confidence interval: 1.13-3.03, P = .005).

CONCLUSION

Shoulder arthroscopy performed within 2 years before shoulder arthroplasty is associated with a higher infection rate in the first year after shoulder arthroplasty.

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up

PURPOSE

To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.

METHODS

A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.

RESULTS

There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.

CONCLUSIONS

AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.

LEVEL OF EVIDENCE

IV (Case Series).

Reliability of the modified Walch classification for advanced glenohumeral osteoarthritis using 3-dimensional computed tomography analysis: a study of the ASES B2 Glenoid Multicenter Research Group

BACKGROUND

Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group.

METHODS

Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories.

RESULTS

Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87).

DISCUSSION

Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.

Survivorship of a Medialized Glenoid and Lateralized Onlay Humerus Reverse Shoulder Arthroplasty Is High at Midterm Follow-up

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a common treatment of a variety of disabling shoulder conditions. The purpose of this study was to determine revision-free survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus implant and to identify etiologies of revision.

METHODS

All RSAs performed using the Comprehensive^® Reverse Shoulder System (Zimmer Biomet, Inc.; Warsaw, IN, USA) at one institution from 2008 to 2014 were identified through a retrospective review. Charts were reviewed to determine whether the RSA was a primary or revision surgery. Patients were contacted by telephone, and survivorship was defined as no subsequent surgery after RSA. Of the 526 RSAs performed, responses were obtained from 403 patients (77%). A Kaplan-Meier analysis was performed to determine survivorship over time. A χ ² test was used to determine differences between revision rates after RSA.

RESULTS

Minimum follow-up was 3 years, and average follow-up was 4.83 ± 1.60 years. Survivorship was 96% at 2 years and 93% at 5 years after RSA. Revisions were performed for instability (n = 8), humeral tray-taper junction failure (n = 5), acute fracture (n = 4), infection (n = 3), glenoid loosening (n = 3), osteolysis (n = 1), or notching (n = 1). Fourteen of the 151 patients (9.2%) who had surgery prior to RSA required revision after RSA. Having shoulder surgery prior to RSA was associated with higher rates of subsequent revision after RSA.

CONCLUSION

Overall, survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus RSA is high, and prostheses implanted in native shoulders have lower rates of revision at midterm follow-up. Instability (1.9%) was the most common reason for revision.

Delay to Arthroscopic Rotator Cuff Repair Is Associated With Increased Risk of Revision Rotator Cuff Surgery

The purpose of this study was to determine the association between time from the diagnosis of rotator cuff tear to repair and the rate of subsequent revision surgery for re-tear. A national insurance database was queried from 2007 to 2016 for patients who underwent arthroscopic rotator cuff repair after a diagnosis of rotator cuff tear with minimum 5-year follow-up. On the basis of time from diagnosis to repair, patients were stratified into an early (<6 weeks), a routine (between 6 weeks and 12 months), or a delayed (>12 months) repair cohort. The rates of subsequent revision rotator cuff repair were compared pairwise between cohorts with Pearson's chi-square tests. Multivariate logistic regression was used to adjust for patient demographics and comorbidity burden. A total of 2759 patients were included, with 1510 (54.7%) undergoing early repair, 1104 (40.0%) undergoing routine repair, and 145 (5.3%) having delayed repair. The overall revision rate at 5-year follow-up was 9.6%. The revision rate was higher in the delayed group (15.2%) relative to the early (9.9%) and routine (8.3%) groups (P=.048 and P=.007, respectively). On multivariate analysis, delayed repair was associated with increased odds of revision surgery (odds ratio, 1.97; P=.009) compared with routine repair. Delayed rotator cuff repair beyond 12 months of diagnosis was associated with an increased risk of undergoing subsequent revision rotator cuff repair while controlling for age and comorbidity burden. [Orthopedics. 2020;43(6):340-344.].

Visual Observation of Apparent Infraspinatus Muscle Atrophy in Male Professional Tennis Players

Background:

Previous studies have reported visually observed apparent muscle atrophy in the infraspinous fossa of the dominant arm of overhead athletes. Several mechanisms have been proposed as etiological factors, including eccentric overload, compressive spinoglenoid notch paralabral cysts, and cumulative tensile suprascapular neurapraxia.

Purpose:

To report the prevalence of apparent infraspinatus atrophy in male professional tennis players and to determine whether the suspected atrophy correlates with objectively measured weakness of external rotation.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 153 male professional tennis players underwent a musculoskeletal screening examination that included visual inspection of the infraspinous fossa. Infraspinatus atrophy was defined as hollowing or loss of soft tissue bulk inferior to the scapular spine in the infraspinous fossa of one extremity that was visibly different from the contralateral extremity. This finding was observed and independently agreed upon by both an orthopaedic surgeon and a physical therapist during the examination. Also assessed were rotator cuff instrument-assisted manual muscle testing, visual observation of scapular kinesis (or motion), and glenohumeral joint range of motion for internal and external rotation and horizontal adduction.

Results:

In the 153 players, dominant-arm infraspinatus atrophy was observed in 92 players (60.1%), and only 1 player (0.7%) was identified with nondominant infraspinatus atrophy. A Pearson correlation showed a significant relationship between the presence of dominant-arm infraspinatus atrophy and dominant-arm external rotation strength measured in neutral abduction/adduction (at the side) (P = .001) as well as between the presence of dominant-arm infraspinatus atrophy and bilateral external rotation strength measured at 90° of glenohumeral joint abduction (P = .009 for dominant arm and .002 for nondominant arm). No significant correlation was found with scapular dyskinesis, glenohumeral range of motion, or instrument-assisted manual muscle testing of the supraspinatus (empty-can test).

Conclusion:

Visually observed infraspinatus muscle atrophy is a common finding in the dominant shoulder of asymptomatic male professional tennis players and is significantly correlated with external rotation weakness. This condition is present in uninjured players without known shoulder pathology and is not related to glenohumeral joint internal rotation, total rotation range of motion, or scapular dysfunction. Players with visually observed infraspinatus atrophy should be evaluated for external rotation strength and may require preventive strengthening.

Return to Work After Shoulder Replacement for Glenohumeral Osteoarthritis Is Similar When Hemiarthroplasty Is Compared to Total Shoulder Arthroplasty

BACKGROUND

Return to work after shoulder arthroplasty for glenohumeral osteoarthritis (OA) is an important consideration for an aging workforce.

QUESTIONS/PURPOSES

The aim of this study was to compare the shoulder function, pain levels, and rate of return to work in patients treated with anatomic total shoulder arthroplasty (aTSA) versus humeral hemiarthroplasty (HHA).

METHODS

A retrospective review of consecutive HHA patients was performed of our institution's shoulder arthroplasty registry. Inclusion criteria were pre-operative diagnosis of end-stage OA and more than 2 years' follow-up. HHA patients were statistically matched to aTSA patients and then screened for pre-operative work status; 26 HHA and 23 aTSA patients worked before surgery. There was no difference in average age (HHA, 62.4 years; aTSA, 61.7 years) or follow-up (HHA, 67.5 months; aTSA, 66.9 months).

RESULTS

Average American Shoulder and Elbow Surgeons (ASES) scores (HHA, 37.6 to 70.3; aTSA, 35.6 to 80.1) and visual analogue scale (VAS) for pain scores (HHA, 6.1 to 2.3; aTSA, 6.5 to 0.6) improved in both groups. However, HHA patients had worse final VAS scores, and aTSA patients were more satisfied (100% vs 77%); 61.5% of HHA patients returned to work post-operatively versus 87.0% of aTSA patients. There was no difference in time to return to work (HHA, 1.9 ± 2.3 months; aTSA, 1.3 ± 1.0 months).

CONCLUSION

Patients with shoulder OA undergoing aTSA have higher rates of return to work, function, and satisfaction than those undergoing HHA.

Does Having a Rotator Cuff Repair Before Total Shoulder Arthroplasty Influence Outcomes?

Background:

The number of rotator cuff repairs (RCRs) is increasing each year. Total shoulder arthroplasty (TSA) is a successful treatment option for patients with glenohumeral osteoarthritis with a functioning rotator cuff.

Purpose/Hypothesis:

The purposes of this study were to report the outcomes of TSA in patients with ipsilateral RCR and determine whether patients with a history of ipsilateral RCR who subsequently underwent TSA had differences in outcomes compared with matched controls who underwent TSA with no history of RCR. We hypothesized that patients with prior RCR will have significant improvements in clinical outcome scores, with no difference in outcomes after TSA compared with those with no prior RCR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients eligible for inclusion were those with a history of prior RCR who underwent TSA at a single institution with a minimum 2-year follow-up between 2000 and 2015. Outcomes for this group, including American Shoulder and Elbow Surgeons (ASES) scores, were reported and then compared with a matched control group of patients who underwent TSA with no history of prior RCR. Controls were matched based on age, sex, and preoperative ASES score.

Results:

Overall, 14 patients (64% males; mean ± SD age, 65.1 ± 11.1 years) underwent prior ipsilateral RCR before TSA. ASES scores significantly improved from 42.9 to 78.5 at 2 years and to 86.6 at 5 years. When compared with 42 matched control patients (matched 1:3) who underwent TSA with no history of RCR, there was no significant difference in ASES scores at 2 years (78.5 vs 85.3; P = .19) and 5 years (86.6 vs 90.9; P = .72) between the prior RCR and no RCR groups.

Conclusion:

TSA in patients with a history of prior ipsilateral RCR led to significant improvements in clinical outcomes. No difference in clinical outcomes at 2 or 5 years after TSA was found between patients with and without a history of prior ipsilateral RCR.

The Effect of Patient Characteristics and Comorbidities on the Rate of Revision Rotator Cuff Repair

PURPOSE

To describe the national rates of failed primary rotator cuff repair (RCR) requiring revision repair, using numerous patient characteristics previously defined in orthopaedic literature, including smoking history, diabetes mellitus (DM), hyperlipidemia (HLD), vitamin D deficiency, and osteoporosis to determine which factors independently affect the success of primary RCR.

METHODS

A combined public and private national insurance database was searched from 2007 to 2016 for all patients who underwent RCR. Current Procedural Terminology codes were used to identify RCRs. Laterality modifiers for the primary surgery were used to identify subsequent revision RCRs. All patients who did not have a linked laterality modifier for the RCR Current Procedural Terminology code were excluded from the study. Basic demographics were recorded. International Classification of Diseases Ninth Revision codes were used to identify patient characteristics including Charlson Comorbidity Index, smoking status, DM, obesity, HLD, vitamin D deficiency, and osteoporosis. Patient age categorized as <60, 60-69, 70-74, or 75+ years old. Dichotomous data were analyzed with χ² testing. Multivariable logistic regression was used to characterize independent associations with revision RCR.

RESULTS

Included in the study were 41,467 patients (41,844 shoulders, 52.7% male patients) who underwent primary arthroscopic RCR. Of all arthroscopic RCRs, 3072 patients (3463 shoulders, 53.5% male patients) underwent revision RCR (8.38%). In both primary and revision RCR, patients age 60 to 69 years were most prevalent, accounting for 38.4% and 37.6% of the cohorts, respectively. The average time from primary RCR to revision was 414.9 days (median 214.0 days). Increasing age and male sex (odds ratio [OR] 1.10, P = .019, 95% confidence interval [CI] 1.02-1.19) were significantly predictive of revision RCR. Of the remaining patient characteristics, smoking most strongly predicted revision RCR (OR 1.36, P < .001, CI 1.23-1.49). Obesity (OR 1.32, P < .001, CI 1.21-1.43), hyperlipidemia (OR 1.09, P = .032, CI 1.01-1.18), and vitamin D deficiency (OR 1.18, P < .001, CI 1.08-1.28) also increased risk of revision RCR significantly. DM was found to be protective against revision surgery (OR 0.84, P < .001, CI 0.76-0.92). Overall comorbidity burden as measured by the Charlson Comorbidity Index was not predictive of revision RCR.

CONCLUSIONS

Smoking, obesity, vitamin D deficiency, and HLD are shown to be independent risk factors for failure of primary RCR requiring revision RCR. However, despite the suggestions of previous studies, DM, osteoporosis, and overall comorbidity burden did not demonstrate independent associations in this study.

LEVEL OF EVIDENCE

IV, Case Series.

Scapular Ring Preservation: Coracoacromial Ligament Transection Increases Scapular Spine Strains Following Reverse Total Shoulder Arthroplasty

BACKGROUND

Scapular fractures following reverse total shoulder arthroplasty (RSA) are devastating complications with substantial functional implications. The role of the coracoacromial ligament (CAL), which is often transected during surgical exposure for RSA, is not fully known. We hypothesized that the CAL contributes to the structural integrity of the "scapular ring" and that the transection of this ligament during RSA alters the scapular strain patterns.

METHODS

RSA was performed on 8 cadaveric specimens without evidence of a prior surgical procedure in the shoulder. Strain rosettes were fixed onto the acromial body (at the location of Levy type-II fractures) and the scapular spine (Levy type III). With use of a shoulder simulator, strains were recorded at 0°, 30°, and 60° glenohumeral abductions before and after CAL transection. The deltoid and glenohumeral joints were functionally loaded (middle deltoid = 150 N, posterior deltoid = 75 N, and joint compression = 300 N). Maximum principal strains were calculated from each rosette at each abduction angle. A repeated-measures analysis of variance with post hoc analysis was performed to compare the maximum principal strain at each abduction angle.

RESULTS

With the CAL intact, there was no significant difference between strain experienced by the acromion and scapular spine at 0°, 30°, and 60° of glenohumeral abduction. CAL transection generated significantly increased strain in the scapular spine at all abduction angles compared with an intact CAL. The maximum scapular spine strain observed was increased 19.7% at 0° of abduction following CAL transection (1,216 ± 300.0 microstrain; p = 0.011). Following CAL transection, acromial strains paradoxically decreased at all abduction angles (p < 0.05 for all). The smallest strains were observed at 60° of glenohumeral abduction at the acromion following CAL transection (296 ± 121.3 microstrain; p = 0.048).

CONCLUSIONS

The CAL is an important structure that completes the "scapular ring" and therefore serves to help distribute strain in a more normalized fashion. Transection of the CAL substantially alters strain patterns, resulting in increased strain at the scapular spine following RSA.

CLINICAL RELEVANCE

CAL preservation is a modifiable risk factor that may reduce the risk of bone microdamage and thus the occurrence of fatigue/stress fractures in the scapular spine following RSA.

The biomechanics of subscapularis repair in reverse shoulder arthroplasty: The effect of lateralization and insertion site

Functional outcomes of subscapularis (SSc) repair following reverse shoulder arthroplasty (RSA) remains controversial. SSc repair in combination with glenosphere lateralization was reported to yield worse clinical outcomes compared with the non-lateralized glenosphere. The aim of this biomechanical study was to investigate how glenosphere lateralization and different re-insertion sites can affect the biomechanics of the SSc after RSA. Nine patient-specific RSA shoulder models were created from patients' computed tomography scans. Moment arms and SSc length were calculated for abduction, forward flexion, and internal rotation in 20° and 90° abduction for three configurations of glenosphere lateralization (standard/+0, +5, and +10 mm) and three SSc repair sites (native, superior, and inferior) and compared with the native shoulder. When compared with the native shoulder, RSA resulted in large adducting SSc moment arms that were antagonistic to the deltoid. Glenosphere lateralization had no effect on SSc moment arms in any motion. However, lateralization increased SSc tension beyond its anatomic length for +5 and +10 mm of lateralization when attached to its native insertion. A superior SSc repair site created the least adductive moment arm as well as the least amount of SSc lengthening. Increased glenosphere lateralization showed a significant increase in the SSc length, which in combination with its adductive moment arm can be antagonistic to deltoid function. However, a superior SSc repair site may help reduce the adductive SSc moment arm and allow for reduced tension on the repair as its length in that location is less than that of the native SSc. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:888-894, 2020.

Failed Proximal Humerus Osteosynthesis Using Intramedullary Fibular Strut Allograft Conversion to Reverse Shoulder Arthroplasty

Comminuted proximal humerus fractures are more frequently being treated utilizing an intramedullary fibular strut allograft to assist with open reduction internal fixation. Although this technique has led to improved outcomes, avascular necrosis, rotator cuff failure, and/or prominent hardware may still occur necessitating conversion to reverse shoulder arthroplasty. The presence of an intramedullary strut allograft makes this conversion technically demanding and creates certain potential complications unique to this group. This manuscript details the conversion of a proximal humerus open reduction internal fixation with a fibular strut allograft to reverse shoulder arthroplasty including presurgical workup, surgical techniques, and pitfalls for undertaking this increasingly common scenario.

Quantifying the Impact of Patient-Specific Factors and Disease Severity on Clinical Decision Making in Cuff Tear Arthropathy: A Case-Based Survey

BACKGROUND

Rotator cuff tears are a common cause of disability. Some patients with massive and irreparable tears can develop cuff tear arthropathy (CTA), which makes management more challenging.

QUESTIONS/PURPOSES

We sought to examine how orthopedists determine treatment for patients with CTA. Specifically, we investigated (1) the effect of patient age, symptoms, activity level, range of motion, and radiographic findings on the decision making of shoulder specialists and (2) the observer reliability of the Seebauer and Hamada grading systems.

METHODS

Five shoulder surgeons were each sent 108 simulated patient cases. Each simulated patient had a different combination of factors, including patient age, symptoms, activity level, range of motion, and radiographs. Responders graded the radiographs and chose a treatment (non-operative, arthroscopic, hemiarthroplasty, or reverse total shoulder arthroplasty). Spearman's correlations and χ 2 tests were used to assess the relationship between factors and treatments. Sub-analysis was performed on surgical cases. An intra-class correlation (ICC) was used to assess observer agreement.

RESULTS

The significant Spearman's correlations were symptoms (0.45), Hamada grade (0.38), patient age (0.34), and Seebauer type (0.29). In sub-analysis of operative cases, the significant correlations were Hamada grade (0.56), patient age (0.51), Seebauer type (0.46), activity level (-0.13). The χ 2 analysis was significant for all factors except activity level. The inter- and intraobserver reliabilities were, respectively, Seebauer type (0.59 and 0.63) and Hamada grade (0.58 and 0.65). Interobserver reliability for patient management was 0.44.

CONCLUSION

When evaluating CTA, patient symptoms, radiographic grade, and patient age are the factors most strongly associated with the decision making of shoulder specialists. Additionally, the Seebauer and Hamada classifications had similar reliability and clinical utility. However, there was only fair agreement regarding treatment, which indicates that CTA management remains controversial.

PROMIS physical function underperforms psychometrically relative to American Shoulder and Elbow Surgeons score in patients undergoing anatomic total shoulder arthroplasty

BACKGROUND

The purpose of this study was to evaluate the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF-CAT) relative to the American Shoulder and Elbow Surgeons (ASES) score in patients with glenohumeral osteoarthritis undergoing primary anatomic total shoulder arthroplasty (TSA).

METHODS

A retrospective study of an institutional TSA registry was performed. Preoperative PROMIS PF-CAT and ASES scores were collected. Floor and ceiling effects were determined, and convergent validity was established through Pearson correlations. Rasch partial credit modeling was used for psychometric analysis of the validity of PF-CAT and ASES question items. Person-item maps were generated to characterize the distribution of question responses along the latent dimension of shoulder disability.

RESULTS

Responses from 179 patients (184 shoulders) were included. PF-CAT had a moderate correlation to ASES (r = 0.487; P < .001), with no floor or ceiling effects; ASES had a 1.1% floor effect and no ceiling effect. With iterative Rasch model item-reduction analysis eliminating poorly fitting question items, all possible PF-CAT items were eliminated after 6 iterations. With ASES, just 1 function question item was dropped. Person-item maps showed ASES to be superior to PROMIS PF-CAT psychometrically, with sequential and improved coverage of the latent dimension of shoulder disability.

CONCLUSION

Despite moderate correlation with ASES, PROMIS PF-CAT demonstrated inferior validity and psychometric properties in patients undergoing TSA. PF-CAT should not replace the ASES in this population of patients.

Acromion Compromise Does Not Significantly Affect Clinical Outcomes After Reverse Shoulder Arthroplasty: A Matched Case-Control Study

BACKGROUND

The effect of a pre-operative compromised acromion on reverse shoulder arthroplasty (RSA) is not well-studied.

PURPOSES/QUESTIONS

We sought to determine the effect of a pre-operative compromised acromion on outcomes following RSA.

METHODS

We conducted a retrospective case-control study of consecutive patients who underwent RSA over a 6-year period (June 2007 to June 2013) with a diagnosis of rotator cuff tear arthropathy. Pre-operative plain radiographs were examined to determine the presence of acromion compromise (n = 11). Acromion compromise was defined as (1) less than 25% of the normal acromion thickness (8.8 mm), (2) less than 50% of the normal acromion anteroposterior width (46.1 mm), (3) presence of an os acromiale, or (4) presence of acromial fragmentation. An age- and sex-matched control cohort without acromial compromise was also identified (n = 33). The primary outcome variable was the final minimum 2-year American Shoulder and Elbow Surgeons (ASES) score. Secondary outcomes included final minimum 2-year scores on the 12-Item Short-Form Health Survey (SF-12), with the physical component score (PCS) and mental component score (MCS); 2-year Marx shoulder activity scale scores; and final 2-year satisfaction scores.

RESULTS

At 2 years post-operatively, there were no significant differences in final scores using ASES, SF-12 PCS or MCS, or Marx shoulder activity scale. There were no significant differences between groups for satisfaction scores in any of the assessed domains. No complications were reported at 2 years' follow-up in any of the study patients or controls.

CONCLUSIONS

Between patients with and without pre-operative acromion compromise, there were no differences in clinical outcomes, satisfaction levels, or complication rates after RSA. Our findings suggest that surgeons performing RSA in the setting of pre-operative acromion compromise, including os acromiale, acromial fragmentation, or severe thinning, should not expect poor post-operative clinical outcomes.

Biomechanics of lower trapezius and latissimus dorsi transfers in rotator cuff-deficient shoulders

BACKGROUND

Irreparable posterosuperior rotator cuff tears cause pain and impaired shoulder function. Latissimus dorsi (LD) transfer has been proven to improve shoulder function, but lower trapezius (LT) transfer has recently been proposed as an alternative. This study aimed to compare the biomechanics of LD and LT transfers and how they are affected by different insertion sites.

METHODS

The Newcastle shoulder model was used to investigate the biomechanics of these 2 tendon transfers. Computed tomography data sets from 10 healthy subjects were used to customize the model, and virtual LD and LT transfers were performed on supraspinatus, infraspinatus, and teres minor insertion sites. Muscle moment arms and lengths were computed for abduction, forward flexion, and external rotation.

RESULTS

The LT yields greater abduction moment arms compared with the LD when it is transferred to the native supraspinatus and infraspinatus insertion sites. However, they become adductors when transferred to the native teres minor insertion. Both muscles show strong external rotation moment arms, except for the LT with a supraspinatus insertion. Resting muscle strains were 0.21 (±0.03), 0.12 (±0.02), and 0.06 (±0.03) for the LD and 0.70 (±0.15), 0.61 (±0.13), and 0.58 (±0.13) for the LT for the supraspinatus, infraspinatus, and teres minor insertions, respectively.

CONCLUSIONS

LT provided better abduction and external rotation moment arms when transferred to the infraspinatus insertion. LD performed better when transferred to the supraspinatus insertion. Overall, LT transfer showed a biomechanical advantage compared with LD transfer because of stronger abduction moment arms. However, significantly larger muscle strains after LT transfer necessitate a tendon allograft to prevent muscle overtensioning.

Preoperative patient expectations of elective reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine patients' preoperative expectations before primary elective reverse shoulder arthroplasty (RSA). We hypothesized that younger patients, patients with better preoperative function, patients with shoulder osteoarthritis (OA), and patients with no prior joint replacements would have higher expectations of RSA.

METHODS

We prospectively studied 333 primary RSAs performed for cuff tear arthropathy (n = 242), OA (n = 68), or post-traumatic arthritis (n = 23). Expectations were assessed preoperatively using the Hospital for Special Surgery's shoulder surgery expectations survey. Preoperative patient-reported measures were assessed with the American Shoulder and Elbow Surgeons shoulder score; Shoulder Activity Scale score; Short Form 12 mental component and physical component scores; and visual analog scale scores for pain, fatigue, and general health. A Poisson regression model was performed to control for potential confounding variables.

RESULTS

Relief of night-time pain, relief of daytime pain, improvement in self-care, improvement in the ability to drive or put on a seat belt, and improvement in the ability to perform daily activities were reported as "very important" by approximately half of patients. No association was found between age and overall expectations. Multivariate analysis showed that better preoperative Shoulder Activity Scale and Short Form 12 physical component scores were associated with greater expectations (P < .001). OA was associated with greater expectations compared with cuff tear arthropathy (P < .001). A history of either contralateral RSA or any joint replacement was associated with lower expectations (P < .001).

CONCLUSION

Patients have the highest expectations for pain relief and the performance of simple tasks after RSA. Patients with higher preoperative function, OA, and no previous joint replacements have greater expectations of RSA.

What Pain Levels Do TSA Patients Experience When Given a Long-acting Nerve Block and Multimodal Analgesia?

BACKGROUND

The pain experience for total shoulder arthroplasty (TSA) patients in the first 2 weeks after surgery has not been well described. Many approaches to pain management have been used, with none emerging as clearly superior; it is important that any approach minimizes postoperative opioid use.

QUESTIONS/PURPOSES

(1) With a long-acting nerve block and comprehensive multimodal analgesia, what are the pain levels after TSA from day of surgery until postoperative day (POD) 14? (2) How many opioids do TSA patients take from the day of surgery until POD 14? (3) What are the PainOUT responses at POD 1 and POD 14, focusing on side effects from opioids usage?

METHODS

From January 27, 2017 to December 6, 2017, 154 TSA patients were identified as potentially eligible for this prospective, institutional review board-approved observational study. Of those, 46 patients (30%) were excluded (either because they were deemed not appropriate for the study, research staff were not available, patients were not eligible, or they declined to participate), and another six (4%) had incomplete followup data and could not be studied, leaving 102 patients (66%) for analysis here. Median preoperative pain with movement was 7 (interquartile range [IQR], 5-9) and 13 of 102 patients used preoperative opioids. All patients received a single-injection bupivacaine interscalene block with adjuvant clonidine, dexamethasone, and buprenorphine. Multimodal analgesia included acetaminophen, NSAIDs, and opioids. The primary outcome was the Numerical Rating Scale (NRS) pain score with movement on POD 14. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). Secondary outcomes included NRS pain scores at rest and with movement (day of surgery, and PODs 1, 3, 7 and 14), daily analgesic use from day of surgery to POD 14 (both oral and intravenous), Opioid-Related Symptom Distress Scale (which assesses 12 symptoms ranging from 0 to 4, with 4 being the most distressing; the composite score is the mean of the 12 symptom-specific scores) on POD 1, and the PainOut questionnaire on POD 1 and POD 14. The PainOut questionnaire includes questions rating nausea, drowsiness, itching from 0 (none) to 10 (severe), as well as rating difficulty staying asleep from 0 (does not interfere) to 10 (completely interferes).

RESULTS

The median NRS pain scores with movement were 2 (IQR, 0-5) on POD 1, 5 (IQR, 3-6) on POD 3, and the pain score was 3 (IQR, 1-5) on POD 14. Median total opioid use (converted to oral morphine equivalents) was 16 mg (4-50 mg) for the first 24 hours, 30 mg (8-63 mg) for the third, and 0 mg (0-20 mg) by the eighth 24-hour period, while the most frequent number of activations of the intravenous patient-controlled analgesia device was 0. Median PainOut scores on POD 1 and POD 14 for sleep interference, nausea, drowsiness and itching were 0, and the median composite Opioid-Related Symptom Distress Scale score on day 1 was 0.3 (IQR, 0.1-0.5).

CONCLUSIONS

Clinicians using this protocol, which combines a long-acting, single-injection nerve block with multimodal analgesia, can inform TSA patients that their postoperative pain will likely be less than their preoperative pain, and that on average they will stop using opioids after 7 days. Future research could investigate what the individual components of this protocol contribute. Larger cohort studies or registries would document the incidence of rare complications. Randomized controlled trials could directly compare analgesic effectiveness and cost-benefits for this protocol versus alternative strategies, such as perineural catheters or liposomal bupivacaine. Perhaps most importantly, future studies could seek ways to further reduce peak pain and opioid usage on POD 2 and POD 3.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Continued Inpatient Care After Primary Total Shoulder Arthroplasty Is Associated With Increased Short-term Postdischarge Morbidity: A Propensity Score-Adjusted Analysis

Advances in surgical technique and implant design during the past several decades have resulted in annual increases in shoulder arthroplasty procedures performed in the United States. The purpose of this investigation was to use the National Surgical Quality Improvement Program database to analyze the rates of morbidity following shoulder arthroplasty. The authors hypothesized that, independent of predischarge patient factors, discharge to inpatient facilities is associated with increased short-term morbidity. Patient demographics, intraoperative variables, and information about postoperative complications/readmissions up to 30 days after the operative event were collected from the National Surgical Quality Improvement Program database for the period 2005 to 2015. Patients were divided into 2 cohorts based on discharge to home vs non-home facilities. Unadjusted baseline patient characteristics were compared using Pearson's chi-square test, and a propensity score-adjusted comparison was also performed. Overall, 9058 patients were included. Of these, 7996 (88.3%) were discharged to home and 1062 (11.7%) were discharged to a non-home facility. On propensity-adjusted analysis, complications determined to be statistically significantly associated with non-home discharge included cardiac (odds ratio, 4.19; 95% confidence interval, 1.75-10.04; P=.001), respiratory (odds ratio, 2.63; 95% confidence interval, 1.47-4.70; P=.001), urinary tract infection (odds ratio, 2.66; 95% confidence interval, 1.52-4.67; P=.001), and death (odds ratio, 7.51; 95% confidence interval, 2.42-23.27; P<.001). Overall, complications were statistically significantly associated with non-home discharges (odds ratio, 2.05; 95% confidence interval, 1.59-2.64; propensity-adjusted P<.001). This investigation indicated an association between postdischarge placement into non-home facilities and an increase in short-term morbidity, regardless of preoperative patient comorbidities. [Orthopedics. 2019; 42(2):e225-e231.].

Effect of preoperative patient expectations on outcomes after reverse total shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the effect of preoperative expectations on outcomes after reverse shoulder arthroplasty (RSA). We hypothesized that patients with greater expectations would have better outcomes.

METHODS

Patients undergoing primary RSA completed the Hospital for Special Surgery's Shoulder Expectations Survey preoperatively. Preoperative and 2-year postoperative clinical outcomes were measured with the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Shoulder Activity Scale (SAS), 36-Item Short Form Health Survey (SF-36), and visual analog scales (VASs). Pearson correlations were used to assess the relationship between the number of expectations and outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation question were assessed by independent samples t test. Multivariable linear regression analysis was used to control for potential confounding factors.

RESULTS

We evaluated 135 patients at 2 years postoperatively. Patients had higher expectations for relieving pain, improving self-care, improving ability to perform daily activities, and improving ability to drive or put on a seatbelt. Patients with a greater number of high expectations preoperatively did not have better ASES, SAS, or VAS pain scores postoperatively. However, higher expectations for relieving nighttime pain was associated with ASES (β = 7.0, P = .048) and VAS pain scores (β = -5.9, P = .047) as well as 2-year improvement of VAS pain (β = -6.1, P = .039). Higher expectations for improving the ability to participate in nonoverhead sports was associated with improvements in SAS (β = 2.8, P = .020).

CONCLUSION

A higher level of expectations for relief of nighttime pain and improving ability to participate in nonoverhead sports is associated with improved outcomes after RSA.

Risk factors for failing to achieve improvement after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis

BACKGROUND

Although anatomic total shoulder arthroplasty (TSA) successfully improves pain and function, not all patients improve clinically. This study was conducted to determine patient-related factors for failure to achieve improvement after primary TSA for osteoarthritis at 2 years postoperatively.

METHODS

This prospective study reviewed an institutional shoulder registry for consecutive patients who underwent primary TSA for osteoarthritis from 2007 to 2013 with baseline and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form scores. A failed outcome was defined as (1) a failure to reach the ASES minimal clinically important difference of 16.1 points or (2) revision surgery within 2 years of the index procedure, or both. Univariate and multivariable analyses of clinical and demographic patient factors were performed using logistic regression.

RESULTS

Of 459 arthroplasties that met inclusion criteria, 411 were deemed successful by the aforementioned criteria, and 48 (10.5%) failed to achieve a desirable outcome. Clinical risk factors associated with failure included previous surgery to the shoulder (P = .047), presence of a torn rotator cuff (P = .025), and presence of diabetes (P = .036), after adjusting for age, sex, race, and body mass index. A higher preoperative ASES score at baseline was associated with failure (P < .001).

CONCLUSION

Previous shoulder surgery, a rotator cuff tear requiring repair during TSA, presence of diabetes, surgery on the nondominant arm, and a higher baseline ASES score were associated with a higher risk of failing to achieve improvement after anatomic TSA.

Trends in the Surgical Management of Acromioclavicular Joint Arthritis Among Board-Eligible US Orthopaedic Surgeons

PURPOSE

(1) Define the epidemiologic trend of distal clavicle excision (DCE) for acromioclavicular (AC) joint arthritis among board-eligible orthopaedic surgeons in the United States, (2) describe the rates and types of reported complications of open and arthroscopic DCE, and (3) evaluate the effect of fellowship training on preferred technique and reported complication rates.

METHODS

The American Board of Orthopaedic Surgery (ABOS) database was used to identify DCE cases submitted by ABOS Part II Board Certification examination candidates. Inclusion criteria were predetermined using a combination of ICD-9 and CPT codes. Cases were dichotomized into 2 groups: open or arthroscopic DCE. The 2 groups were then analyzed to determine trends in annual incidence, complication rates, and surgeon fellowship training.

RESULTS

From April 2004 to September 2013, there were 3,229 open and 12,782 arthroscopic DCE procedures performed and submitted by ABOS Part II Board Eligible candidates. Overall, the annual incidence of open DCE decreased (78-37 cases per 10,000 submitted cases, P = .023). Although the annual number of arthroscopic DCE remained steady (1160-1125, P = .622), the percentage of DCE cases performed arthroscopically increased (65%-79%, P = .033). Surgeons without fellowship training were most likely to perform a DCE via an open approach (31%) whereas surgeons with sports medicine training were more likely to perform DCE arthroscopically compared with other fellowship groups (88%, P < .001). Open DCE was associated with a higher surgical complication rate overall when compared with arthroscopic DCE (9.4% vs 7.6%, respectively; P < .001). When compared with other fellowship-trained surgeons, sports medicine surgeons maintained a lower reported surgical complication rate whether performing open or arthroscopic DCE (5.5%, P = .027).

CONCLUSIONS

In recent years, open management of AC joint arthritis has declined among newly trained, board-eligible orthopaedic surgeons, possibly because of an increased complication rate associated with open treatment. Fellowship training was significantly associated with the type of treatment (open vs arthroscopic) rendered and complication rates.

LEVEL OF EVIDENCE

Level IV, case series.

Return to Work After Anatomic Total Shoulder Arthroplasty for Patients 55 Years and Younger at Average 5-Year Follow-up

As the number of anatomic total shoulder arthroplasties performed on younger patients continues to grow, return to work after surgery becomes increasingly important. The purpose of this study was to evaluate the ability of anatomic total shoulder arthroplasty to return patients 55 years or younger to work postoperatively. A retrospective review was performed of consecutive anatomic total shoulder arthroplasty patients. Inclusion criteria were age 55 years or younger at surgery, greater than 2 years of follow-up, and employment within 3 years of surgery. Employment was stratified by intensity of work (sedentary, light, moderate, or heavy). Return to work status and time out of work were also evaluated. Fifty-two patients worked before surgery. Average age was 48.4 years, with average follow-up of 5.4 years. Seventy-three percent were male, and average body mass index was 28.0 kg/m². Average visual analog scale score improved from 5.5 to 0.9 (P<.0001) and American Shoulder and Elbow Society score improved from 39.9 to 88.3 (P<.0001). Forty-eight (92%) of 52 returned to work postoperatively after an average of 2.1 months. When stratified by intensity, all patients with sedentary, light, or moderate work returned, whereas 64% returned to heavy work (P<.01). Eighty-seven percent were satisfied to very satisfied after surgery. In summary, most patients (92%) who undergo anatomic total shoulder arthroplasty at 55 years or younger return to work, on average, 2.1 months after surgery. [Orthopedics. 2018; 41(3):e310-e315.].

Epidemiology of injuries in tennis players

PURPOSE OF REVIEW

To review the recent literature regarding the epidemiology of tennis injuries at all levels of play, and to discuss recent findings in injury surveillance by the Association of Tennis Professionals (ATP).

RECENT FINDINGS

Following the release of a consensus statement in 2009 calling for standardized documentation and analysis of tennis-related injuries, multiple studies have been published describing longitudinal injury incidences at Grand Slam tournaments and the Davis Cup. Recent efforts by the ATP have further elucidated injury patterns on tour. There have also been recent high-quality studies on injury trends among collegiate and elite junior tennis players, bringing attention to musculoskeletal injuries and systemic illnesses that young tennis players may be susceptible to. Recent efforts in injury surveillance by the ATP and at the collegiate and junior levels have highlighted injury trends that will help guide injury prevention strategies at various levels of play.

Long Head of Biceps Tendon Management: a Survey of the American Shoulder and Elbow Surgeons

BACKGROUND

Management of symptomatic long head of biceps tendon (LHBT) pathology remains a source of debate.

QUESTIONS/PURPOSES

The purpose of this study was to identify consensus trends for the treatment of LHBT pathology among specialists.

METHODS

A survey was distributed to members of the American Shoulder and Elbow Society (ASES), consisting of three sections-demographics, case scenarios, and general LHBT pathology management. Cases presented common clinical scenarios, and surgeons reported their management preferences. Consensus responses were defined as > 50% of participants giving a single response.

RESULTS

One hundred and forty-two of 417 (34%) surgeons completed surveys. Forty-seven percent of questions reached a consensus answer. Biceps tenodesis was the overwhelmingly preferred technique in cases demonstrating LHBT pathology, as compared to tenotomy. No consensus, however, was reached regarding a specific surgical technique for biceps tenodesis. The two most popular techniques were arthroscopic tenodesis to bone and open subpectoral biceps tenodesis. Fellowship-trained arthroscopic surgeons and surgeons with a largely arthroscopic practice were more likely to perform tenodesis arthroscopically.

CONCLUSION

ASES members favored biceps tenodesis over tenotomy for surgical management of LHBT pathology, without consensus regarding a specific surgical technique.

Increased Shoulder Arthroscopy Time Is Associated With Overnight Hospital Stay and Surgical Site Infection

PURPOSE

The purpose of this study was to characterize the rates of short-term postoperative complications, readmissions, and overnight hospital stays as a function of shoulder arthroscopy procedure time. A secondary aim of this current study was to identify baseline patient risk factors for adverse outcomes.

METHODS

This study used the American College of Surgeons National Surgical Quality Improvement Program registry from 2012 to 2015. Shoulder arthroscopy cases were categorized based on operative time, either <45 minutes, between 45 and 90 minutes, or >90 minutes. The rates of 30-day postoperative complications, readmissions, and overnight hospital stays were compared with bivariate and multivariate analysis.

RESULTS

In total, 33,095 shoulder arthroscopy procedures were identified. Of these, 7,027 (21.2%) were <45 minutes, 16,610 (50.2%) were between 45 and 90 minutes, and 9,458 (28.6%) were >90 minutes. Multivariate analysis identified increased the risk of superficial surgical site infections (SSIs) for procedures lasting between 45 and 90 minutes (odds ratio [OR] = 3.63; P = .036) and for procedures >90 minutes (OR = 4.40; P = .019), compared with procedures <45 minutes. Furthermore, there was an increased risk of overnight hospital stay for patients who had a shoulder arthroscopy lasting between 45 and 90 minutes (OR = 1.33) and >90 minutes (OR = 2.14), compared with procedures <45 minutes. A body mass index >30 kg/m² was an independent predictor of both overnight hospital stay and superficial SSI (P = .020). Age >60, female gender, American Society of Anesthesiologists class ≥3, and a history of diabetes mellitus, hypertension, or chronic obstructive pulmonary disease were additional predictors of overnight hospital stay (P < .001 for all comparisons, unless otherwise noted).

CONCLUSIONS

Increased shoulder arthroscopy procedure time is associated with adverse short-term outcomes, particularly superficial SSI and overnight hospital stay. This information may be useful for patient counseling and postoperative risk stratification, as operative time is an easily measured surrogate for surgical complexity or difficulty.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Revision Total Shoulder Arthroplasty is Associated with Increased Thirty-Day Postoperative Complications and Wound Infections Relative to Primary Total Shoulder Arthroplasty

BACKGROUND

With an increasing volume of primary total shoulder arthroplasties (TSA), the number of revision TSA cases is expected to increase as well. However, the postoperative medical morbidity of revision TSA has not been clearly described.

QUESTIONS/PURPOSES

The purpose of this study was to determine the rate of postoperative complications following revision TSA, relative to primary TSA. In addition, we sought to identify independent predictors of complications, as well as to compare operative time and postoperative length of stay between primary and revision TSA.

METHODS

Patients who underwent primary/revision TSA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Differences in complications, readmission rates, operative time, length of stay, and predictors of complications were evaluated using bivariate and multivariate analyses.

RESULTS

A total of 10,371 primary TSA (95.4%) and 496 revision TSA cases (4.6%) were identified. The overall complication rate was 6.5% in primary and 10.7% in revision TSA patients (p < 0.001). Multivariate analysis identified an increased risk of any complication (odds ratio 1.73, p < 0.001), major complication (2.08, p = 0.001), and wound infection (3.45, p = 0.001) in revision TSA patients, relative to primary cases. Operative time was increased in revision cases (mean ± standard deviation, 125 ± 62.5), relative to primary (115 ± 47.7, p < 0.001). Age > 75, female sex, history of diabetes or chronic obstructive pulmonary disease, and American Society of Anesthesiologists classification ≥ 3 were associated with increased risk of any complication. Smoking history was the only significant predictor of wound infection.

CONCLUSION

Revision TSA, in comparison to primary, poses an increased risk of postoperative complications, particularly wound infections. A history of smoking was an independent predictor of wound infections.