Faculty Bibliography

BACKGROUND:Pre-osteoarthritic posterior subluxation of the humeral head (PPSHH), also referred to as a Walch B0 glenoid, is characterized by pathologic posterior subluxation of the humeral head without degenerative bony changes on plain radiographs. The purpose of this study was to describe the imaging findings of PPSHH and to assess the relationship between glenoid retroversion and HH subluxation. METHODS:This was a retrospective case series of patients with symptomatic PPSHH. Retroversion was measured on magnetic resonance imaging based on both Friedman's line and the scapular axis line. HH subluxation was measured based on the glenohumeral index (GHI) and the scapulohumeral index (SHI). The relationship between retroversion and HH subluxation was evaluated. The difference in glenoid cartilage thickness between the anterior and posterior aspects of the glenoid was compared. RESULTS:Eight patients were included (mean age, 34.0±4.7 years). Mean retroversion was 17.2°±5.8° based on Friedman's line and 14.0°±5.6° based on scapular axis line. Mean HH subluxation was 63.7%±6.2% based on GHI and 77.5%±9.9% based on SHI. Cartilage thickness was less in the posterior glenoid compared to anterior glenoid, and all patients had selective chondral wear on the posterior glenoid with a posterior labral tear. There was a direct relationship between the degree of glenoid retroversion and HH subluxation. CONCLUSIONS:PPSHH is characterized by posterior glenoid chondral thinning and posterior labral tears in the setting of HH subluxation without erosive osseous changes. This pathology can present with varying degrees of retroversion and HH subluxation, and increasing retroversion is associated with more severe subluxation. Level of evidence: IV.

BACKGROUND/UNASSIGNED:The Patient-Reported Outcome Measurement Information System (PROMIS) has been widely used to assess clinical improvement in orthopedic procedures, providing a standardized and responsive measure of function and pain. While PROMIS has been effective in evaluating recovery in upper extremity surgery, specific thresholds for meaningful improvement following the Latarjet procedure (LP) have not been established. The purpose of this study was to determine the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) of PROMIS Upper Extremity (P-UE) Computer Adaptive Testing v2.0, Pain Interference (P-Interference), and Pain Intensity (P-Intensity) scores in patients undergoing the LP for shoulder instability. We hypothesize that PROMIS instruments will effectively distinguish these thresholds for clinically significant improvement with respect to shoulder function and pain following LP. METHODS/UNASSIGNED:MCID, SCB, and PASS were calculated using an anchor-based approach at a minimum follow-up of 1 year. The optimal cutoff values for change in PROMIS scores were determined via receiver operating characteristic curves and area under the curve analysis. Regression analysis was conducted to identify patient factors associated with achievement of the MCID, SCB, and PASS thresholds. RESULTS/UNASSIGNED:A total of 72 patients were included in our analysis. MCID for P-UE, P-Interference, and P-Intensity was determined to be 3.2, -6.3, and -9.4, respectively. Respective SCB values were determined to be 8.1, -10.7, and -11.4. Respective PASS values were determined to be 42.6, 56.7, and 39.4. Corresponding effect size and standardized response means were: P-UE (1.6, 3.4), P-Interference (1.4, 1.2), and P-Intensity (1.7, 1.2). For P-UE, generalized joint laxity was associated with lower odds of achieving SCB. For P-Interference, history of recurrent dislocations was linked to lower odds of achieving MCID. For P-Intensity, generalized joint laxity and history of recurrent dislocations were associated with lower odds of achieving MCID and SCB. Larger Hill-Sachs lesion depth was associated with lower odds of achieving P-intensity PASS. CONCLUSION/UNASSIGNED:This study establishes MCID, SCB, and PASS values for PROMIS instruments following LP. Knowledge of these thresholds and patient factors associated with achieving them provide surgeons useful tools for predicting and measuring clinically meaningful outcomes following surgery.

INTRODUCTION/BACKGROUND:Closed treatment of comminuted, displaced greater tuberosity fractures (GTFs) can result in nonunion or malunion, causing rotator cuff dysfunction and/or subacromial impingement. This study evaluates the outcomes and complications of combined suture anchor and screw fixation technique for the treatment of GTFs. MATERIALS AND METHODS/METHODS:This retrospective case series included 13 patients with displaced GTFs (> 5 mm) who underwent screw and double-row suture bridge fixation from 2019 to 2024 at a single institution. Patient demographics, injury mechanisms, fracture characteristics, associated injuries, and operative data were collected. All fractures were fixed using screw and double row suture bridge fixation via a lateral deltoid split approach. Postoperative outcomes included range of motion, Patient-Reported Outcome Measurement Information System (PROMIS) scores, American Shoulder and Elbow Surgeons (ASES), Visual Analogue Scale (VAS), radiographic outcomes, and postoperative complications. RESULTS:Thirteen patients (13 shoulders; 9 males, 4 females) with a mean age of 53.2 (29-73) years were followed for an average of 11.7 (6-27) months. The most common mechanism of injury was a traumatic fall (9/13). The mean postoperative PROMIS Upper Extremity score was 42.7 ± 8.9, and the mean ASES score was 79.3 ± 13.8. Latest postoperative radiographs showed evidence of healed fractures in 12 out of 13 patients (92%) with no further fracture displacement. Two patients (15%) required reoperation: one for screw migration/loosening and one for late infection with greater tuberosity resorption and screw displacement. CONCLUSION/CONCLUSIONS:Treatment of displaced GT fractures with combined screw fixation and double row suture bridge technique results in predictable fracture healing and favorable functional outcomes. Limitations include the retrospective case series design, small cohort size, and absence of a control group. LEVEL OF EVIDENCE/METHODS:IV, case series.

BACKGROUND:Guidance technology in total joint arthroplasty has gained popularity over the last few decades. Computer-assisted navigation (CAN) was recently introduced for glenoid implantation in total shoulder arthroplasty (TSA). However, utilization trends of CAN TSA are not currently known. This study aims to determine the prevalence and trends of CAN usage in TSA from its introduction in 2017 until 2023. METHODS:A retrospective review was performed of all TSAs (anatomic TSA [aTSA] or reverse TSA [rTSA]) implanted using a single computer navigation shoulder system (ExactechGPS; Gainseville, FL, USA). Intraoperative navigation was performed for the glenoid component only. Utilization of CAN was reported per year to determine trends in the prevalence of CAN cases, number of users, new users, dropped users, high-volume users (>50 CAN cases/year), and the number of cases completed by high-volume users. The data was also stratified by type of TSA (aTSA vs. rTSA) and type of glenoid component used (augmented or non-augmented). RESULTS:From 2017 to 2023, navigated TSAs increased from 654 to 9777 cases per year, with a greater increase in navigated rTSA than aTSA volume. The number of CAN cases using augmented implants grew 1435% while non-augmented implants grew 1352%. By 2023, the overall number of CAN users increased from 79 to 667 users. High-volume CAN surgeons increased to 50 users by 2023. Over this period, the number of CAN TSA performed by high-volume surgeons increased more rapidly than the actual number of high-volume surgeons per year. CONCLUSIONS:This study demonstrates an exponential increase in the use of CAN for TSA in the last eight years. This increase is driven by progressive growth in both the volume of new users as well as CAN TSAs performed by existing users by several hundred folds. These upwards trends in utilization of guidance technology for TSA are likely to continue in future.

BACKGROUND:Outcome thresholds such as the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) are commonly used to define meaningful clinical improvement. However, these measures apply uniform cutoffs that do not account for individual baseline scores. Maximal Possible Improvement (MPI) offers a patient-specific approach by considering the maximal potential gain in function or reduction in pain. The percentage of MPI (%MPI) that correlates with high postoperative patient satisfaction following the Latarjet procedure has not been defined. The purpose of this study was to (1) establish %MPI thresholds predictive of high patient satisfaction for the American Shoulder and Elbow Surgeons (ASES) score, and the Patient-Reported Outcomes Measurement Information System (PROMIS) domains of Upper Extremity Function (PUE), Pain Interference (P-Interference), and Pain Intensity (P-Intensity); and (2) identify patient-level factors associated with achieving these thresholds for ASES and PUE. METHODS:A retrospective review identified 81 eligible patients who underwent the Latarjet procedure with minimum 1-year follow-up. Preoperative and postoperative ASES, PUE, P-Interference, and P-Intensity scores, along with postoperative patient degree of satisfaction were recorded. Receiver operating characteristic curve analyses were performed to identify individual % MPI thresholds in each of the 4 scores that best predicted high satisfaction at minimum 1 year postoperatively. Univariate and multivariate logistic regression analyses were conducted sequentially to identify patient factors that were associated with achievement of the ASES and PUE thresholds. RESULTS:Among the 81 patients that met the inclusion criteria, the %MPI thresholds associated with high satisfaction were 65% for ASES (Area under the curve [AUC]: 0.86), 29% for PUE (AUC: 0.84), 57% for P-Interference (AUC: 0.78), and 59% for P-Intensity (AUC: 0.77). Higher body mass index (odds ratio [OR]: 1.16, p = 0.048) and surgery on the dominant arm (OR: 3.87, p = 0.024) were associated with higher odds of achieving the ASES threshold. Recurrent dislocations preoperatively (OR: 0.20, p = 0.022) were associated with lower odds of achieving the PUE threshold. CONCLUSION/CONCLUSIONS:The percentage of maximal possible improvement (%MPI) following the Latarjet procedure offers an individualized measure of clinical success and accounts for baseline variability and mitigates ceiling effects. Thresholds associated with high patient satisfaction following the Latarjet procedure were ≥65% for ASES, ≥29% for PUE, ≥57% for P-Interference, and ≥59% for P-Intensity.

BACKGROUND:Patient-Reported Outcome Measurement Information Systems (PROMIS) is increasingly being utilized across the United States as a patient-reported outcome evaluation tool for a wide variety of musculoskeletal conditions. However, PROMIS Upper Extremity (P-UE) physical function has demonstrated limited responsiveness in the early postoperative period after total shoulder arthroplasty (TSA). The aim of this study is to determine if addition of PROMIS Pain Interference (P-Interference) or Pain Intensity (P-Intensity) scores improve the ability to detect postoperative changes in the 1-year postoperative period following TSA. METHODS:Patients who were indicated for and elected to undergo TSA between 2020 and 2022 were prospectively enrolled. Prospective data were collected for patient surveys (American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test, P-UE, P-Interference and P-Intensity) at the 2-week, 6-week, 3-month, 6-month, and 12-month timepoints. Instrument responsiveness for each PROM was evaluated using the effect size (ES; Cohen d). Responsiveness was defined by the absolute values of each measurement, previously reported as small (0.2), medium (0.5), or large (0.8). Statistical analysis (2 sample t-tests and Fisher's tests) was performed using R studio version 4.2.3 (Boston, MA, USA). RESULTS:A total of 127 subjects were enrolled in this study. All survey instruments demonstrated large responsiveness (>0.8) at 3, 6, and 12 months. P-Intensity was the only instrument to demonstrate large responsiveness at 2-weeks with its addition to P-UE showing an improved responsiveness at all-time points. Moreover, the addition of P-Intensity had a lower response burden at all-time points when compared to the legacy measures (ASES, Simple Shoulder Test, and Oxford Shoulder Score) at all-time points albeit no difference to ASES (P = .55) at 12-months after surgery. P-Interference and other legacy scores demonstrated large responsiveness starting at 6-weeks postoperatively. CONCLUSION/CONCLUSIONS:The responsiveness of PROMIS UE can be improved by coupling the outcome measure to P-Intensity scores with a significantly lower response burden when compared to the legacy measures evaluated at nearly all time points.

BACKGROUND/UNASSIGNED:Liposomal bupivacaine (LB) was developed to provide longer lasting postoperative analgesia, but its clinical role is still being elucidated. We assessed the opioid-sparing effect of LB in patients undergoing total shoulder arthroplasty (TSA) with an interscalene block (ISB). METHODS/UNASSIGNED:Patients scheduled for TSA were randomized to receive either 20 mL of bupivacaine 5 mg/mL control or 10 ml of bupivacaine 5 mg/mL plus LB 133 mg experimental [EXP] for an ISB. The primary outcome was opioid consumption from 24 to 72 hours. The secondary outcomes were cumulative opioid consumption on postoperative days (PODs) 7, 14, and 30 and pain intensity scores measured by the Patient Reported Outcomes Measurement Information System scale. RESULTS/UNASSIGNED:< .05). CONCLUSION/UNASSIGNED:The addition of LB to plain bupivacaine for an ISB is associated with a statistically significant but not clinically meaningful reduction in opioid consumption over the first 72 hours following TSA. These findings should be considered when making an economical decision to use LB.

BACKGROUND/UNASSIGNED:In the past 20 years, the incidence of total shoulder arthroplasty (TSA) has increased greatly, and it is expected to continue growing. Current literature lacks future projections for the utilization of TSA. These projections can help predict demand quantities and anticipate the future burden on the healthcare system. The aim of this study is to determine the predictions of utilization for TSA, primary and revision, through 2060. METHODS/UNASSIGNED:This analysis used the publicly available 2000-2019 data from the Center for Medicare and Medicaid Services Medicare Part-B National Summary. Procedure volumes, including TSA and revision TSA, were determined using Current Procedural Terminology codes and were uplifted to account for the growing number of Medicare eligible patients covered under Medicare Advantage. Log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average models were applied to the procedural volumes to generate projections from 2020-2060. The Poisson model was chosen to display the data based on error analysis and prior literature. RESULTS/UNASSIGNED:The projected annual growth from 2020 to 2060 rates for primary and revision TSA are 11.65% growth (95% confidence interval 11.60%-11.69%) and 13.89% growth (95% confidence interval 13.35%-14.42%), respectively. By 2060, the demand for primary TSA and revision TSA is projected to be 10,029,260 and 1,690,634, respectively. CONCLUSION/UNASSIGNED:The results of this study concluded that both primary and revision TSA procedures are projected to exponentially increase from 2020 to 2060. Additionally, revision procedures are projected to increase at greater rates than their respective primary counterparts.

BACKGROUND:Although Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (P-UE) has been validated in upper extremity orthopedics, its ability to capture a patient's functional recovery after arthroscopic rotator cuff repair (aRCR), as measured by its responsiveness, is minimal in the early postoperative period. The primary purpose of this study is to determine if the addition of PROMIS Pain Intensity (P-Intensity) or Pain Interference (P-Interference) scores to PROMIS UE improves the responsiveness throughout the 1-year postoperative period after aRCR. METHODS:This prospective, longitudinal study included 100 patients who underwent aRCR. Patients completed P-UE, P-Interference, P-Intensity, American Shoulder and Elbow Surgeons, and Western Ontario Rotator Cuff Index scores preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgery. Responsiveness at each time point relative to preoperative baseline and 1-way analysis of variance with post hoc analysis was conducted for each PROM. The responsiveness of the outcome score was determined using the effect size, graded as small (0.2), medium (0.5), or large (0.8). The Pearson correlation coefficient (r) was determined between these instruments at each time point. RESULTS:In isolation, P-UE, P-Interference, and P-Intensity showed a medium-large ability to detect change (positive and negative) throughout the 1-year postoperative period. The addition of PROMIS pain scores to P-UE improved the responsiveness of the instrument (from medium to a large effect size) starting at 3 months and continued throughout the 12-month follow-up period. Although the addition of pain scores increases the response burden for PROMIS, this was still lower than the response burden for the legacy outcome scores (P < .05). CONCLUSION/CONCLUSIONS:The addition of PROMIS pain instruments improves the responsiveness of the P-UE function score in patients undergoing aRCR.

BACKGROUND:Health care disparity exists in utilization and delivery of musculoskeletal care and continues to be an obstacle for orthopedic health care providers to mitigate. Racial and ethnic disparities exist within various surgical fields including orthopedic surgery and are expected to continue to rise in upcoming years. The aim of this systematic review is to analyze the racial and ethnic disparities on utilization and outcomes after common shoulder surgical procedures. METHODS:A primary literature search was performed using PubMed, Embase, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases using comprehensive Medical Subject Headings and subject-heading search terms. Studies were included if they reported utilization and or outcomes across 2 or more racial/ethnic groups in patients (age >16) who underwent total shoulder arthroplasty (TSA), rotator cuff repair (RCR), arthroscopic Bankart repair, Latarjet procedure, and open reduction internal fixation of proximal humerus fracture (PHF). Baseline demographics, data on procedure utilization, perioperative measures including mortality, operative time, length of stay, readmission, and complications were extracted from included studies, and descriptive statistical analysis performed. RESULTS:Eighteen studies were identified for full text review of which 13 found race and ethnicity as factors affecting utilization and outcomes in TSA, RCR, arthroscopic Bankart repair, Latarjet procedure, and open reduction internal fixation of PHF. Compared to White patients, Black patients were found to have decreased utilization, longer length of stay, and greater operative time and mortality after TSA; Black patients also had longer operative times and time to discharge, and lower levels of reported satisfaction after RCR. Hispanic/Latino ethnicity was reported as an independent risk factor for postoperative falls following TSA. Hispanic/Latino and Black patients have a higher risk of delayed surgery and greater risk of readmission after surgical treatment of PHF compared to patients of White race. CONCLUSION/CONCLUSIONS:This systematic review highlights the limited literature reporting the existence of racial and ethnic disparities in utilization and outcomes after common shoulder surgical procedures. Additionally, there is a paucity of studies exploring the underlying etiology of racial and ethnic disparity in outcomes after shoulder surgery. More research is necessary to pave the way for evidence-based action plans to mitigate health care disparities after shoulder surgeries, but this review serves as a baseline for where efforts in direct improvement can begin.