Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the effect that associated glenohumeral dislocations have on outcomes following surgical treatment of proximal humerus fractures. METHODS:This IRB-approved study reports on 301 patients, who underwent operative treatment for proximal humerus fractures at an academic medical center from January 2006 to January 2023. Fractures were classified according to the Neer system. Patients were separated into two cohorts based on whether a glenohumeral dislocation was present at the time of initial injury. Outcomes measured included the Disabilities of the Arm, Shoulder, and Hand (DASH) score, shoulder range of motion (forward elevation, external rotation, internal rotation), readmission rates, complications, hardware removal, and need for revision surgery. Independent samples t-tests and chi-squared analysis were used for continuous and categorical variables, respectively. A binary logistic regression was performed to analyze the influence of these factors on complication rate. RESULTS:230 patients sustained an isolated fracture (PHF) and 71 sustained a fracture-dislocation (FD). Significant differences were observed between the FD and PHF groups in all measured outcomes. The FD group had a poorer DASH score (24.38 ± 19.09 vs 10.54 ± 13.67; P < 0.001) and reduced range of shoulder motion in forward elevation (114° ± 40° vs 162° ± 19°; P < 0.001), external rotation (40° ± 19° vs 66° ± 19°; P < 0.001), and internal rotation (57° ± 26° vs 82° ± 21°; P < 0.001). Readmission rates were higher in the FD group (0.28 ± 0.85 vs 0.05 ± 0.28; P < 0.001). The FD cohort also had a higher rate of complications (25.35% vs 6.52%; P < 0.001), need for removal of hardware (14.08% vs 3.04%; P = 0.002), and overall revision surgery (11.27% vs 1.30%; P < 0.001). The FD cohort demonstrated a greater incidence of AVN (12.68% vs 4.35%; P = 0.012). No significant difference was observed regarding rates of fracture healing and recurrent dislocation. Multivariate analysis in the form of binary logistic regression indicated that fracture-dislocation significantly increased the complication risk (OR = 3.310, 95% CI = 1.42-7.70; P = 0.005). CONCLUSION/CONCLUSIONS:Proximal humerus fracture-dislocations are associated with worse functional outcomes and higher complication rates compared to those without dislocations. These findings highlight the potential need for specialized treatment strategies to mitigate the impact of dislocation on recovery.

BACKGROUND/UNASSIGNED:The aim of this study was to evaluate the association between Area Deprivation Index (ADI) and patient outcomes following reverse total shoulder arthroplasty (rTSA). METHODS/UNASSIGNED:A retrospective analysis of patients who underwent an rTSA at a single institution between 2011 and 2021 with minimum 2-year follow-up. Each patient's home address was mapped to the ADI to determine the level of socioeconomic disadvantage. Patients were categorized into 5 groups based on socioeconomic status (SES): ADI group 1; the least deprived group and ADI group 5; the most deprived group. Bivariate analysis was performed to determine the association between the level of SES and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score. Multivariable regression analysis was utilized to assess the role of independent variables in achieving minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for ASES. RESULTS/UNASSIGNED:= .047). ADI group 1 had the highest postoperative ASES score of 78.6 ± 21.6 compared to 70.0 ± 24.1 in group 5. There was no difference in change preoperative to postoperative ASES scores across ADI subgroups with an average delta ASES score of 42.8 ± 26.2. Like preoperative ROM, there was no difference across ADI subgroups in terms of postoperative ROM. The average percentage of the cohort of patients across ADI subgroups that achieved MCID, SCB, and PASS for ASES was 87.6%, 68.9%, and 57.5%, respectively. There was no difference in terms of achieving MCID, SCB, or PASS for ASES across ADI subgroups. CONCLUSION/UNASSIGNED:The current study supports an inverse relationship between ADI and postoperative outcomes in patients undergoing rTSA. Additionally, our study found that a patient's ability to achieve MCID, SCB, or PASS for ASES at a minimum of 2 years after rTSA was not dependent on SES. Lastly, our study demonstrated that the risk of suffering an adverse event or undergoing a revision surgery were not associated with SES.

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:Patients with anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) can have different short-term rate of improvement (ROI) and different long-term rate of decline (ROD) in range of motion (ROM). This study aims to quantify and compare these rates and identify risk factors associated with a slow ROI and a fast ROD after both aTSA and rTSA. METHODS/UNASSIGNED:This 8-year minimum longitudinal outcome study compares active ROM in 1272 primary aTSA (n = 688) and rTSA (n = 584) patients across 8357 visits and identified patient cohorts with a slow, average, and fast ROI from 0-2 years after surgery and a slow, average, and fast ROD 8 years after surgery relative to peak improvement achieved 2-3 years after surgery. A multivariate regression analysis was performed to identify patient, implant/operative, or postoperative risk factors associated with a slow ROI and fast ROD after both aTSA and rTSA. RESULTS/UNASSIGNED:The results of this 1272 patient long-term clinical outcome study demonstrates that aTSA and rTSA patients with a slow ROI were associated with high preoperative ROM and patients with a fast ROI were associated with low preoperative ROM. aTSA and rTSA patients with high preoperative ROM experienced declines in ROM during the first 3 months, but later recovered at a similar rate and achieved similar peak improvements. aTSA patients with a slow ROI had significantly higher preoperative abduction, internal rotation score, and external rotation, whereas rTSA patients with a slow ROI were significantly more likely to have diabetes, injections, and significantly higher preoperative abduction and internal rotation score. aTSA patients with a fast ROD were significantly more likely to have heart disease and glenoid radiolucent lines, whereas rTSA patients with a fast ROD were significantly more likely to have comorbidities and experience revision surgery. DISCUSSION/UNASSIGNED:The rate of improvement in ROM during the short-term recovery period after aTSA and rTSA is highly dependent on preoperative ROM, whereas the rate of decline in ROM at long-term follow-up is generally impacted by systemic health issues (ie, heart disease and more comorbidities), compromised implant fixation (ie, radiolucent lines after aTSA), and the onset of revision surgery. These findings may be beneficial for patient counseling and expectation management, especially to encourage patients who may have experienced a decline in ROM during the first 3 months after surgery.

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:The goal of this study was to utilize preoperative computed-tomography(CT) scans to identify differences in the Hounsfield units(HU) of the acromion in patients who did and did not develop a postoperative acromial and scapular-spine fracture(ASF) after primary reverse total shoulder arthroplasty (rTSA). METHODS:A retrospective analysis was performed at a single institution. All patients undergoing a rTSA with either a 135° neck/shaft angle(NSA) humeral inlay design combined with a lateralized center-of-rotation(COR) glenosphere or a 145° NSA onlay combined with a medialized COR glenosphere design between 2011-2021 with a minimum follow-up of 24-months were included. Demographic characteristics and clinical outcome metric scores were recorded. Preoperative CT scans were analyzed to obtain acromion trabecular bone density measurements in HU in each zone of the scapula based on the Levy classification. Radiographic parameters were evaluated to determine their association with ASF. RESULTS:In total 263-patients were included, 140-patients with a 135° NSA humeral-inlay design;123-patients with a 145° NSA humeral-onlay design. There were no significant differences in baseline demographics between cohorts. The rate of ASF was 6.4%(9/140) for the 135° NSA-inlay-design versus 2.4%(3/123) in the 145° NSA-onlay design. In the non-fracture cohort there was a linear increase in bone density from zone-1(173.9HU)→zone-3(396.5HU)(lateral→medial). In the fracture cohort there was a decrease in bone density from zone-1(282.6HU)→zone-3(154.5HU). Measuring preoperative bone density in all Levy specific fracture-zones resulted in an AUC of 0.96 correlating to excellent predictive value. A threshold cutoff of 99.9 resulted in a sensitivity of 91.6% and specificity of 75.3%. A HU of 99.9 in any of the three-zones resulted in OR 5.1(p<0.0001) for sustaining an ASF postoperatively. A threshold of<50HU was associated with an 8-times higher-likelihood of developing a fracture in that specific zone. Greater than 5° of superior tilt in combination with ≥24mm of distalization was associated with an OR 6.4(p=0.0004) of sustaining an ASF. CONCLUSION/CONCLUSIONS:The current study demonstrates an accurate method of measuring HU at each of the described Levy fracture zones with excellent predictability of patients who are at risk of an ASF following rTSA. Additionally, we found that a HU threshold of <50 HU at any of the three Levy zones was associated with a nearly 8 times higher likelihood of developing a fracture in that specific zone. Lastly, we found that >5° of superior tilt in combination with ≥24mm of distalization was associated with 6.4 times higher likelihood of sustaining an ASF agnostic to prosthesis design.

INTRODUCTION/UNASSIGNED:There has been an emergence of evidence in the area of frozen shoulder (FS) within the past decade related to risk factors, etiology, diagnosis, and management. It has become increasingly challenging for clinicians and researchers to stay up to date in these areas, particularly with the clinical practice guidelines that are available being few and outdated. To this end, the aim of this study was to produce an international consensus on the risk factors, etiology, diagnosis and management for individuals with FS. METHODS/UNASSIGNED:During phase one a steering committee was formed in order to identify experts in the area of FS, examine the current evidence related to FS and identify key areas lacking consensus. Phase two consisted of inviting experts to participate in a three-round survey with a priori consensus level set at 80%. Descriptive statistics were utilized to determine the characteristics of the expert panel, response rate, and level of consensus. RESULTS/UNASSIGNED:A total of 14 international experts responded to all three rounds of the Delphi survey with 100% response rate following round one. Consensus was reached for 101 items (57 in the first round, 37 in the second round and 7 in the third and final round). Specific to key topic areas, the following number of items reached consensus; etiology 9 items (diabetes mellitus, trauma, shoulder arthroscopy, thyroid disease, prolonged immobilization, adrenocorticotropic hormone deficiency, metabolic synderome, connective tissue disorders, and hyperlipidemia), risk factors 40 items (including biophysical factors for developing FS and biophysical and psychosocial factors influencing the Management and course of outcomes related to FS), diagnosis 19 items (4 confounding the diagnosis and 15 signs and symptoms associated with FS), Management 33 items overall and categorized into effectiveness for early and later stages of FS). CONCLUSION/UNASSIGNED:The results of this international Delphi study help to provide a consensus on key elements to consider in clinical practice related to etiology, risk factors, diagnosis, and management for those with FS.

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: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: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.