Faculty Bibliography

Background: The purpose of this study was to determine if addition of CT to axillary radiographs (AXR) alters preoperative decision making for shoulder arthroplasty. Methods: Preoperative deidentified images (XR alone and XR with CT) of 50 patients with glenohumeral arthritis were reviewed independently by 3 reviewers in a blinded fashion. Each reviewer graded images for glenoid wear pattern as simple (Walch A1 or B1) or advanced [A2, B2, C]), adequacy of AXR and need for advanced imaging. The reviewers determined a preoperative plan for all patients based on XR alone vs. XR and CT including the arthroplasty type (anatomic or reverse total shoulder) and their plan for treating glenoid wear (eccentric or standard reaming vs. bone graft or augment). Kappa values (κ) were calculated to determine inter-rater agreement and consistency among multiple reviewers. Fisher's exact test was used to assess any difference in preoperative plan once the shoulders were separated into simple and advanced glenoid wear patterns. Results: The 3 reviewers agreed that quality of AXRs was significantly inadequate (P <.001) for assessing glenoid wear in advanced glenoid wear patterns compared to simple wear patterns. Following evaluation on AXRs alone, the need for CT imaging was significantly higher in advanced glenoid wear patterns compare to simple ones (81% vs. 31%; P <.001). The addition of CT images did not result in a significant change to the preoperative plan in simple glenoid wear patterns but in advanced glenoid wear, addition of CT can change the preoperative plan with respect to arthroplasty type and/or strategy for addressing glenoid wear. Conclusion: Axillary radiographs are often inadequate for preoperative planning in shoulder arthritis with advanced glenoid wear patterns (Walch A2, B2, C types). Addition of CT imaging to radiographs in shoulder arthritis with advanced glenoid wear can affect the preoperative decision with respect to type of shoulder arthroplasty and/or plan for addressing glenoid wear (reaming, bone graft or augmented glenoids). Level of evidence: Level IV

Background: The aim of this study was to compare outcomes of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) after prior shoulder stabilization versus matched cohorts without previous stabilization surgery. Hypotheses were as follows: (1) patients undergoing aTSA or rTSA after stabilization procedures would have worse outcomes than matched cohorts and (2) patients undergoing TSA would have better outcomes after soft-tissue stabilization procedures (aTSAST or rTSAST) than after bony stabilization procedures (aTSAB or rTSAB). Methods: Retrospective cohort study was performed comparing (1) 36 patients who underwent aTSA and (2) 32 patients who underwent rTSA with prior shoulder stabilization with 3-to-1 matched cohorts (based on age, gender, and follow-up length) with no prior shoulder instability or surgery. Baseline demographics, perioperative data, adverse events (AEs), radiographic outcomes, functional outcome scores, range of motion (ROM), and patient satisfaction were analyzed. Subgroup analyses compared patients who underwent aTSAST or rTSAST with patients who underwent aTSAB or rTSAB. Results: The postoperative AE rate was 8.3% and 4.6% in the aTSA group and matched cohort, respectively (P =.404), with a trend toward a significantly higher incidence of aseptic glenoid loosening in the aTSA group (8.3% vs. 1.9%, P =.067). Functional outcomes, ROM, and patient satisfaction did not differ at follow-up >4 years. In the subgroup analysis, two AEs required reoperation among 25 patients who underwent aTSAST versus one among 11 patients who underwent aTSAB, all related to aseptic loosening. There was a trend toward greater functional outcomes and satisfaction among patients who underwent aTSAST. There was a trend toward a clinically significant difference in active abduction at final follow-up favoring aTSAST (128 vs. 108 degrees, P =.096). The postoperative AE rate was 6.3% and 4.2% among the rTSA group and matched cohort, respectively (P =.632). Functional outcomes, ROM, and patient satisfaction did not differ at 4-year follow-up. In the subgroup analysis, no AEs were reported among 18 patients who underwent rTSAST and 14 patients who underwent rTSAB. A trend toward greater functional outcomes and patient satisfaction favored patients who underwent rTSAB, who achieved greater improvements in ROM from baseline and greater ROM in all planes at the final follow-up. Conclusion: Both aTSA and rTSA are reliable options for the treatment of dislocation arthropathy in appropriately selected patients. aTSA and rTSA after prior shoulder stabilization procedures have nearly equal rates of AEs and yield similar clinical and functional outcomes as matched cohorts. There may be an increased risk of glenoid aseptic loosening in aTSA after prior shoulder stabilization. Functional outcomes tend to be greater for patients who underwent aTSAST than those for patients who underwent aTSAB. On the contrary, rTSA may optimize postoperative function when performed for dislocation arthropathy after bony rather than soft-tissue stabilization procedures. Level of evidence: Level III; Retrospective Cohort Design; Treatment Study

Background: Glenoid wear is a common challenge in patients undergoing reverse total shoulder arthroplasty (rTSA). Augmented baseplates have recently been designed to address this. The purpose of this study is to determine the clinical outcomes, complications, and revision rates of patients undergoing rTSA with an augmented baseplate compared to those that received a standard, non-augmented baseplate. Methods: Preoperative and postoperative data were analyzed for 414 patients with glenoid bone loss who underwent primary rTSA with either an 8° posterior augmented glenoid baseplate, a 10° superior augmented baseplate (SAB), or an 8° posterior/10° superior augmented baseplate (P/SAB). These patients were compared to 1547 primary rTSA patients who received a standard baseplate. Clinical outcomes were scored using the Simple Shoulder Test (SST), UCLA, ASES, Constant and SPADI clinical outcome scoring metrics. Range of motion for active abduction, forward flexion, internal rotation and external rotation were used to quantify function. Complication and revision rates were also documented, and postoperative radiographs were analyzed for scapular notching. A two-tailed, unpaired t-test was used to identify differences between continuous parameters and a Chi Square test was used for categorical parameters, with P < .05 denoting a significant difference. Results: At an average follow-up of 47.1 ± 23.1 months, the augmented baseplates performed as well, or better, than standard baseplates, with a similar complication rate, revision rate, aseptic glenoid loosening rate, and scapular notching rate. Discussion: Augmented baseplates are a safe and effective option for patients with glenoid bone loss in the setting of rTSA at mid-term follow-up. For each baseplate type, the outcomes were similar, and the complication/revision and scapular notching rates were low and comparable to that of the standard baseplate cohort. Level of evidence: Level III

BACKGROUND:The number of reverse total shoulder arthroplasties (RTSAs) performed annually has increased, and the indications for RTSA have expanded beyond rotator cuff arthropathy to include treatment of complex proximal humeral fractures. No studies exist comparing clinical, functional, and radiographic outcomes in patients receiving RTSA for the treatment of acute fracture vs. those undergoing the procedure for degenerative conditions. This study was designed to fill the void in this knowledge gap. We hypothesized that patients undergoing RTSA for fracture treatment would experience worse clinical outcomes than those undergoing elective RTSA. METHODS:A prospectively collected database was queried for patients undergoing RTSA between 2007 and 2016. Patients were sorted based on the indication for RTSA: treatment of acute proximal humeral fracture vs. "elective" treatment of degenerative conditions of the shoulder. Baseline demographic characteristics, intraoperative and perioperative complications, and clinical, functional, and radiographic outcomes were collected. Only patients with ≥2 years' follow-up were included. Final outcomes were compared between the fracture and elective groups. RESULTS:In total, 1984 patients met the inclusion criteria, with 1876 in the elective group and 108 in the fracture group. Compared with the elective RTSA group, the group undergoing RTSA for fracture treatment was older, was female dominant, and was less likely to have undergone a previous operation on the ipsilateral shoulder. RTSA for fracture was associated with a longer hospital length of stay and greater intraoperative blood loss. The incidence of postoperative adverse events was 7.1% in the elective group vs. 4.6% in the fracture group. Functional outcomes did not differ beyond 1 year or at mean final follow-up > 40 months. CONCLUSION/CONCLUSIONS:Despite differences in patient demographic characteristics, the outcome and complication profiles are similar between patients undergoing RTSA for acute fracture and those indicated for the treatment of degenerative conditions of the shoulder.

BACKGROUND:Preoperative 3D planning and intraoperative navigation for shoulder arthroplasty has recently gained interest because of the potential to enhance the surgeon's understanding of glenoid anatomy and improve the accuracy of glenoid component positioning. The purpose of our study was to assess the impact of preoperative 3D planning on the surgeon's selection of the glenoid component (standard vs. augmented) and compare duration of surgery with and without intraoperative navigation. METHODS:We retrospectively analyzed 200 consecutive patients who underwent shoulder arthroplasty. The first group of 100 patients underwent shoulder arthroplasty using standard 2D preoperative planning based on standard radiographs and computed tomographic scans. The second group of 100 patients underwent shoulder arthroplasty using 3D preoperative planning and intraoperative navigation. Type of glenoid component and operative time were recorded in each case. RESULTS:For the group of patients with standard preoperative planning, only 15 augmented glenoid components were used, whereas in the group of patients with 3D preoperative planning and navigation, 54 augments were used (P < .001). The operative time was 11 minutes longer for the procedures that used intraoperative navigation, compared with those that did not (P < .001). This difference diminished as the surgeon became more proficient with the navigation technique. CONCLUSION/CONCLUSIONS:Use of preoperative 3D planning changes the surgeon's understanding of the patient's glenoid anatomy. In our study, using 3D planning increased the likelihood that the surgeon selected an augmented glenoid component compared with 2D planning. Intraoperative navigation slightly lengthened the duration of surgery, but this became insignificant as part of a learning curve within 6 months.

Background/UNASSIGNED:Contemporary studies note sustained clinical benefit and decreasing complications after reverse total shoulder arthroplasty (RTSA), which warrant a comparison with the standard anatomic total shoulder arthroplasty (ATSA). The purpose of this study is to evaluate and compare differences in midterm survivorship between ATSA and RTSA patients treated with a single platform shoulder prosthesis. Secondary objectives include a comparison of the clinical outcomes and complication profile for each procedure. Methods/UNASSIGNED:A prospective analysis of all primary ATSA and RTSA performed by 3 surgeons between 2007 and 2012 was conducted. Selection of the ATSA or RTSA implant configuration was determined by the surgeons per their clinical understanding of each individual patient's glenoid morphology, rotator cuff, and patient expectations. All 778 procedures were performed using a single platform shoulder system. Results/UNASSIGNED:= .414). Conclusions/UNASSIGNED:On the basis of this cohort comparison, both ATSA and RTSA demonstrated similar survivorship at 8 years after surgery with multiple surgeons practicing in different countries. Our results demonstrate that the RTSA and ATSA implants have comparable results and can be expected to provide similar implant longevity over the midterm with excellent functional outcomes.

The COVID-19 pandemic has had unprecedented impact on the United States health care system. One of the consider-ations was the decision to halt elective orthopedic surgery to preserve consumption of scarce resources. However, as the number of COVID-19 cases decrease, there will be discus-sions regarding the modality of resuming elective orthopedic surgery. Ethical considerations will come to the forefront in terms of determining the best course of action, patient selection, resource rationing, and financial implications. These factors will be examined through the lens of the four tenets of bioethics, beneficence, maleficence, autonomy, and justice, to elucidate the best approach in ethically manag-ing elective orthopedic surgery during a global pandemic.

BACKGROUND:Preoperative planning software is widely available for most anatomic total shoulder arthroplasty (ATSA) systems. It can be most useful in determining implant selection and placement with advanced glenoid wear. The purpose of this study was to quantify inter- and intrasurgeon variability in preoperative planning of a series of ATSA cases. METHODS:Forty-nine computed tomography scans were planned for ATSA by 9 fellowship-trained shoulder surgeons using the ExactechGPS platform (Exactech Inc., Gainesville, FL, USA). Each case was planned a second time between 4 and 12 weeks later. Variability within and between surgeons was measured for implant type, size, version and inclination correction, and implant face position. Interclass correlation coefficients, Pearson, and Light's kappa coefficients were used for statistical analysis. RESULTS:There was considerable variation in the frequency of augment use between surgeons and between rounds for the same surgeon. Thresholds for augment use also varied between surgeons. Interclass correlation coefficients for intersurgeon variability were 0.37 for version, 0.80 for inclination, 0.36 for implant type, and 0.36 for implant size. Pearson coefficients for intrasurgeon variability were 0.17 for version and 0.53 for inclination. Light's kappa coefficient for implant type was 0.64. CONCLUSIONS:This study demonstrates substantial inter- and intrasurgeon variability in preoperative planning of ATSA. Although the magnitude of differences in correction was small, surgeons differed significantly in the use of augments to achieve the resultant plan. Surgeons differed from each other on thresholds for augment use and maximum allowable residual retroversion. This suggests that there may a range of acceptable corrections for each shoulder rather than a single optimal plan.