Faculty Bibliography

Background: Massive irreparable rotator cuff tears (MIRCT) are challenging problems for both patients and surgeons. Reverse total shoulder arthroplasty (RTSA) is a treatment option for patients with MIRCTs. However, previous reports have shown inconsistent results, varying patient satisfaction, and higher complication rates. Methods: This is a retrospective multi-institutional study (22 institutions, 24 surgeons) of 203 patients (average age, 71 years) who underwent RTSA for MIRCT without glenohumeral arthritis with a mean follow-up of 50 months. Patients were divided into 4 groups based on preoperative shoulder active forward elevation (aFE) (<60°, <90°, ≥90°, >120°). Clinical outcomes were assessed using multiple patient-reported outcome measures (PROs), postoperative range of motion (ROM), patient satisfaction, and complication rate. Radiographic outcomes assessment included evaluation of postoperative scapular notching and humeral radiolucent lines. Results: Patients in each group had significant (P≤ 0.02) improvements in PROs and ROM postoperatively. Patient satisfaction was highest in the group with >120° preoperative aFE (44/44, 100%). Scapular notching and humeral radiolucency were noted in 6% and 7% of patients, respectively. There were only 3 complications that required 2 revision surgeries. Overall, the complication rate (1.6%) and reoperation rate (1.1%) were considerably lower than previously reported. Conclusion: RTSA is a reliable treatment for MIRCTs without glenohumeral arthritis that results in significant improvements in PROs and shoulder ROM. Compared to previous studies, we report a substantially higher satisfaction rates in all patients, especially in those with better preoperative ROM (aFE >120°), and a lower overall complication rate. Level of evidence: Level IV; Therapeutic Study

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

Introduction: The purpose of this study is to evaluate the relationship between patients"™ own health expectations and treatment outcomes following surgical repair of proximal humerus fractures. Hypothesis: Patients"™ health expectations will correlate with treatment outcomes following surgical repair of proximal humerus fractures. Material and methods: Over a 14-year period, 247 patients with a displaced proximal humerus fracture who underwent ORIF with locking compression plates were prospectively followed at one academic institution. Minimum follow-up period was 12 months. Patient-reported functional outcome data for the latest follow up visit (12 months and greater) was obtained from Disabilities of Arm, Shoulder, and Hand (DASH) questionnaires. Survey responses regarding health expectations were recorded at 3-month follow-up and converted to dichotomous variables. Two groups were identified: the high expectations and the low expectations groups. Statistical analysis comparing the two groups and their functional and clinical outcomes was performed using the independent t-test, using p < 0.05 for significance. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to further statistically characterize the relationship between health expectations at 3 months and long-term outcomes. Results: 185 (75.0%) patients available for analysis with a mean follow-up length of 24.8 months. The cohort included 124 (67%) females and 61 (33%) males and the average age at time of injury was 59.5 years. Eighty-six (46.5%) patients had low expectations for their overall health and 99 (53.5%) patients had high expectations for their health. No significant differences were seen between groups in regards to age, gender, follow-up length, Charlson Comorbidity Index (CCI), smoking and tobacco use, fracture pattern (OTA and Neer classifications), early complications (p > 0.05), fracture healing, and avascular necrosis. The mean DASH score at the latest follow up for patients with low expectations was 31.42 ± 22.8 whereas the mean for those with high expectations was 16.76 ± 20.2 (p < 0.0005). The mean forward flexion of the shoulder for patients with low expectations was 137.8 ± 31.5 degrees as compared to 148.5 ± 26.3 degrees (p < 0.05). The positive predictive value of good expectations correlating with good outcomes was 71,7%. Discussion: Patients with high expectations for their health early following injury had better outcomes in the long term. These high expectations also appeared to have an optimal influence on range of shoulder motion. This data suggests attitudinal and psychological factors that affect patient health expectations early on in the course of treatment may also influence patients"™ functional and clinical outcomes. Level of evidence: II; Retrospective Study.

Background: An important psychometric parameter of validity that is rarely assessed is predictive value. In this study we utilize machine learning to analyze the predictive value of 3 commonly used clinical measures to assess 2-year outcomes after total shoulder arthroplasty (TSA). Methods: XGBoost was used to analyze data from 2790 TSA patients and create predictive algorithms for the American Shoulder and Elbow Surgeons (ASES), Constant, and the University of California Los Angeles (UCLA) scores and also quantify the most meaningful predictive features utilized by these measures and for all questions comprising each measure to rank and compare their value to predict 2-year outcomes after TSA. Results: Our results demonstrate that the ASES, Constant, and UCLA measures rarely considered the most-predictive features relevant to 2-year TSA outcomes and that each outcome measure was composed of questions with different distributions of predictive value. Specifically, the questions composing the UCLA score were of greater predictive value than the Constant questions, and the questions composing the Constant score were of greater predictive value than the ASES questions. We also found the preoperative Shoulder Pain and Disability Index (SPADI) score to be of greater predictive value than the preoperative ASES, Constant, and UCLA scores. Finally, we identified the types of preoperative input questions that were most-predictive (subjective self-assessments of pain and objective measurements of active range of motion and strength) and also those that were least-predictive of 2-year TSA outcomes (subjective task-specific activities of daily living questions). Discussion: Machine learning can quantify the predictive value of the ASES, Constant, and UCLA scores after TSA. Future work should utilize this and related techniques to construct a more efficient and effective clinical outcome measure that incorporates subjective and objective input questions to better account for the preoperative factors that influence postoperative outcomes after TSA. Level of Evidence: Level III; Retrospective Comparative Study