Faculty Bibliography

» Treatment of glenoid bone loss continues to be a challenge in total shoulder arthroplasty (TSA). Although correcting glenoid wear to patient's native anatomy is desirable in TSA, there is lack of consensus regarding how much glenoid wear correction is acceptable and necessary in both anatomic and reverse TSA.» Use of augmented glenoid components is a relatively new treatment strategy for addressing moderate-to-severe glenoid wear in TSA. Augmented glenoid components allow for predictable and easy correction of glenoid wear in the coronal and/or axial planes while at the same time maximizing implant seating, improving rotator cuff biomechanics, and preserving glenoid bone stock because of off-axis glenoid reaming.» Augmented glenoid components have distinct advantages over glenoid bone grafting. Glenoid bone grafting is technically demanding, adds to the surgical time, and carries a risk of nonunion and graft resorption with subsequent failure of the glenoid component.» The use of augmented glenoid components in TSA is steadily increasing with easy availability of computed tomography-based preoperative planning software and guidance technology (patient-specific instrumentation and computer navigation).» Although different augment designs (full wedge, half wedge, and step cut) are available and a particular design may provide advantages in specific glenoid wear patterns to minimize bone removal (i.e. a half wedge in B2 glenoids), there is no evidence to demonstrate the superiority of 1 design over others.

BACKGROUND:Parkinson's Disease (PD) is an established risk factor for higher rates of complications and revision surgery following shoulder arthroplasty, yet the economic burden of PD remains to be elucidated. The purpose of this study is to compare rates of complication and revisions as well as inpatient charges for shoulder arthroplasty procedures between PD and non-PD patients using an all-payer statewide database. METHODS:Patients undergoing primary shoulder arthroplasty from 2010-2020 were identified from the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database. Study groups were assigned based on concomitant diagnosis of PD at time of index procedure. Baseline demographics, inpatient data, and medical comorbidities were collected. Primary outcomes measured were accommodation, ancillary, and total inpatient charges. Secondary outcomes included postoperative complication and reoperation rates. Logistic regression was performed to evaluate effect of PD on shoulder arthroplasty revision and complication rates. All statistical analysis was performed using R (R Foundation for Statistical Computing; Vienna, Austria). RESULTS:39,011 patients (429 PD versus 38,582 non-PD) underwent 43,432 primary shoulder arthroplasties (477 PD versus 42,955 non-PD) with mean follow-up duration of 2.9 +/- 2.8 years. The PD cohort was older (72.3 +/- 8.0 versus 68.6 +/- 10.4 years, p<0.001), with greater male composition (50.8% versus 43.0%, p=0.001), and higher mean Elixhauser scores (1.0 +/- 4.6 versus 7.2 +/- 4.3, p<0.001). The PD cohort had significantly greater accommodation charges ($10,967 vs $7,661, p<0.001) and total inpatient charges ($62,000 and $56,000, p<0.001). PD patients had significantly higher rates of revision surgery (7.7% versus 4.2%, p=0.002) and complications (14.1% versus 10.5%, p=0.040), as well as significantly higher incidences of readmission at 3- and 12-months postoperatively. After controlling for age and baseline comorbidities, PD patients had 1.64 times greater odds of reoperation compared to non-PD patients (OR = 1.64, 95% CI [1.10, 2.37], p = 0.012) and a hazard ratio of 1.54 for reoperation when evaluating revision-free survival following primary shoulder arthroplasty (HR = 1.54, 95% CI [1.07, 2.20], p = 0.019). CONCLUSIONS:PD confers a longer length of stay, higher rates of postoperative complications and revisions, and greater inpatient charges in patients undergoing TSA. Knowledge of the associated risks and resource requirements of this population will aid surgeons in their decision making as they continue to provide care to a growing number of patients affected by PD.

BACKGROUND/UNASSIGNED:The exact pathogenesis of idiopathic adhesive capsulitis (IAC) is not fully understood, but an inflammatory profibrotic cascade, largely mediated by transforming growth factor-beta 1 (TGF- β1) has been implicated. Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACE-Is) both decrease the activity of TGF-β1. The aim of this study was to determine the impact of ACE-Is or ARBs use on the need for operative intervention in IAC. METHODS/UNASSIGNED:This was a retrospective cohort study of patients from a single institutional database with IAC, divided into two cohorts, with and without ACE-I and/or ARB use as the primary exposure and a minimum 2-year follow-up. The primary outcome measured was the incidence of operative intervention including manipulation under anesthesia (MUA) and arthroscopic capsular release (ACR). Additional multivariable logistic regression analysis was performed to evaluate associations between ACE-I/ARB use and likelihood of undergoing an operative procedure. RESULTS/UNASSIGNED: < .001) demonstrating reduced odds as compared to patients aged <30 years. CONCLUSION/UNASSIGNED:Patients with IAC have an overall low (2.4%) rate of requiring surgical intervention. While the antifibrotic mechanism of ACE inhibitors and ARBs did not significantly affect the rate of requiring surgical intervention, male gender, obesity, younger age, and diabetes, all increased the risk for operative intervention. Losartan, specifically, may have a disease modifying effect on IAC that should be investigated with larger controlled trials.

BACKGROUND:The goal of this longitudinal analysis of aTSA and rTSA utilization from 2007-2021 is to quantify changes in clinical outcomes, cost, and value, resulting from the introduction and adoption of new shoulder arthroplasty technologies. METHODS:We analyzed an international database of a single shoulder arthroplasty prosthesis (Equinoxe; Exactech, Inc; Gainesville, FL, USA) for all clinical sites that have continuously enrolled cases from 2007 to 2021 to compare changes in primary aTSA and primary rTSA utilization and outcomes across three, 5-year cohorts based upon the date of implantation. A value analysis was conducted across the 5-year implantation cohorts, with value measured by the ratio of each postoperative outcome measure at 24-36 months and 36-60 months after surgery and the average implant selling price each year for the US sites in constant 2007 US dollars, these measures of value were compared between cohorts to quantify the impact of new technology introduced over the study period. RESULTS:A dramatic increase in rTSA utilization was observed across the 6 sites over the 15-year study period, along with a rapid adoption of new aTSA and rTSA technologies. The average patient receiving primary aTSA and primary rTSA changed over the 15-year study period, with significant shifts in diagnosis, comorbidities, and preoperative functional status. A comparison of postoperative results demonstrated that both aTSA and rTSA clinical and radiographic outcomes showed improvement relative to 2007-2011. Over this 15-year study period, the average aTSA implant selling price has been relatively stable while the average rTSA implant selling price has significantly declined. As a result, the value associated with the Equinoxe rTSA significantly increased for nearly every outcome measure at 24-36 months and 36-60 months after surgery, while value associated with the Equinoxe aTSA stayed relatively constant from 2007-2021. CONCLUSION/CONCLUSIONS:Our 6,042-patient longitudinal analysis quantified numerous changes in utilization, outcomes, and value across 6 clinical sites over the past 15-years. Rapid adoption of new aTSA and rTSA technologies was observed and clinical and radiographic outcomes improved relative to 2007-2011. These clinical improvements, in combination with steady aTSA and declining rTSA implant prices, have driven rTSA value to continuously increase while aTSA value has been maintained at a high-level over the 15-year study period with this particular shoulder arthroplasty system, even when considering the cost and adoption of new technologies.

BACKGROUND:The purpose of this study was to compare clinical, implant related and patient reported outcomes of shoulders converted to reverse total shoulder arthroplasty (rTSA) following a previous ORIF to when rTSA is used as a primary treatment modality for an acute proximal humerus fracture (PHF) in patients ≥65 years of age. METHODS:A retrospective analysis was performed on a prospectively collected cohort of patients who underwent primary-rTSA for PHF versus a cohort who underwent conversion arthroplasty with rTSA following fracture repair between 2009-2020. Outcomes were assessed preoperatively and at the latest follow-up. Demographics and outcomes between cohorts were analyzed using conventional statistics as well as stratification by MCID and SCB thresholds where applicable. RESULTS:406 patients met criteria, 322 primary-rTSA for PHF versus 84 conversion-rTSA after failed PHF ORIF. The conversion-rTSA cohort was on average seven years younger (65±10 vs 72±9, p<0.001). Follow-up was similar between cohorts, average 47.1 months (range:24-138 months). The percentage of Neer 3-(41.9%vs45.2%) and 4-part (49.1%vs46.4%) PHFs were similar (p>0.99). The primary-rTSA cohort achieved higher forward elevation (FE), external rotation, PROMs including simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES) Score, University of California Los Angeles (UCLA) score, Constant Score, Shoulder Arthroplasty Smart (SAS) Score and Shoulder Pain and Disability Index (SPADI) score at a minimum of 24-months postop (p<0.05 for all). Patient satisfaction was higher in the primary-rTSA group compared to the conversion-rTSA cohort (p=0.002). Patient reported outcome measures uniformly favored the primary-rTSA cohort, rising to the level of statistical significance for FE, ASES and SPADI (p<0.05) relative to SCB. The AE rate and revision rate in the conversion-rTSA cohort was higher than the primary-rTSA cohort [(26.2% vs. 2.5%, p<0.001) and (8.3% vs. 1.6%, p=0.001)]. At 10-years postop revision free implant survival rates are significantly lower in the conversion cohort compared to the primary cohort, 66% vs 94% (p=0.012). Lastly, the hazard ratio of revision was 3.69 in the conversion cohort compared to only 1.0 in the primary-rTSA cohort. CONCLUSION/CONCLUSIONS:The current study demonstrates that elderly patients who undergo rTSA as a conversion procedure following previous osteosynthesis do not fare as well as those treated with rTSA for an acute displaced PHF. Conversion patients report lower patient satisfaction, have significantly restricted range of shoulder motion, higher risk of complications, higher risk of revision, poorer patient reported outcomes, and shorter implant survival at 10 years compared to those undergoing acute rTSA.

PURPOSE/OBJECTIVE:The purposes of this study were 1) to assess the outcome of nonoperative management of GT fractures with > 5 mm of displacement and 2) to assess whether there is a correlation between degree of displacement and outcome. METHODS:This study was a retrospective review of consecutive low-energy GT fractures from 2011 to 2020. Radiographs from all visits were reviewed. The direction of maximal displacement was assessed. Subjects were stratified based on the amount of maximal displacement: Group 1: 0-5 mm, Group 2: 5-10 mm, Group 3: > 10 mm. Range of motion (ROM) at the time of final follow-up was assessed. The presence of persistent shoulder pain after healing was noted, as well as whether supplemental subacromial corticosteroid injection was provided as part of long-term treatment. RESULTS:A cohort of 93 fractures comprised the study group. Mean age was 62 years. Mean follow-up was 20 months. All fractures went on to union. Mean displacement was 6.2 mm. There were 43 patients in Group 1, 43 in Group 2, and 7 in Group 3. Maximal displacement was most commonly inferolateral or lateral, accounting for a combined 77% of all patients. There was no difference in final ROM between displacement groups, with at least 155 degrees of forward elevation and 45 degrees of ER in all three groups. There was no difference between Group 1 and Groups 2/3 in frequency of persistent pain or likelihood of receiving a steroid injection. CONCLUSION/CONCLUSIONS:Our findings do not support a discrete 5 mm displacement threshold for surgical repair of isolated greater tuberosity fractures.

INTRODUCTION/BACKGROUND:Early reverse total shoulder arthroplasty (rTSA) designs had high failure rates, mainly from loosening of the glenoid baseplate. The purpose of this study is to determine the incidence of aseptic glenoid baseplate loosening after primary rTSA using a contemporary medialized glenoid/lateralized humeral system and identify significant risk factors associated with loosening. METHODS:7,162 primary rTSA were treated with a single platform rTSA system between April 2007 and August 2021, from which 3,127 primary rTSA patients with a minimum 2-year follow-up were identified. Patients with aseptic glenoid baseplate loosening were compared to all other primary rTSA without loosening. Univariate and multivariate analyses were performed to compare these cohorts and identify the demographic, comorbidities, operative, and implants associated aseptic glenoid loosening after rTSA. Odds ratios were calculated for each significant risk factor and for multiple combinations of risk factors. RESULTS:Irrespective of minimum follow-up, fifty-three (31F/22M) of 7,162 primary rTSA shoulders experienced aseptic glenoid loosening, for an overall rate of 0.74%. At latest 2-year minimum follow-up, thirty of 3,127 patients experienced aseptic glenoid loosening and had significantly lower clinical scores, function, active ROM, and higher pain scores as compared to patients without loosening. Univariate analysis identified that patients with rheumatoid arthritis (RA, p=0.029, OR = 2.74) and diabetes (p=0.028, OR=1.84) and multivariate analysis identified Walch glenoid types B2 (p=0.002, OR= 4.513) and B3 (p=0.002, OR=14.804), use of expanded lateralized glenospheres (p=0.025, OR=2.57) and use of augmented baseplates (p=0.001, OR=2.50) as significant risk factors for aseptic glenoid loosening after rTSA. CONCLUSION/CONCLUSIONS:The incidence of aseptic glenoid baseplate loosening was 0.74% for this medialized glenoid/lateralized humeral rTSA system. Numerous risk factors for aseptic loosening were identified, including: RA, diabetes, Walch B2 and B3 glenoids, posterior/superior augmented baseplates, and expanded lateralized glenospheres. Finally, analysis of multiple combinations of risk factors identified patients and implant configurations with the greatest risk of aseptic glenoid loosening.

BACKGROUND:Primary idiopathic adhesive capsulitis (AC) is characterized by shoulder pain and global limitations in range of motion (ROM). The aim of this study was to determine (1) if a spectrum of symptom severity exists during the freezing phase of AC and (2) identify factors associated with patient selection of corticosteroid injection (CSI) for treatment. METHODS:Patients presenting within 6-months of symptom onset of AC (freezing phase) were enrolled in this single-site retrospective case control study. Visual analog pain score (VAS), shoulder ROM, American Shoulder and Elbow Surgeons (ASES) scores, and Patient-Reported Outcomes Measurement Information System (PROMIS function and pain) scores were collected. Each patient was offered oral anti-inflammatory medication, physical therapy, and intraarticular corticosteroid injection (CSI). Patients were divided into two cohorts: those electing versus those deferring CSI. Multivariable logistic regression was performed to identify patient or symptom characteristics predictive of electing CSI. RESULTS:A total of 112 patients [mean age=54.7+/-8.8, female=76 (67.9%), mean symptom duration in weeks=13.2+/-7.9, elected CSI=74 (66.1%)] were included in our analysis. The overall study population demonstrated a wide spectrum of VAS pain scores [6.0+/-2.8 (range: 0-10)] and ROM: forward elevation (FE) [99.1°+/-27.0° (range: 30°-150°)], abduction (Abd) [81.5°+/-23.5° (range: 30°-130°)], external rotation (ER) [46.6°+/-13.0° (range: 0°-90°)], internal rotation (IR) [38.47°+/- 25.9° (range: 5°-90°)]. The CSI group had higher mean VAS pain score [6.6+/-2.5 versus 4.9+/-3.0, p=0.005] and greater limitations in ROM for FE [91.9°+/-26.9° versus 112.9°+/- 24.6°, p = 0.001] and Abd [77.2°+/- 23.6° versus 89.9°+/- 21.1°, p = 0.005] compared to the non-CSI cohort. The CSI group demonstrated significantly worse shoulder function based on Constant (p<.05), ASES (P=0.001), P-UE (P=0.016), P-Intensity (p=0.002), and P-Interference (p=0.004). Logistic regression demonstrated decreased total shoulder ROM in FE and Abd plains [OR=0.98 (95% CI=0.97-0.99), p=0.004)], Hispanic ethnicity and increased VAS pain score [OR=1.20 (95% CI=1.01-1.43), p=0.04] were associated with increased likelihood of electing CSI. CONCLUSION/CONCLUSIONS:A spectrum of symptom severity exists during the freezing phase of primary AC, despite similar etiology. AC patients with greater pain severity, and greater limitations in ROM at initial evaluation were associated with patient selection of CSI.