Faculty Bibliography

BACKGROUND:The Shoulder Arthroplasty Smart (SAS) score is a new, validated machine learning-derived outcome measure that requires six input parameters. The SAS score has the potential to replace legacy shoulder outcome scores. METHODS:We conducted a retrospective review of a multinational shoulder arthroplasty database of one platform shoulder prosthesis (used interchangeably for anatomic and reverse total shoulder arthroplasty). All primary shoulder arthroplasties with a minimum of two-year follow-up and an available SAS score were evaluated. Associations between scoring systems were assessed using Pearson correlations, with 95% confidence intervals stratified by time point (preoperatively and postoperatively at 2- and 5-year follow-ups, respectively) and procedure (anatomic verses reverse total shoulder arthroplasty). Conversion equations were developed using the best-fit line from linear regression analysis. Ceiling effects were assessed based on two definitions: (1) >15% of participants scoring the maximal possible score and (2) a standardized distance less than 1.0, whereby the standardized distance is calculated by subtracting the mean from the maximal score and dividing by the standard deviation. RESULTS:Two thousand four hundred six shoulders were evaluated at 4,553 clinical encounters. For preoperatively collected data, the SAS score correlated strongly with the Constant (R = 0.83), University of California at Los Angeles (R = 0.85), and Shoulder Pain and Disability Index (R = -0.70) scores and moderately with the American Shoulder and Elbow Surgeons (R = 0.69) and Simple Shoulder Test (R = 0.65) scores. The SAS score strongly correlated (R > 0.7) with all legacy outcome scores collected at 2- and 5-year postoperative visits. Score predictions made using the conversion equations between the SAS score and legacy outcome scores strongly correlated with their actual values. Neither the SAS nor the Constant score were influenced by ceiling effects. All other outcome scores evaluated demonstrated ceiling effects. CONCLUSION/CONCLUSIONS:The SAS score correlates well with legacy shoulder scores after primary shoulder arthroplasty while mitigating ceiling effects. Surgeons may decrease patient questionnaire burden by using the brief six-question SAS score.

Background: Glenoid component positioning is an important and challenging aspect of total shoulder arthroplasty. The use of freehand technique with standard instrumentation or preoperative planning based on 2-dimensional computed tomography (CT) scans provides an opportunity for improvement in terms of component accuracy, precision, and deformity correction. These techniques have produced varying outcomes. Methods: Preoperative planning software (PPS), patient specific instrumentation (PSI), and intraoperative navigation (NAV) have been developed to improve the accuracy of implant placement and deformity correction with the ultimate goals of improved patient outcomes and implant longevity. Literature search was conducted on published and available studies comparing the accuracy of glenoid component placement and improvements in surgical and patient outcomes amongst the aforementioned techniques. Results: PPS, PSI, and NAV have demonstrated improved accuracy over freehand techniques with standard instrumentation. However, data demonstrating the clinical benefit and cost effectiveness of these new technologies are lacking. Discussion: In this paper, we reviewed the evidence available to answer the question of whether or not advanced shoulder arthroplasty technologies have been beneficial and reviewed future technologies in development such as virtual/mixed-reality and robotic assisted shoulder surgery. Level of Evidence: 4.

Background: The purpose of this investigation was to compare minimum two-year outcomes of anatomic total shoulder arthroplasty (aTSA) performed with humeral head resurfacing (HHR) vs. stemless implants. Methods: A retrospective review of a large multicenter database was conducted. All patients who underwent aTSA with either HHR or stemless implants with minimum two-year follow-up were evaluated. Range of motion (ROM) and patient-reported outcomes (PROs) including Constant Score, Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons score, University of California Los Angeles Shoulder Score, Shoulder Pain and Disability Index, and Shoulder Arthroplasty Smart score were collected for all patients presurgery and postsurgery. Radiographic data was collected to determine the presence of radiolucent lines as well as evaluate implant sizing and anatomic shoulder restoration. Results: Overall, 127 patients were included with 49 patients receiving HHR and 78 stemless aTSA. Preoperatively, patients in the HHR group had worse ROM and PRO scores (P < .05). Although the stemless group had significantly greater active abduction (148 ± 28 vs. 116 ± 22, P < .001), forward flexion (154 ± 21 vs. 141 ± 15, P < .001) and external rotation (50 ± 16 vs. 34 ± 17, P < .001) and exhibited better scores on the SST (10.4 ± 2.0 vs. 9.5 ± 1.9, P = .014) at final postoperative evaluation, the HHR group had a greater improvement from preoperative to final postoperative evaluation in active forward flexion (50 ± 22 vs. 32 ± 20, P < .001) and internal rotation (3 ± 2 vs. 1 ± 2, P = .004) as well as all PROs measured (P < .01). Both groups demonstrated significant improvements in all PROs and ROM from presurgery to postsurgery (P < .05). Rates of overstuffing (8.7% in HHR vs. 20.8% stemless, P = .098), oversizing (39.1% in HHR vs. 31.3% in stemless, P = .436), and radiolucent lines around the glenoid components (13.0% in HHR vs. 18.8% in stemless, P = .450) were not significantly different between the groups. One patient in the stemless group required a revision surgery for aseptic glenoid loosening, otherwise no other major complications were reported. Conclusion: aTSA performed both with stemless implants and HHR resulted in significant improvements in ROM and multiple PROs at minimum two-year follow-up with a low complication rate. The HHR group had worse preoperative shoulder function, which contributed to a greater magnitude of improvement in ROM and across all PROs from presurgery to postsurgery, despite the stemless group having better ROM and SST scores at final follow-up.

BACKGROUND/UNASSIGNED:The aim of this study is to investigate the pattern of changes in activities of daily living (ADLs), sleep disturbance, and pain in the early postoperative period following a total shoulder arthroplasty (TSA). METHODS/UNASSIGNED:Prospective data on patterns of limitation in ADLs, sleep disturbance, and pain were collected from patients undergoing elective TSA preoperatively and at specific time points postoperatively (2, 6, and 12 weeks). At each time point, patients were asked regarding the major limitation affecting their shoulder. Limitations in ADLs and sleep disturbances were scored on a 3-point scale (0 = unable to do, 3 = no difficulty) modeled after the ADL which require active external rotation score and visual analog scale scores were used for pain. Patient responses were analyzed with respect to patient factors (demographics, arm dominance, function of opposite arm, and ambulation status), and living situation (alone, or with caregiver). RESULTS/UNASSIGNED:Shoulder pain (43%) and inability to perform ADLs (38%) were the 2 most commonly reported limitations prior to undergoing TSA. Patients noticed progressive improvements in pain with 37% reductions in visual analog scale scores at 2 weeks and 67% reduction at 3 months. At 2 weeks after TSA, sleep disturbances were the most disabling issue in 33% of the cohort, with considerable improvements (104%) in sleep scores at 3 months compared to pre-op. The ADLs involving forward elevation and working at the waist level improved considerably between 6 weeks and 3 months, but activities involving rotation including reaching behind the back, across the chest, and use of strength showed mild improvements by 3 months. CONCLUSION/UNASSIGNED:This prospective study demonstrates the chronology of improvements in pattern of limitations experienced by patients with respect to pain, sleep, and ADLs in the early postoperative period after TSA. Majority of patients can expect to have 2/3 resolution of pain, improved sleep, and improvement in ADLs involving forward elevation and waist level function by 3 months.

INTRODUCTION/BACKGROUND:Glenoid baseplate augments have recently been introduced as a way of managing glenoid monoplanar or biplanar abnormalities in reverse shoulder arthroplasty (RSA). The purpose of this study is to evaluate the difference in clinical outcomes, complications, and revision rates between augmented and standard baseplates in RSA for rotator cuff arthropathy patients with glenoid deformity. METHODS:A multicenter retrospective analysis of 171 patients with glenoid bone loss who underwent RSA with and without augmented baseplates was performed. Preoperative inclusion criteria included: minimum follow-up of 2 years and preoperative retroversion of 15 to 30 degrees and/or a beta angle 70 to 80 degrees. Version and beta angle measured on CT, when available, and plain X-rays. Shoulder range of motion (ROM) and patient-reported outcomes were obtained from preoperative and multiple postoperative timepoints. RESULTS:The study consisted of 84 standard baseplate patients and 87 augmented baseplate patients. The augment cohort had greater mean preoperative glenoid retroversion (17 vs. 9 degrees, p<0.001). At 5+ year follow-up, the increase in postoperative active abduction (52 vs. 31 degrees, p=0.023), forward flexion (58 vs. 35 degrees, p=0.020) and internal rotation score (2.8 vs. 1.1 degrees, p=0.001) was significantly greater in the augment cohort. Additionally, 5+ year follow-up ASES score (87.0 ± 16.6 vs. 75.9 ± 22.4, p=0.022), Constant score (78.0 ± 9.7 vs. 64.6 ± 15.1, p<0.001) and Shoulder Arthroplasty Smart score (81.2 ± 6.5 vs. 71.2 ± 13.6, p=0.003) were significantly higher in the augment cohort. Revision rate was low overall with no difference between the augment and no augment groups (0.7% vs. 3.0%, p=0.151). CONCLUSION/CONCLUSIONS:In comparing augments to standard non-augment baseplates in the setting of RSA with glenoid deformity, our results demonstrate greater postoperative improvements in multiple planes of active range of motion in the augment cohort. Additionally, the augment cohort demonstrated greater postoperative level and improvement in scores for multiple clinical outcome metrics up to 5+ years of follow-up with no difference in complication or revision rates, supporting the use of augmented glenoid baseplates in RSA with glenoid deformity.

OBJECTIVE:To compare MRI with 3D reconstructions and 3D-CT with respect to assessment of glenoid wear in osteoarthritic shoulders. METHODS:3D reconstructions were generated for CT and MR (utilizing the Dixon technique) imaging performed on 29 osteoarthritic shoulders. Two reviewers independently performed glenoid morphometric measurements and evaluated glenoid erosion. Mean differences between the two modalities were calculated. Inter-observer agreement was calculated using kappa coefficient. RESULTS:The combined mean absolute difference (bias) in glenoid version between 3D-CT and 3D-MRI was 2.7° ± 1.6° (range 0.15-7.85, P value = 0.7). The combined mean absolute difference in glenoid inclination between 3D-CT and 3D-MRI was 6.8° ± 4.1° (range 0.8°-15.75°, P value = 0.17). No significant inter-reader variation in glenoid version and inclination measurements on 3D-CT and 3D-MRI was found (P > 0.05). The inter-reader reliability for both CT and MRI was high for Walch grading of glenoid bone loss (κ = 1, κ = 0.81, respectively). CONCLUSIONS:3D-MRI is comparable to 3D-CT with respect to axial glenoid bone loss, as measured by glenoid version. However, for coronal bone loss estimation, measured by glenoid inclination, 3D-CT remains the gold standard. Thus, 3D-MR can be used as an alternative for preoperative assessment of glenoid version in arthritic shoulders.

PURPOSE/OBJECTIVE:Coracoid fracture is a rare injury. The aim of this study is to present the demographics, clinical and radiologic characteristics, and outcomes of coracoid fracture in a cohort of 32 patients. METHODS:We queried our institutional electronic medical record database (years 2012-2020) to identify patients with coracoid fractures using specific International Classification of Disease-10 codes. Demographic data, injury details including mechanism of injury and associated injuries, imaging performed, and treatment outcomes were obtained from retrospective chart review. A radiologist reviewed all available imaging studies (radiographs/CT/MRI) and classified the fractures according to Ogawa and Eyres classifications. Missed diagnoses were determined by comparing initial imaging reports with the follow-up imaging obtained in the office. RESULTS:Thirty-two patients with coracoid fractures were identified during the study period. Sixteen fractures (50%) occurred in the setting of low-energy trauma. Twelve fractures were missed on initial radiographs, and diagnosis with three-view radiographs (AP, scapular-Y and axillary) was 88% compared to 33% (p < 0.03) with two views (AP, scapular-Y). The majority of fractures were non-displaced (94%), and 56% were Ogawa Type-II fractures. Associated injuries were seen in 81% of patients. Most fractures (94%) were treated without surgery with excellent outcomes. CONCLUSION/CONCLUSIONS:Coracoid fractures continue to be a rare injury. In contrast to previous studies, in this case series of 32 patients, half of the fractures were associated with low-energy trauma, which correlated with higher percentage of non-displaced fractures and Ogawa Type-II fractures. Addition of the axillary view in the trauma radiographic series significantly improved the initial fracture detection rate. LEVEL IV/UNASSIGNED:Retrospective study.

INTRODUCTION/BACKGROUND:Since the introduction of the Grammont style reverse total shoulder arthroplasty (RTSA), the humeral stem design has been modified with improved clinical outcomes. Two distinct humeral designs have been utilized extensively: the inlay where the humeral tray is seated within the metaphysis and the onlay design where the humerus tray sits on the metaphysis at the level of the humeral neck cut. The purpose of this systematic review is to determine if there are differences in clinical outcomes and complication rates between these designs. METHODS:The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform this systematic review. A search was performed on Medline, PubMed, and Embase to identify all studies comparing clinical results of both humeral designs. Primary outcomes included patient-reported outcomes measures (PROMs), shoulder range of motion, and incidence of complications. RESULTS:From the 156 identified publications, 12 studies were included in the final review. A total of 1447 patients were included with a minimum follow-up of 12 months. At final follow-up, both implants demonstrated significant improvements in comparison to preoperative baseline. When comparing inlay versus onlay groups, the American Shoulder and Elbow Surgeons (ASES) score was higher in the inlay group (mean difference of 2.53 [95% CI: 0.27-4.78] p=0.03). Postoperative motion, even if statically greater in the onlay group (difference in forward flexion 5°(p<0.001), abduction 3° (p=0.003) and external rotation 4°(p<0.001)) are not clinically different. When comparing complications, the inlay group reported more instances of scapular notching (93/322 versus 70/415, OR 0.35 p<0.001) but fewer scapular spine fractures (26/727 versus 21/559, p=0.09). DISCUSSION/CONCLUSIONS:Inlay and onlay humeral tray designs in reverse total shoulder arthroplasty demonstrate similar clinical improvements postoperatively. The onlay implants have low rate of scapular notching but higher rate of scapular spine fracture. Understanding the strength and weaknesses of the two humeral tray designs is important to provide surgeons with options to tailor surgical plan for high risk patients.

INTRODUCTION/BACKGROUND:This study's purpose is to compare clinical and radiographic outcomes of primary anatomic total shoulder arthroplasty (aTSA) and primary reverse total shoulder arthroplasty (rTSA) patients with osteoarthritis (OA) and an intact rotator cuff with no previous history of shoulder surgery using a single platform TSA system at a minimum follow-up of 2 years. METHODS:A total of 370 aTSA patients and 370 rTSA patients matched for age, sex, and length of follow-up from an international multi-institutional Western Institutional Review Board approved registry with a minimum 2-year follow-up were reviewed for this study. All patients had a diagnosis of OA, an intact rotator cuff, and no previous shoulder surgery. All patients were evaluated and scored preoperatively and at latest follow-up using six outcome scoring metrics and four active range of motion measurements. RESULTS:Mean follow-up was 41 months, and the mean age was 73 years. Preoperatively, the rTSA patients had lower outcome metrics and less motion. Postoperatively, aTSA and rTSA patients had similar clinical outcomes, motion, and function, with the only exception being greater external rotation in aTSA exceeding the minimal clinically important difference. Pain relief was excellent, and patient satisfaction was high in both groups. Humeral radiolucent lines were similar in both groups (8%). Complications were significantly higher with aTSA (aTSA = 4.9%; rTSA = 2.2%; P = 0.045), but revisions were similar (aTSA = 3.2%; rTSA = 1.4%; P = 0.086). CONCLUSION/CONCLUSIONS:At a mean of 41 month follow-up, primary aTSA and rTSA patients with OA and an intact rotator cuff with no previous history of shoulder surgery had similar clinical and radiographic outcomes. Greater external rotation was noted in aTSA patients at follow-up. However, aTSA patients had a significantly greater rate of complications compared with rTSA patients. rTSA is a viable treatment option in patients with an intact rotator cuff and no previous shoulder surgery, offering similar clinical outcomes with a lower complication rate. LEVEL OF EVIDENCE/METHODS:Level III.

The Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test (PROMIS UE CAT) is a newer patient-reported outcome measure for upper extremity physical function. To date, no longitudinal study exists assessing PROMIS UE CAT responsiveness in patients undergoing shoulder arthroplasty. The purpose of this prospective longitudinal study is to report PROMIS UE CAT responsiveness to change and correlation to legacy instruments in patients undergoing total shoulder arthroplasty (TSA). Ninety-six patients (97 shoulders) undergoing TSA completed the PROMIS UE, Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) preoperatively and postoperatively at 6 weeks, 12 weeks, and after 6 months. Spearman's correlation coefficients (r) were calculated between PROMIS UE and other scores at each time-point. Responsiveness to change was assessed using the effect size (Cohen's d) and standardized response mean compared with the preoperative time-point. Floor and ceiling effects were also assessed. PROMIS UE CAT demonstrated positive responsiveness at all time-points after TSA. It demonstrated excellent correlation (range: 0.68-0.84) with ASES, SST, and OSS at all postoperative time-points, but the correlation was weaker (r < 0.6, except OSS) preoperatively. Only OSS and SST showed ceiling effects at the 6-12-month time-point (16.8% and 18.2%, respectively). PROMIS UE CAT responsiveness to change and strength of correlation with legacy instruments improves with time elapsed after TSA. Further quantification of meaningful responsiveness to change will require estimation of the minimal clinically important difference and substantial clinical benefit for PROMIS UE CAT.