Faculty Bibliography

AIMS/UNASSIGNED:The aim of this study was to longitudinally compare the clinical and radiological outcomes of anatomical total shoulder arthroplasty (aTSA) up to long-term follow-up, when using cemented keel, cemented peg, and hybrid cage peg glenoid components and the same humeral system. METHODS/UNASSIGNED:We retrospectively analyzed a multicentre, international clinical database of a single platform shoulder system to compare the short-, mid-, and long-term clinical outcomes associated with three designs of aTSA glenoid components: 294 cemented keel, 527 cemented peg, and 981 hybrid cage glenoids. Outcomes were evaluated at 4,746 postoperative timepoints for 1,802 primary aTSA, with a mean follow-up of 65 months (24 to 217). RESULTS/UNASSIGNED:Relative to their preoperative condition, each glenoid cohort had significant improvements in clinical outcomes from two years to ten years after surgery. Patients with cage glenoids had significantly better clinical outcomes, with higher patient-reported outcome scores and significantly increased active range of motion, compared with those with keel and peg glenoids. Those with cage glenoids also had significantly fewer complications (keel: 13.3%, peg: 13.1%, cage: 7.4%), revisions (keel: 7.1%, peg 9.7%, cage 3.5%), and aseptic glenoid loosening and failure (keel: 4.7%, peg: 5.8%, cage: 2.5%). Regarding radiological outcomes, 70 patients (11.2%) with cage glenoids had glenoid radiolucent lines (RLLs). The cage glenoid RLL rate was 3.3-times (p < 0.001) less than those with keel glenoids (37.3%) and 4.6-times (p < 0.001) less than those with peg glenoids (51.2%). CONCLUSION/UNASSIGNED:These findings show that good long-term clinical and radiological outcomes can be achieved with each of the three aTSA designs of glenoid component analyzed in this study. However, there were some differences in clinical and radiological outcomes: generally, cage glenoids performed best, followed by cemented keel glenoids, and finally cemented peg glenoids.

INTRODUCTION/BACKGROUND:We compare the two-year clinical outcomes of both anatomic and reverse total shoulder arthroplasty (ATSA and RTSA) utilizing intraoperative navigation compared to traditional positioning techniques. We also examine the effect of glenoid implant retroversion on clinical outcomes. HYPOTHESIS/OBJECTIVE:In both ATSA and RTSA, computer navigation will be associated with equal or better outcomes with fewer complications. Final glenoid version and degree of correction will not show outcome differences. MATERIAL AND METHODS/METHODS:A total of 216 ATSAs and 533 RTSAs were performed using preoperative planning and intraoperative navigation with a minimum of 2-year follow-up. Matched cohorts (2:1) for age, gender and follow-up for cases without intraoperative navigation were compared using all standard shoulder arthroplasty clinical outcome metrics. Two sub-analyses were performed on navigated cases comparing glenoids positioned greater or less than 10° of retroversion and glenoids corrected more or less than 15°. RESULTS:for dislocations. No difference was found in the revision rate, glenoid implant loosening, acromial stress fracture rates, or scapular notching. Navigated RTSA patients demonstrated significant improvements over non-navigated patients in internal rotation, external rotation, maximum lifting weight, the simple shoulder test (SST), Constant, and shoulder arthroplasty smart (SAS) scores. For the navigated sub-cohorts, ATSA cases with a higher degree of final retroversion showed significant improvement in pain, Constant, ASES, SST, UCLA and SPADI. No significant differences were found in the RTSA sub-cohort. Higher degrees of version correction showed improvement in external rotation, SST and Constant scores for ATSA and forward elevation, internal rotation, pain, SST, Constant, ASES, UCLA, SPADI, and SAS scores for RTSA. CONCLUSION/CONCLUSIONS:The use of intraoperative navigation shoulder arthroplasty is safe, produces at least equally as good outcomes at two years compared to standard instrumentation without any increased risk of complications. The effect of final implant position above or below 10° of glenoid retroversion and correction more or less than 15° do not negatively impact outcomes.

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.

Introduction: While lateralization of the glenohumeral center of rotation during reverse shoulder arthroplasty (RSA) has benefits of maintaining tension on the remaining rotator cuff and decreasing implant impingement on the glenoid, few clinical studies have evaluated the isolated effect of glenoid lateralization in RSA. The purpose of this study was to evaluate if clinical outcomes are affected by isolated glenosphere lateralization using a single implant design. Methods: A retrospective review from a multicenter shoulder arthroplasty research database was performed between 2011 and 2018 using a single implant system to perform this case-controlled study. Inclusion criteria included primary RSAs with adequate preoperative and postoperative active and passive range of motion (ROM) measurements, outcome scores, and a minimum two-year follow-up. Revision shoulder arthroplasties and RSA for fractures were excluded from analysis. 102 RSAs (61 females, 41 males) using a + 4 mm lateralized glenosphere were compared to 102 sex, age, and glenosphere diameter matched control shoulders with standard glenospheres (whose center of rotation (CoR) is 2 mm lateral to the glenoid fossa). The mean age at surgery was 70.4 years. Mean follow up was 43.6 + 18.9 months. All RSAs were performed with the same implant system (Equinoxe, Exactech, Gainesville, FL). Clinical outcome measures included ROM, ASES, Constant, UCLA, SST, SPADI scores, and VAS pain scores. We used the chi-squared test and Fisher exact test for bivariate analysis and the student t-test for continuous variables. Results: Both groups were of similar average age and follow-up. They also had comparable rates of prior surgery and comorbidities. The lateralized glenosphere group had a slightly higher BMI (31.2 vs. 29.2, p = 0.04). Both groups demonstrated significant improvements in all outcome scores that exceeded the MCID and the SCB. The groups demonstrated similar preoperative, postoperative and improvements in ROM as well as outcome scores. The overall complication rate was similar between groups (4 % in lateralized and 5 % in controls, p = 0.73). Scapular or acromial fractures differences were not statistically significant between groups (1 % in lateralized group vs. 3 % in standard group, p = 0.31). Scapular notching was more frequent in the standard group compared to the lateralized group (9 % vs. 2 %, p = 0.03). Conclusion: In a medialized glenosphere/lateralized humerus design, a + 4 mm lateralized glenosphere provided no significant advantage in postoperative pain, ROM, or outcome scores. However, lateralized glenospheres did demonstrate significantly lower scapular notching rates. Level of Evidence: III; Retrospective Cohort Comparison; Treatment Study.

PURPOSE/UNASSIGNED:To assess the preoperative and postoperative performance of the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE, version 2.0) outcome score in comparison to the American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) instruments in patients undergoing rotator cuff repair. METHODS/UNASSIGNED:) between these tools was calculated at each time point. Correlations were graded as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), or poor (<0.4). Responsiveness to change was assessed using the effect size and the standardized response mean. Floor and ceiling effects for each instrument were also assessed. RESULTS/UNASSIGNED:The PROMIS-UE instrument showed good to excellent correlation with the legacy instruments at all time points. There were variations in the measured effect sizes of the various instruments, with the PROMIS-UE instrument showing responsiveness to change at 3 and 12 months but the ASES and WORC instruments showing responsiveness at 6 weeks, 3 months, and 12 months. Both PROMIS-UE and ASES scores displayed ceiling effects at 12 months. CONCLUSIONS/UNASSIGNED:The PROMIS-UE instrument shows excellent correlation with the ASES instrument and a rotator cuff-specific outcome instrument-the WORC instrument-preoperatively and at 1 year after arthroscopic rotator cuff repair. Variations in the measured effect sizes at different postoperative time points and high ceiling effects of the PROMIS-UE instrument at the 1-year time point may limit its utility in the early postoperative phase and at long-term follow-up after rotator cuff repair. CLINICAL RELEVANCE/UNASSIGNED:The performance of the PROMIS-UE outcome measure after arthroscopic rotator cuff repair was investigated.

PURPOSE/UNASSIGNED:The purposes of this study were to determine why athletes did not return to play (RTP) following operative management of superior-labrum anterior-posterior (SLAP) tears, compare these athletes to those who did RTP, and evaluate the SLAP-Return to Sport after Injury (SLAP-RSI) score to assess the psychological readiness of athletes to RTP after operative management of SLAP tears. METHODS/UNASSIGNED:A retrospective review of athletes who underwent operative management of SLAP tears with a minimum of 24-month follow-up was performed. Outcome data, including visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, patient satisfaction, and whether they would undergo the same surgery again was collected. Additionally, the rate and timing of return to work (RTW), the rate and timing of RTP, SLAP-RSI score, and VAS during sport were evaluated, with subgroup analysis among overhead and contact athletes. The SLAP-RSI is a modification of the Shoulder Instability-Return to Sport after Injury (SI-RSI) score, with a score >56 considered to be a passing score for being psychologically ready to RTP. RESULTS/UNASSIGNED: = .001) were all associated with greater likelihood of return to sports at final follow-up. CONCLUSIONS/UNASSIGNED:Following the operative management of SLAP tears, patients who are unable to RTP exhibit poor psychological readiness to return, which may be due to residual pain in overhead athletes or fear of reinjury in contact athletes. Lastly, the SLAP-RSI tool in combination with ASES proved to be useful in identifying patients' psychological and physical readiness to RTP. LEVEL OF EVIDENCE/UNASSIGNED:Level IV, prognostic case series.

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.

BACKGROUND:Identifying risk factors for acromial and scapular fractures improves our understanding about which variables are relevant to this fracture complication; however, this data is difficult to integrate into clinical practice because the majority of rTSA patients have 1 or more risk factors. The goal of this study is to better facilitate preoperative identification of patients at-risk for acromial and scapular fracture and quantify the impact of accumulating risk factors on the incidence of fracture. METHODS:We retrospectively analyzed 9,079 rTSA patients from a multi-center database of a single medialized glenoid/lateralized humerus onlay rTSA prosthesis to quantify the rate of acromial and scapular fractures. A univariate and multivariate analysis was performed to identify risk factors for fracture. Next, we quantified the number of patients with one or multiple significant risk factors for fracture. Finally, to facilitate preoperative identification of patients most at-risk for fracture, we stratified our dataset by multiple combinations of age, gender, and diagnosis risk factors and calculated the odds ratio for each cohort to quantify the impact of accumulating risk factors on the incidence of fracture. RESULTS:138 of 9,079 patients were radiographically identified to have a fracture of the acromion or scapula for a rate of 1.52%. Patients with fractures were more likely older, female, more likely to have a RA diagnosis, CTA diagnosis, and less likely to have diabetes diagnosis. 85% of rTSA patients had at least 1 fracture risk factor. Individually, age, gender, or diagnosis failed to identify any patient cohort with an odds ratio >2.5. Use of multiple combinations of patient risk factors refined identification of at-risk patients better than any individual or 2-risk factor combination and demonstrated that the patients with the greatest fracture risk were females with RA diagnosis >70 years, >75 years, and >80 years. CONCLUSION/CONCLUSIONS:This 9,079 rTSA multi-center study demonstrated that 1.52% of patients experienced acromial and/or scapular fractures with single medialized glenoid/lateralized humerus onlay rTSA prosthesis. Our analysis identified numerous risk factors and quantified the impact of accumulating risk factors on fracture incidence. Patients considering rTSA with these age, gender, and diagnosis risk factors should be made aware of their elevated complication risk.

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.