Faculty Bibliography

BACKGROUND:The purpose of this study was to determine the relationship between admission source and postoperative length of stay (LOS), index admission hospital charges, and discharge disposition, in patients undergoing shoulder arthroplasty. METHODS:The New York Statewide Planning and Research Cooperative System (SPARCS) was used to identify all patients that underwent elective shoulder arthroplasty from 1994 through 2015. Patients were grouped into institutionalized (INS) versus non-institutionalized (n-INS) groups based on admission source. The two groups were compared regarding demographics, Charleston comorbidity index (CCI), postoperative blood transfusion requirement, LOS, and total charges. RESULTS:A total of 33,248 patients were identified (32,875 n-INS, 373 INS). Patientsin the INS cohort were significantly older (71.9 versus 68.1 years) and had a higher CCI (1.3 vs. 0.7). The mean LOS in the INS group was nearly 1 week longer(9.5 days vs. 2.8 days) and had a significantly higher postoperative blood transfusion rate (37.5% vs. 9.2%, odds ratio: 5.9). The mean total hospital charges in the INS group were also significantly higher ($63,988 vs. $36,826). DISCUSSION/CONCLUSIONS:Institutionalized patients undergoing shoulder arthroplasty have a protracted postoperative hospital course and this ultimately resulted in poorer outcomes and increased resource utilization.

BACKGROUND:Legacy shoulder outcome scores have postoperative ceiling scores effects when quantifying clinical outcomes for anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty patients. This study utilizes data from an international database of a single shoulder prosthesis utilizing data from 30 different clinical sites to quantify and compare the percent of aTSA and rTSA patients achieving postoperative ceiling scores with multiple outcome measures and defines the patient demographics, comorbidities, implant, and operative parameters associated with ceiling scores for each outcome measure. METHODS:Clinical outcomes for 1817 aTSA and 2635 rTSA patients between 2007 and 2019 were quantified with the ASES, SST, UCLA, Constant, and SAS scores. The number of aTSA and rTSA patients with ceiling scores were calculated and sorted into those that achieved ceiling scores with the SST, ASES, and UCLA measures and compared to patients without ceiling scores. A univariate and multivariate analysis then identified the patient demographics, comorbidities and implant and operative parameters associated with ceiling scores for each outcome measure. RESULTS:aTSA patients achieved ceiling scores at a significantly greater rate than rTSA patients for all outcome measures, except SAS. The SST score was the most susceptible to ceiling scores (aTSA=43.4%, rTSA=34.1%, p<0.0001), followed by the ASES (aTSA=23.7%, rTSA=13.3%, p<0.0001), and UCLA (aTSA=22.2%, rTSA=10.6%, p<0.0001) scores. Ceiling scores were least likely with the Constant (aTSA=0.4%, rTSA=0%, p=0.0060) and SAS (aTSA=0.1%, rTSA=0%, p=0.0750) scores. Male patients had a significantly higher ceiling score rate than female patients using the SST and ASES scores and no differences in ceiling score rates were observed with the UCLA, Constant, or SAS scores. Finally, we identified numerous patient demographic, comorbidity, implant, and operative parameters associated with SST, ASES, and UCLA ceiling scores for aTSA and rTSA patients. DISCUSSION/CONCLUSIONS:Postoperative ceiling scores occur at a high rate for aTSA and rTSA patients with the SST, ASES, and UCLA scores. Patients most susceptible to ceiling scores are aTSA patients treated with cage glenoids, aTSA patients of lower BMI, rTSA patients of male gender, rTSA patients with OA diagnosis, and rTSA patients with subscapularis repair. Clinical researchers should consider utilizing alternative scores, such as the SAS score, to ensure a more normalized distribution of data and more accurately quantify aTSA and rTSA outcomes.

PURPOSE/OBJECTIVE:To assess longer-term (> 5 years) function and outcome in patients treated with anatomic locking plates for proximal humerus fractures. METHODS:This retrospective cohort study was conducted at an urban, academic level 1 trauma center and an orthopedic specialty hospital. Patients treated operatively for proximal humerus fractures with an anatomic locking plate by three orthopedic trauma surgeons and two shoulder surgeons from 2003 to 2015 were reviewed. Patient demographics and injury characteristics, disabilities of the arm, shoulder, and hand (DASH) scores, complications, secondary surgeries, and shoulder range of motion were compared at 1 year and at latest follow-up. RESULTS:Seventy-five of 173 fractures were eligible for analysis. At a minimum 5 years and a mean of 10.0 ± 3.2 years following surgery, DASH scores did not differ from one-year compared to long-term follow-up (16.3 ± 17.4 vs. 15.1 ± 18.2, p = 0.555). Shoulder motion including: active forward flexion (145.5 vs. 151.5 degrees, p = 0.186), internal rotation (T10 vs. T9, p = 0.204), and external rotation measurements (48.4 vs. 57.9, p = 0.074) also did not differ from one year compared to long-term follow-up. By one year, all fractures had healed. After 1-year post-operatively, four patients underwent reoperation, but none for AVN or screw penetration. CONCLUSIONS:Patient-reported functional outcome scores and shoulder range of motion are stable after one year following proximal humerus fracture fixation, and outcomes do not deteriorate thereafter. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms.

»/UNASSIGNED:The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population. »/UNASSIGNED:Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence. »/UNASSIGNED:RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve. »/UNASSIGNED:RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures. »/UNASSIGNED:RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.

Background/UNASSIGNED:Patient's willingness and barriers for discharge after shoulder arthroplasty (SA) has not been studied. The aim of this study was to prospectively analyze patient's willingness for discharge and barriers to discharge beyond postoperative day #1 (POD#1) after SA. Methods/UNASSIGNED:In this prospective study, patients undergoing primary or revision SA (anatomic, reverse, or hemiarthroplasty) at our institution were enrolled to determine their willingness and concerns for discharge after SA. Patient's willingness for discharge was inquired daily until discharge. Demographic information, patient's medical history, intraoperative details (duration of surgery, estimated blood loss, intraoperative complication), discharge disposition, length of stay (LOS), and reasons for extension of LOS beyond POD#1 were analyzed. Results/UNASSIGNED:A total of 184 patients who underwent SA were included. Eight patients were discharged on POD#0, 114 patients on POD#1, 37 patients on POD#2, and 25 patients after POD#2. One hundred nineteen (119) patients were discharged to home, 40 were discharged to home with services, 15 were discharged to nursing facilities, and 10 were discharged to rehabilitation centers. Reasons for extension of LOS past POD#1 included patients failing to clear home safety evaluation (n = 4), inadequate pain control (n = 6), worsening of preexisting medical conditions (n = 8), delay in patient disposition (awaiting placement in a rehabilitation facility [n = 6] and awaiting culture results [n = 9]). Social reasons (n = 29) were the most common reasons for extension of LOS. These included patients requesting an extra day of stay (n = 20), patients requesting rehabilitation facility placement (n = 5), lack of a timely ride home (n = 2), and family-related reasons (death in the family [n = 1], lack of home help [n = 1]). Conclusions/UNASSIGNED:This prospective study demonstrates modifiable factors associated with LOS beyond POD#1 (inadequate pain control, logistic delays in disposition, and patient-related social concerns) after SA. With increasing interest in same-day discharge and rising concerns to control cost and use bundled payment initiatives with SA, improving patient's willingness to discharge by addressing their concerns can improve early discharge after SA.

Background/UNASSIGNED:History of prior rotator cuff repair (RCR) may adversely affect the outcomes of reverse total shoulder arthroplasty (RTSA), but there is no information regarding the influence of prior superior capsular reconstruction (SCR) surgery on the outcomes of RTSA. The purpose of this study is to evaluate the outcomes of RTSA following failed arthroscopic SCR. Methods/UNASSIGNED:All patients who underwent RTSA for failed SCR (SCR cohort) at our institution were identified from our institutional database. A comparative cohort of patients who had RTSA with a history of failed RCR (Control cohort) was also reviewed. Demographic information, 90-day complication rate, 90-day emergency department visits, length of stay, and outcome scores (patient-reported outcomes measurement information system [PROMIS] physical function upper extremity, Visual Analog Scale score, and range of motion) were compared. Results/UNASSIGNED:From 2015 to 2020, 87 arthroscopic SCRs were performed at our institution and of these, 13 patients underwent RTSA at a mean time of 14.6 months (5.8-32.4) after SCR and were followed up for an average of 17.9 months (1.6-44.6). The average number of shoulder surgeries prior to RTSA was 2.8 (1-7), with the last surgery being SCR. During the same period, we identified 15 patients who underwent an RTSA after a failed RCR (control cohort). The RTSA in the control cohort was performed on average at 12.8 months (1.5-39.5) following the last RCR, and patients were followed up for an average of 27.7 months (2.8-53.9). The average number of shoulder surgeries before the RTSA in the control cohort was 1.4 (1-3). Although the SCR cohort had significant improvements in pain scores and forward flexion (FF), there was only a modest functional improvement with PROMIS scores and no meaningful improvement with external rotation. Complications (23%) in the SCR cohort included 1 periprosthetic joint infection requiring 2-stage revision, 1 acromion stress fracture, and 1 ulnar neuritis. Overall, compared to the SCR cohort, patients in the control cohort had better function (PROMIS physical function upper extremity), lower Visual Analog Scale score, and greater range of motion (FF and external rotation) preoperatively and at last follow-up, but there were no differences in the length of stay and 90-day emergency department visits, infection, and complication rate between the 2 cohorts. Conclusion/UNASSIGNED:RTSA after failed SCR improves pain and FF but is associated with modest functional improvements and high complication rates. However, these findings will require confirmation in a larger cohort with longer follow-up.

The biomechanical concepts underlying total shoulder arthroplasty including differences between the anatomic total and reverse total shoulder arthroplasty (RTSA) are reviewed. The concept of lateralization and its implications on outcomes after RTSA is explained through a historical perspective. Finally, how lateralization can be achieved via different components of an RTSA construct, as well as the potential disadvantages or trade-offs that must be considered when lateralizing in reverse shoulder arthroplasty, are discussed.

Glenohumeral osteoarthritis (GHOA) in the young adult remains a challenging clinical problem to treat. These difficulties stem from the high physical demands and expectations of this patient population, limited longevity of existing treatment modalities, and need for a future revision surgery after primary surgical intervention. Given the heterogeneous etiology, clinical presentation, and radiographic findings, a thorough understanding of the pathology, patient expectations, and outcomes of existing treatment options available is necessary to deliver a treatment that is tailored to individual needs of the patient. None of the available treatment options have shown to alter the natural history of GHOA. Nonsurgical modalities continue to be the first line treatment but there is no consensus if one treatment is more effective than the other. Surgical options include shoulder preserving and shoulder replacing procedures and are usually considered after the nonsurgical options become ineffective in controlling a patient's symptoms. Total shoulder arthroplasty provides predictable pain relief and improvement of function but is limited by the longevity of the implant. Despite the growing research, there continues to be search for a long lasting, durable treatment option that would compete with a young adult's lifetime.

Background: Both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) are the standard of care for various end-stage degenerative conditions of the glenohumeral joint. The purpose of this prospective study was to compare clinical outcomes of aTSA and rTSA using the same platform total shoulder arthroplasty system at a minimum follow-up of 8 years. Methods: An international multicenter data registry was used to identify patients undergoing primary aTSA or rTSA with a minimum of 8-year follow-up. Patients were scored preoperatively and at latest follow-up using 6 outcome and 4 range of motion metrics. Patients graded global shoulder function on a 0-10 scale. Patient satisfaction was classified as much better, better, unchanged, or worse. Pain was graded using the Visual Analog Scale. A student's 2-tailed paired t-test, Chi-squared test, or Wilcoxon rank-sum test were used when appropriate, where P <.05 indicates significant differences. Results: A total of 364 aTSA patients and 278 rTSA patients were included. rTSA had greater mean age (aTSA 65.1, rTSA 71.2, P <.0001) and shorter mean follow-up (aTSA 115.2 months, rTSA 109.7 months; P =.0002). Postoperatively, all patients demonstrated significant improvements in pain and function. Preoperatively, aTSA patients had greater active abduction and forward elevation, global function, Constant Score, and the University of California, Los Angeles score. At latest follow-up, aTSA had greater active abduction, forward elevation, external rotation, and Simple Shoulder Test scores. There were no postoperative differences in patient satisfaction, shoulder function, pain, or any other outcome measure between the groups. aTSA patients had a greater revision rate (aTSA 5.8%, rTSA 1.8%; P =.0114), with no difference in complication rates. Humeral radiolucent lines were present in 20.9% of aTSA patients and 37.1% of rTSA patients (P =.0011). Glenoid radiolucent lines were present in 48.0% of aTSA patients (average score of 1.5). Scapular notching was present in 14.5% of rTSA patients (average grade of 0.26). Conclusion: This study is one of the largest to date that compares aTSA and rTSA with a minimum follow-up of 8 years. Significant improvements are seen in both aTSA and rTSA. For both groups, the complication rate was lower than previously reported in the literature. At the latest follow-up, pain relief and global function were significantly improved with high patient satisfaction in both groups, with no statistical differences found. This study provides physicians with information to help guide them when advising patients as to what they can expect at a minimum of 8 years after aTSA and rTSA.