Faculty Bibliography

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/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.

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.

Background: This study aimed to determine whether there is a long-term difference in outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) performed for proximal humerus fracture (PHF) sequelae. Hypotheses were as follows: (1) patients undergoing aTSA would have improved functional outcomes but a greater incidence of adverse events (AEs) and reoperation than those undergoing rTSA and (2) patients undergoing shoulder arthroplasty after open reduction internal fixation (ORIF) would have worse outcomes with more AEs and reoperations than those undergoing shoulder arthroplasty for sequelae of nonoperatively managed PHF. Methods: A prospectively collected database was queried for patients with PHF sequelae undergoing aTSA or rTSA between 2007 and 2020 with minimum 2-year follow-up. Baseline demographics, perioperative data, postoperative AEs, functional outcomes, and range of motion (ROM) were compared between aTSA and rTSA groups. A secondary analysis was performed to compare patients treated with prior PHF ORIF vs. those treated nonoperatively. Results: There were 17 patients in the aTSA group and 83 patients in the rTSA group. Type I PHF sequelae predominated among patients who underwent aTSA (71% vs. 40%, P = .026). Incidence of total postoperative AEs was greater after aTSA than that after rTSA (12% vs. 5%, P = .277), with a significantly higher rate of glenoid aseptic loosening after aTSA (6% vs. 0%, P = .026). All AEs required reoperation except one in the rTSA group. The mean follow-up was 66 months for aTSA compared with 45 months for rTSA (P = .002). No differences in functional outcomes or ROM between aTSA and rTSA persisted beyond 3 months or at the final follow-up except external rotation, which favored aTSA for 3 years postoperatively. In the secondary analysis, there were 33 patients in the ORIF group and 67 in the non-ORIF group. One (3%) postoperative AE occurred in the ORIF group vs. five (7%) in the non-ORIF group (P = .385). At a mean follow-up of 4 years, there were no differences in functional outcome scores or ROM between ORIF and non-ORIF groups, except for patient-reported shoulder function (6.3 vs. 7.4, respectively, P = .037). Conclusion: For treatment of PHF sequelae, aTSA may result in a higher incidence of postoperative AEs and reoperation than rTSA, particularly due to glenoid aseptic loosening. No difference in functional outcome scores between aTSA and rTSA persists beyond 3 months or at the final follow-up. Although active external rotation is significantly improved after aTSA for the first 3 years postoperatively, no differences in ROM exist beyond 4 years at the final follow-up. Patients undergoing shoulder arthroplasty for PHF sequelae have comparable outcomes regardless of prior ORIF or nonoperative management. Level of evidence: Level III; Retrospective Cohort Design; Treatment Study

BACKGROUND:The objective of this study is to assess patient satisfaction and preference for telemedicine- versus in-person visits for outpatient shoulder and elbow musculoskeletal consultation during the COVID-19 pandemic and in the future. METHODS:Patients who had telemedicine visits for shoulder and elbow musculoskeletal complaints at a single institution from March through June, 2020, were invited to respond to a post-visit survey. The survey included a standardized questionnaire that focused on the patient's satisfaction with the telemedicine visit(s) during the pandemic and preference for using the telemedicine platform in the future following the pandemic. Additional details regarding their virtual visits (severity of their medical condition, previous virtual- or ER visits) were also obtained. Data regarding patient demographics and visit details (primary diagnosis, type of visit, length of visit, treating physician) were extracted from electronic medical records. RESULTS:In total, 153 patients participated in the study. Overall, high satisfaction scores regarding the telemedicine visit were noted: 91% of patients reported that their concerns were adequately addressed, 89% would recommend telemedicine to a friend and 94% stated that they would use this platform again in the presence of a situation like the COVID-19 pandemic. However, the majority of patients (76%) reported a preference for in-person visits for the same musculoskeletal complaint if it were not for COVID-19. A telemedicine visit duration of more than 10 minutes and a first-time telemedicine visit correlated with higher satisfaction rates (P=0.037 and P=0.001, respectively). CONCLUSIONS:COVID-19 has provided a boost to the use of our telemedicine platform, with a high satisfaction rate among patients with shoulder and elbow musculoskeletal complaints, largely due to safety reasons and limited access to in-person doctor visits. However, a considerable number of patients would have preferred in-person visits for similar health complaints if there were no pandemic. Further research on optimizing the selection of patients for telemedicine visits and addressing their expectations and concerns regarding their visits will improve patients' preference for future telemedicine visits.

»:For shoulder arthroplasty, regional anesthesia is safer when compared with general anesthesia. There is insufficient evidence to demonstrate the superiority of regional anesthesia with respect to pulmonary complications and hospital length of stay. »:Infiltration of the shoulder with local anesthetics offers no additional benefits compared with single-shot or continuous brachial plexus blocks for shoulder arthroplasty. »:There is high-quality evidence (Level I) demonstrating lower pain scores and lower perioperative opioid requirements after a continuous peripheral nerve block compared with a single-shot nerve block. However, catheter dislodgment and logistical issues with catheter insertion are impediments to the widespread usage of a continuous nerve block with an indwelling catheter. »:Liposomal bupivacaine is comparable with non-liposomal local anesthetic agents with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after total shoulder arthroplasty. »:Perioperative dexamethasone administration improves postoperative pain control, decreases perioperative opioid requirements, and reduces postoperative nausea.

BACKGROUND:We propose a new clinical assessment tool constructed using machine learning, called the Shoulder Arthroplasty Smart (SAS) score to quantify outcomes following total shoulder arthroplasty (TSA). METHODS:Clinical data from 3667 TSA patients with 8104 postoperative follow-up reports were used to quantify the psychometric properties of validity, responsiveness, and clinical interpretability for the proposed SAS score and each of the Simple Shoulder Test (SST), Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), University of California Los Angeles (UCLA), and Shoulder Pain and Disability Index (SPADI) scores. RESULTS:Convergent construct validity was demonstrated, with all 6 outcome measures being moderately to highly correlated preoperatively and highly correlated postoperatively when quantifying TSA outcomes. The SAS score was most correlated with the UCLA score and least correlated with the SST. No clinical outcome score exhibited significant floor effects preoperatively or postoperatively or significant ceiling effects preoperatively; however, significant ceiling effects occurred postoperatively for each of the SST (44.3%), UCLA (13.9%), ASES (18.7%), and SPADI (19.3%) measures. Ceiling effects were more pronounced for anatomic than reverse TSA, and generally, men, younger patients, and whites who received TSA were more likely to experience a ceiling effect than TSA patients who were female, older, and of non-white race or ethnicity. The SAS score had the least number of patients with floor and ceiling effects and also exhibited no response bias in any patient characteristic analyzed in this study. Regarding clinical interpretability, patient satisfaction anchor-based thresholds for minimal clinically importance difference and substantial clinical benefit were quantified for all 6 outcome measures; the SAS score thresholds were most similar in magnitude to the Constant score. Regarding responsiveness, all 6 outcome measures detected a large effect, with the UCLA exhibiting the most responsiveness and the SST exhibiting the least. Finally, each of the SAS, ASES, Constant, and SPADI scores had similarly large standardized response mean and effect size responsiveness. DISCUSSION/CONCLUSIONS:The 6-question SAS score is an efficient TSA-specific outcome measure with equivalent or better validity, responsiveness, and clinical interpretability as 5 other historical assessment tools. The SAS score has an appropriate response range without floor or ceiling effects and without bias in any target patient characteristic, unlike the age, gender, or race/ethnicity bias observed in the ceiling scores with the other outcome measures. Because of these substantial benefits, we recommend the use of the new SAS score for quantifying TSA outcomes.