Faculty Bibliography

BACKGROUND:Cervical spine pathology can affect the supporting muscles and function of the shoulder and contribute to shoulder and arm pain and hence may impact postoperative outcomes following shoulder arthroplasty. The purpose of this study is to evaluate the impact of a history of cervical spine arthrodesis and its timing, before or after TSA, on the outcomes of total shoulder arthroplasty (TSA). Our hypothesis is that a history of cervical arthrodesis will negatively impact patient outcomes after shoulder arthroplasty METHODS: A retrospective analysis was performed on a prospectively collected cohort at a single institution. Anatomic and reverse TSA patients (aTSA, rTSA) with cervical arthrodesis (CA) were identified and compared to a cohort of patients without cervical arthrodesis (NCA) enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant type, range of motion (ROM), adverse events and clinical outcome metric scores (American Shoulder and Elbow Surgeons (ASES), Constant, Shoulder Function Score, patient satisfaction) were recorded. Outcomes between cohorts were analyzed using conventional statistics as well as stratification by MCID and SCB thresholds where applicable. RESULTS:Of the 573 TSA evaluated, 48 (20a CA-aTSA and 28 CA-rTSA) had a history of and 425 (280 NCA-aTSA and 245 NCA-rTSA) had no history of cervical arthrodesis. The CA-TSA (aTSA and rTSA) had lower Constant, ASES and Shoulder Function, PROMs postoperatively as well as less improvement in active ER and an overall lower satisfaction rating (p<0.05 for all) compared to NCA-TSA. The adverse event rate in the CA-TSA cohort was higher compared to NCA-TSA cohort (25% vs. 6.5 [rTSA; p=0.004] and 24.5% vs 11% [aTSA; p=0.068]). Optimal cutoff analysis showed that a time from CA to TSA of greater than 1.33 years had a sensitivity of 75.0% and specificity of 75.0% in predicting achievement of SCB for ASES. CONCLUSION/CONCLUSIONS:The current study demonstrates that patients with a history of cervical arthrodesis undergoing shoulder arthroplasty results in lower postoperative functional outcomes, lower patient satisfaction, and higher rates of postoperative adverse events requiring surgical revision when compared to a cohort without a history of cervical arthrodesis. Additionally, the current study demonstrates that a time interval of at least 16 months between cervical arthrodesis and shoulder arthroplasty optimizes chances of achieving SCB for ASES.

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.

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.

INTRODUCTION/BACKGROUND: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 +4mm lateralized glenosphere were compared to 102 sex, age, and glenosphere diameter matched control shoulders with standard glenospheres (whose center of rotation (CoR) is 2mm 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/CONCLUSIONS:In a medialized glenosphere/lateralized humerus design, a +4mm 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/METHODS:III; Retrospective Cohort Comparison; Treatment Study.

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.

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.