Faculty Bibliography

BACKGROUND:The goal of this longitudinal analysis of aTSA and rTSA utilization from 2007-2021 is to quantify changes in clinical outcomes, cost, and value, resulting from the introduction and adoption of new shoulder arthroplasty technologies. METHODS:We analyzed an international database of a single shoulder arthroplasty prosthesis (Equinoxe; Exactech, Inc; Gainesville, FL, USA) for all clinical sites that have continuously enrolled cases from 2007 to 2021 to compare changes in primary aTSA and primary rTSA utilization and outcomes across three, 5-year cohorts based upon the date of implantation. A value analysis was conducted across the 5-year implantation cohorts, with value measured by the ratio of each postoperative outcome measure at 24-36 months and 36-60 months after surgery and the average implant selling price each year for the US sites in constant 2007 US dollars, these measures of value were compared between cohorts to quantify the impact of new technology introduced over the study period. RESULTS:A dramatic increase in rTSA utilization was observed across the 6 sites over the 15-year study period, along with a rapid adoption of new aTSA and rTSA technologies. The average patient receiving primary aTSA and primary rTSA changed over the 15-year study period, with significant shifts in diagnosis, comorbidities, and preoperative functional status. A comparison of postoperative results demonstrated that both aTSA and rTSA clinical and radiographic outcomes showed improvement relative to 2007-2011. Over this 15-year study period, the average aTSA implant selling price has been relatively stable while the average rTSA implant selling price has significantly declined. As a result, the value associated with the Equinoxe rTSA significantly increased for nearly every outcome measure at 24-36 months and 36-60 months after surgery, while value associated with the Equinoxe aTSA stayed relatively constant from 2007-2021. CONCLUSION/CONCLUSIONS:Our 6,042-patient longitudinal analysis quantified numerous changes in utilization, outcomes, and value across 6 clinical sites over the past 15-years. Rapid adoption of new aTSA and rTSA technologies was observed and clinical and radiographic outcomes improved relative to 2007-2011. These clinical improvements, in combination with steady aTSA and declining rTSA implant prices, have driven rTSA value to continuously increase while aTSA value has been maintained at a high-level over the 15-year study period with this particular shoulder arthroplasty system, even when considering the cost and adoption of new technologies.

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.

INTRODUCTION/BACKGROUND:Early reverse total shoulder arthroplasty (rTSA) designs had high failure rates, mainly from loosening of the glenoid baseplate. The purpose of this study is to determine the incidence of aseptic glenoid baseplate loosening after primary rTSA using a contemporary medialized glenoid/lateralized humeral system and identify significant risk factors associated with loosening. METHODS:7,162 primary rTSA were treated with a single platform rTSA system between April 2007 and August 2021, from which 3,127 primary rTSA patients with a minimum 2-year follow-up were identified. Patients with aseptic glenoid baseplate loosening were compared to all other primary rTSA without loosening. Univariate and multivariate analyses were performed to compare these cohorts and identify the demographic, comorbidities, operative, and implants associated aseptic glenoid loosening after rTSA. Odds ratios were calculated for each significant risk factor and for multiple combinations of risk factors. RESULTS:Irrespective of minimum follow-up, fifty-three (31F/22M) of 7,162 primary rTSA shoulders experienced aseptic glenoid loosening, for an overall rate of 0.74%. At latest 2-year minimum follow-up, thirty of 3,127 patients experienced aseptic glenoid loosening and had significantly lower clinical scores, function, active ROM, and higher pain scores as compared to patients without loosening. Univariate analysis identified that patients with rheumatoid arthritis (RA, p=0.029, OR = 2.74) and diabetes (p=0.028, OR=1.84) and multivariate analysis identified Walch glenoid types B2 (p=0.002, OR= 4.513) and B3 (p=0.002, OR=14.804), use of expanded lateralized glenospheres (p=0.025, OR=2.57) and use of augmented baseplates (p=0.001, OR=2.50) as significant risk factors for aseptic glenoid loosening after rTSA. CONCLUSION/CONCLUSIONS:The incidence of aseptic glenoid baseplate loosening was 0.74% for this medialized glenoid/lateralized humeral rTSA system. Numerous risk factors for aseptic loosening were identified, including: RA, diabetes, Walch B2 and B3 glenoids, posterior/superior augmented baseplates, and expanded lateralized glenospheres. Finally, analysis of multiple combinations of risk factors identified patients and implant configurations with the greatest risk of aseptic glenoid loosening.

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.

PURPOSE/OBJECTIVE:To calculate and determine what factors are associated with achieving the Minimal Clinically Important Difference (MCID) and the Substantial Clinical Benefit (SCB) of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Testing v2.0 (UE), Pain Interference (P-Interference), and Pain Intensity (P-Intensity) in patients undergoing arthroscopic rotator cuff repair (aRCR). METHODS:The change in PROMIS scores representing the optimal cutoff for a ROC curve with an area under the curve analysis was used to calculate the anchor-based MCID and SCB. To assess the responsiveness of each PROM, effect sizes and standardized response means (SRM) were calculated. To identify factors associated with attaining the MCID and SCB, univariate and multivariate logistic regression analyses were performed. RESULTS:A total of 323 patients with an average age of 59.9 ± 9.5 were enrolled in this study, of which, 187/323 [57.9%] were male and 136/323 [42.1%] were female. The anchor-based MCID for PROMIS UE, P-Interference, and P-Intensity was: 9.0, 7.5, and 11.2, respectively. The respective SCB was 10.9, 9.3, and 12.7. Effect size and SRM were: PROMIS UE (1.4, 1.3), P-Interference (1.8, 1.5), and P-Intensity (2.3, 2.0). Lower preoperative P-Intensity scores (p = 0.02), dominant arm involvement (p = 0.03), and concomitant biceps tenodesis (p = 0.03) were associated with patients achieving the SCB for PROMIS UE. CONCLUSION/CONCLUSIONS:A large responsiveness for each of the PROMIS instruments due to the majority of patients reporting great improvement after aRCR and a small standard deviation across all outcome measures was shown in our study. Lower preoperative P-Intensity scores and concomitant biceps tenodesis were associated with higher odds of achieving the SCB for PROMIS UE. The knowledge of MCID and SCB values for PROMIS instruments will allow the surgeon to determine whether the improvements in the PROMIS scores after aRCR are clinically meaningful. LEVEL OF EVIDENCE/METHODS:Level III.

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:The purpose of this study was to implement a modified Delphi technique among a group of experts affiliated with American Shoulder and Elbow Surgeons (ASES) and European Society for Surgery of the Shoulder and Elbow (SECEC) to determine areas of consensus regarding what factors influence their decision to manage a patient surgically and what specific treatment modalities they utilize for patients ≤ 50 years of age with glenohumeral arthritis (GHA). METHODS:The panel of experts comprised 168 shoulder and elbow specialists, 138 ASES and 30 SECEC members. In the first round, an open-ended questionnaire was utilized to solicit features that are important in making decisions regarding treatment. The second round involved ranking the features identified in the first round as to their importance in helping decision making for surgery. The results of round two were then utilized and 18 complex surgical cases previously treated by one of the lead authors were provided for the study. One additional case was included to address the management of Cutibacterium acne (C.Acne) infection. RESULTS:159 (95.0%) participants completed the round one survey, 142 (89%) responded to the second and third round survey. In total 50 individual factors were positively associated with the decision to proceed with surgery. Ten of these were strongly supportive of surgery. Eight out of 18 clinical cases demonstrated >80% agreement on the surgical treatment modality chosen. Over 90% of respondents chose rTSA to manage pathology when an incompetent rotator cuff was present. Over 90% of respondents managed AVN with hemiarthroplasty (HA). Over 70% of respondents chose aTSA for inflammatory arthritis with low demand on their shoulder. 79% of respondents chose a stemless humeral component when a HA or aTSA was chosen in response to the proposed surgical cases. If arthroscopy was chosen there was good agreement on five core procedures. There was only fair consensus on the approach to C.acnes in patients with GH OA≤ 50 years of age. CONCLUSION/CONCLUSIONS:The optimal treatment of glenohumeral arthritis in patients ≤ 50 years of age remains controversial, and there are many treatment options to consider when responding to the variety of clinical presentations and anatomic pathologies. While physicians and patients engage in the shared decision-making process regarding the final choice for management, this consensus statement serves as a basis for discussion amongst colleagues and between patients and surgeons though it clearly demonstrates that the topic must be further investigated prospectively and with large cohorts.

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.

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.