Faculty Bibliography

BACKGROUND:Preoperative planning software and intraoperative guidance technology is being increasingly used for managing complex glenoid deformity in anatomic and reverse total shoulder arthroplasty (aTSA; rTSA). The aim of this study is to review the intraoperative efficacy and complications of computer assisted navigation (CAN) surgery for treating glenoid deformity in TSA. METHODS:A retrospective review was performed of all the TSAs implanted using a single computer navigation shoulder system. All patients underwent preoperative planning using a CT based preoperative planning software. The starting point on the glenoid, and the final version and inclination of the central post (cage) of the glenoid component were reviewed on the intraoperative navigation guidance report and compared to these parameters on the preoperative plan for each patient. The intraoperative accuracy of CAN for the glenoid was determined by the deviation of the starting point and final position of the central cage drill in the glenoid compared to preoperative plan. Intraoperative complications and the number of times the navigation system was abandoned intraoperatively were collected. RESULTS:A total of 16,723 aTSAs and rTSAs performed worldwide with this navigation system were included in this review. 16,368 cases (98%) completed every step in the navigation procedure without abandoning use of the system intraoperatively. There was minimal deviation in the intraoperative execution of the preoperative plan with respect to version (0.6° ± 1.96°), inclination (0.2° ± 2.04°) and starting point on the glenoid face (1.90mm ± 1.2 mm). There were 9 coracoid fractures (0.05%) reported in this cohort. CONCLUSION/CONCLUSIONS:And Discussion: This study demonstrates the safety and efficacy of computer assisted navigation for glenoid implantation in TSA. Future studies should continue to focus on the impact of CAN on longevity and survival of the glenoid component and improve cost-effectiveness of this technology.

BACKGROUND:Anxiety and depression are the two most commonly diagnosed psychiatric disorders in the US. The effect of these disorders on total shoulder arthroplasty (TSA) outcomes must be appreciated. The purpose of this study was to examine the correlation between preoperative diagnosis of anxiety and depression and its association with postoperative outcomes after TSA. The secondary goals were to determine whether patients contemporaneously being treated with medicine for their mental health diagnosis fared better than a non-medicated cohort and to examine the degree to which PROMIS Mental Health (PROMIS-MH) scores correlate with patient outcomes. Our hypothesis is that a history of anxiety and/or depression will negatively impact patient outcomes after TSA. METHODS:A retrospective analysis was performed on a prospectively collected cohort at a single institution. Anatomic and reverse TSA patients (aTSA, rTSA) with either anxiety and/or depression (aTSApsych+, rTSApsych+) were identified and compared to a cohort of patients without a mental health diagnosis enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant type, range of motion (ROM), adverse events (AE) and clinical outcome metric scores:PROMIS-MH, American Shoulder and Elbow Surgeons (ASES), Constant, Shoulder Arthroplasty Smart Score (SAS) were recorded. Outcomes between cohorts were analyzed using conventional statistics as well as stratification by MCID and SCB thresholds where applicable. RESULTS:218 patients (114 rTSA and 95 aTSA) had a diagnosis of either anxiety and/or depression and 378 (153 rTSA and 217 aTSA) had no history. Although both cohorts achieved MCID and SCB for postoperative ASES, the psych+ cohort resulted in lower postoperative outcomes scores (p<0.05), higher AE, and significantly lower Δ differences in all variables when compared to the psych negative cohort. There were no differences in outcome scores after rTSApsych+ or aTSApsych+ between patients being treated for anxiety/depression compared to not receiving treatment. PROMIS-MH score was positively correlated with postoperative outcomes and patient satisfaction. CONCLUSION/CONCLUSIONS:The current study demonstrates that patients with anxiety and/or depression who undergo TSA have inferior postoperative outcomes and higher rates of AE compared to a cohort without a mental health diagnosis. Additionally, patients on medications for treatment of depression and/or anxiety did not gain any significant benefit in terms of their postoperative shoulder outcomes or satisfaction rate compared to those with a diagnosis but not on medication. Additionally, we found that, independent of a patient's underlying shoulder pathology or psychiatric diagnosis, lower PROMIS-MH scores was correlated with worse postoperative outcomes.

PURPOSE/OBJECTIVE:The purpose of this study was to compare the outcomes of primary rTSA utilizing glenoid bone grafting (BG rTSA) to primary rTSA utilizing augmented glenoid baseplates (Aug rTSA) with a minimum 2-year follow-up. METHODS:520 primary rTSA patients treated with 8° posterior glenoid augments (n=246), 10° superior glenoid augments (n=97), or combined 10° superior/8° posterior glenoid augments (n=177) were compared to 47 patients undergoing glenoid bone grafting for glenoid bone insufficiency. Mean follow-up of 37.0(±16) and 53.0(±27) months. Outcomes were analyzed preoperatively and at the latest follow-up using conventional statistics and stratification by minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds where applicable. Radiographs were analyzed for baseplate failure and the incidence of postoperative complications and revisions were recorded. RESULTS:The glenoid Aug rTSA cohort had greater improvements in patient reported outcome measures (PROMs) and ROM when compared to the BG rTSA group at a minimum of 2-year follow-up including: simple shoulder test (SST), Constant Score, American Shoulder and Elbow Surgeons (ASES)score, University of California Los Angeles (UCLA)score, Shoulder Pain and Disability Index (SPADI)score, Shoulder Function, Shoulder Arthroplasty Smart (SAS)score, abduction, and external rotation(p<0.05). Patient satisfaction was higher in Aug rTSA group compared to BG rTSA group(p=0.006). The utilization of an augmented glenoid component instead of glenoid bone grafting resulted in approximately 50% less total intraoperative time (p<0.001), nearly 33% less intraoperative blood loss volume (p<0.001), approximately threefold less scapular notching (p<0.01) and approximately fifteenfold less adverse events requiring revision (p<0.01) when compared to BG rTSA cohort. Aside from SCB for abduction, the Aug rTSA cohort achieved higher rates of exceeding MCID and SCB for every PROM compared to BG rTSA. More specifically, 77.6% and 70.2% of the Aug rTSA achieved SCB for ASES and SPADI versus 55% and 48.6% in the BG rTSA, respectively(p=0.003 and p=0.013). CONCLUSION/CONCLUSIONS:The present midterm clinical and radiographic study demonstrates that the utilization of an augmented base plate for insufficient glenoid bone stock is superior as judged by multiple PROMs and ROM metrics when compared to bone graft augmentation at minimum 2-year follow-up. Additionally, when analyzed according to MCID and SCB thresholds, the use of augmented baseplates outperforms the use of glenoid bone grafting. Complication and revision rates also favor the use of augmented glenoid baseplates over glenoid bone grafting. Long-term clinical and radiographic follow-up is necessary to confirm that these promising mid-term results are durable.

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.

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.

Background: The purpose of this study was to identify prognostic factors that are associated with improvements in patient-reported outcomes measures (PROMs) related to upper extremity function and pain in those suffering from idiopathic adhesive capsulitis. Methods: All patients treated conservatively for primary idiopathic adhesive capsulitis were identified from our institutional database between 2019 and 2021. Exclusion criteria included any patients treated surgically, follow-up less than one year, or incomplete survey results. PROMs including Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test Version 2.0 (P-UE), Pain Interference (P-Interference), Pain Intensity (P-Intensity), and visual analog scale (VAS) pain scores. They were obtained at initial consultation and at one year to assess patient-perceived impact of their condition. Multiple linear and multivariable logistic regressions were performed to identify factors associated with improvement in patient-perceived pain and shoulder function using final PROM scores and difference in PROM scores from initial consultation. An independent t-test was used to compare baseline and one-year minimum follow-up PROMs. Odds ratios and their 95% confidence intervals were calculated for each factor; a P value of < .05 was considered statistically significant. Results: A total of 56 patients (40 females and 16 males) were enrolled in the study with an average age of 54.7 ± 7.7 years. A significant improvement (P < .001) was demonstrated at one-year minimum outcomes for P-UE, P-Interference, P-Intensity, and VAS scores. With respect to comorbid conditions, hypothyroidism [P-UE (β: 9.57, P = .006)] was associated with greater improvements in PROMs, while hyperlipidemia [P-UE (β: −4.13, P = .01) and P-Intensity (β: 2.40, P = .02)] and anxiety [P-UE (β: −4.13, P = .03)] were associated with poorer reported changes in PROMs. Female sex [P-UE (β: 4.03, P = .007) and P-Interference (β: −2.65, P = .04)] and employment in manual labor professions [P-Interference (β: −3.07, P = .01), P-Intensity (β: −2.92, P = .006), and VAS (β: −0.66, P = .03)] were associated with significantly better patient-perceived outcomes. Hispanic heritage was associated with higher reported changes of P-Intensity (β: 8.45, P = .004) and VAS (β: 2.65, P = .002). Conclusion: Patient-perceived improvements in PROMIS score during the natural history of adhesive capsulitis are likely multifactorial, with anxiety, hyperlipidemia, increased body mass index, and Hispanic heritage associated with reduced improvement in PROMIS scores.

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.

INTRODUCTION/BACKGROUND:The purpose of this study is to calculate the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) 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 treated nonoperatively for idiopathic adhesive capsulitis (IAC). METHODS:The anchor-based MCID, SCB, and PASS were calculated as the change in PROMIS scores representing the optimal cutoff for a ROC curve with an area under the curve (AUC) analysis. The distribution-based MCID was calculated as a range between the average standard error of measurement multiplied by two different constants: 1 and 2.77. Effect sizes and standardized response means (SRM) were calculated to assess the responsiveness of each PROMIS instrument while regression analyses were performed to identify factors associated with achieving these thresholds. RESULTS:This study enrolled 115 patients. The anchor-based MCID for PROMIS UE, P-Interference, and P-Intensity was 5.11, 4.16, and 8.16, respectively. The respective SCB was 8.44, 6.65, and 10.05. The respective PASS was 8.47, 7.01, and 10.41. The odds of achieving MCID values in adhesive capsulitis were negatively affected by gender (male), higher forward elevation at the time of presentation, higher pain scores (P-Interference), need for ≥ 2 corticosteroid injections, and a concomitant diagnosis of diabetes. CONCLUSION/CONCLUSIONS:The MCID, SCB, and PASS parameters for PROMIS scores can be utilized to determine the clinical meaningfulness of patient-reported improvements in these instruments during the nonoperative treatment and as a research tool to compare the efficacy of new treatments for adhesive capsulitis. LEVEL OF EVIDENCE/METHODS:Level III, basic science study, validation of outcome instruments. Key points • This is the first study to calculate the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for the Patient-Reported Outcome Measurement Information System (PROMIS) Upper Extremity and Pain instruments in patients with idiopathic adhesive capsulitis (IAC) of the shoulder.• This study determined the impact of symptom severity, demographics, and comorbidities on achieving the MCID, SCB, and PASS for PROMIS instruments in IAC patients treated nonoperatively.

BACKGROUND:The Shoulder Arthroplasty Smart (SAS) score is a new, validated machine learning-derived outcome measure that requires six input parameters. The SAS score has the potential to replace legacy shoulder outcome scores. METHODS:We conducted a retrospective review of a multinational shoulder arthroplasty database of one platform shoulder prosthesis (used interchangeably for anatomic and reverse total shoulder arthroplasty). All primary shoulder arthroplasties with a minimum of two-year follow-up and an available SAS score were evaluated. Associations between scoring systems were assessed using Pearson correlations, with 95% confidence intervals stratified by time point (preoperatively and postoperatively at 2- and 5-year follow-ups, respectively) and procedure (anatomic verses reverse total shoulder arthroplasty). Conversion equations were developed using the best-fit line from linear regression analysis. Ceiling effects were assessed based on two definitions: (1) >15% of participants scoring the maximal possible score and (2) a standardized distance less than 1.0, whereby the standardized distance is calculated by subtracting the mean from the maximal score and dividing by the standard deviation. RESULTS:Two thousand four hundred six shoulders were evaluated at 4,553 clinical encounters. For preoperatively collected data, the SAS score correlated strongly with the Constant (R = 0.83), University of California at Los Angeles (R = 0.85), and Shoulder Pain and Disability Index (R = -0.70) scores and moderately with the American Shoulder and Elbow Surgeons (R = 0.69) and Simple Shoulder Test (R = 0.65) scores. The SAS score strongly correlated (R > 0.7) with all legacy outcome scores collected at 2- and 5-year postoperative visits. Score predictions made using the conversion equations between the SAS score and legacy outcome scores strongly correlated with their actual values. Neither the SAS nor the Constant score were influenced by ceiling effects. All other outcome scores evaluated demonstrated ceiling effects. CONCLUSION/CONCLUSIONS:The SAS score correlates well with legacy shoulder scores after primary shoulder arthroplasty while mitigating ceiling effects. Surgeons may decrease patient questionnaire burden by using the brief six-question SAS score.