BACKGROUND:Multiple grafts have been described for glenoid resurfacing in the setting of anterior shoulder instability with glenoid bone loss. The medial tibial plateau has been shown to have a similar radius of curvature to the glenoid and may be an appropriate anatomic match for glenoid resurfacing. PURPOSE:To evaluate restoration of glenoid concavity and anterior glenohumeral stability among the distal tibial allograft (DTA), distal clavicle autograft (DCA), and medial tibial plateau allograft (MTPA). STUDY DESIGN:Controlled laboratory study. METHODS:Nine sets of fresh-frozen unpaired shoulder, knee, and ankle cadaveric specimens were obtained (mean specimen age, 58.7 years; range, 51-63). Specimens underwent preoperative computed tomography to assess glenoid depth and radius to define the bony shoulder stability ratio (BSSR; glenoid depth over radius). A Kuka robot was used to assess shoulder stability with forces loaded through the rotator cuff and the shoulder in 90° of abduction and neutral rotation. Glenoid bone loss was created via a 10-mm cut, with each graft restoring 100% of the native glenoid width. The following conditions were tested: intact state followed by reconstructions with the DTA, MTPA, and DCA. Posttest computed tomography scans were obtained to calculate the reconstructed BSSR, and motion detectors were used to calculate maximum anterior humeral translation. RESULTS:The BSSR was similar between the intact state (mean ± SD, 0.39 ± 0.11) and 3 reconstructed glenoid grafts (DCA, 0.46 ± 0.11 [P = .10]; MTPA, 0.43 ± 0.07 [P = .45]; DTA, 0.39 ± 0.11 [P = .21]). Maximum anterior translation did not differ between the 3 grafts (DCA, 6.4 ± 3.0 mm [P = .29]; MTPA, 8.4 ± 5.3 mm [P = .11]; DTA, 6.7 ± 3.6 mm [P = .21]) and the intact state (6.0 ± 2.8). CONCLUSION:By way of a cadaveric analysis, the DCA, MTPA, and DTA restored glenoid concavity to a point similar to the intact state. Future investigations with larger sample sizes are warranted to confirm these biomechanical trends and determine clinical significance. CLINICAL RELEVANCE:Restoration of glenoid concavity is essential for achieving stability in patients with anterior shoulder instability and critical glenoid bone loss. This biomechanical study demonstrates that distal clavicle autograft, distal tibia allograft, and medial tibial plateau allograft each restore native glenoid concavity comparable to the intact state, supporting their use as reliable free bone block options for anatomic glenoid reconstruction. Future clinical studies are warranted to determine whether these biomechanical findings translate to improved clinical outcomes.

Background Walch B-type glenoids have been associated with decreased implant survival in anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA). The literature suggests that posteriorly-based eccentric glenoid wear driven by posterior humeral head subluxation may occur in conjunction with rotator cuff muscular imbalances around the shoulder. This study aims to identify existing rotator cuff and deltoid muscular imbalances in patients undergoing aTSA and rTSA and their association with different Walch-types of glenoid wear. Methods Patients with primary glenohumeral osteoarthritis (OA) or rotator cuff arthropathy who underwent preoperative computed tomography (CT) scans of the affected shoulder from 8/1/2020 to 12/31/2021 were included. Patients were included if they were over 18 years old with Walch-type A or B glenoids as identified on CT within a year of surgery and had at least two years of follow-up. Fatty infiltration was assessed using Goutallier grading, and muscle volumes were quantified using previously established methodologies. Ratios of anterior to posterior muscle volumes were established for the rotator cuff (‘RCR’), deltoid (‘DMR’), and the rotator cuff and deltoid combined (‘CMR’). Glenoid retroversion, inclination, and humeral head subluxation were recorded. Muscle volume ratios were compared between glenoid types using univariate and multivariable regression and Welch’s t-test. Results The included final cohort of 146 patients had a mean age of 64.3 (±10.6) years and mean BMI of 27.7 (±5.7) kg/m2. Glenoid retroversion was greatest in type B2 glenoids (p<0.0001). DMR (p=0.0176) and CMR (p=0.0066) were lower in B2 compared to A1 glenoids, suggesting greater posterior muscle volume in B2 glenoids. RCR was lower in B2 compared to A2 glenoids (p=0.0003); however, DMR (p=0.3809) and CMR (p=0.0569) were not significantly different between these two groups. CMR (p=0.0086), and RCR (p=0.0097) were significantly lower in B2 compared to A1 and A2 glenoids combined, further suggesting greater posterior muscle volume in B2 glenoids. Goutallier scores were not significantly different across the various glenoid types. Conclusion Patients with type B2 glenoids exhibited a higher ratio of posterior to anterior shoulder muscle volumes when accounting for both the rotator cuff and deltoid. Fatty infiltration of the rotator cuff, however, was not associated with a specific wear pattern. This study substantiates existing evidence to suggest that increased posterior muscle volume may play a role in the pathogenesis of posteriorly-based eccentric glenoid wear, warranting further longitudinal studies to confirm these findings.

Background: Cervical spine pathology may influence outcomes following total shoulder arthroplasty (TSA) through its biomechanical and neurologic effects on shoulder motion and function. This study compared post-operative clinical outcomes after TSA in patients with a history of cervical spine fusion vs. a matched cohort without cervical pathology. Methods: Patients who underwent anatomic or reverse TSA between 2016 and 2021 at a tertiary care institution were retrospectively reviewed. Nineteen patients with prior cervical spine fusion and complete pre-operative and post-operative patient-reported outcome measures were identified and matched 1:1 to controls without cervical pathology based on age, sex, laterality, diagnosis, and implant type. The American Shoulder and Elbow Surgeons (ASES) and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function 10-item (PROMIS-PF 10) scores were analyzed. The Minimal Clinically Important Difference (MCID) for ASES improvement was defined as ≥ 12 points. Results: Both groups demonstrated significant ASES improvement (P < .0001). ASES improved from 40.4 ± 20.6 to 66.3 ± 23.4 in the cervical fusion group and from 37.1 ± 22.5 to 85.2 ± 19.1 in controls (P < .0001 between groups). PROMIS-PF 10 improved slightly in the cervical fusion group (44.9 ± 7.1 to 48.5 ± 6.3) but remained stable in controls (54.1 ± 8.9 to 52.7 ± 7.5; P = .13). MCID achievement was comparable (68.4% vs. 89.5%, P = .23). Among fusion patients, single-level fusions had higher post-operative ASES and PROMIS-PF 10 scores than multilevel fusions, though MCID rates were similar. Conclusion: Patients with a history of prior cervical spine fusion experience reduced clinical improvements following TSA at early follow-up compared to a matched cohort of patients without history of cervical spine pathology. Further studies are needed to assess whether this impairment is proportional or commensurate with the number of levels fused or their location within the cervical spine.

Background Reverse total shoulder arthroplasty (rTSA) utilization in the United States has steadily increased, alongside expanding indications. The utility of rTSA in younger patient populations, however, is unclear. The purpose of this study was to evaluate patient reported outcome measures (PROMs) and complication rates in patients ≤ 55 years of age with a minimum 2-year follow up. Methods A single-institution retrospective review was conducted on consecutive patients aged ≤ 55 years treated with primary rTSA between February 1st, 2016, and July 1st, 2022 who had completed baseline ASES score, and follow up ASES score. Patient demographics, surgical indications, PROMs (including ASES and SANE scores), patient satisfaction, and complications were collected. Sub-analyses were also conducted specifically in patients aged ≤ 50 with minimum 1-year and 2-year follow-up. Statistical comparisons were made using paired t-tests and Fisher’s exact test. Results There were 108 patients, 6 bilateral, who underwent a rTSA during our study timeframe and were 55 or younger at the date of surgery. After excluding revision cases, missing ASES score at baseline, and patients with less than 1 year follow up, our study cohort included 81 patients, with 3 bilateral. Among patients ≤ 55 years of age with minimum 2-year follow up (n=46), mean ASES scores significantly improved from 29.9 ± 16.0 to 69.8 ± 28.9 (p < 0.001), and SANE improved from 18.3 ± 20.3 to 75.1 ± 21.2 (p < 0.001). Patient satisfaction was high. Similar improvements were observed among patients ≤ 50 years of age with minimum 2-year follow up (n = 15). Patients aged ≤ 55 had a total rate of complication rate of 19.6%, a revision rate of 13.0% and had 87% implant survival. Similar functional improvements, complication rate and revision rate were observed in the patients aged ≤ 50 cohort. Conclusions RTSA in patients ≤ 55 years results in significant improvements in function, pain relief and satisfaction at short- to mid-term follow up. Future investigations in larger cohorts are warranted to further elucidate the influence of preoperative diagnosis on outcomes, and to assess the long-term survivorship, rate of complication, and efficacy of rTSA in this younger patient population.

Background:Comparative studies of reverse total shoulder arthroplasty (rTSA) for proximal humerus fractures (PHFs) versus rotator cuff arthropathy (RCA) have yielded conflicting findings and lack comprehensive synthesis to guide perioperative counseling. This study aimed to systematically compare clinical and functional outcomes between patients undergoing rTSA for PHFs and RCA. Methods:A PROSPERO-pre-registered systematic review and meta-analysis queried PubMed, CINAHL, MEDLINE, and Web of Science on July 25, 2025, for studies comparing PHF- versus RCA-indicated rTSA. Study quality was assessed using the Methodological Index for Non-Randomized Studies scale. Extracted variables included patient demographics, survey scores, range of motion, and revisions. Patient-reported outcome measures and functional outcomes were compared between patients undergoing rTSA for PHFs and RCA. Results:Eleven observational studies encompassing 6,698 patients (1,832 PHF; 4,866 RCA) met criteria; overall evidence quality was moderate. Compared with RCA, PHF patients had lower American Shoulder and Elbow Surgeons scores (mean difference -5 points; P = .045) and reduced forward flexion (-14°; P < .001) and abduction (-17°; P < .001). Pain scores were similar (visual analog scale; P = .62). Overall revision risk did not differ, but PHF patients had a higher revision risk from dislocation (risk ratio 1.59; P = .04). Implant survivorship appeared similar across groups. Conclusion:RTSA for PHF yields slightly lower shoulder function, range of motion, and a higher dislocation-related revision risk compared with RCA; though, absolute differences were modest. These findings support nuanced preoperative counseling, highlighting opportunities to optimize PHF-specific surgical strategies.

Background Humeral implant fixation techniques for reverse total shoulder arthroplasty (rTSA) have primarily consisted of press-fit or cemented approaches. Humeral implant fixation is critical for durable rTSA outcomes, and inadequate fixation such as early subsidence or loosening, can compromise these outcomes and complicate potential revision. Limited data exist on outcomes associated with hybrid humeral stem fixation which utilizes cement distally and press-fit proximally, which may help achieve good initial fixation while allowing for bone ingrowth in patients with poor bone quality. Methods A retrospective cohort study was conducted using data from the an institutional shoulder arthroplasty clinical registry. The study included 11 patients who underwent primary rTSA with hybrid humeral stem fixation between February 1, 2016, and July 31, 2022. Data collected included patient demographics, operative details, and clinical outcomes. Patient-reported outcome measures (PROMs)—including ASES, SANE, VAS—and range of motion (ROM) were assessed preoperatively and at final follow-up. Descriptive statistics were used for analysis. Results A total of 11 patients underwent rTSA with hybrid humeral stem fixation. Average time to final PROMs was 38.7 ± 17.1 months (14.8 - 50.1 months) and the average time to final in-person follow up/radiographic imaging was 21.1 ± 11.9 months (3.8 - 38.7 months). The mean age of the cohort was 72.55 ± 4.96 years, and mean BMI was 28.73 ± 7.22. Primary diagnoses included cuff tear arthropathy (45.5%), osteoarthritis (45.5%), and avascular necrosis (9.1%). Intraoperative rotator cuff status was reported as torn (63.6%), intact (27.3%), and attenuated (9.1%) and all patients underwent biceps tenodesis. The mean ASES score improved from 46.32 ± 15.60 to 91.91 ± 9.31 (p < 0.0001). Forward elevation increased from 86.36° ± 28.05° to 142.27° ± 20.15° (p < 0.0001), and external rotation improved from 27.73° ± 15.13° to 55° ± 11.08° (p < 0.0005. VAS pain scores decreased from 6.82 ± 1.59 to 0.18 ± 0.39 (p < 0.0001). SANE scores (available for 72.7% of patients) improved from 20.63 ± 18.87 to 77.25 ± 30.86 (p < 0.0001). Conclusion Reverse total shoulder arthroplasty with hybrid humeral stem fixation resulted in significant improvements in pain relief, range of motion, and functional outcomes, with low rates of early radiographic concern at short-term follow-up. The findings support hybrid fixation as a promising alternative to fully cemented or press-fit techniques, warranting larger comparative studies with mid-term radiographic follow-up to define durability and ideal indications. Level of Evidence Level IV; Retrospective Case Series

BACKGROUND:Primary total shoulder arthroplasty (TSA) utilization has grown substantially in recent years. As procedure volume increases, understanding how operative volume is distributed across the surgeon workforce has become important, as concentration of cases among a limited number of high-volume surgeons vs. broader decentralization has implications for training exposure, care accessibility, and long-term workforce capacity. However, trends in surgeon-level case volume distribution for TSA over time remain unclear. METHODS:A retrospective longitudinal analysis of primary TSA procedures performed in the United States from 2013 to 2023 was conducted using the Centers for Medicare and Medicaid Services "Medicare Physician & Other Practitioners" dataset. Surgeons were included for any year in which they submitted ≥ 11 primary TSA claims. Case volume concentration was measured annually using the Herfindahl-Hirschman Index (HHI), applied at the surgeon level. State-level variation was assessed by calculating HHI separately for each state. Entrant surgeons were defined as those listed in the Centers for Medicare and Medicaid Services database without having been listed in either of the 2 preceding years. Linear regression was used to evaluate temporal trends. RESULTS:National primary TSA volume increased from 32,208 procedures in 2013 to 93,167 in 2023. Surgeon-level case concentration decreased significantly, with HHI declining from 10.97 to 4.52 (β = -0.55 per year, P < .001). The number of surgeons performing TSA increased from 1,351 to 3,439. State-level analysis demonstrated widespread decentralization, with a mean ΔHHI of -955.9 from 2013 to 2023. The number of entrant surgeons increased from 463 to 792 (β = +36 per year, P = .004), while entrant surgeons' volume share declined from 30.4% to 23.0% (β = -0.008 per year, P = .050). CONCLUSIONS:Surgeon-level case volume concentration in TSA decreased substantially from 2013 to 2023, reflecting broader distribution of operative volume across a growing workforce. However, reductions in entrant surgeon case share suggest that increased TSA adoption may be primarily absorbed by existing surgeons rather than new entrants.

Objectives: To compare return to sport (RTS), time to RTS, satisfaction, and American Shoulder and Elbow Surgeons (ASES) outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) in patients aged 65 years or younger. Methods: Retrospective matched cohort (Level III) using a prospectively maintained institutional registry of primary glenohumeral osteoarthritis (2016-2021). rTSA patients were matched 1:2 to aTSA by age, sex, body mass index, and Charlson Comorbidity Index. Pre- and postoperative sport participation, timing and level of RTS, reasons for non-return, and satisfaction were collected with a standardized survey; ASES scores were obtained from the registry. Exclusions included rotator cuff tear arthropathy and revision procedures. Group comparisons used t-tests and chi-square analyses. Results: A total of 150 patients were included after matching (100 aTSA, 50 rTSA) with no significant baseline differences (Table 1). Golf was the most frequently reported sport at 41.0% for aTSA and 42.9% for rTSA. RTS at any level occurred in 76.9% of aTSA and 85.7% of rTSA patients (p=0.42), while RTS at the same or higher level occurred in 46.2% for aTSA vs 57.1% for rTSA (p=0.42). Median time to RTS was 176 days for aTSA and 154 days for rTSA (p=0.57). Satisfaction was high and similar (91.0% for aTSA vs 86.0% for rTSA, p=0.35). Preoperative ASES scores did not differ (41.0±19.1 for aTSA vs 37.2±18.5 for rTSA, p=0.25), and mean improvement at final follow-up was comparable (45.2±21.7 for aTSA vs 41.9±25.6 for rTSA, p=0.50) (Table 2). Conclusions: In active patients <=65 years with primary glenohumeral osteoarthritis, rTSA and aTSA yielded comparable RTS rates, time to return, satisfaction, and functional improvement. These findings support rTSA as a viable option for select younger patients when appropriately indicated; prospective sport-specific studies with longer follow-up are warranted.

BACKGROUND:Compared with the traditional Grammont design, modern reverse total shoulder arthroplasty (rTSA) implant designs often introduce lateralization of the glenoid and/or humeral components. This study aimed to evaluate the impact of different strategies for achieving lateralization (ie, humeral or glenoid lateralization) in rTSA implant design on rotator cuff biomechanics. METHODS:Computed tomography scans from 16 nonosteoarthritic subjects were used to build customized computational 3-dimensional shoulder models based on the Newcastle Shoulder Model. Four rTSA implant constructs were created: (1) medialized glenoid-medialized humerus (MG-MH); (2) medialized glenoid-lateralized humerus (MG-LH); (3) lateralized glenoid-medialized humerus (LG-MH); and (4) lateralized glenoid-lateralized humerus (LG-LH). All constructs used a humeral stem with 135° neck-shaft angle where the diameter of the glenosphere was 36mm. Simulated rTSA constructs included a subscapularis tendon repaired to its native attachment on the lesser tuberosity. For each design construct, moment arms for both the subscapularis and infraspinatus were calculated for 4 motions: humeral elevation in frontal and scapular plane, internal/external rotation at 20° and 90° of abduction. Moment arms for each construct were also compared to those in a native shoulder. RESULTS:All rTSA constructs influenced the moment arms of the rotator cuff muscles. During humeral elevation, both the subscapularis and infraspinatus exhibited increased adductive moment arms compared to the native shoulder, particularly at lower angles of elevation (0-80° in abduction and 0-50° in the scapular plane). Glenoid lateralization did not significantly affect these changes; however, humeral lateralization enhanced the adductive moment arms of both muscles. Additionally, all rTSA constructs altered the internal and external rotation moment arms of the RC muscles relative to the native shoulder. The subscapularis showed increased internal rotation moment arms that got larger than the native shoulder only after 40° of internal rotation, while the infraspinatus demonstrated increased external rotation moment arms during all external rotation range of motion. Again, glenoid lateralization did not significantly impact these rotational moment arms, whereas humeral lateralization led to an increase in both internal (subscapularis) and external (infraspinatus) rotation moment arms. CONCLUSIONS:While glenoid lateralization of an rTSA implant construct does not substantially alter rotator cuff moment arms, humeral lateralization may have a dual effect: potentially introducing an antagonistic adductive moment relative to the deltoid during early abduction, while also augmenting beneficial rotational moment arms-namely, increased internal rotation from the subscapularis and increased external rotation from the infraspinatus.

Modern reverse total shoulder arthroplasty (rTSA) designs allow for lateralization of glenoid and humeral components. Prior studies have assessed lateralization biomechanics by evaluating moment arms and muscle forces. However, torque, the product of muscle force and moment arm, is the most direct measure of a muscle's ability to generate joint rotation and a more comprehensive metric to assess rTSA lateralization. Our aim was to evaluate how different lateralization strategies affect the glenohumeral joint torque generated by the rotator cuff and deltoid muscles. To achieve this, we created 16 subject-specific biomechanical shoulder models using computed tomography scans. Four implant configurations were virtually implanted into each subject: medialized glenoid - medialized humerus (MG/MH), medialized glenoid - lateralized humerus (MG/LH), lateralized glenoid - medialized humerus (LG/MH), lateralized glenoid - lateralized humerus (LG/LH). For each design, we evaluated the maximum torque generated by the middle deltoid during scapular plane elevation, alongside the maximum torque generated by the infraspinatus and subscapularis during external and internal rotation at 90° of abduction. The MG/LH configuration generated the greatest middle deltoid torque during early arm elevation, despite having an equivalent moment arm to the MG/MH. Infraspinatus and subscapularis torque were enhanced by progressive lateralization resulting in the MG/MH demonstrating the least torque generating capacity and the LG/LH configuration the greatest, but at the expense of excessive middle deltoid strain, which may increase acromial stress fracture risk. Our findings suggest that joint torque provides a more comprehensive assessment of rTSA lateralization than moment arms or muscle force production alone.

Background:Total shoulder arthroplasty (TSA) is an effective treatment for glenohumeral osteoarthritis (GHOA), with utilization increasing over time. While prior studies have examined racial and ethnic disparities, the impact of broader social determinants of health (SDOH) on TSA utilization and outcomes remains unclear. Methods:The TriNetX database was used to identify patients with GHOA and stratify them by SDOH disparities. Patients were matched 1:1 using propensity scores. The primary outcome was TSA utilization within 5 years. Secondary outcomes included 90-day and 1-year postoperative complications. Bonferroni correction was applied. Results:After matching, 84,767 patients were included per utilization cohort. TSA utilization was higher in patients without SDOH disparities (5.78% vs. 3.14%, p < 0.001). The complications cohorts included 2071 patients each. The SDOH cohort had higher rates of emergency department visits and cardiac events at 90 days and 1 year (p < 0.001). At 1 year, acute kidney injury, urinary tract infection, pneumonia (p < 0.001), and pulmonary embolism (p = 0.002) were also higher. Mechanical complications were higher at 1 year on unadjusted analysis only. Revision, periprosthetic joint infection, and fracture rates were similar. Conclusions:SDOH disparities are associated with lower TSA utilization and increased postoperative medical complications, suggesting disparities in access to care and healthcare utilization rather than surgical durability. Level of evidence:Level III.

Objective: To evaluate whether hand dominance influences return to sport (RTS) after anatomic total shoulder arthroplasty (aTSA) in patients aged 65 years or younger. Methods: Retrospective cohort study of patients <=65 years who underwent primary aTSA for glenohumeral osteoarthritis between 2016 and 2021 in a prospectively maintained institutional registry. Patients were contacted to assess hand dominance, pre- and postoperative sport participation, timing and level of RTS, and satisfaction. Patients with ambidextrous dominance or bilateral surgery were excluded. Participants who played sports preoperatively were grouped by dominant- versus nondominant-sided surgery. Univariate comparisons and sensitivity multivariable logistic regressions were performed; American Shoulder and Elbow Surgeons (ASES) score changes were compared. Results: Of 279 eligible patients, 165 (59.1%) reported preoperative sport participation (dominant-sided aTSA n=95, nondominant n=70) with no baseline differences between groups (all p>0.15, Table 1). Golf (26.1%) was the most commonly reported sport and racquet sports (17.0%) were the second most frequently reported (Table 2). Successful RTS at any level was more common after nondominant-sided aTSA versus dominant-sided aTSA (85.7% vs 69.5%, p=0.015). RTS at the same or higher level was also more frequent after nondominant-sided surgery (61.4% vs 45.3%, p=0.040). Among those who desired to return, nondominant-sided patients had higher RTS (92.3% vs 75.0%, p=0.006). Median time to RTS was similar (219 vs 202 days, p=0.83). Satisfaction trended higher after nondominant-sided surgery ('somewhat' or 'very satisfied' 91.2% vs 80.0%, p=0.051). Improvements in ASES scores at a mean follow-up of 2.8±1.7 years were not significantly different (46.2 [30.5-60.8] for non-dominant vs 37.0 [21.9-59.4] for dominant, p=0.11) (Table 3). Of the 79 patients who failed to RTS at the same level or higher, 'Pain/Discomfort in Shoulder' was the most frequently cited reason for not doing so (32.9%). Sensitivity analyses adjusting for overhead sport, age, sex, BMI, and comorbidity burden yielded consistent results (Table 4). Conclusions: In active patients aged 65 years or younger, nondominant-sided aTSA was associated with significantly higher RTS rates, including return at the same or higher level, with similar functional improvement. Hand dominance may be an important and underrecognized factor to consider in counseling and expectation setting for RTS after aTSA.

PURPOSE:To assess the impact of prior or concurrent cervical spine pathology on clinical outcomes following shoulder surgery. METHODS:A systematic literature search was performed of the MEDLINE, Embase, and Cochrane databases. The inclusion criteria were English-language studies with Level IV evidence or greater in which shoulder outcomes data were stratified according to whether patients previously had a documented cervical spine procedure or pathology. Eligible studies were categorized based on the type of shoulder procedure performed. The directionality and magnitude of impact of prior cervical spine pathology on clinical outcomes following shoulder surgery were summated. RESULTS:Among 129 unique studies identified, 9 studies were included for analysis. All included studies were Level III evidence. Six studies reported outcomes pertaining to arthroscopic shoulder surgeries, and 3 studies reported outcomes pertaining to shoulder arthroplasty. Eight studies included patients who had prior or subsequent cervical spine surgery, while 1 study evaluated patients with a diagnosis of a cervical spine condition. Five of 9 studies found either inferior postoperative patient-reported outcomes (PROs) or increased perioperative complications, with 1 study reporting decreased minimal clinically important difference and substantial clinical benefit attainment. No studies reported improved shoulder outcomes, complication rates, or minimal clinically important difference/substantial clinical benefit attainment. These findings were consistent regardless of how cervical pathology was defined (surgical or nonsurgical). The sequence of shoulder and cervical spine surgery was not associated with differences in PROs or perioperative complication rate following shoulder surgery. CONCLUSIONS:Patients undergoing shoulder surgery with a history of a cervical spine condition have increased rates of surgical complications and mixed but consistently nonsuperior PROs compared to patients without dual shoulder-cervical spine pathology. The sequence of undergoing shoulder and cervical spine surgery was not associated with clinical outcomes following shoulder surgery. LEVEL OF EVIDENCE:Level III, systematic review of Level III studies.

Background Total shoulder arthroplasty (TSA) is increasingly performed at high-volume tertiary care centers, with many patients either electing or required to travel long distances to receive specialized care. This study aimed to investigate the impact of geographic travel distance on preoperative patient expectations and postoperative clinical outcomes following TSA. Methods A retrospective cohort analysis was performed evaluating patients undergoing anatomic TSA (aTSA) and reverse TSA (rTSA) from 2016 through 2021 at an urban, academic medical center. For each aTSA and rTSA, patients were stratified into two cohorts based on travel distance to the surgical center: local (<50 miles) or long-distance (>100 miles). Preoperative expectations, as defined by the HSS Expectations Survey (HSS-ES), functional outcomes (ASES, SANE, SAS), and patient satisfaction were assessed at baseline and minimum two-year follow-up. Parametric test, non-parametric tests, and multivariable linear regression were used to compare patient groups for both aTSA and rTSA. Results Among 1,406 total patients, 885 aTSA patients (local = 737; long-distance = 148) and 521 rTSA patients (local = 413; long-distance = 108) were included in the study. Among patients undergoing aTSA, long-distance patients had significantly higher education levels (p = 0.01) and were more likely to identify as White (p = 0.01). Preoperative expectations scores (HSS-ES) among aTSA patients did not differ significantly between cohorts (local: 74.87 ± 15.75, n = 737; long: 77.64 ± 14.70, n = 148; p = 0.067). Functional outcomes and satisfaction improved regardless of travel distance (p>0.05). In the rTSA cohort, multivariable regression analysis revealed that travel distance was not a significant predictor of higher preoperative patient expectations (p<0.05). Clinical outcomes and satisfaction following both aTSA and rTSA demonstrated comparable and clinically meaningful improvements in both long-distance and local patient groups. In multivariable analysis for both aTSA and rTSA, travel distance did not influence patient-related outcomes (p>0.05). Conclusion Patients traveling longer distances to undergo aTSA and rTSA at an urban, academic medical center had comparable preoperative expectations to patients residing locally. Long-distance patients achieved similar postoperative outcomes and satisfaction as local patients at an urban, tertiary care center. These findings suggest that intentional urban academic medical center selection, regardless of travel distance, does not negatively impact patient-related outcomes or satisfaction following TSA. However, they should be interpreted in the context of our patient population, where long-distance travel often reflected elective choice. Level of evidence Level III; Retrospective Cohort Study

Background: Patients undergoing reverse total shoulder arthroplasty (rTSA) for rotator cuff arthropathy may present with an external rotation (ER) lag due to posterior rotator cuff insufficiency. As a result, the addition of a latissimus dorsi (LD) tendon transfer in combination with rTSA has become increasingly utilized. Initial descriptions of LD tendon transfer involved rerouting of the LD tendon posterior to the long head of the triceps tendon. However, more recent techniques involve rerouting the LD tendon anterior to the long head of the triceps tendon via the deltopectoral approach utilized for rTSA. The purpose of this cadaveric study was to assess the biomechanical effect on ER force of LD tendon transfer anterior vs. posterior to the long head of the triceps tendon in combination with rTSA. Methods: Eight fresh frozen cadaveric shoulders were utilized. A shoulder fellowship trained orthopedic surgeon performed rTSA in each specimen. The rotator cuff tendon attachments were cut to simulate a massive rotator cuff tear. The LD tendon was transferred to the greater tuberosity first anterior to the long head of the triceps, and then posterior to the long head of the triceps. The specimens underwent biomechanical testing for each condition using an established cadaveric shoulder simulator with 6 degrees of freedom for glenohumeral joint motion. Results: Both anterior and posterior LD tendon transfers successfully achieved ER of the humerus when force was applied to the LD tendon. Posterior LD tendon transfer resulted in less required force to achieve ER of the arm throughout range of motion compared to anterior LD tendon transfer (33.4 N vs. 48.6 N, P <.001), which was maintained irrespective of glenohumeral abduction angle. Loading of the long head of the triceps tendon was associated with significantly increased force required for generation of ER only in the anterior LD tendon transfer condition (48.6 N loaded vs. 39.4 N unloaded; P < .001). Conclusion: LD tendon transfer posterior to the long head of the triceps resulted in more efficient humeral ER movements in the setting of rTSA, irrespective of degree of shoulder abduction. Our results also demonstrate that long head of the triceps tension results in decreased efficiency of the LD tendon transfer when performed anterior to the long head of the triceps. While technically more difficult, transfer of the LD tendon posterior to the long head of the triceps provides a mechanical advantage that may improve clinical outcomes in patients with rTSA lacking ER. Level of evidence: Basic Science Study; Biomechanics (c) 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

BACKGROUND:Distal tibial allograft (DTA) reconstruction for glenoid bone loss (GBL) has gained popularity. While recent studies have demonstrated that glenoid concavity is an important factor in native glenohumeral stability, there remains a paucity of data regarding concavity restoration during reconstructive procedures for GBL and its biomechanical effect. PURPOSE:To compare the restoration of anterior glenohumeral stability and glenoid concavity after DTA and classic Latarjet procedures. STUDY DESIGN:Controlled laboratory study. METHODS:Nine human cadaveric specimens (mean age, 62.2 years; range, 52-69 years) underwent pretesting computed tomography (CT) to assess native glenoid concavity as determined by the glenoid depth and bony shoulder stability ratio (BSSR). GBL was created so the DTA and Latarjet graft could restore 100% of the native glenoid width. The rotator cuff tendons were loaded, and anterior stability testing was performed using a KUKA robot to apply a controlled anterior force with the shoulder in 90° of abduction and neutral external rotation. A motion capture system recorded humeral head translation. The following conditions were tested: intact, soft tissue Bankart lesion; bone loss model with DTA reconstruction; classic Latarjet procedure without conjoint tendon loaded; and classic Latarjet procedure with conjoint tendon loaded (sling effect). All specimens underwent posttesting CT to measure the BSSR of the DTA and Latarjet reconstructions. A repeated-measures analysis of variance was performed to compare the BSSR and anterior translations between the DTA and Latarjet reconstructions. RESULTS:DTA produced greater concavity than the Latarjet procedure (BSSR: 0.45 vs 0.35; P < .001). There was no difference in anterior translation between the DTA and Latarjet procedures with the sling effect (5.1 mm vs 4.7 mm; P > .999). However, maximum anterior translation was decreased after the DTA procedure when compared with the Latarjet technique without the sling effect (5.1 mm vs 10.3 mm; P = .045). CONCLUSION:DTA produces a more concave reconstruction and decreased anterior translation compared with the flatter reconstruction produced by the classic Latarjet procedure without the sling effect. DTA and the classic Latarjet procedure with conjoint tendon loading, however, yielded equivalent reductions in anterior translation. CLINICAL RELEVANCE:Distal tibial allograft reconstruction is a biomechanically equivalent alternative to the classic Latarjet due to the restoration of glenoid concavity in addition to glenoid width. Surgeons should consider the role of concavity when addressing glenohumeral instability with bone loss.

BACKGROUND:Despite heightened focus on delivering high-value, cost-conscious healthcare, existing reimbursement practices differ for hospital systems and surgeons. This study aimed to investigate the relationship between patient risk and reimbursement for hospitals and surgeons among US Medicare patients undergoing primary total shoulder arthroplasty (TSA). METHODS:A retrospective analysis of clinical and financial data was performed using the publicly available "2022 Medicare Physician and Other Practitioner" and "2022 Medicare Inpatient Hospitals" files. Patients were dichotomized into a sicker cohort, defined as a Hierarchical Condition Category (HCC) risk score of 1.5 or greater, and a healthier cohort with HCC risk scores less than 1.5. Surgeon and hospital reimbursement data were collected and compared across patient cohorts. RESULTS:In 2022, 79,668 TSA procedures were billed to US Medicare, with an overall mean surgeon reimbursement of $798.04. Among these patients, 1065 had an HCC risk score greater than 1.5 and were categorized as high-risk, while the remaining 78,603 patients had lower scores and were categorized as standard-risk. Mean surgeon reimbursement for the high-risk cohort trended to be less than the standard-risk cohort ($787.78 vs. $798.19). Among patients in the high-risk cohort, HCC risk score had a significant negative effect on mean surgeon reimbursement (P < .001). Among 16,734 Medicare patients who were admitted as inpatients for primary shoulder arthroplasty in 2022, the mean hospital reimbursement was $18,586.60. In contrast to surgeon reimbursement, hospital reimbursement was significantly greater for the high-risk cohort, with a mean payment of $19,063.27 compared to $15,239.36 for the standard-risk cohort (P < .001). CONCLUSIONS:Although US hospital reimbursement for TSA increased among higher-risk patients with greater medical comorbidities, surgeon reimbursement among higher-risk patients was relatively unchanged, with a trend toward a small decrease. Such a discrepancy may create disparate incentives for hospitals and surgeons to take on extra risk in caring for complex patients. These data may inform future healthcare policies that promote continued access to shoulder arthroplasty care among higher-risk patients.

Background Anatomic and reverse total shoulder arthroplasties (aTSA and rTSA) are increasingly common procedures with generally high satisfaction rates. While hand dominance influences the performance of activities of daily living, its role in patient-reported outcomes and satisfaction following aTSA or rTSA remains unclear. This study aims to evaluate the influence of hand dominance on ipsilateral aTSA and rTSA patient-reported outcome measures. Methods A single-institution retrospective cohort study was performed by assessing -clinical outcomes following aTSA or rTSA procedures performed from 2016 to 2022. Patients were stratified based on dominant vs. nondominant limb shoulder arthroplasty procedures. Independent t-tests and linear regression models adjusting for patient-reported confounding variables were used to evaluate the association between hand dominance and postoperative clinical outcomes following aTSA and rTSA. Results A total of 488 patients undergoing a primary shoulder arthroplasty procedure (362 aTSA [200 dominant hand; 162 nondominant hand]; 126 rTSA [71 dominant hand; 55 nondominant hand]) met inclusion criteria. After stratifying by procedure type, no significant differences in postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS-PI), Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE), or Shoulder Arthroplasty Smart scores were observed between dominant and nondominant limb arthroplasty cohorts (P > .05). Conclusions Patient-reported outcomes following total shoulder arthroplasty were not associated with hand dominance. These findings may be used as an adjunct to counsel patients regarding postoperative outcomes following shoulder arthroplasty regardless of hand dominance.

BACKGROUND:Scapulohumeral rhythm (SHR) describes the relative contributions of the humerus and scapula to total shoulder motion and is defined as the ratio of glenohumeral (GH) elevation to scapulothoracic (ST) upward rotation. The impact of reverse total shoulder arthroplasty (rTSA) on scapular kinematics and SHR has not been fully elucidated. The purpose of the present study was to perform a systematic review and meta-analysis of the literature to compare SHR among patients following rTSA and asymptomatic controls. METHODS:A literature search was performed by querying PubMed, EMBASE, and the Cochrane computerized databases to identify studies that assess SHR, or the relationship of GH elevation to ST upward rotation, in patients after rTSA. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Quantitative review was performed for studies that reported either SHR directly, or reported GH and ST rotation. Differences in SHR were compared between different ranges of humeral elevation including rest-30°, 30-60°, 60-90°, and the total arc of elevation. RESULTS:Twenty-seven studies comprised of 464 patients who underwent rTSA were included in the final analysis for review. Among the studies included, 19 (70%) directly assessed SHR. The average SHR across all elevation ranges in the scapular plane was 1.6 (range: 0.8-2.7). The average SHR in the rest-30°, 30-60°, and 60-90° elevation arc ranges were 4.3 (range: 0.8-34), 2.0 (range: 0.7-4), and 1.8 (range: 0.8-3), respectively. Compared to controls, patients who underwent rTSA had greater ST upward rotation, quantified as a significantly lower SHR (1.9 vs. 3.2, P = .0238). CONCLUSION:There is an increased contribution of ST rotation relative to GH motion throughout arm elevation following rTSA compared to asymptomatic shoulders. The average SHR was lowest between 60° and 90° of arm elevation compared to the other measured ranges of arm elevation, indicating a greater contribution of ST rotation required at higher angles of arm elevation. Further investigations are needed to determine the clinical implications of greater ST motion in patients following rTSA, as well as the biomechanical causes and consequences of this alteration in scapular kinematics.