Background: Although os acromiale is often noted on preoperative imaging in patients undergoing reverse total shoulder arthroplasty (rTSA), its clinical significance is ill-defined. The purpose of this study was to compare the clinical outcomes in shoulders with an os acromiale undergoing rTSA with a matched control group. Methods: We conducted a retrospective review of a prospectively collected shoulder arthroplasty database for patients who underwent primary rTSA with a minimum 2-year clinical follow-up. Preoperative imaging studies taken within 6 months of surgery were assessed for an os acromiale. Sixty-four shoulders with os acromiale were identified and were matched in a ratio of 1:5 to a control group (n = 320) based on age (within 3 years), sex (exact), preoperative diagnosis, preoperative forward elevation (within 5°) and American Shoulder and Elbow Surgeons score (within five points). Clinical outcome scores, shoulder strength, and active range of motion assessed preoperatively and at latest follow-up as well as the incidence of complications were compared between cohorts. Outcomes of meso- and meta-acromion were grouped and compared with preacromion shoulders. Results: The incidence of os acromiale was 9.7% (64/663) in our institution. Of these, 55% (n = 34) were preacromion, 38% (n = 24) were mesoacromion, and 8% (n = 5) were meta-acromion. No statistically significant differences were found in any outcome score, shoulder strength, or range of motion measures between shoulders with os acromiale and matched controls. Similar proportions of each cohort achieved a clinically significant benefit (minimal clinically important difference/substantial clinical benefit) for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, constant score, abduction, forward flexion, external rotation, and internal rotation. Shoulders with os acromiale had a similar overall complication rate compared with matched controls (14% vs. 12%; P = 0.658). No statistical difference in outcomes were observed between the pre- and meso-/meta-acromion shoulders. Conclusions: Patients with os acromiale undergoing rTSA have similar postoperative functional outcomes and pain relief compared with matched controls. Level of Evidence: Ⅲ, Retrospective Matched Cohort Study.

Background: While immediate post-operative pain control after total shoulder arthroplasty (TSA) has been associated with improved long-term functional outcomes, the effect of pain levels beyond the initial recovery period remains unclear. This study aimed to evaluate whether decreased pain at 12 weeks post-operatively after anatomic TSA (aTSA) and reverse TSA (rTSA) is associated with improved shoulder range of motion (ROM) and pain control up to 2 years post-operatively compared to patients with elevated pain during the post-operative recovery period. Methods: We performed a retrospective review of 605 primary TSAs (206 aTSA, 399 rTSA) at a single institution from 2007 to 2022. Perioperatively, patients received a cervical paravertebral nerve catheter. Post-operatively, patients were discharged on a multimodal oral analgesic regimen consisting of both opioid and nonopioid medications. Pre-operative to post-operative improvement in ROM was evaluated at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years follow-up. Mixed-effects models were used to evaluate whether minimal post-operative pain (defined as patient-reported pain at worst < 3/10) at 12-week follow-up was associated with improved ROM (forward elevation [FE], abduction, external rotation, and internal rotation [IR]) and pain at each of the next follow-up time point compared to those with elevated pain. Clinical significance was evaluated by comparing improvement to the minimum clinically important difference (MCID) and substantial clinical benefit (SCB). Results: For aTSA, patients with pain < 3/10 at 12 weeks demonstrated significantly greater pre-operative to post-operative improvement in abduction, FE, and IR at all follow-up points, including 2 years post-operatively. For rTSA, patients with minimal pain at 12 weeks had significantly greater pre-operative to post-operative improvement in abduction and IR at all follow-up points, including 2 years post-operatively. For both aTSA and rTSA cohorts, patients with minimal pain at 12 weeks had significantly greater mean improvement in daily pain and pain at worst at all follow-up points, including 2 years post-operatively. Patients with minimal pain after aTSA achieved the MCID earlier for abduction and FE and the SCB earlier for abduction, FE, and IR. Patients with minimal early pain after rTSA achieved the MCID earlier for FE and the SCB earlier for external rotation and IR. Conclusion: Minimal pain at 12 weeks post-operatively is associated with sustained superior ROM gains and reduced pain up to 2 years post-operatively after aTSA and rTSA. Future prospective studies are needed to determine what patient and surgery factors lead to poor early pain control and which can be optimized to improve the functional benefits of TSA.

Aims:Reverse shoulder arthroplasty (RSA) after prior rotator cuff repair (RCR) is commonly performed for recurrence of pain and arthritic progression; however, the influence of prior RCR timing and technique on outcomes of RSA has not been adequately explored. Our primary aim was to evaluate the relationship between the postoperative American Shoulder and Elbow Surgeons (ASES) score, whether prior RCR was performed open or arthroscopic, and the time interval between RSA and prior RCR. Secondary outcomes were forward elevation (FE) and external rotation (ER). Methods:A prospectively collected single-institution shoulder arthroplasty database was queried to identify patients undergoing primary RSA after prior RCR between 2004 and 2022 for non-tumour and non-fracture indications with minimum two-year follow-up. We evaluated the relationship between the postoperative ASES score, FE, and ER stratified by prior RCR approach (open vs arthroscopic) and time between RSA and RCR. Multivariable analysis was used to adjust for potential confounders. Results:We included 104 RSAs (99 patients) with a mean 8.8 years (SD 7.3) after RCR and a mean age of 68 years (SD 8.3). Prior RCR was performed arthroscopically in 40 RSAs (38%). Mean follow-up was 4.8 years (SD 2.8). On multivariable analysis, arthroscopic RCR was independently associated with a 13-point greater postoperative ASES score (p = 0.008), 14° greater forward elevation (p = 0.011), and 8° greater external rotation (p = 0.018) compared with open RCR. A ten-year increase in time between RCR and RSA was associated with a seven-point greater postoperative ASES score (p = 0.029) and 5° greater external rotation (p = 0.015). Conclusion:A greater time interval between prior RCR and RSA, as well as arthroscopic techniques, is associated with improved outcomes after primary RSA in patients with prior RCR.

Background Total elbow arthroplasty (TEA) is increasingly performed for complex elbow pathology, yet revision procedures remain challenging due to high complication rates and limited bone stalk. While TEA may produce satisfactory functional outcomes for select patients, it is often burdened by high complication rates, necessitating revision TEA, often with extensive bone loss. Among available reconstructive strategies, allograft–prosthesis composite (APC) reconstruction has emerged as a possible technique; however, reported outcomes remain heterogeneous. This systematic review aims to characterize the use and outcomes of APC reconstruction in revision TEA for patients with significant bone loss. Methods We searched the PubMed/Medline, Embase, Web of Science, and Cochrane databases to identify clinical studies of revision TEA performed with an APC published between inception of each database and 2023. Outcomes of interest were patient-reported outcome measures (PROMs), range of motion (ROM), radiographic outcomes, and complications. Results We included five studies that reported on 85 elbows with APC TEA revisions for extensive bone loss. PROMs and ROM were reported for 70 elbows, yielding a mean postoperative Mayo Elbow Performance Score of 64 points and an active elbow arc of 24°–120°. The complication rate across 85 elbows was 38.8% (33 elbows). The graft–host junction non-union rates of humeral and ulnar allografts were 40% (20 elbows) and 16% (5 elbows), respectively. Conclusions APC provides a salvage option in revision TEA with severe bone loss but is associated with high complication and non-union rates.

Background: The effect of smoking status on clinical outcomes in reverse total shoulder arthroplasty (rTSA) has not been thoroughly characterized. We sought to compare pain and functional outcomes, complications, and revision-free survivorship between current smokers, former smokers, and nonsmokers undergoing primary rTSA. Methods: We retrospectively reviewed a prospectively collected shoulder arthroplasty database from 2004-2020 to identify patients who underwent primary rTSA. Three cohorts were created based on smoking status: current smokers, former smokers, and nonsmokers. Outcome scores (Shoulder Pain and Disability Index [SPADI], Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES], University of California, Los Angeles [UCLA], and Constant), range of motion (external rotation, forward elevation, abduction, and internal rotation), and shoulder strength (external rotation and forward elevation) evaluated at 2-4-year follow-up were compared between cohorts. The incidence of complication and revision-free implant survivorship were evaluated. Results: We included 676 primary rTSAs, including 38 current smokers (44 +/- 47 pack-years), 84 former smokers who quit on average 20 +/- 14 years (range: 0.5-57 years) prior to surgery (38 +/- 32 pack-years), and 544 nonsmokers. At 2-4-year follow-up, current smokers had less favorable SPADI, SST, ASES scores, UCLA scores, and Constant scores compared to former smokers and nonsmokers. On multivariable analysis, current smokers had less favorable SPADI, SST, ASES score, UCLA score, and Constant score compared to nonsmokers. There were no significant differences between cohorts in complication rate and revision-free survivorship. Conclusion: Our data showed that current smokers may have poorer functional outcomes after rTSA compared to former smokers and nonsmokers, despite the incidence of complications and revision surgery not differing significantly between cohorts. Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees.

Background: The role of tendon transfer and ideal insertion sites to improve axial rotation in reverse total shoulder arthroplasty (RTSA) is debated. We systematically reviewed the available biomechanical evidence to elucidate the ideal tendon transfer and insertion sites for restoration of external and internal rotation in the setting of RTSA and the influence of implant lateralization. Patients and methods: We queried the PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify biomechanical studies examining the application of tendon transfer to augment shoulder external or internal rotation range of motion in the setting of concomitant RTSA. A descriptive synthesis of six included articles was conducted to elucidate trends in the literature. Results: Biomechanics literature demonstrates that increasing humeral-sided lateralization optimized tendon transfers performed for both ER and IR. The optimal latissimus dorsi (LD) transfer site for ER is posterior to the greater tuberosity (adjacent to the teres minor insertion); however, LD transfer to this site results in greater tendon excursion compared to posterodistal insertion site. In a small series with nearly 7-year mean follow-up, the LD transfer demonstrated longevity with all 10 shoulders having > 50% ER strength compared to the contralateral native shoulder and a negative Hornblower's at latest follow-up; however, reduced electromyography activity of the transferred LD compared to the native contralateral side was noted. One study found that transfer of the pectoralis major has the greatest potential to restore IR in the setting of lateralized humerus RTSA. Conclusion: To restore ER, LD transfer posterior on the greater tuberosity provides optimal biomechanics with functional longevity. The pectoralis major has the greatest potential to restore IR. Future clinical investigation applying the biomechanical principles summarized herein is needed to substantiate the role of tendon transfer in the modern era of lateralized RTSA. Level of evidence: IV; systematic review. (c) 2024 Published by Elsevier Masson SAS.

Background: A subset of patients undergoing anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) lag behind their peers in regaining overhead range of motion (ROM) after surgery. The primary purpose of this study was to compare the rate of recovery of ROM after aTSA and rTSA performed in stiff (preoperative passive external rotation [ER] <= 0 degrees) versus non-stiff (preoperative passive ER >0 degrees) shoulders with RCI-GHOA. Hypothesis: We hypothesized that preoperatively stiff shoulders (preoperative passive ER <= 0 degrees) would have slower recovery in ROM postoperatively with lower postoperative motion compared to non-stiff shoulders. Methods and materials: A retrospective review of a multi-institution shoulder arthroplasty database was performed between 2001 and 2021. We identified 1,164 aTSAs and 539 rTSAs performed for RCI-GHOA with a minimum of 2-year clinical follow-up along with follow-up between 3-6 months and a third visit at any other time point. Primarily, the rate of recovery in ROM and time to maximum ROM was evaluated. Secondarily, we assessed six outcome scores and the influence of subscapularis repair during rTSA. Recovery in each outcome was modeled using continuous two-phase segmented linear regression models with random effects. Rate of recovery was defined as the slope of the first segment. Patients were considered to have recovered after surgery at the timepoint corresponding to the inflection point between piecewise segments. Results: Of the 1,164 aTSAs and 539 rTSAs included, 172 aTSAs (15%) and 80 rTSAs (15%) were stiff preoperatively, respectively. Compared to preoperatively stiff aTSAs, non-stiff aTSAs regained ER, abduction, internal rotation (IR), and forward elevation (FE) faster over a shorter duration. Similarly, non-stiff rTSAs regained ER, abduction, and FE faster and over a shorter duration compared to stiff rTSAs, but regained IR more slowly over a longer duration. Stiff rTSAs performed with subscapularis repair did not have any appreciable gain in ER after the immediate postoperative period. Although non-stiff and stiff rTSAs performed without subscapularis repair regained ER at a similar rate (4.4 vs. 4.2 degrees/month), stiff rTSAs continued to regain ER 1.9-times longer (11.9 vs. 6.4 months). When the subscapularis was repaired, non-stiff rTSAs regained abduction and IR faster over a short duration compared to stiff rTSAs. Conclusions: Preoperative stiffness is associated with slower recovery of active ROM over a longer duration in patients undergoing shoulder arthroplasty for RCI-GHOA.

Background: Low socioeconomic status has been shown to contribute to poor outcomes in patients undergoing joint replacement surgery. However, there is a paucity of studies investigating shoulder arthroplasty. The purpose of this study was to evaluate the effect of socioeconomic status on baseline and postoperative outcome scores and implant survivorship after anatomic and reverse primary total Methods: A retrospective review of a prospectively collected single-institution database was performed to identify patients who underwent primary TSA. Zip codes were collected and converted to Area Deprivation Index (ADI) scores. We performed a correlation analysis between national ADI scores and preoperative, postoperative, and preoperative to postoperative improvement in range of motion (ROM), shoulder strength, and functional outcome scores in patients with minimum 2-year follow-up. Patients were additionally grouped into groups according to their national ADI. Achievement of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) and revision-free survivorship were compared between groups. Results: A total of 1148 procedures including 415 anatomic and 733 reverse total shoulder arthroplasties with a mean age of 64 +/- 8.2 and 69.9 +/- 8.0 years, respectively, were included. The mean follow-up was 6.3 +/- 3.6 years for anatomic and 4.9 +/- 2.7 years for reverse total shoulder arthroplasty. We identified a weak negative correlation between national ADI and most functional outcome scores and ROM preoperatively (R range 0.07-0.16), postoperatively (R range 0.09-0.14), and preoperative to postoperative improvement (R range 0.01-0.17). Thus, greater area deprivation was weakly associated with poorer function preoperatively, poorer final outcomes, and poorer improvement in outcomes. There was no difference in the proportion of each ADI group achieving MCID, SCB, and PASS in the anatomic total shoulder arthroplasty cohort. However, in the reverse total shoulder arthroplasty cohort, the proportion of patients achieving MCID, SCB, and PASS decreased with greater deprivation. There was no difference in survivorship between Conclusions: We found a negative effect of low socioeconomic status on baseline and postoperative patient outcomes and ROM; however, the correlations were relatively weak. Patients that reside in socioeconomically deprived areas have poorer functional outcomes before and after TSA and achieve less improvement from surgery. We should strive to identify modifiable factors to improve the success of TSA in socioeconomically deprived areas. Level of evidence: Level III; Retrospective Cohort Comparison; Prognosis Study (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:The primary purpose of this study was to assess whether the difference between the distance from the acromion to the glenosphere center of rotation (DA) and the distance from the greater tuberosity to the glenosphere center (DGT) influences the incidence of subacromial notching (SaN) in shoulders following reverse total shoulder arthroplasty (rTSA) with a medialized glenoid and a lateralized humerus. The secondary purpose was to evaluate whether this relationship also impacts the incidence of acromion or scapular spine fractures. METHODS:We conducted a retrospective cohort study of patients who underwent rTSA with a medialized glenoid and a lateralized humerus between 2007 and 2021. A total of 526 shoulders were included. Preoperative and postoperative functional outcome scores were evaluated. The Grashey view on plain radiographs preoperatively, within 3 months postoperatively, and at the final follow-up were evaluated. Shoulders were classified into 2 groups: DA ≥ DGT or DA < DGT. Propensity score matching was used to ensure comparability between groups. Clinical outcomes, SaN, and acromion or scapular spine fractures were assessed. RESULTS:After propensity score matching, 360 shoulders were analyzed (240 in the DA ≥ DGT group and 120 in the DA < DGT group). The DA ≥ DGT group exhibited a significantly lower incidence of SaN (0%) compared to the DA < DGT group (10.8%, P < .001). Additionally, the DA ≥ DGT group had a lower rate of acromion or scapular spine fractures (0.4%) compared to the DA < DGT group (5.0%, P = .006). Both groups showed significant and similar improvements in clinical outcomes postoperatively. CONCLUSIONS:Implanting components such that DA is greater than DGT in rTSA with a medialized glenoid and a lateralized humerus is associated with a lower incidence of SaN and acromion or scapular spine fractures. These findings suggest that adjusting humeral lateralization or glenosphere distalization to achieve DA ≥ DGT may reduce postoperative complications.

Background: When missing data are present in clinical outcomes studies, complete-case analysis (CCA) is often performed, whereby patients with missing data are excluded. While simple, CCA analysis may impart selection bias and reduce statistical power, leading to erroneous statistical results in some cases. However, there exist more rigorous statistical approaches, such as single and multiple imputation, which approximate the associations that would have been present in a full dataset and preserve the study's power. The purpose of this study is to evaluate how statistical results differ when performed after CCA analysis versus imputation methods. Methods: This simulation study analyzed a sample dataset consisting of 2204 shoulders, with complete datapoints from a larger multicenter total shoulder arthroplasty database. From the sampled dataset of demographics, surgical characteristics, and clinical outcomes, we created five test datasets, ranging from 100 to 2000 shoulders, and simulated 10-50% missingness in the postoperative American Shoulder and Elbow Surgeons (ASES) score and range of motion in four planes in missing completely at random (MCAR), missing at random (MAR), and not missing at random (NMAR) patterns. Missingness in outcomes was remedied using CCA, three single imputation techniques, and two multiple imputation techniques. The imputation performance was evaluated relative to the native complete dataset using the root mean squared error (RMSE) and the mean absolute percentage error (MAPE). We also compared the mean and standard deviation (SD) of the postoperative ASES score and the results of multivariable linear and logistic regression to understand the effects of imputation on the study results. Results: The average overall RMSE and MAPE were similar for MCAR (22.6 and 27.2%) and MAR (19.2 and 17.7%) missingness patterns, but were substantially poorer for NMAR (37.5 and 79.2%); the sample size and the percentage of data missingness minimally affected RMSE and MAPE. Aggregated mean postoperative ASES scores were within 5% of the true value when missing data were remedied with CCA, and all candidate imputation methods for nearly all ranges of sample size and data missingness when data were MCAR or MAR, but not when data were NMAR. When data were MAR, CCA resulted in overestimates of the SD. When data were MCAR or MAR, the accuracy of the regression estimate (β or OR) and its corresponding 95% CI varied substantially based on the sample size and proportion of missing data for multivariable linear regression, but not logistic regression. When data were MAR, the width of the 95% CI was up to 300% larger when CCA was used, whereas most imputation methods maintained the width of the 95% CI within 50% of the true value. Single imputation with k-nearest neighbor (kNN) method and multiple imputation with predictive mean matching (MICE-PMM) best-reproduced point estimates and intervariable relationships resembling the native dataset. Availability of correlated outcome scores improved the RMSE, MAPE, accuracy of the mean postoperative ASES score, and multivariable linear regression model estimates. Conclusions: Complete-case analysis can introduce selection bias when data are MAR, and it results in loss of statistical power, resulting in loss of precision (i.e., expansion of the 95% CI) and predisposition to false-negative findings. Our data demonstrate that imputation can reliably reproduce missing clinical data and generate accurate population estimates that closely resemble results derived from native primary shoulder arthroplasty datasets (i.e., prior to simulated data missingness). Further study of the use of imputation in clinical database research is critical, as the use of CCA may lead to different conclusions in comparison to more rigorous imputation approaches.

Acromion and scapular spine fractures (ASFs) pose significant challenges in the management of patients undergoing reverse total shoulder arthroplasty and there is a pressing need for effective preventive measures. Current predictive factors for ASF include female sex, osteoporosis, older age, and anatomical considerations such as glenoid medialization and acromial morphology. However, surgical options to mitigate ASF risk are limited. In this study, we propose a novel technique: incorporation of distal acromial tip fusion (DATF) during primary reverse total shoulder arthroplasty procedures. DATF involves bony fusion between the undersurface of the anterolateral acromion and the region where the superior rim of the glenoid meets the lateral base of the coracoid using a strut graft. The primary objective is to reinforce the anterior acromion process, thereby enhancing shoulder suspensory complex rigidity and theoretically reducing ASF risk. The technique involves precise positioning and exposure, graft preparation, and fixation. While DATF shows promise in ASF prevention, further biomechanical and clinical data are needed to validate its efficacy and safety. Nevertheless, in patients with a high risk of ASF, DATF may offer a viable prophylactic intervention alongside existing management strategies.

BACKGROUND:Revision reverse total shoulder arthroplasty (rTSA) is performed as a salvage procedure after failed shoulder arthroplasty. However, it presents substantial challenges compared to primary rTSA due to altered anatomy and compromised bone quality. This study aimed to compare clinical outcomes of revision rTSA based on the revision humeral stem fixation methods (cemented vs. cementless) and stem length (short vs. standard vs. long). METHODS:We conducted a retrospective analysis using a prospectively maintained shoulder arthroplasty database from a single institution. All revision rTSAs performed between 2005 and 2023 with a minimum 2-year follow-up were included. Patients were excluded for revision from a primary antibiotic spacer placed in the native shoulder or a history of multiple arthroplasty procedures. The final cohort consisted of 113 revision rTSAs (45 cemented vs. 68 cementless; 16 short vs. 79 standard vs. 18 long). Demographic data, surgical characteristics, outcome scores, active range of motion (ROM), complications, and re-revision rates were compared across cohorts. RESULTS:Revision rTSA showed no significant differences in active ROM or outcome scores between the cemented and cementless humeral fixation cohorts. The short and standard stem cohorts demonstrated greater improvement in active abduction compared to the long stem cohort (34 ± 32 vs. 0 ± 18; P = .045; 37 ± 41 vs. 0 ± 18; P = .001). Similarly, they exhibited greater improvement in the Constant score (23.5 ± 17.7 vs. 3.5 ± 10.5; P = .018; 19.1 ± 19.5 vs. 3.5 ± 10.5; P = .012). Overall re-revision rates in the cemented and cementless cohorts were 7.2% and 14.9%, respectively, and humeral stem re-revision rates were 7.2% and 9.9%, respectively. (P = .204 and P = .746). Overall re-revision rates in the short, standard, and long stem cohorts were 3.7%, 13.7%, and 11.5%, respectively, and humeral stem re-revision rates were 0%, 10.3%, and 11.5%, respectively. (P = .361 and P = .199). CONCLUSION:The use of a short stem in revision rTSA demonstrated clinical outcomes comparable to other stem lengths. Complications and re-revision rates did not significantly differ by cement use or stem length.

PURPOSE:To assess the definitions of return to play (RTP) and return to same level of play (RTSP) used in literature describing ulnar collateral ligament (UCL) injuries in professional baseball players. METHODS:A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases were queried to identify all articles that included UCL injuries between January 2002 and October 2022. Studies of only Major League Baseball (MLB) and Minor League Baseball (MiLB) players were included and summarized descriptively. RESULTS:We included 29 articles (24 reporting RTP, 23 reporting RTSP). Minimum level of play was not included in 46% of RTP definitions and 26% of RTSP definitions; when defined, return to MLB level only was most common in RTP definitions (25%) and return to either MLB or MiLB level was most common in RTSP definitions (39%). Time to return was frequently not included (96% of RTP and RTSP definitions); when defined, return within 2 full seasons after injury was the sole definition used. Duration of play after return was frequently not included (50% and 61%, respectively); when defined, a one game minimum was most used (42% and 17%, respectively). No study used performance measures (e.g., strikeouts, earned run average, etc.) to define RTP or RTSP. CONCLUSIONS:Definitions of RTP and RTSP in the UCL injury literature for professional baseball players of all positions are vague, heterogenous, and prohibit cross-study comparison. CLINICAL RELEVANCE:The present study investigates the definitions for RTP and RTSP used across professional baseball UCL injury literature in hopes of identifying common threads to promote future cross-study comparison.

BACKGROUND:To investigate whether patients who initially underwent anatomic total shoulder arthroplasty (aTSA) for glenohumeral osteoarthritis and were subsequently revised to reverse TSA (rTSA) due to rotator cuff failure or glenoid loosening ultimately attained a similar clinical outcome compared with those who underwent primary rTSA and identify predictors of poor outcomes in the former population. METHODS:We did a single-center retrospective review of 63 shoulders who underwent revision rTSA after primary aTSA that failed due to glenoid component loosening (n = 32), rotator cuff failure (n = 24), or recurrent instability (n = 7). Pain and functional outcomes at minimum 2-year follow-up were compared between patients undergoing revision rTSA (n = 45) and a matched control group of primary rTSAs performed for primary osteoarthritis with an intact rotator cuff. Predictors of a poor American Shoulder and Elbow Surgeons score and baseplate loosening in the former cohort were identified. RESULTS:After revision rTSA, patients demonstrated statistically significant ( P < 0.05) improvement in overhead motion, functional outcome scores, and pain but no improvement in external or internal rotation. A 35% complication rate was observed, most commonly baseplate loosening (21%). The implant survivorship following revision rTSA was 97% after 2 years and 75% after 5 years. No notable differences in any outcome scores, range of motion, shoulder strength, or pain measures were found between revision rTSAs and matched primary rTSA controls at a mean of 8 years since index surgery. Humeral stem retention was independently associated with poorer postoperative American Shoulder and Elbow Surgeons scores, whereas a lesser interval between index and revision surgery and use of a structural bone graft were associated with a higher risk of baseplate loosening. CONCLUSION:Patients who undergo aseptic revision rTSA after failed primary aTSA for cuff-intact glenohumeral osteoarthritis attain similar pain and functional outcomes compared with those who underwent primary rTSA when matched by time since index surgery. LEVEL OF EVIDENCE:Level III, Case-Control Study.

BACKGROUND:This study's aim was to quantify the carbon footprint of the 2023 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting and compare it to an alternative meeting structure. MATERIALS AND METHODS:We conducted a retrospective analysis of estimated greenhouse gas emissions from the AAOS 2023 Annual Meeting in Las Vegas, NV. We also modeled theoretical meetings held in locations including Chicago, IL, New Orleans, LA, and New York City, NY, as well as a hybrid meeting occurring across four regional hubs. Emissions for air travel were determined by computing emissions of direct flights to Las Vegas and the closest major airport for each state, using an emissions calculator. Attendees were assumed to use ground travel if they lived within a 250-mile radius of the meeting location. Travel by international attendees was also calculated. We also determined the geographic density of surgeons by state using data from the Association of American Medical Colleges workforce report. RESULTS:The 2023 AAOS Annual Meeting was estimated to have generated 9,458 metric tons of travel-related CO2 equivalents compared with 7,073 (Chicago), 7,678 (New York City), and 7,396 (New Orleans) metric tons. The hybrid regional hub model, which excluded intercontinental travel, was estimated to generate only 1,368 metric tons. CONCLUSION:Total miles traveled had the most significant impact on carbon emissions. This may aid meeting planners in selection of future meeting locations that minimize air travel. In addition, adoption of a regional hub structure with interactive videoconferencing is a potential option for reducing the carbon footprint of the AAOS Annual Meeting.

Background Total elbow arthroplasty (TEA) outcomes are historically modest with high rates of complications. While many studies have explored means of improving TEA outcomes, lack of standardization of outcome measures has made cross-study comparison difficult. This systematic review aims to characterize patient-reported outcome measures (PROMs), elbow range of motion (ROM), strength, and complications across the TEA literature. Methods We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify clinical studies on TEA from 1969 to 2023. Studies were excluded if they lacked clinical outcomes or included allograft prosthetic composites, hemiarthroplasties, or oncologic indications for TEA. Results We included 271 articles reporting on 23,005 elbows (21,665 patients) that underwent TEA (median age 62 years, 41% female, and median follow-up of 58 months). PROMs were reported by 60% (n = 161) of studies. The most common of the 15 identified PROMs was the Mayo Elbow Performance Score (89%, n = 144) followed by the visual analog scale for pain (15%, n = 24); Disabilities of Arm, Shoulder, and Hand score (12%, n = 20); Quick Disabilities of Arm, Shoulder, and Hand score (8%, n = 13); and Oxford Elbow score (7%, n = 11). The number of PROMs reported per study increased over time (P < .001) and decreased with increasing cohort size (P = .004). Elbow ROM was reported by 82% (n = 223) of studies; arm strength was reported by 4% (n = 11) of studies, and complications were reported in 92% (n = 250) of studies. Conclusion Significant heterogeneity exists in the reporting of outcome measures in the TEA literature. To facilitate future cross-study comparison, we recommend reporting of at least the Mayo Elbow Performance Score, visual analog scale for pain, elbow ROM (flexion, extension, pronation, and supination), and elbow strength via objective elbow extension measurements.

BackgroundBiomechanical research demonstrates increased subscapularis abduction range-of-motion (ROM) when the tendon’s upper two-thirds is repaired over-the-top of the center of rotation (OTTR) during reverse shoulder arthroplasty (RSA). This study compares clinical outcomes of patients undergoing RSA with OTTR to patients without repair.MethodsWe retrospectively reviewed 97 consecutive RSAs with either OTTR of the subscapularis (N=75) or no repair (N=22). Repair was attempted in all patients but not performed if the subscapularis could not be brought to the over-the-top position in 20° of external rotation and 30° of abduction. Improvements in ROM were compared to the minimal clinically important difference (MCID) for RSA.ResultsMean follow-up was 3.8±1.6 years. Demographics were similar between groups. Preoperatively, patients undergoing repair had greater external rotation when compared to those without repair (15±16°vs.5±12°,P=.003). Postoperatively, patients undergoing repair had greater forward elevation (132±21°vs.126±22°,P=.268) and abduction (114±26°vs.106±23°,P=.193) with both exceeding the MCID (-2.9°and-1.9°, respectively); however, not statistically significant. Patients with repair were more frequently able to reach the small of their back postoperatively (65%vs.21%, P=.006) but had less improvement in external rotation (13±20°vs. 24±20°,P=.028). Postoperative outcome scores, complications, and reoperations were similar between groups.DiscussionOTTR of the subscapularis in RSA had similar ROM and outcome scores compared to no repair, but a significantly larger proportion of patients with repair achieved functional internal rotation to the small of the back. External rotation limitations seen after conventional repair may also apply to this novel technique, but without a corresponding detrimental effect on forward elevation or abduction.

Background To compare clinical outcomes following lateralized reverse shoulder arthroplasty (RSA) versus RSA with latissimus dorsi transfer (LDT) in patients with poor preoperative active external rotation (ER). Methods We performed a systematic review per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We queried PubMed/Medline, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of RSA with LDT or lateralized RSA alone performed in patients with preoperative ER ≤0°. Our primary outcomes were active ER, active forward elevation (FE), Constant score, and the incidence of complications. Results We included 12 RSA with LDT studies with 188 shoulders and 4 lateralized RSA without transfer studies with 250 shoulders. Mean preoperative ER in RSA with LDT was –14°, while mean preoperative ER in lateralized RSA alone was –11°. Lateralized RSA alone was associated with superior postoperative ER (28° vs. 22°, P=0.010) and Constant score (69 vs. 65, P=0.014), but similar postoperative FE (P=0.590). Pre- to postoperative improvement in ER and FE was similar between cohorts. RSA with LDT had a higher incidence of nerve-related complications (2.1% vs. 0%) and dislocation (2.8% vs. 0.8%) compared to lateralized RSA alone. Conclusions Both RSA with LDT and lateralized RSA are reliable options to restore ER in patients with significantly limited preoperative ER. Our analysis suggests that lateralized RSA alone is superior to RSA with LDT in patients with either a medialized or lateralized implant design and confers a lower risk of complications, particularly nerve injury and dislocation. However, the addition of an LDT may still be indicated in certain patient populations with very severe ER loss. Level of evidence IV.

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.