Glenoid morphology in patients undergoing reverse total shoulder arthroplasty (rTSA) due to arthritis has been previously studied; however, it has not been as thoroughly evaluated in fracture populations. The purpose of this study is to utilize pre-operative computed tomography (CT) scans to better understand the glenoid anatomy of those patients undergoing rTSA due to fracture. Patients over the age of 18 who underwent rTSA for proximal humerus fractures from January 1, 2015 to October 31, 2023 at two university health system affiliated hospitals were included if they had a CT scan available for review and image reconstruction. Patients were excluded if a pathologic fracture was identified, surgery was performed greater than 6 weeks after the initial injury, surgery was a conversion or revision surgery, or if a glenoid fracture was present. Glenoid version and reverse shoulder arthroplasty (RSA) angles were measured by a musculoskeletal fellowship-trained radiologist and a shoulder and elbow fellowship-trained orthopaedic surgeon and averaged for final values. Glenoid morphologies were determined using the Walch and Favard classifications. A total of 53 patients with a mean age of 70.4 years (range 36.6–91.2) were included in this study, 84.9

BACKGROUND:Anatomic total shoulder arthroplasty (aTSA) is a well-described technique for addressing glenohumeral osteoarthritis. Little has been written on outcomes for newer stemless humeral implants in older patients, with none looking specifically at an implant relying on screw fixation. The purpose of this study is to evaluate the clinical and radiographic outcomes for patients over 70 years of age undergoing aTSA with the Eclipse (Arthrex Inc., Naples, FL, USA) stemless humeral component. METHODS:A retrospective review using a multicenter shoulder arthroplasty registry was performed evaluating all patients over 70 years of age who underwent aTSA with a stemless humeral implant for a diagnosis of glenohumeral osteoarthritis and had a minimum follow-up of 2 years. Thirty-seven patients met the study criteria and were matched for comparative analysis to 37 patients 65 years and younger. Outcome scores were obtained preoperatively and at 2 years postoperatively using the visual analog scale, Constant-Murley, American Shoulder and Elbow Surgeons (ASES), and Western Ontario Osteoarthritis Index (WOOS) scores. The percentage of patients in each group who exceeded the Minimal Clinically Important Difference (MCID) for the ASES and WOOS was reported. When available, postoperative radiographs were evaluated for the presence of radiolucent lines and calcar resorption. RESULTS:There was a statistically significantly higher preoperative WOOS score in the older patient group; otherwise, there was no statistical difference between the 2 groups in regard to baseline scores or range of motion. At 2-year follow-up, older patients were noted to have significantly better visual analog scale, ASES, WOOS, and Constant-Murley scores than younger patients (P < .05). For the ASES, all patients over the age of 70 years achieved MCID compared with 84% of those 65 years and younger (P = .011), whereas for the WOOS, 100% of older patients achieved MCID compared with 86% of those in the control group (P = .022). Postoperative range of motion was generally not different between the 2 groups, although older patients had better active internal rotation at 90° of abduction (P = .002). Partial calcar resorption was noted in 1 patient in each age group. Radiolucent lines were noted in 2 patients over the age of 70 years and 1 patient 65 years or younger. DISCUSSION:Patients over the age of 70 years with glenohumeral osteoarthritis undergoing aTSA with a stemless humeral component have equivalent, if not better, outcomes when compared with younger patients. Age alone does not appear a limitation for stemless aTSA.

BACKGROUND:Traumatic elbow instability is a complex problem, and treatment often involves addressing bony injury followed by ligament and capsular repair with or without external fixation. The internal joint stabilizer (IJS) is a dynamic internal fixator that is an alternative treatment for addressing soft tissue injuries that has gained popularity among treating surgeons. The purpose of this study is to compare the outcome of an IJS with conventional primary repair approaches in the treatment of traumatic elbow instability. METHODS:Patient demographics, injury characteristics, surgical findings, and postoperative results were obtained retrospectively from 3 trauma centers using Current Procedural Terminology codes from the electronic medical record. Patients were then matched by age, and the group of patients who were treated with the IJS were compared to those who did not. Range of motion at the elbow and wrist, and data regarding secondary surgeries was gathered longitudinally for 6 months postoperatively. RESULTS:A total of 106 patients met the inclusion criteria, 27 of which had an IJS implanted. After matching, 26 patients from each treatment group were included in the study. There were no statistically significant differences in flexion, extension, supination, pronation, supination-pronation arc, and flexion-extension arc (all P > .05). The IJS group had a higher rate of reoperation (P = .03). CONCLUSION:Patients who underwent placement of the IJS had equivalent elbow and wrist range of motion at 6 months with a higher reoperation rate compared to the non-IJS cohort.

Understanding who is most likely to return to care following same-day discharge (SDD) shoulder arthroplasty might improve our understanding of the indications for home recovery. Therefore, we sought to identify risk factors for early returns to care following same-day shoulder arthroplasty. Patients aged ≥18 years who underwent a primary shoulder arthroplasty and were discharged on the same day as their procedure were identified using a health care system's shoulder arthroplasty registry (2009-2020). The outcome of most interest was early returns to care, defined as an emergency department visit or readmission within 1 day and 2 days of the discharge date. Factors associated with returns in univariable logistic regression with P < .1 were included in the final multivariable model where a P < .05 was the threshold for statistical significance. The study cohort included 3666 SDD shoulder arthroplasty. Of the final sample, 93 (2.5%) and 144 (3.9%) patients returned to care within 1 day and 2 days after discharge, respectively. Patients with a history of chronic pulmonary disease had a higher likelihood of returning to care within 1 day, while the addition of liposomal bupivacaine or single-shot regional anesthesia when compared to continuous catheter anesthesia associated with a lower likelihood of return. Patients with a history of neurological disorders had a higher likelihood of return within 2 days. Patients with a history of peptic ulcer disease/bleeding had a higher likelihood of return within 1 day and 2 days postoperative, while an operative start time of noon or later and a longer operative time were associated with a lower likelihood at both time points. Less than 4% of patients in a large integrated health care system experienced a return to care within 2 days of SDD shoulder arthroplasty. Risk factors for returns varied depending on the window evaluated with some medical comorbidities and continuous catheters associated with a higher likelihood of early returns.

Anatomic total shoulder arthroplasty (aTSA) is an accepted treatment for a variety of degenerative conditions of the glenohumeral joint. The manner in which the subscapularis tendon is handled during the approach in aTSA is not universally agreed on. Failure of the repair after aTSA has been shown to be associated with poorer outcomes in some cases. There is no con- sensus on how to treat failures, as all techniques described in the literature demonstrate shortcomings. The purpose of this review is to evaluate the methods of handling the tendon in aTSA and to review options for treating failure following surgery. [Orthopedics. 2023;46(5):e264-e272.]

1Indiana University School of Medicine, Indianapolis, Indiana Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (https://links.lww.com/JBJS/H575).

The popularity of softball is rising among female athletes with more than two million players between the ages of 12 and 18 competing per year. As participation rates increase, the frequency of injuries related to softball is on the rise. Softball injuries can differ from baseball injuries, and only a small amount of current literature focuses exclusively on softball injuries. Orthopaedic surgeons need to be prepared to evaluate, diagnose, and treat common injuries sustained while playing softball. The purpose of this study is to investigate the mechanisms of injury that are commonly encountered by female athletes in competitive fast-pitch softball and review current safety initiatives that have been implemented to aide in injury prevention.

Little is known regarding reasons for return to the emergency department (ED) or readmission following primary shoulder arthroplasty, especially immediately after discharge and for same-day discharge patients. We sought to identify primary reasons for return to care after this procedure. We conducted a descriptive study comprising patients aged ≥18 years who underwent primary elective shoulder arthroplasty from 2009 to 2018 and subsequently had a 90-day ED-only visit or readmission. Patients were identified using our integrated health care system's shoulder arthroplasty registry, and primary return reasons were determined through manual electronic health record review. Frequencies and proportions were used to describe reasons for 90-day ED and readmission returns, while subcategorizing by surgical and medical reasons. Return reasons were also reported by timing of the postdischarge return and by same-day discharge vs. inpatient stay. Of 9976 primary elective shoulder arthroplasty patients, 1261 (12.6%) had an ED visit, and 465 (4.7%) had a readmission. Over half (52.9%) of all 90-day ED visits were for reasons related to the procedure, while only a little over a third (35.5%) of all 90-day readmissions were surgically related. The top reasons for 90-day ED visits were postoperative pain, falls, and other nonsurgically treated musculoskeletal complaints. Pain, genitourinary complaints, and pulmonary complaints were the most frequent reasons for ED visit within 2 days of discharge, whereas postoperative pain and falls were the top reasons for ED visit specifically following same-day discharge. The top reasons for 90-day readmissions were all medical related: gastrointestinal, cardiovascular, and pulmonary. Pain related to the procedure, pulmonary complaints, and gastrointestinal complaints were the most frequent reasons for readmission within 2 days of discharge. Almost three-fourths of readmissions following same-day discharge were for medical reasons. Knowledge of underlying reasons for returns following shoulder arthroplasty is crucial to improve patient safety, satisfaction, and comfort. While postoperative pain remains an obvious problem, a large proportion of patients also returned to the ED owing to falls. As most ED returns were related to the postoperative surgical care pathway, these returns may potentially be reduced with improved preoperative planning measures.

BACKGROUND:Although the COVID-19 pandemic has disrupted elective shoulder arthroplasty throughput, traumatic shoulder arthroplasty procedures are less apt to be postponed. We sought to evaluate shoulder arthroplasty utilization for fracture during the COVID-19 pandemic and California's associated shelter-in-place order compared to historical controls.METHODS:We conducted a cohort study with historical controls, identifying patients who underwent shoulder arthroplasty for proximal humerus fracture in California using our integrated electronic health record. The time period of interest was following the implementation of the statewide shelter-in-place order: March 19, 2020-May 31, 2020. This was compared to three historical periods: January 1, 2020-March 18, 2020, March 18, 2019-May 31, 2019, and January 1, 2019-March 18, 2019. Procedure volume, patient characteristics, in-hospital length of stay, and 30-day events (emergency department visit, readmission, infection, pneumonia, and death) were reported. Changes over time were analyzed using linear regression adjusted for usual seasonal and yearly changes and age, sex, comorbidities, and postadmission factors.RESULTS:Surgical volume dropped from an average of 4.4, 5.2, and 2.6 surgeries per week in the historical time periods, respectively, to 2.4 surgeries per week after shelter-in-place. While no more than 30% of all shoulder arthroplasty procedures performed during any given week were for fracture during the historical time periods, arthroplasties performed for fracture was the overwhelming primary indication immediately after the shelter-in-place order. More patients were discharged the day of surgery (+33.2%, P = .019) after the shelter-in-place order, but we did not observe a change in any of the corresponding 30-day events.CONCLUSIONS:The volume of shoulder arthroplasty for fracture dropped during the time of COVID-19. The reduction in volume could be due to less shoulder trauma due to shelter-in-place or a change in the indications for arthroplasty given the perceived higher risks associated with intubation and surgical care. We noted more patients undergoing shoulder arthroplasty for fracture were safely discharged on the day of surgery, suggesting this may be a safe practice that can be adopted moving forward.LEVEL OF EVIDENCE:Level III; Retrospective Case-control Comparative Study.

Background Recent literature has described an increase in overall rates of shoulder arthroplasty procedures being performed. To date few reports have characterized the yearly trended earliest incidence of introduction of the then innovative reverse total shoulder arthroplasty (RTSA) since FDA approval in 2003. This study aimed to describe the earliest surgical trends in RTSA use performed in the United States over time. We believe this knowledge will help show how early trends in new innovations provide experience to understand later iterative innovation in the same device. Methods Two complementary datasets that recorded RTSA use discretely at the advent of use in America were reviewed to compare the rates of RTSA being performed on national and regional levels over time. The American Board of Orthopaedic Surgery (ABOS) national database was reviewed, to identify all shoulder arthroplasty cases reported by Part II candidates from 2005-2010. RTSA, total shoulder arthroplasty (TSA), and shoulder hemiarthroplasty cases were each identified separately. Additionally, a regional integrated healthcare system implant registry was reviewed to identify all RTSA, TSA, and shoulder hemiarthroplasty cases performed from 2005-2010. Surgical trends in RTSA rates from both datasets were calculated and compared. Results From 2005-2010 the national ABOS database reported 2,674 shoulder arthroplasty cases, of which 425 were RTSA. In 2005, 19 RTSA cases were reported to the ABOS and constituted 5.2% of all shoulder arthroplasty cases reported. In 2010, 108 RTSA cases were reported and constituted 24.5% of all shoulder arthroplasty cases, an increase of 369%. Meanwhile the regional integrated healthcare system implant registry from 2005-2010 reported 1519 shoulder arthroplasty cases of which 174 were RTSA. In 2005, 8 RTSA cases were reported through this registry and constituted 4.1% of all shoulder arthroplasty cases. In 2010, 49 RTSA cases were performed and constituted 14.9% of all shoulder arthroplasty cases, an increase of 173%. Conclusion Rates of RTSA being performed have increased dramatically since FDA approval. Both regional and national rates showed this increase, suggesting a lack of regional bias. The rise of RTSA use has continued since these early documented rates with newer literature supporting increases in indications and volumes. This report serves as a retrospective comparison of the earliest documented RTSA use. The use rates early in the experience of the innovative idea of RTSA may be instructive and educational to surgeons in this time of expanding indications for RTSA and with utilization of newer RTSA designs. Level of Evidence Level III Retrospective Comparative Study

Purpose Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system. Methods All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients' characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated. Results A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%-16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively. Conclusions This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large. Copyright (C) 2021 by the American Society for Surgery of the Hand. All rights reserved.

HYPOTHESIS:The concept of the critical shoulder angle (CSA) was introduced in 2013, with studies showing that larger CSA is associated with rotator cuff tears (RCTs) and smaller CSA with glenohumeral osteoarthritis. We hypothesized outcomes following total shoulder arthroplasty (TSA) would differ depending on CSA. METHODS:We conducted a matched case-control study using Kaiser Permanente's Shoulder Arthroplasty Registry to identify patients who underwent primary elective anatomic TSA for the diagnosis of osteoarthritis from 2009-2018. Seventy-eight adult patients who underwent revision following the primary TSA due to glenoid component failure or rotator cuff tear comprised the case group. A control group of nonrevised patients were identified from the same source population. Two controls were matched to each case by age, gender, body mass index, American Society of Anesthesiologists classification, surgeon who performed the index TSA, and post-TSA follow-up time. The relationship between revision and CSA as measured on radiographs were analyzed as a 1:2 matched-pairs case-control study with use of multiple conditional multivariable logistic regression. RESULTS:Revised cases had a higher likelihood of a CSA ≥35° (odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.27-4.59). A higher likelihood of CSA ≥35° was observed for those revised for glenoid loosening (OR = 4.58, 95% CI = 1.20-17.50) and revised for rotator cuff tear (OR = 2.41, 95% CI = 1.18-4.92) compared with nonrevised controls. Every 5° increase in CSA had higher odds of overall revision (OR = 1.62, 95% CI = 1.18-2.21), glenoid loosening (OR = 2.50, 95% CI = 1.27-4.92), and rotator cuff tear (OR = 1.51, 95% CI = 1.07-2.14). CONCLUSION:In a matched case-control study of primary anatomic TSA, individuals who were revised for aseptic glenoid loosening and superior cuff failure had a higher CSA compared with nonrevised individuals. These data suggest that surgeons may consider using reverse arthroplasty in cases of primary shoulder arthritis with a CSA of 35° or greater.

Abstract Background With the heightened focus on lowering adverse postoperative events through preoperative patient optimization, malnutrition may be a modifiable risk factor that could be addressed and lead to improved postoperative outcomes. However, an understanding of the association between malnutrition status and adverse postoperative events following shoulder arthroplasty is lacking. We sought to evaluate the association between preoperative malnutrition status, identified via the total serum lymphocyte count, and adverse postoperative events following shoulder arthroplasty. Methods We conducted a cohort study using data from Kaiser Permanente's Shoulder Arthroplasty Registry. Patients who underwent elective primary shoulder arthroplasty were identified (2005-2016). Patients with a preoperative total lymphocyte count Results The final study cohort comprised 6956 shoulder arthroplasty patients, with 2133 (30.7%) identified as malnourished. No difference in septic or aseptic revision risks was observed when comparing patients with and without malnutrition; however, malnourished patients had a higher risk for death, regardless of age ( Conclusion Only a higher mortality risk was observed to be associated with total lymphocyte count-defined malnutrition in patients undergoing elective shoulder arthroplasty. When instead looking at total lymphocyte count continuously, an optimal threshold for discriminating risk of adverse postoperative events could not be identified. Further study is needed to identify an appropriate indicator of malnutrition in shoulder arthroplasty patients and if this indicator can be modified to improve patient status and quality of care. Level of evidence : Level III

Introduction The purpose of this retrospective review was to identify risk factors associated with removal or revision following radial head arthroplasty. Methods Patients undergoing primary radial head arthroplasty between 2009 and 2015 with a minimum follow-up of 1 year were identified. Descriptive and bivariate statistics were used to analyze the characteristics of patients requiring implant removal or revision and multivariable analysis was performed to calculate hazard ratios. Results There were 312 patients included in the final cohort with a median follow-up of 3.8 years. Thirty-five patients (11.2%) underwent prosthesis removal or revision. There was an increased percentage of implants removed or revised in patients under age 40, with surgery performed for chronic indications compared to acute trauma, and with the use of press-fit stems compared to polished. Discussion It appears younger patient age, chronic surgical indications, and certain aspects of prosthesis design may influence rates of removal or revision.

Background: Shoulder arthroplasty is a common orthopedic procedure, performed historically in the inpatient setting. However, interest in same-day discharge has increased. We sought to evaluate 90-day readmission, 90-day emergency department (ED) visit, 90-day deep infection, 90-day venous thromboembolism (VTE), and 1-year mortality after same-day shoulder arthroplasty compared with an inpatient stay. Methods: We conducted a retrospective cohort study using data from an integrated health care system's Shoulder Arthroplasty Registry. A total of 6503 elective primary unilateral total shoulder and reverse total shoulder arthroplasties performed between 2005 and 2016 were included; 405 (6%) had same-day discharge. The likelihood of 90-day events, including readmission, ED visit, deep infection, and VTE, and 1-year mortality after same-day discharge was compared with 1- to 4-night inpatient stay using generalized estimating equations with noninferiority testing, adjusting for age, sex, body mass index, race, American Society of Anesthesiologists classification, select comorbidities, osteoarthritis, anesthesia type, procedure type, and surgeon effect. Results: We failed to observe a difference between same-day discharge and 1- to 4-night stay in terms of 90-day readmission, 90-day ED visit, and 1-year mortality. Same-day discharge was not inferior to 1- to 4-night stay regarding 90-day readmission, but we did not have evidence to support noninferiority for 90-day ED visits or 1-year mortality. Ninety-day deep infections and VTE were too infrequent for adjusted analysis. Conclusions: We found same-day shoulder arthroplasty not to be inferior to an inpatient stay for 90-day readmission. Future investigation into the reasons for readmission and ED visit after same-day shoulder arthroplasty and interventions to mitigate these adverse events is needed. (C) 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: Successful repair of a torn rotator cuff may prevent progression to rotator cuff arthropathy. However, previous studies have shown a substantial rate of failure after rotator cuff repair and characteristics of surgically repaired rotator cuffs that go on to shoulder arthroplasty have not been fully elucidated. The purpose of this study was to determine the patient characteristics and rate at which patients who underwent rotator cuff repair progressed to shoulder arthroplasty. Methods: This was a retrospective study of patients who underwent rotator cuff repair in a large, closed healthcare system in 2008. The EMR was queried for rotator cuff repair CPT with ICD-9 codes for rotator cuff. The resultant dataset was then cross-referenced with a separate internal shoulder arthroplasty registry to determine which patients went onto shoulder arthroplasty. Demographic variables, descriptors of tear pathology and repair characteristics were collected and compared between patients who subsequently underwent shoulder arthroplasty and those that did not. Results: A total of 882 rotator cuff repair patients were included within this study. Of the initial 882 cuff repairs, there were 12 patients (1.4%) that went on to have arthroplasty. Patients who underwent shoulder arthroplasty after rotator cuff repair were significantly older at time of surgery and had greater comorbidity burdens. Patients who ended up with shoulder arthroplasty had the procedure an average of 4.77 +/- 3.28 (SD) years after rotator cuff repair, with 11 of 12 patients having a diagnosis of rotator cuff arthropathy at the time of shoulder replacement. Conclusion: In a closed system, tracking rotator cuff repairs over 9.1 years revealed a small number that went on to subsequent shoulder arthroplasty. Patients who underwent shoulder arthroplasty were significantly older and had greater comorbidity burdens than those who did not. Patients who underwent shoulder arthroplasty usually either had shoulder arthroplasty within 1 year or after 5 years. Enhanced understanding of which patients may progress to arthroplasty may provide a better initial choice of operative intervention in those patients.

Introduction: Anatomic total shoulder arthroplasty (TSA) is a proven treatment for glenohumeral joint osteoarthritis, with superior results compared with hemiarthroplasty. However, glenoid component loosening remains a problem and is one of the most common causes of failure in TSA. Multiple component designs have been developed in an attempt to reduce loosening rates. The purpose of this study was to evaluate risk of revision after anatomic TSA according to the glenoid component design. Methods: We conducted a cohort study including patients aged >= 18 years who underwent primary elective TSA for the diagnosis of osteoarthritis between 2010 and 2017. Patients with missing implant information, who received stemless humeral implants, or who received augmented glenoid implants, were excluded. Glenoid component designs used were categorized into 4 mutually exclusive treatment groups: polyethylene central-pegged ingrowth, polyethylene-metal hybrid, polyethylene all-cemented pegged, and polyethylene cemented keeled. Multivariable competing risk regression was used to evaluate the risk of glenoid loosening as a cause-specific revision by the glenoid component design. Results: Of the 5566 TSA included in the final cohort, 39.2% of glenoid implants were polyethylene central-pegged ingrowth, 31.1% were polyethylene-metal hybrid. 26.0% were polyethylene all-cemented pegged, and 3.6% were polyethylene cemented keeled. At 6year final follow-up, 4.1% of TSA were revised for any cause, and 1.4% for glenoid loosening. Compared with the polyethylene central-pegged ingrowth design, no difference in glenoid loosening revision risk was observed for the polyethylene-metal hybrid design (hazard ratio [HR] = 1.15, 95% confidence interval [Cl] = 0.42-3.20). However, both the polyethylene all-cemented pegged (HR = 2.48, 95% CI = 1.08-5.66) and polyethylene cemented keeled (HR = 3.84, 95% CI = 1.13-13.00) designs had higher risks for revision due to glenoid loosening. Conclusions: We observed glenoid component designs to be associated with differential risks in revision due to glenoid loosening with polyethylene all-cemented pegged glenoids and polyethylene cemented keeled glenoids having higher risks when compared with polyethylene central-pegged ingrowth glenoids. Surgeons may want to consider the glenoid component design when performing anatomic TSA. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

BACKGROUNDThis study determines whether infection rates differ between prophylactic antibiotic use for patients with or without penicillin allergy before shoulder arthroplasty surgery.METHODSSeven thousand one hundred forty primary shoulder arthroplasties operated between 2005 and 2016 were identified. We compared deep surgical site infection risk of patients who received perioperative vancomycin alone (6.2%, N = 444) or clindamycin alone (7.1%, N = 508) for penicillin allergy versus patients who received cefazolin alone without penicillin allergy (86.7%, N = 6,188).RESULTSSeventy deep infections (1.2% 5-year cumulative incidence) were observed. The most common organism was Cutibacterium acnes (39.4%, N = 27). Compared with patients treated with cefazolin, infection risk was not different for those treated with vancomycin (hazard ratio = 1.17, 95% confidence interval 0.42 to 3.30, P = 0.8), but a higher risk of infection was identified for those treated with clindamycin alone (hazard ratio = 3.45, 95% confidence interval 1.84 to 6.47, P < 0.001).CONCLUSIONA higher risk of postoperative infection is found after prophylactic use of intravenous clindamycin antibiotic after shoulder arthroplasty. Vancomycin is preferred over clindamycin for patients with penicillin allergy.LEVEL OF EVIDENCEIII, retrospective cohort study.

Background: As total joint arthroplasty (TJA) utilization increases, arthroplasties of multiple joints in a patient are more common. An understanding of the success of shoulder arthroplasty patients also requiring a lower-extremity (hip or knee) TJA is lacking. We evaluated the following questions: (1) Is there a difference in the revision risk following shoulder arthroplasty in patients who also undergo a lower-extremity TJA compared with those who do not? (2) Does the revision risk differ depending on the sequence of the procedures? Methods: Patients who underwent elective primary shoulder arthroplasty from 2009 through 2015 were identified using Kaiser Permanente's shoulder arthroplasty registry. Patients with a lower-extremity TJA were identified using the institution's total joint replacement registry. Revision related to the index shoulder was modeled via Cox regression stratified by procedure type and adjusted for confounders. Results: Of the 4751 shoulder arthroplasties identified, 1285 (27.0%) underwent a prior hip and/or knee arthroplasty and 483 (10.2%) underwent a hip and/or knee arthroplasty following the index shoulder arthroplasty. No difference was found in all-cause shoulder revision risk with lower-extremity TJA before (hazard ratio, 1.38: 95% confidence interval, 0.97-1.96) or after (hazard ratio, 1.30: 95% confidence interval, 0.82-2.06) the index shoulder arthroplasty compared with patients who underwent a shoulder arthroplasty only. Conclusion: In our study sample, we did not observe shoulder revision surgery risk to be different in patients who also underwent a lower-extremity TJA, regardless of the sequence of the 2 procedures. Future prospective studies should investigate whether the timing of the lower-extremity TJA in relation to the shoulder procedure impacts the latter's success. (C) 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

INTRODUCTION:Revision shoulder arthroplasty is an expensive undertaking with notable morbidity to the patient and less predictable outcomes. Therefore, it is important to avoid even further surgery in these patients. We sought to report the annual revision burden from a large integrated healthcare system and identify patient and operative factors that may predispose patients to revision failure, necessitating further surgery. METHODS:Annual revision burden as a proportion of the overall shoulder arthroplasties performed from 2005 to 2017 was obtained. Patients who underwent aseptic revision between 2005 and 2017 comprised the study sample. Patient characteristics evaluated for re-revision risk included age, sex, body mass index (BMI), race, and diabetes status, whereas surgical characteristics included surgeon cumulative revision volume, revision procedure type, and top reason for revision by primary procedure type. Multivariable Cox proportional hazards regression was used to evaluate the association between the specified factors and re-revision risk. RESULTS:From 2005 to 2017, revisions represented 5.3% to 7.8% of all shoulder arthroplasty procedures performed. Factors associated with re-revision surgery risk by procedure type included increasing BMI and hemiarthroplasty revision procedure compared with reverse total shoulder arthroplasty (RTSA) revision procedure for hemiarthroplasty primaries; diabetes, revision because of instability, and lower cumulative surgeon revision procedure volume for RTSA primaries; and TSA revision procedure compared with RTSA revision procedure for TSA primaries. CONCLUSION:The annual revision shoulder arthroplasty volume increased over the study period. Patient factors, including BMI and diabetes were associated with higher re-revision risks for hemiarthroplasty and RTSA primaries, respectively. RTSA revised for instability had a higher risk of re-revision compared with other indications. TSA and hemiarthroplasty requiring aseptic revision may be best treated with RTSA as opposed to another TSA or hemiarthroplasty. Further studies are needed to verify these findings and identify how the mechanism of failure may affect the procedure selection in the revision setting. LEVEL OF EVIDENCE:Level III.