BACKGROUND:Despite advances in surgical technique and implant design, internal rotation (IR) after reverse total shoulder arthroplasty (rTSA) continues to be relatively unpredictable. The purpose of this study was to compare patient characteristics, use of 3-dimensional computed tomography (3D CT)-based preoperative planning, and postoperative implant position between patients with high or low IR after rTSA. METHODS:A retrospective review was performed of a multicenter prospectively collected database on patients who underwent primary rTSA (Univers Revers; Arthrex, Inc.) from 2016-2021 with a minimum 2-year follow-up. Patients were selected for a comparative analysis who either achieved high IR (T12 or better) or low IR (below the hip) postoperatively. Baseline demographics and postoperative radiographs were evaluated for association with IR. Implant position was assessed on radiographs for lateralization shoulder angle (LSA), distalization shoulder angle (DSA), inferior glenosphere overhang, and coracoid-to-glenosphere distance. Regression analyses were performed on component and clinical variables to assess for factors predictive of high vs. low IR. RESULTS:A total of 344 rTSAs were eligible, of which 98 patients met criteria for the high-IR group and 50 met criteria for the low-IR group. Decreased body mass index (BMI) (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.01-1.30, P = .044), high preoperative IR (OR 1.30, 95% CI 1.02-1.66, P = .034), and surgery on the dominant arm (OR 5.38, 95% CI 1.31-22.1, P = .019) correlated with an increased odds of high IR. The use of 3D CT-based preoperative planning was associated with having high IR (OR 9.69, 95% CI 1.83-51.3, P = .008). Radiographically, increased DSA (OR 1.09, 95% CI 1.02-1.16, P = .012) and increased inferior glenoid overhang (OR 1.39, 95% CI 1.07-1.80, P = .013) were associated with a greater chance of being in the high-IR group. CONCLUSION:Although specific baseline patient characteristics influence the ability to obtain high IR after rTSA including increased preoperative IR, decreased BMI, and surgery on the dominant arm, there are several factors within the surgeon's control. The use of 3D CT-based preoperative planning greatly increases the odds of obtaining increased postoperative IR. More precisely, mindful implant positioning including inferior glenosphere overhang and slight distalization increased postoperative IR. Therefore, the use of 3D CT-based preoperative planning may be considered in order to carefully and consciously position the glenosphere to slightly increase distalization and inferior overhang in order to optimize IR. However, further evaluation with regard to 3D planned position and postoperative outcomes are required.

BACKGROUND:Partially cemented all-polyethylene glenoids with press-fit fluted central peg (FCP) fixation are commonly used for anatomic total shoulder arthroplasty (aTSA). The purpose of this study was to evaluate clinical outcomes and radiographic findings in patients with ≥48-month follow-up after aTSA with one FCP glenoid design. METHODS:A prospective patient registry was used to identify a consecutive group of patients who had undergone aTSA using a FCP glenoid and had ≥48-month follow-up. Final postoperative radiographs, as well as short-term if available, were assessed by five shoulder specialists for bony incorporation and/or radiolucency about the FCP using a validated discriminatory method of evaluating native glenoid reaction to the FCP. Changes in patient-reported and clinical outcomes were evaluated, and regression analysis was performed to identify predictors of central peg osteolysis (CPO), poor clinical outcome, or revision. RESULTS:Eighty-three shoulders satisfied inclusion criteria. At final follow-up (average 90 months), notable improvements were noted in all outcomes ( P < 0.05), including a 75% satisfaction rate. On final imaging, 16 patients (19%) demonstrated optimal FCP bony ingrowth, and 23 (28%) demonstrated CPO. The radiographic appearance of bone around the central peg tended to deteriorate over time and trended with worsened clinical outcomes, but these differences were not notable. Of 73 patients with short-term and final imaging, progression of radiolucency was observed in 30 (41%) and associated with less improvement in American Shoulder and Elbow Surgeons score ( P = 0.026) and Single Assessment Numeric Evaluation ( P = 0.022) scores. Risk of revision was 13% greater in patients with CPO on final imaging while increased age was associated a lower risk of revision. CONCLUSION:Clinical improvement was observed in most of the patients, but with a dissatisfaction rate of 25%. Progression of CPO was associated with lower improvement in final American Shoulder and Elbow Surgeons score and Single Assessment Numeric Evaluation scores and a higher probability of revision. LEVEL OF EVIDENCE:Level IV Case Series.

BACKGROUND:This study evaluated the progression of humeral head medialization in patients who underwent pyrocarbon hemiarthroplasty (PyC-HA). The authors hypothesized that glenoid erosion would not dramatically progress between the short-term and final imaging evaluations, and that there would be excellent clinical outcomes at ≥5-year follow-up. METHODS:Patients who underwent PyC-HA with ≥60 months of follow-up were included in this prospective study. Relevant data included preoperative demographic characteristics, Walch glenoid classification, changes in clinical outcomes, and revision-free and failure-free survival rates. An investigator, who was blinded to patient outcomes, assessed the glenoid morphology, changes in medialization, joint space, acromiohumeral distance (AHD), critical shoulder and β angles, and posterior subluxation in decentered glenoids at the 2-year and final follow-up visits. RESULTS:Forty-five patients with a mean age of 52 years and a mean follow-up of 73 months met the inclusion criteria. Significant improvements were observed across all outcome measures. The 7-year revision-free survival rate was 95.7%. Posterior subluxation in decentered shoulders decreased from 27.1% preoperatively to 19.8% postoperatively (p = 0.008). The mean medialization of the humeral head was 2.9 ± 2.8 mm at the 2-year follow-up and increased to 4.0 ± 3.3 mm at the time of the final follow-up (p = 0.096). A >2-mm decrease in AHD from early postoperative to final imaging was observed in 82.2% of patients (p < 0.001). All other radiographic changes were not significant. CONCLUSIONS:PyC-HA is a reliable procedure for treating glenohumeral joint disease, demonstrating excellent clinical outcomes and stabilized glenoid morphology in the majority of patients between the 2-year and intermediate-term follow-up. LEVEL OF EVIDENCE:Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Background: Aspherical humeral head morphology has previously been shown to be associated with progression of glenohumeral osteoarthritis. Habermeyer et al classified humeral head morphology as either spherical or aspherical. Aspherical head morphology was associated with increased incidence of glenoid deformity (B2) as well as decentering of the humeral head, but the authors did not correlate these findings to clinical outcomes. The purpose of this investigation is to apply these findings to the evaluation of clinical outcomes following anatomic total shoulder arthroplasty (aTSA) and to further define preoperative humeral head pathomorphology. Methods: We performed a retrospective review of all patients who underwent primary aTSA who had adequate pre- and postoperative radiographs and 2-year follow-up. Preoperative radiographs were analyzed and humeral heads were classified as either spherical, mild aspherical, or major aspherical. Axillary images were evaluated to quantify centering of the humeral head and glenoid morphology. Postoperative radiographs were analyzed to quantify implant center of rotation (COR) utilizing the best fit circle technique. Patient-reported outcomes, range of motion and strength at 2-years postoperatively were recorded. Statistical significance was evaluated using chi-square and paired t-test statistics for both regression analysis and univariate analyses. Results: A total of 259 patients met inclusion criteria for this study. Of these, 158 patients (61%) were classified as spherical, 64 patients (25%) mild aspherical, and 37 patients (14%) major aspherical. Males were higher represented among patients with mild and major aspherical humeral heads. Aspherical humeral heads had a significantly higher incidence of B2 glenoid morphology, while spherical heads had a significantly higher incidence of A1 glenoids. Patients with aspherical humeral heads were found to have significantly worse external rotation preoperatively compared to those with spherical heads. There were no significant differences in postoperative range of motion. However, postoperative improvements in external rotational strength and belly press strength were significantly higher in patients with aspherical humeral heads. Preoperative humeral head morphology did not have any influence on patient-reported outcomes at 2-year follow-up or on radiographic postoperative implant restoration of COR. Discussion/Conclusion: Aspherical head morphology was associated with a higher incidence of male gender and B2 glenoid morphology; however, humeral head deformity alone was not shown to lead to diminished outcomes or worse COR restoration following TSA. Patients with aspherical preoperative humeral head morphology were not found to have worse clinical or radiographic outcomes compared to patients with spherical heads; however, patients with aspherical humeral heads did make significant improvements in rotational strength at 2-year follow-up.

BACKGROUND:A subset of patients from "Part 1- The SHORT trial: Multicenter, Randomized, Controlled Trial of Surgeon-Directed Home Therapy vs. Outpatient Rehabilitation by Physical Therapists for Reverse Total Shoulder Arthroplasty" were analyzed for various personality, psychological, and health motivation scores to elucidate if these characteristics might influence success with either clinic-based physical therapy or surgeon-directed home therapy (HT). METHODS:Three of the original centers from the SHORT trial participated with the same patients and inclusion/exclusion criteria. Surveys designed to capture psychological traits, motivation, and gauge comprehensive patient health were administered to assess for moderating effects on American Shoulder and Elbow Surgeons score, pain intensity score, Single Assessment Numeric Evaluation score, and complications for both physical therapy and HT groups. RESULTS:A total of 89 patients across 3 sites were included for analysis. Moderator analysis demonstrated no association among the Short Grit Scale (P = .54, P = .48, P = .51, P = .61), the Short Health Anxiety Inventory (P = .34, P = .97, P = .37, P = .71), the Motivations and Attitudes Towards Changing Health score (P = .24, P = .41, P = .21, P = .95), the Shoulder Activity Scale (P = .97, P = .42, P = .08, P = .66), the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag assessment tool (OSPRO-YF) negative mood (P = .41, P = .95, P = .33, P = .87), OSPRO-YF fear (P = .38, P = .30, P = .75, P = .37), and OSPRO-YF coping (P = .50, P = .77, P = .75, P = .45) on American Shoulder and Elbow Surgeons scores, pain intensity scores, Single Assessment Numeric Evaluation scores, and complications respectively at final 2-year follow-up. CONCLUSION:No personality, attitude, grit, psychological, or motivational characteristics were found to be associated with success or failure with surgeon-directed HT.

BACKGROUND:The incidence of scapular notching has dramatically reduced with the shift from 155° to 135° humeral inclination in reverse shoulder arthroplasty (rTSA). However, humeral inclination is not the only factor as notching persists with medialized glenospheres. The purpose of this study was to assess the effect of glenoid-sided lateralization on scapular notching with a 135° rTSA. METHODS:A retrospective review was performed from a multicenter prospectively collected database to identify patients who underwent primary rTSA and had a minimum 2-year follow-up. All rTSAs were performed with the Arthrex system using a 135° inlay humeral component. Varying amounts of glenoid-sided lateralization were used from 0 to 8 mm in 2-mm increments based on surgeon preference. Postoperative radiographs were evaluated for scapular notching, distalization shoulder angle, and lateralization shoulder angle. The lateralization shoulder angle was further subdivided into humeral and glenoid contributions. Regression analysis was performed on component and clinical variables to assess for factors predictive of notching and the effect on clinical outcomes. RESULTS:Overall, scapular notching was observed in 56 of 517 shoulders (10.8%). Metallic glenoid lateralization and glenosphere overhang were protective of notching (P = .030 and P = < .001, respectively). For women, 6 mm of lateralization reduced notching compared to 4 mm or less (5.3% vs. 15.6%; P = .016). For men, 8 mm of lateralization reduced notching compared to 6 mm or less but the difference did not meet statistical significance (7.6% vs. 13.6%; P = .161). Notching also was associated with decreased forward flexion by 13° (β -12.79, 95% confidence interval: -19.63 to 5.96 P = < .001). DISCUSSION:With a 135° inlay humerus and lateralized glenoid rTSA, scapular notching decreases with metallic lateralization of 6 mm or more. Additionally, inferior glenosphere positioning is protective of notching. Notching is associated with worse clinical outcomes and lower postoperative range of motion.

Background Patient-reported outcome measures (PROMs) provide a quantifiable rating of a patient's subjective symptoms prior to and following treatment of shoulder pathology. Shoulder Subjective Patient Outcome Tracker (SPOT) is a novel outcomes measure with 10 satisfaction domains to pinpoint shoulder-specific functions. The purpose of this study is to introduce and demonstrate the utility of SPOT for patients undergoing total shoulder arthroplasty. The authors hypothesize SPOT will demonstrate high correlations to existing PROMs with a corresponding large effect size. Methods Over a 1-year evaluation period, SPOT, American Shoulder and Elbow Surgeons (ASES) assessment, and Single Assessment Numeric Evaluation (SANE) scores were administered preoperatively and at 2 years postoperatively for patients undergoing anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA). Additionally, nonsurgical patients with glenohumeral osteoarthritis were administered SPOT at 2 separate time points. Interoutcome agreement, correlation, and sensitivity of SPOT to ASES and SANE were evaluated, and the floor/ceiling effect of SPOT was assessed. Test-retest reliability was conducted on the nonsurgical cohort. Results A total of 139 patients were included with 73 postoperative aTSA and 66 postoperative rTSA patients. Twelve patients managed nonoperatively were included in test-retest analysis. Preoperatively, there was low correlation between SPOT and ASES and moderate correlation between SPOT and SANE. At 2 years postoperatively, there was high correlation between SPOT and ASES and between SPOT and SANE. There was good agreement between SPOT and ASES in both aTSA and rTSA cohorts and between SPOT and SANE in the aTSA cohort. Additionally, the large effect size of SPOT was similar to the effect size of ASES and SANE. There was high correlation in the test-retest evaluation in a nonoperative cohort indicating reliability of SPOT at the 2 time points assessed. Conclusion SPOT is a shoulder-specific, effective PROM with a low administrative burden, tailored for patients undergoing aTSA or rTSA. It demonstrates high reliability, strong correlations, and a large effect size comparable to established shoulder-specific PROMs. SPOT is more discriminatory and specific than the SANE score, offering valuable, detailed insights into patients’ perceived deficits before and after shoulder arthroplasty.

BACKGROUND:The purpose of this investigation was to evaluate the impact of scapular neck length (SNL) on outcomes following reverse total shoulder arthroplasty (rTSA) using a lateralized 135° implant (Univers Revers; Arthrex Inc.; Naples, FL). Our hypothesis was that increased postoperative SNL would be associated with improved range of motion (ROM) following rTSA. METHODS:A multicenter retrospective study was performed on a prospectively collected database. Inclusion criteria were patients undergoing primary rTSA with minimum 2-year follow-up. Preoperative radiographs were analyzed for SNL and glenoid height. Postoperative radiographs were analyzed for scapular notching, inferior glenosphere overhang, effective SNL defined as the distance from medial glenosphere to lateral column of scapula (MGLS), lateralization shoulder angle, and distalization angle. Patient reported outcomes, ROM, and strength at 2 years postoperatively were correlated with outcomes controlling for demographic variables. MGLS was stratified by 0-5 mm, 5-10 mm, and >10 mm for analysis. RESULTS:A total of 485 patients met inclusion criteria for this investigation. Preoperative SNL was negatively associated with external rotational strength at 2 years postoperatively (P = .039), but was not found to influence patient reported outcomes, ROM, or the incidence of scapular notching (P > .05). Increased postoperative MGLS was positively associated with active internal rotation to the highest spinal level (P = .024) and belly press strength (P < .001). Improved abduction strength was observed with MGLS >10 mm (P = .011) and improved belly press strength was observed with a postoperative MGLS of >5 mm (P < .001). Internal rotation was higher in the >10 mm group compared to the 0-5 mm (L3 vs. L4; P < .001). External rotation at 90° was higher in the >10 mm compared to the 5-10 mm group (73° vs. 57°; P = .013). CONCLUSION:Increased effective postoperative SNL, or MGLS, is positively associated with rotational ROM and shoulder strength and following rTSA with the Arthrex Univers Revers. Postoperative MGLS of >10 mm is associated with increased Constant strength and belly press strength compared to an MGLS of 0 to 5 mm. The differences in external rotation at 90° in the >10 mm group compared to the 5-10 mm group and for the internal rotation in the 10 mm group compared to the 0-5 mm group met criteria for a substantial clinical benefit.

BACKGROUND:Reverse total shoulder arthroplasty (rTSA) has experienced exponential growth in popularity, although the optimal rehabilitation strategy remains unclear. The primary purpose of the SHORT multicenter randomized controlled trial was to compare patient reported outcomes (PROs) and range of motion (ROM) after rTSA when rehabilitation is directed by outpatient, clinic-based physical therapists (PT group) versus home therapy, instructed by the patient's surgeon at post-operative appointments (HT group). Secondary aims include comparisons of complications, cost of care, and quality of life between the 2 groups. METHODS:Seven sites with 9 shoulder and elbow fellowship-trained, high-volume arthroplasty surgeons randomized 222 shoulders in 216 consecutive, consented patients. There were 117 shoulders in the PT group and 105 shoulders in the HT group. Data were gathered pre-operatively and at 2, 6, and 12 weeks, 6 months, 1 year, and 2 years following surgery. Active and passive ROM, PROs, complications, and costs were collected. RESULTS:At our primary endpoint of one year, we had 93% (174/187) follow-up, at 2 years we had 88% (161/183). There was no statistically significant difference between the 2 groups at any time point with respect to active and passive ROM: scaption, external rotation at 90° abduction (ER90), ER at 0° abduction (ER0), and internal rotation (IR) at 1 year and 2 years. Similarly, there were no differences with regard to PROs, including pain level, the Single Assessment Numeric Evaluation (SANE) score, the American Shoulder and Elbow Surgeons (ASES) score, and quality of life (measured by PROMIS 29 v.2.0). There was no difference in the complication or revision rate. Crossovers were anticipated and statistical significance was not reached whether analyzed with intention-to-treat including patients who crossed over or per-protocol, truncated to the time patients crossed over. HT group showed decreased 1-year care cycle costs with a statistically significant economic value benefit on incremental cost-effectiveness ratio analysis (PT = $17,837.48 [SD = 2,687.34] and HT = $11,284.97 [SD = 1,578.08], P < .01). CONCLUSION:On average, surgeon-directed home therapy after rTSA offers a better value proposition than formal PT, by providing equivalent clinical benefit at a reduced cost.

Background Anatomic total shoulder arthroplasty (TSA) remains the treatment of choice for primary glenohumeral osteoarthritis with an intact rotator cuff (PGHOA). However, reverse total shoulder arthroplasty (RSA) has gained popularity as a primary procedure in select patients that may be at risk for postoperative rotator cuff dysfunction or glenoid loosening. The purpose of this study was to compare short-term outcomes between TSA and RSA in patients with PGHOA and limited preoperative forward flexion (FF). Methods A retrospective review was performed on a multi-institutional registry of patients to identify patients under the age of 80 undergoing TSA or RSA for PGHOA with preoperative FF ≤90°. Forty-five TSAs were identified and matched by age and sex to 45 patients undergoing RSA. A subset of 22 TSAs and 24 RSAs with severely limited preoperative FF of ≤70° was also analyzed. Range of motion including FF, external rotation (ER) and internal rotation (IR), strength, and patient reported outcomes (PROs) including visual analog scale (VAS) pain score, Western Ontario Osteoarthritis of the Shoulder (WOOS) index score, Veterans RAND 12 (VR-12) mental score, American Shoulder and Elbow Surgeons (ASES) score, and Constant-Murley Score were evaluated at a minimum of 2 years postoperative. Results No significant differences were observed in postoperative FF, ER, or strength measurements between groups. The limited FF TSA group achieved significantly improved IR compared to the RSA group (L2 vs. L4, p<0.002). No significant differences were observed between TSA and RSA in ASES, VAS, Constant or SANE scores (p > .05) for both the overall comparison and subset of patients with FF of ≤70°. However, patients in the RSA cohort showed a significantly higher return to normal sporting activities than the TSA group. Conclusions Patients under the age of 80 with PGHOA and limited preoperative FF achieve similar postoperative range of motion and PROs whether treated with TSA or RSA. Therefore, limited preoperative FF does not appear to be a major determinant of outcomes for PGHOA.

Background:Lateralization in reverse shoulder arthroplasty (RSA) decreases bony impingement and improves rotational range of motion, but has been theorized to increase the risk of subacromial notching (SaN). The purpose of this study was to evaluate the presence of SaN following RSA and its relationship with lateralization with a 135° inlay humeral component. The secondary purpose was to assess the association of SaN with functional outcomes.Methods:A retrospective review was performed from a multicenter prospectively collected database on patients who underwent primary RSA from 2015 to 2021. All RSAs were performed with a 135° inlay humeral component. SaN was defined as bony erosion with sclerotic margins on the undersurface of the acromion on final follow-up radiographs not present preoperatively. Postoperative implant positioning (inclination, distalization, and lateralization) were evaluated on minimum 1-year postoperative radiographs. Regression analyses were performed on implant and clinical variables to assess for risk factors. A separate analysis was performed to determine the association of SaN with clinical outcomes.Results:SaN was identified in 13 out of 442 shoulders (2.9%). Age, sex, body mass index, smoking status, diabetes mellitus, arm dominance had no relationship with SaN. Neither glenoid sided lateralization nor humeral offset were associated with SaN risk. Other implant characteristics such as distalization, glenosphere size, and postoperative inclination did not influence SaN risk. The presence of SaN did not affect patient-reported outcomes (American Shoulder and Elbow Surgeons: P = .357, Visual Analog Scale: P = .210) or range of motion.Conclusion:The rate of SaN is low and not associated with glenoid or humeral prosthetic lateralization when using a 135° inlay humeral component. When SaN occurs, it is not associated with functional outcomes or range of motion at short-term follow-up.

BackgroundOptimal glenosphere positioning in a lateralized reverse shoulder arthroplasty (RSA) to maximize functional outcomes has yet to be clearly defined. Center of rotation (COR) measurements have largely relied on AP radiographs which allow assessment of lateralization and inferior position, but ignore scapular Y radiographs which may provide an assessment of posterior and inferior position relative to the acromion. The purpose of this study was to evaluate the COR in the sagittal plane and assess the effect of glenosphere positioning with functional outcomes utilizing a 135° inlay stem with a lateralized glenoid.MethodsA retrospective review was performed on a prospectively maintained multicenter database on patients who underwent primary RSA from 2015-2021 with a 135° inlay stem. The COR was measured on minimum 2-year postoperative sagittal plain radiographs using a perfect-circle fit method. A perfect circle was made on the glenosphere and the center was marked. From there, four measurements were made: 1) center to the inner cortex of the coracoid, 2) center to the inner cortex of the anterior acromion, 3) center to the inner cortex of the middle acromion, 4) center to the inner cortex of the posterior acromion. Regression analysis was performed to evaluate any association between the position of the COR relative to bony landmarks with functional outcomes.ResultsA total of 136 RSAs met the study criteria. There was no relation with any of the distances with outcome scores (ASES, VAS). In regards to range of motion (ROM), each distance had an effect on at least one parameter. The COR to coracoid distance had the broadest association with ROM with improvements in forward flexion (FF), external rotation (ER0), and internal rotation with arm at 90° (IR90) (p = <0.001, 0.031, <0.001; respectively). The COR to coracoid distance was also the only distance to affect the final FF and IR90. For every 1 mm increase in this distance, there was a 1.8° increase in FF and 1.5° increase in IR90 (ß = 1.78; 95% CI 0.85 – 2.72, p = <0.001, ß = 1.53; 95% CI 0.65 – 2.41, p = <0.001; respectively).ConclusionEvaluating the COR following RSA in the sagittal plane suggests that posteroinferior glenosphere position may improve ROM when using a 135° inlay humeral component and a lateralized glenoid.

Background: Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures. Description: The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling. Alternatives: Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty 1 . Rationale: The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part humeral fractures, including in elderly patients, when the humeral head fragment remains viable 1–5 . Expected Outcomes: Based on available Level-III and IV evidence using this technique, patients should expect recovered motion and the ability to perform daily activities independently, with a mean active elevation of 132° to 136° 1,4,6 , external rotation of 37° to 52° 1,4,6 , and internal rotation to L3 1 . Pain scores improved significantly from preoperatively to postoperatively, with a mean pain score of 1.4 on the visual analogue scale 3,4,6 . Patient-reported outcomes were good to excellent, with Single Assessment Numerical Evaluation (SANE) scores of 80% to 81% 1,6 , mean Constant scores from 71 to 81 1,3,4,6 , and high rates of patient satisfaction (97% satisfied or very satisfied) 4 . Studies also demonstrated good to excellent fracture healing, with no tuberosity migration and low rates of nonunion (0% to 5%) 1,6 and humeral head necrosis (0% to 4%) 1,4 . Revision rates ranged from 10.5% to 16.7% 4,6 . Important Tips: The starting position of the guide-pin must be central and at the zenith of the humeral head on the anteroposterior Grashey and the scapular Y views, and the guide-pin must be aligned with the diaphysis prior to advancing it. Failure to bluntly dissect the percutaneous incisions risks injury to the axillary nerve. Verify correct version of the nail prior to drilling any screws, to avoid incorrect version and potential loss of functional rotation. Acronyms and Abbreviations: ABD = abduction AP = anteroposterior CT = computed tomography ER = external rotation FF = forward flexion (forward elevation) IR = internal rotation SANE = Single Assessment Numerical Evaluation SSV = Subjective Shoulder Value VAS = Visual Analogue Scale

IntroductionIntramedullary nail (IMN) fixation for proximal humerus fractures have been shown to provide satisfactory results. The quality of reduction correlates with clinical outcomes, the rate of complications, avascular necrosis, and postoperative loss of fixation. The purpose of this study was to evaluate the clinical outcomes and complications of 2-part proximal humerus fractures compared to 3- or 4-part proximal humerus fractures.MethodsA single-center retrospective review was carried out of patients who underwent an IMN for a proximal humerus fracture by one of three surgeons between the years of 2009-2022, and who had a minimum of 12-months follow-up. Fracture pattern, ASES score, SANE score, satisfaction, pain score, range of motion (ROM), and complications were recorded. The mechanism of injury (high energy versus low energy), method of reduction (open versus percutaneous), and evidence of radiographic healing were assessed. A p-value of < 0.05 was considered to be statistically significant.ResultsThe study included 78 patients (62 female, 16 male). The number of patients in each group (2-part, N = 32 versus 3- or 4-part, N = 46), mean age (2-part, 64 versus 3- or 4-part,61), follow-up (2-part, 42.5 months versus 3- or 4-part,34.5 months), injury type (2-part, 88% low energy versus 3- or 4-part, 78% low energy), and method of reduction (2-part, 81% percutaneous versus 3- or 4-part 72% percutaneous) were similar among the two groups. There was fracture union in all patients. All patients demonstrated satisfactory patient-reported outcome measures. However, 2-part fractures did have a significantly lower pain score, higher SANE score, and higher percentage of patients being satisfied or very satisfied when compared to 3- or 4-part fractures. The rate of subsequent procedures was 13% (n=4) in 2-part fractures compared to 19% (n=9) in 3- or 4-part fractures but was not statistically significant (p=0.414). The overall rate of conversion to arthroplasty was 3.2% in 2-part fractures and 10.4% in 3- or 4-part fractures.ConclusionMultipart proximal humerus fractures remain difficult to treat. However, this study demonstrates an overall acceptable outcome with improvement in ROM, patient-reported outcomes, and similar complication rates between 2-part versus 3- or 4-part proximal humerus fractures. However, the improvement in certain parameters is not as marked in 3- or 4-part fractures as 2-part fractures.

Background:A proposed etiology of anterior shoulder pain and limited internal rotation after reverse shoulder arthroplasty (RSA) is impingement of the humeral component on the coracoid or conjoint tendon. The primary goal of this study was to investigate radiographic surrogates for potential coracoid or conjoint tendon impingement and their relationship to postoperative pain and internal rotation after RSA.Methods:A retrospective review of a clinical registry was performed to identify patients with (1) primary RSA, (2) minimum 2-year clinical follow-up, and (3) satisfactory postoperative axillary lateral radiographs. The primary radiographic measurement of interest was the subcoracoid distance (SCD), defined as the distance between the posterior aspect of the coracoid and the anterior glenosphere. Additional measurements were as follows: anterior glenosphere overhang, posterior glenosphere overhang, native glenoid width, lateralization of glenosphere relative to the coracoid tip, lateralization shoulder angle, and distalization shoulder angle. The primary clinical outcome of interest was the 2-year postoperative Visual Analog Scale score. Secondary outcomes were (1) internal rotation (IR) defined by spinal level (IRspine), (2) IR at 90 degrees of abduction, (3) American Shoulder and Elbow Surgeons score, (4) forward flexion, and (5) external rotation at 0 degrees of abduction. Linear regression analyses were used to evaluate the relationship of the various radiographic measures on the clinical outcomes of interest.Results:Two hundred seventeen patients were included. There was a statistically significant relationship between the SCD and Visual Analog Scale scores: B = -0.497, P = .047. There was a statistically significant relationship between the SCD and IRspine: B = -1.667, P < .001. Metallic lateralization was also positively associated with improving IRspine; increasing body mass index was negatively associated. There was a statistically significant relationship between the SCD and IR at 90 degrees of abduction: B = 5.844, P = .034.Conclusion:For RSA with a 135° neck shaft angle and lateralized glenoid, the postoperative SCD has a significant association with pain and IR. Decreasing SCD was associated with increased pain and decreased IR, indicating that coracoid or conjoint tendon impingement may be an important and potentially under-recognized etiology of pain and decreased IR following RSA. Further investigations aimed toward identifying a critical SCD to improve pain and IR may allow surgeons to preoperatively plan component position to improve clinical outcomes after RSA.

Background: Current methods available for assessment of radiolucency and in-between fin (IBF) growth of a glenoid component have not undergone interobserver reliability testing for an all-polyethylene fluted central peg (FCP) glenoid. The purpose of this study was to evaluate anteroposterior radiographs of an FCP glenoid component at >= 48 months comparing commonly used scales to a new method adapted to the FCP. Our hypothesis was that the new method would result in acceptable intra- and interobserver agreement and a more accurate description of radiographic findings. Methods: We reviewed >= 48-month follow-up radiographs of patients treated with a primary aTSA using an FCP glenoid. Eighty-three patients were included in the review. Radiographs were evaluated by 5 reviewers using novel IBF radiodensity and radiolucency assessments and the Wirth and Lazarus methods. To assess intraobserver reliability, a subset of 40 images was reviewed. Kappa statistics were calculated to determine intra- and interobserver reliability; correlations were assessed using Pearson correlation. Results: Interobserver agreement (K score) was as follows: IBF 0.71, radiolucency 0.68, Wirth 0.48, and Lazarus 0.22. Intraobserver agreement ranges were as follows: IBF radiodensity 0.36-0.67, radiolucency 0.55-0.62, Wirth 0.11-0.73, and Lazarus 0.04-0.46. Correlation analysis revealed the following: IBF to Wirth r = 0.93, radiolucency to Lazarus r = 0.92 (P value <.001 for all). Conclusion: This study introduces a radiographic assessment method developed specifically for an FCP glenoid component. Results show high interobserver and acceptable intraobserver reliability for the method presented in this study. The new scales provide a more accurate description of radiographic findings, helping to identify glenoid components that may be at risk for loosening. (c) 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

BACKGROUND:Glenoid-sided lateralization in reverse shoulder arthroplasty (RSA) decreases bony impingement and improves rotational range of motion, but has been theorized to increase the risk of acromial or scapular spine fractures (ASFs). The purpose of this study was to assess if glenoid-sided lateralization even up to 8 mm increases the risk for stress fracture following RSA with a 135° inlay humeral component.METHODS:A retrospective review was performed from a multicenter prospectively collected database on patients who underwent primary RSA from 2015 to 2021. All RSAs were performed with a 135° inlay humeral component. Varying amounts of glenoid lateralization were used from 0 to 8 mm. Preoperative radiographs were reviewed for the presence of acromial thinning, acromiohumeral distance (AHD), and inclination. Postoperative implant position (distalization, lateralization, and inclination) as well as the presence of ASF was evaluated on minimum 1-year postoperative radiographs. Regression analyses were performed on component and clinical variables to assess for factors predictive of ASF.RESULTS:Acromial or scapular spine fractures were identified in 26 of 470 shoulders (5.5%). Glenoid-sided lateralization was not associated with ASF risk (P = .890). Furthermore, the incidence of fracture did not vary based on glenoid-sided lateralization (0-2 mm, 7.4%; 4 mm, 5.6%; 6 mm, 4.4%; 8 mm, 6.0%; P > .05 for all comparisons). RSA on the dominant extremity was predictive of fracture (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.20-5.75; P = .037), but there was no relationship between patient age, sex, preoperative acromial thinning, or diagnosis and risk of fracture. Although there was no difference in mean postoperative AHD between groups (P = .443), the pre- to postoperative delta AHD was higher in the stress fracture group (2.0 ± 0.7 cm vs. 1.7 ± 0.7 cm; P = .015). For every centimeter increase in delta AHD, there was a 121% increased risk for fracture (OR 2.21, 95% CI 1.33-3.68; P = .012). Additionally, for every 1-mm increase in inferior glenosphere overhang, there was a 19% increase in fracture risk (P = .025).CONCLUSION:Up to 8 mm of glenoid-sided metallic lateralization does not appear to increase the risk of ASF when combined with a 135° inlay humeral implant. Humeral distalization increases the risk of ASF, particularly when there is a larger change between pre- and postoperative AHD or higher inferior glenosphere overhang. In cases of pronounced preoperative superior humeral migration, it may be a consideration to avoid excessive postoperative distalization, but minimizing bony impingement via glenoid-sided lateralization appears to be safe.

Background: Anatomic total shoulder arthroplasty (aTSA) is a successful and reproducible treatment for patients with painful gleno-humeral arthritis. However, long-term outcomes using traditional onlay glenoid components have been tempered by glenoid loosening. Inset components have been proposed to minimize glenoid loosening by reducing edge-loading and opposite-edge lift-off forces with humeral translation. Successful short-and long-term outcomes have been reported while using inset glenoid implants. The current study is the largest study presenting a minimum of 2-year follow-up data following aTSA with an all-polyethylene inset glenoid component (Shoulder Innovations, Holland, MI, USA).Methods: A dual center, retrospective review of patients undergoing aTSA using an Inset glenoid component by 2 fellowship-trained shoulder surgeons at 2 separate institutions from August, 2016, to August, 2019, was performed. Minimum follow-up was 2 years. Range of motion (ROM), visual analog scale (VAS) pain scores, Single Assessment Numeric Evaluation (SANE), and American Shoul-der and Elbow Surgeons (ASES) scores were obtained. Radiographic outcomes, including central peg lucency and glenoid loosening, were assessed by 3 independent reviewers on the postoperative Grashey and axillary radiographs obtained at the final follow-up.Results: Seventy-five shoulders were included for the final analysis. The mean age of the entire cohort was 64 (+/- 11.4) years. Twenty-one (28%) glenoids were type A1, 10 (13.3%) were type A2, 13 (17.3%) were type B1, 22 (29.3%) were type B2, 6 (8%) were type B3, and 3 (4%) were type D. At a minimum follow-up of 24 months (mean: 28.7 months), a significant improvement in ROM in all planes was observed. Significant improvements in VAS (5.1-0.9, P < .001), SANE (39.5-91.2, P < .001), and ASES (43.7-86.6, P < .001) scores were observed. There were 4 (5.3%) cases of central peg lucency about the inset glenoid component and one (1.3%) case of glenoid loosening. No revisions were performed for glenoid loosening.Conclusion: At a minimum of 2 years postoperatively, there were significant improvements in ROM, VAS, SANE, and ASES scores with very low rates of central peg lucency and glenoid loosening in patients undergoing aTSA with an inset glenoid component. Further work is needed to determine the long-term benefit of this novel implant.Level of evidence: Level IV; Case Series; Treatment Study (c) 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: Improvements in pain control after shoulder arthroplasty with a reduction in narcotic use continues to be an important postoperative goal. With the increased utilization of stemless anatomic total shoulder arthroplasty (aTSA), it is relevant to compare between stemmed and stemless arthroplasty to assess if there is any association between this implant design change and early postoperative pain. Methods: Patients from a multicenter, prospectively-maintained database who had undergone a stemless aTSA with a minimum of two year clinical follow-up were retrospectively identified. Patients who underwent aTSA with a short stem were identified in the same registry, and matched to the stemless aTSA patients by age, sex and preoperative pain score. The primary study outcome was the Visual Analog Scale pain score. Secondary pain outcomes were the American Shoulder and Elbow Surgeons shoulder pain subscore, Western Ontario Osteoarthritis of the Shoulder physical symptoms subscore, and the Single Assessment Numeric Evaluation score. Finally, the percentage of patients who could sleep on the affected shoulder was assessed for each group. These pain-related clinical outcomes were assessed and compared preoperatively, and postoperatively at 9 weeks, 26 weeks, one year and two years. For all statistical comparisons, P > .05 was considered significant. Results: 124 patients were included in the study; 62 in each group. At 9 weeks after surgery, statistically significantly improved pain control was reported by patients undergoing stemless aTSA, as assessed by the Visual Analog Scale (stemless: 1.5, stemmed: 2.5, P = .001), American Shoulder and Elbow Surgeons pain subscore (stemless: 42.4, stemmed: 37.3, P < .001), Western Ontario Osteoarthritis of the Shoulder Physical Symptoms (stemless: 80.3, stemmed: 73.1, P = .006) and Single Assessment Numeric Evaluation (stemless: 58.1, stemmed: 47.4, P = .011). Patients who underwent a stemless aTSA were significantly more likely to be able to sleep on the affected shoulder at 9 weeks (29% vs. 11%, odds ratio 3.2, 95% confidence interval 1.2-8.4, P = .014). By 26 weeks postoperatively, there were no differences in all pain-specific outcomes. At two years postoperatively, patient-reported outcomes, range of motion, and strength measures were all similar between the two cohorts. Conclusion: Stemless aTSA provides earlier improvement in postoperative shoulder pain compared to matched patients undergoing short-stem aTSA. Additionally, earlier return to sleeping on the affected shoulder was reported in the stemless aTSA group. The majority of these differences dissipate by 26 weeks postoperatively and there were no differences in pain, patient-reported outcomes, range of motion or strength measures between stemless and short-stem aTSA at 2 years postoperatively.