Background: Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of proximal humerus fractures (PHFs) with reliable clinical improvement. Lateralized RSA implants have conferred superior outcomes compared with the original Grammont design in patients with nontraumatic indications. However, in the setting of a PHF, lateralized components can place increased tension across the tuberosity fracture site and potentially compromise tuberosity healing and outcomes. This systematic review and meta-analysis sought to determine the effect of implant design on clinical outcomes after RSA for PHFs. Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported implant manufacturer details. Our primary outcomes included postoperative external rotation (ER), forward elevation (FE), abduction, Constant score, rate of greater tuberosity (GT) healing, and the incidence of complications compared between medialized vs. lateralized global implant design. Results: Globally lateralized RSA cohorts (478 RSAs total with cumulative lateral offset achieved through humeral or glenoid lateralization or both humeral and glenoid lateralization) were found to have a greater mean postoperative Constant score compared with globally medialized (medialized glenoid and medialized humerus) RSA cohorts with 1,494 total medialized RSAs (66 vs. 59, p = 0.006), but there was no significant difference regarding mean postoperative ER (30° vs. 22°, p = 0.078), FE (117° vs. 119°, p = 0.708), or abduction (103° vs. 107°, p = 0.377). On meta-regression, neither implant design nor tuberosity status significantly influenced postoperative ER, FE, abduction, or Constant score on meta-regression independent of mean follow-up and age at surgery. The rate of GT healing was greater in lateralized compared with medialized RSAs (88% vs. 72%, p < 0.001). On meta-regression, medialized RSA design was associated with a 73% lower odds of GT healing (odds ratio = 0.27, 95% confidence interval = 0.11-0.68, p = 0.007) independent of mean follow-up and age at surgery. Conclusion: Lateralized RSA implants conferred no significant functional benefit over medialized implants when used in patients with PHFs. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

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.

The diagnosis and optimal management of radial tunnel syndrome (RTS) is controversial with little consensus among the many possible pathophysiological mechanisms and surgical approaches. Thus, we performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on studies reporting outcomes of surgical treatment for RTS. PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases were queried. Patient demographics, surgical approach, intraoperative findings, postoperative patient-reported outcomes, and complications were recorded and synthesized. We included 11 studies comprising 401 upper extremities (381 patients). Of the included forearms, 54% (n = 155) were approached dorsally, and 46% (n = 130) were approached volarly. Studies that utilized a dorsal approach between the extensor carpi radialis brevis and extensor digitorum communis had the most favorable Roles and Maudsley scores and patient satisfaction when compared with volar approaches. However, volar approaches identified a greater number of constrictions at the arcade of Frohse (19% vs 7%) when compared with dorsal approaches. Wide variability of surgical approaches used for treatment of RTS is present in the literature. Compared with volar approaches, dorsal approaches are associated with favorable reported outcomes. However, in RTS secondary to vascular constriction, volar approaches may be better suited for release.

BACKGROUND:There has been a trend toward the use of shorter humeral components with the goal of preserving bone, decreasing operative time, and a theoretical decrease in stress shielding. The purpose of this study was to compare the clinical and functional outcomes of anatomic total shoulder arthroplasty among standard-length stem, short-stem, and stemless humeral components, with a minimum of 2-year follow-up. METHODS:A retrospective review of a multicenter international database was performed for anatomic total shoulder arthroplasty with a minimum of 2-year follow-up between 2018 and 2021 using Standard Equinoxe stems, Equinoxe Preserve (Short) stems, or Equinoxe Stemless components (Exactech, Inc., Gainesville, FL, USA). Outcome measures included range of motion and patient-reported outcome measures (PROMs). Postoperative radiographic findings including the presence of glenoid and humeral radiolucent lines in zones specific to the stem design were evaluated. Complication and revision rates were recorded. RESULTS:A total of 825 patients were included (164 standard-length stem, 356 short-stem, and 305 stemless). The mean follow-up was 37.9 ± 12.6 months. There was no significant difference in previous shoulder surgeries or medical comorbidities among the groups. The mean final forward elevation for standard-length stem, short-stem, and stemless components was 156°, 158°, and 156°, respectively (P = .636). Final external rotation for standard-length stem, short-stem, and stemless components was 58°, 57°, and 51°, respectively (P < .001). Final internal rotation scores were similar across groups (P = .090). Final PROMs did not meet the minimal clinically important difference across cohorts. The mean operative time for the standard-length stem group was 101.8 minutes, for the short-stem group 92.7 minutes, and for the stemless group 89.2 minutes (P < .001). There was no statistically significant difference in complication rate or revision rate. The rate of humeral component radiolucent lines was greater for standard-length stems (P < .001) with a rate of 11.9% for standard-length stem, 1.7% for short-stem, and 1.6% for stemless components. Patient satisfaction was also similar among the 3 cohorts (P = .757). CONCLUSIONS:Our findings demonstrate similar postoperative motion and PROM scores irrespective of the humeral stem component used. Complication and revision rates were similar for all 3 cohorts. Radiolucent lines were lowest with the stemless component. Early data support the use of stemless and short-stem humeral components that may be advantageous in decreasing operative time and preserving humeral bone for potential revision. Longer term studies are needed to confirm the survivability and durability of these shorter components.

Background The purpose of this study was to characterize trends in the demographic characteristics, comorbidities, and episode-of-care outcomes for patients who underwent primary elective anatomic and reverse total shoulder arthroplasty between 2012 and 2020. Methods The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patient demographic characteristics, comorbidities, and episode-of-care outcomes for patients who underwent primary elective anatomic and reverse total shoulder arthroplasty between 2012 and 2020 (n = 32,112). Trends in continuous and categorical variables were evaluated using linear regression and the Cochran-Armitage trend test, respectively. Results Over the study period, the proportion of patients ages 60-80 years undergoing elective total shoulder arthroplasty (TSA) increased, while patients ≤60 and >80 years decreased (P < .001). There was a trend towards increasing obesity in patients undergoing elective TSA (P = .008). There was a reduction in the proportion of white patients undergoing elective TSA, with a concomitant increase in minority patients during the study period (P < .001). There was an overall increase in the proportion of patients with an American Society of Anesthesiologists physical status score ≥3 (P < .001) and a history of heart failure (P = .014). Conversely, there was a decrease in the proportion of patients with hypertension requiring medication and patients who received dialysis (P = .038 and P = .006, respectively). The rate of 30-day medical complications decreased from 8.5% to 4.5% during the study period (P < .001). Conclusion Despite increasing medical complexity and increasing diversity of patients undergoing elective TSA during the study period (2012-2020), the rate of 30-day postoperative medical complication rates decreased. These findings demonstrate an improvement in the delivery of care in patients undergoing elective TSA. Reimbursement adjustments should reflect rising patient medical complexity, requiring a reevaluation of frameworks to align with evolving health care models and resource demands.

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:Baseplate failure is a rare but serious complication following reverse shoulder arthroplasty (rTSA), often leading to poor outcomes and revision surgery. Existing studies are limited by small samples or single-center designs. This multicenter study aimed to identify surgical, implant, and patient-related risk factors for baseplate failure after rTSA. METHODS:A multicenter, retrospective study was conducted across 15 U S. institutions involving 24 ASES surgeons. Patients who underwent rTSA from June 2013 to May 2019 with a minimum 3-month follow-up were included. Study parameters were established using the Delphi method. Patients with confirmed baseplate failure were compared to those without using univariate and multivariable logistic regression analyses. Failure was defined radiographically as gross baseplate shift or hardware breakage. RESULTS:Among 5,049 cases, 83 (1.6%) experienced baseplate failure at a median of 72 weeks post-surgery. Most failures (76%) were atraumatic; 12% were traumatic, and 12% had an unknown mechanism. Radiographs showed hardware breakage in 68.7% of the failures-33.3% involved central screw/post fractures and 86.0% involved peripheral screw fractures. Baseplate shift occurred in 78.3% of cases. Independent predictors of failure included revision arthroplasty (OR = 4.57; P < .001), use of bone graft (OR = 2.81; P < .001), and total glenoid-sided lateral offset (OR = 1.08; P = .002). Central screw fixation reduced failure risk (OR = 0.55; P = .014). In primary rTSA, bone grafting (OR = 4.42; P < .001) and lateral offset (OR = 1.07; P = .046) were significant predictors. In revision rTSA, only bone grafting remained significant (OR = 3.75; P < .001). Allograft use led to higher failure rates than autograft (14.7% vs 3.9%; P = .001). CONCLUSION:Revision surgery, bone grafting (especially allografts), and increased lateral offset were significantly associated with higher odds of baseplate failure after rTSA. Central screw fixation appears protective. Most failures were atraumatic, underscoring the importance of achieving stable bone ingrowth. These findings may inform surgical planning and patient counseling regarding factors associated with increased failure risk.

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.

While anatomic total shoulder arthroplasty is a successful procedure that provides reliable pain relief and restoration of function in most patients, its success has been limited by glenoid component loosening. While series reporting the outcomes of inlay glenoid components have demonstrated excellent clinical outcomes with low rates of component loosening and need for revision, surgeons have been hesitant to adopt these implants due to concerns of inadequate pain relief secondary to the remaining glenoid rim contacting the humeral head implant. The inset glenoid component, a variant of the traditional inlay components, has gained interest because its design aims to achieve similar stability to traditional inlay components through implantation within strong subchondral bone, reduce the amount of glenoid vault removed compared to inlay components, and has a glenoid face designed to limit the rocking-horse phenomenon. In limited series, the inset glenoid component has demonstrated superior biomechanical and clinical performance compared to traditional onlay glenoid components. Although there have been minimal clinical studies investigating the inset glenoid in comparison to onlay and inlay components to date, a subset of case series with short-term follow-up have demonstrated favorable outcomes. The purpose of this article was to review the design rationale, biomechanical evidence, and clinical performance of the inset glenoid component.

BACKGROUND:Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of proximal humerus fractures (PHFs) with reliable clinical improvement. Lateralized RSA implants have conferred superior outcomes compared with the original Grammont design in patients with nontraumatic indications. However, in the setting of a PHF, lateralized components can place increased tension across the tuberosity fracture site and potentially compromise tuberosity healing and outcomes. This systematic review and meta-analysis sought to determine the effect of implant design on clinical outcomes after RSA for PHFs. METHODS:A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported implant manufacturer details. Our primary outcomes included postoperative external rotation (ER), forward elevation (FE), abduction, Constant score, rate of greater tuberosity (GT) healing, and the incidence of complications compared between medialized vs. lateralized global implant design. RESULTS:Globally lateralized RSA cohorts (478 RSAs total with cumulative lateral offset achieved through humeral or glenoid lateralization or both humeral and glenoid lateralization) were found to have a greater mean postoperative Constant score compared with globally medialized (medialized glenoid and medialized humerus) RSA cohorts with 1,494 total medialized RSAs (66 vs. 59, p = 0.006), but there was no significant difference regarding mean postoperative ER (30° vs. 22°, p = 0.078), FE (117° vs. 119°, p = 0.708), or abduction (103° vs. 107°, p = 0.377). On meta-regression, neither implant design nor tuberosity status significantly influenced postoperative ER, FE, abduction, or Constant score on meta-regression independent of mean follow-up and age at surgery. The rate of GT healing was greater in lateralized compared with medialized RSAs (88% vs. 72%, p < 0.001). On meta-regression, medialized RSA design was associated with a 73% lower odds of GT healing (odds ratio = 0.27, 95% confidence interval = 0.11-0.68, p = 0.007) independent of mean follow-up and age at surgery. CONCLUSION:Lateralized RSA implants conferred no significant functional benefit over medialized implants when used in patients with PHFs. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Studies comparing anatomic and reverse total shoulder arthroplasty (aTSA, rTSA) for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA) frequently fail to control for selection bias secondary to glenoid bone loss. Comparisons of similar patient populations without glenoid deformity may better evaluate potential differences in outcomes. The purpose of this study is to compare the outcomes of a matched cohort of aTSA and rTSA patients with RCI-GHOA and no glenoid bone loss. METHODS:A retrospective review of primary aTSA/rTSA for RCI-GHOA with an A1 or B1 glenoid between 2007 and 2020 was performed. Matched cohorts were conceived based on age, sex, follow-up, Walch class, prior surgery, preoperative shoulder arthroplasty smart (SAS) score, preoperative forward elevation, and preoperative abduction. Range of motion, outcome scores, and rates of complications and reoperations were compared. RESULTS:A total of 310 matched shoulders (155 aTSA, 155 rTSA) were evaluated at a mean 3.2 years follow-up. Postoperatively, aTSAs had more favorable abduction (146 ± 27° vs. 133 ± 26°, P < .001), internal rotation score (4.6 ± 1.3 vs. 4.1 ± 1.3, P = .004), external rotation (53 ± 15° vs. 43 ± 14°, P < .001), Constant score (73.6 ± 10.5 vs. 70.5 ± 12.8, P = .039), and SAS score (81.1 ± 9.7 vs. 77.2 ± 10.2, P = .002). However, when assessing improvement from preoperative state, only abduction remained significantly greater in the aTSA cohort (60° vs. 47°, P = .024). Patients undergoing aTSA achieved substantial clinical benefit at a higher rate for abduction (78% vs. 64%, P = .034) and external rotation (61% vs. 45%, P = .034). There was no difference in the incidence of complications (3.9% vs. 1.9%, P = .501) or revision surgery (3.2% vs. 0.6%, P = .214). CONCLUSION:In patients with RCI-GHOA with no bone loss, treatment with rTSA demonstrated similar improvements compared to a matched aTSA cohort except for less improvement in abduction. rTSA does not appear to offer functional benefits over aTSA in this population. Longer term follow-up of this cohort needs to be considered to assess the longitudinal functional and revision rates of these patients.

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.

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 Many surgeons and practices have adopted age cutoffs for performing TSA. The purpose of this study was to determine whether there exists an age cutoff of increased risk for 30-day medical complications, unplanned readmissions, and death after elective total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried to identify patients aged 40-89 who underwent elective primary TSA from 2012-2020. Receiver operator curve analysis was used to attempt to identify a threshold in age that discriminated likelihood of a 30-day postoperative medical complications, unplanned readmissions, or death. The area under the curve (AUC) and the Matthews Correlation Coefficient (MCC) were determined for each model to identify their predictive value (AUC of 0.5 and MCC of 0 reflect no better than chance). Analyses were performed on the overall cohort and sub-cohorts stratified by sex, body mass index (BMI), and 5-item modified frailty index (mFI-5). Results We included 31,741 patients (56% female) that underwent elective primary TSA. 21% of patients had a mFI-5 of ≥2. The rate of 30-day postoperative medical complications, unplanned readmissions, and death was 6.3%, with unplanned readmissions (2.8%), intraoperative or postoperative transfusions (2.1%), and urinary tract infections (0.7%) being the most common complications. The AUC and MCC for the 30-day medical complications in the overall cohort (age threshold: 74-years old) were 0.59 and 0.08 respectively, reflecting poor predictive value. After stratifying based on sex, BMI, and mFI-5, the highest AUC and MCC values obtained were 0.62 and 0.14, reflecting poor predictive value. Conclusion Age cutoffs poorly predict the risk of 30-day medical complications, unplanned readmissions, or death after elective TSA. Rather than a strict age cutoff, surgeons should consider multivariable risk stratification tools and clinical acumen to identify patients at risk for early postoperative medical complications.

BACKGROUND:Shoulders capable of achieving active abduction greater than 90° following reverse total shoulder arthroplasty (rTSA) have been reported to exhibit better scapulohumeral rhythm (SHR) compared to those limited to less than 90 degrees of active abduction. This study aimed to calculate SHR in shoulders following semi-inlay rTSA and to investigate whether improved SHR is associated with better postoperative patient-reported outcome measures in shoulders achieving active abduction greater than 90°. METHODS:Twenty shoulders of 19 patients who underwent semi-inlay rTSA were analyzed. Each shoulder underwent computed tomography and fluoroscopy. Fluoroscopic images were acquired during scapular plane abduction. Using model-image registration techniques, the poses of 3-dimensional models were iteratively adjusted to match the silhouettes in the fluoroscopic images. SHR was defined as (ΔH-ΔS)/ΔS, where ΔH is the increment in humeral elevation angle and ΔS is the increment in scapular upward rotation angle. The mean postoperative SHR assessed from 20° to 90° of humeral abduction was used to divide the shoulders into 2 groups: SHR <2 or SHR ≥2. American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score was evaluated preoperatively and 1 year after surgery. RESULTS:The mean postoperative SHR was 1.7. Fourteen shoulders had SHR <2, while 6 shoulders had SHR ≥2. There were no significant differences in demographic data, preoperative active range of motion, or preoperative ASES scores between the groups. Although no significant differences in postoperative range of motion were observed, shoulders with SHR ≥2 had significantly higher postoperative ASES scores (94.3 ± 4.6) compared to those with SHR <2 (82.1 ± 9.4, P = .007). A significant positive correlation was observed between the postoperative ASES scores and both the mean SHR (r = 0.452, P = .045) and the overall SHR measured from arm at side to maximum abduction (r = 0.478, P = .033) across all shoulders. CONCLUSIONS:Shoulders following semi-inlay rTSA with SHR ≥2 exhibited significantly higher postoperative ASES scores compared to those with SHR <2. A significant positive correlation was also observed between the mean SHR and postoperative ASES scores across all shoulders, highlighting the positive impact of improved SHR on achieving superior postoperative patient-reported outcome measures.

Background: Patients with severe glenoid bone loss are at increased risk for poor implant fixation, scapular notching, dislocation, joint kinematic disturbances, and prosthetic failure following reverse total shoulder arthroplasty (rTSA). Glenoid bone grafting has proven useful when performing rTSA in patients with inadequate glenoid bone stock, although the current literature is limited. The purpose of this study is to evaluate clinical outcomes in patients with significant glenoid deformity undergoing primary rTSA with one-stage glenoid reconstruction using a humeral head autograft. Methods: A database of prospectively enrolled patients was reviewed to identify patients who underwent primary rTSA with humeral head autograft (n = 40) between 2008 and 2020 by 6 high-volume shoulder arthroplasty surgeons with a minimum 2-year follow-up. Variables studied included demographics, medical comorbidities, range of motion, Constant score, American Shoulder and Elbow Surgeons score, pain score, patient satisfaction, glenoid deformity, revisions, and complications. Preoperative glenoid deformity was characterized using glenoid version and beta-angles, measured on computed tomography. Improvement at final follow-up was compared to a matched control group of 120 standard primary rTSA patients. Following the post hoc Bonferroni correction, an adjusted alpha value of 0.004 was used to define statistical significance. Results: Forty patients were included with a mean follow-up of 5.3 (range, 2.0-13.2) years. Patients exhibited a mean preoperative glenoid retroversion and beta-angle of 29 degrees and 80 degrees, respectively. At final follow-up, patients who received a graft exhibited lower mean scores for active external rotation (25 degrees vs. 39 degrees; P = .001) in comparison to those who did not receive a graft. No differences were observed in active abduction (P = .029), active forward elevation (P = .009), active internal rotation (P = .147), passive external rotation (P = .082), Global Shoulder Function score (P = .157), Constant score (P = .036), American Shoulder and Elbow Surgeons score (P = .009), or pain score (P = .186) between groups. Seven patients (17.5%) exhibited complications of which the most common being aseptic glenoid loosening (15%). Conclusion: This study demonstrates that patients undergoing primary rTSA with autogenous humeral head autograft for severe glenoid deficiency experience postoperative improvements in range of motion and functional outcome scores that exceeded the minimal clinically important difference and substantial clinical benefit but inferior to matched controls. This suggests that glenoid reconstruction using a resected humeral head autograft is an effective strategy when conducting primary rTSA in patients with significant glenoid deformity. Level of evidence: Level III; Retrospective Cohort Design; 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: Pain relief plays a major deterministic role when assessing postoperative patient satisfaction; however, whether anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) provides the most durable pain relief has not been studied. The purpose of this study was to evaluate the durability of pain relief after aTSA compared with rTSA in patients undergoing surgery for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA). Methods: A retrospective review of a multicenter shoulder arthroplasty database (Exactech Equinoxe) was performed. We included 1848 aTSAs and 1464 rTSAs performed for RCI-GHOA between 2007 and 2023. Pain after surgery was assessed postoperatively at 3 months, 6 months, and yearly thereafter. Average postoperative pain on a daily basis and pain at worst were compared between aTSA and rTSA up to 8 years postoperatively. Kaplan-Meier survivorship analysis for pain relief maintenance was performed to compare the maintenance of clinically relevant pain relief defined as pain scores that achieved the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS). Maintenance of favorable patient satisfaction over time was also evaluated. Multivariable cox regression was performed to determine whether the type of prosthesis (aTSA vs. rTSA) was independently associated with pain recurrence. Results: Maintenance of achievement of the MCID and SCB for both daily pain and pain at worst as well as favorable patient satisfaction was similar between aTSAs and rTSAs. However, aTSA had longer maintenance of average daily pain below the PASS compared with rTSA (P 1/4 .024). This was confirmed on multivariable cox regression analysis, which found that rTSAs had a 34% greater likelihood of recurrence of postoperative average daily pain exceeding the PASS (visual analog scale score rating 1/10) compared with aTSAs. Conclusion: Patients who undergo either aTSA or rTSA for RCI-GHOA and achieve initial pain relief postoperatively can expect to maintain their clinically relevant pain improvement at similar rates up to 8 years postoperatively. However, recurrence of low levels of daily pain was significantly higher after rTSA.