Top fifty cited articles on humeral fractures.

Background: Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature. Methods: The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables. Results: Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = -0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01). Conclusion: The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.

Accuracy of machine learning to predict the outcomes of shoulder arthroplasty: a systematic review.

BACKGROUND: Artificial intelligence (AI) uses computer systems to simulate cognitive capacities to accomplish goals like problem-solving and decision-making. Machine learning (ML), a branch of AI, makes algorithms find connections between preset variables, thereby producing prediction models. ML can aid shoulder surgeons in determining which patients may be susceptible to worse outcomes and complications following shoulder arthroplasty (SA) and align patient expectations following SA. However, limited literature is available on ML utilization in total shoulder arthroplasty (TSA) and reverse TSA. METHODS: A systematic literature review in accordance with PRISMA guidelines was performed to identify primary research articles evaluating ML's ability to predict SA outcomes. With duplicates removed, the initial query yielded 327 articles, and after applying inclusion and exclusion criteria, 12 articles that had at least 1 month follow-up time were included. RESULTS: ML can predict 30-day postoperative complications with a 90% accuracy, postoperative range of motion with a higher-than-85% accuracy, and clinical improvement in patient-reported outcome measures above minimal clinically important differences with a 93%-99% accuracy. ML can predict length of stay, operative time, discharge disposition, and hospitalization costs. CONCLUSION: ML can accurately predict outcomes and complications following SA and healthcare utilization. Outcomes are highly dependent on the type of algorithms used, data input, and features selected for the model. LEVEL OF EVIDENCE: III.

Sleep disturbances in rotator cuff pathology: insights into mechanisms and clinical implications.

Rotator cuff disease is highly prevalent and can have a detrimental effect on the quality of life of affected patients. One of the most common complaints from rotator cuff disease is sleep disturbance due to shoulder pain. Numerous studies have attempted to explore the relationship between rotator cuff disease and sleep disturbance, but results are inconsistent and limited. In this setting, the Pittsburgh Sleep Quality Index (PSQI) plays an important role in preoperative assessment and evaluation of sleep in rotator cuff patients. However, despite the current efforts, the literature presents conflicting results regarding the relationships between magnetic resonance imaging characteristics of rotator cuff tear and PSQI score, signifying a gap in understanding. That being said, it has been shown that rotator cuff repair surgery can alleviate sleep disturbances witnessed preoperatively in and can restore quality of life.

Glenohumeral internal rotation deficit: insights into pathologic, clinical, diagnostic, and therapeutic characteristics.

Overhead athletes undergo significant biomechanical adaptations due to repetitive overhead movements, primarily affecting the glenohumeral joint. These adaptations can lead to glenohumeral internal rotation deficit (GIRD), which is characterized by posterior capsule stiffness that results in glenohumeral joint translation and a shift in the center of gravity. The severity of GIRD is dependent upon the presence of asymmetry between gained external and lost internal rotation, which is defined clinically as an asymmetry exceeding 20º; this reduces the total range of motion compared to the unaffected limb or baseline measurements. Diagnosis is challenging, as it can be mistaken for chronic scapular adaptations. To mitigate misdiagnosis, a high clinical suspicion is crucial in overhead athletes, especially those who began performing forceful overhead movements before closure of growth plates. Periodic physical examinations should establish baseline values for glenohumeral rotation and track changes in glenohumeral motion to aid in diagnosis. Symptoms of GIRD include shoulder pain, stiffness, and decreased force exertion. Magnetic resonance imaging is the preferred imaging method for evaluating GIRD and assessing concomitant soft tissue pathologies. Untreated GIRD can lead to rotator cuff strength imbalances. Treatment mainly involves conservative measures, such as physical therapy, to improve internal rotation and alleviate posterior tightness. Surgical interventions are considered when symptoms persist despite conservative treatment with physical therapy or in the presence of concomitant pathologies.

Editorial Commentary: Arthroscopic Subscapular Sling Procedure for Anterior Glenohumeral Instability Has Limitations: Dynamic Anterior Stabilization Using Long Head of the Biceps Tendon May Represent a More Favorable Alternative.

Anterior shoulder instability is common. Cases of mild glenoid bone loss are typically addressed with conventional arthroscopic Bankart repair procedures, whereas more critical glenoid bone loss often necessitates more invasive, bone-blocking procedures. Recently, for cases that fall between the need for arthroscopic repair and open procedures, surgeons have developed methods for using soft tissue grafts to create a "sling" effect and augment glenoid labral repair. The subscapular sling procedure aims to restore stability by introducing a semitendinosus autograft into the glenohumeral joint to reconstruct the torn labrum; the graft is wrapped around the subscapularis to create a suspensory sling. Limitations include harvest site morbidity; increased surgical time; subscapularis split, which can compromise the tendon integrity, resulting in loss of internal rotation; and a persistently positive apprehension test. Finally, the technique is complex, and similar alternatives with fewer limitations may include a dynamic anterior stabilization technique using the long head of the biceps tendon, which creates a stabilizing sling effect without graft harvest from the leg and has positive reported outcomes.

The "Balloon Dip": Insights into a Post-operative Trend in Patients Undergoing Subacromial Balloon Procedure.

Introduction: The subacromial balloon is a novel therapeutic device that is used in patients with massive irreparable rotator cuff tears (MIRCTs). The novelty of this device implies that there is still a lot to be known about its mechanism of action and rehabilitation trends. One rehabilitation trend that has been noticed is the "balloon dip", where a patient exhibits exacerbations in pain and function around 3 months following balloon implantation and after having experienced earlier symptomatic relief post-operative. We discuss the clinical, diagnostic, and therapeutic aspects of the patient's management while providing additional insight into this prognostic trend. Case Report: In this report, we present the case of a 65-year-old male patient who underwent a subacromial balloon procedure for a MIRCT. During his recovery, the patient exhibited a classic "balloon dip" evident by an exacerbation of pain and function around the 3-month mark. After a notable deterioration in pain and function, the patient was examined, reassured, and educated on the importance of adhering to physical therapy. He was able to successfully recover and showed gradual improvement in pain and function along the course of the year. Conclusion: The "balloon dip" is a rehabilitation pattern that occurs 3-6 months following subacromial balloon spacer implantation. In the majority of cases, careful clinical assessment, watchful monitoring, and education on the importance of following up with physical therapy are sufficient to overcome the dip.

Improving shoulder function and pain in a paraplegic patient with massive irreparable rotator cuff tear using a subacromial balloon spacer.

The subacromial balloon spacer is a promising treatment option for alleviating symptoms in patients with massive irreparable rotator cuff tears (MIRCTs). The balloon provides faster pain relief and easier rehabilitation than other options (such as arthroscopic partial rotator cuff repair). For a paraplegic MIRCT patient, the need for speedy recovery and rehabilitation is crucial, as these patients rely on their upper limbs for daily life activities and independence. In this report, we present a 60-year-old male paraplegic patient who presented to the clinic with an MIRCT of the right shoulder. After a holistic investigation and assessment of the patient, a subacromial balloon spacer with an upper border subscapularis repair was chosen as the treatment of choice. The patient had an uneventful recovery, and at the 1-year mark, had forward elevation of 170°, an American Shoulder and Elbow Surgeons score of 95, and a visual analogue scale pain score of 0.

Assessment of therapeutic clinical trials for proximal humeral fractures.

Background: Proximal humeral fractures (PHFs) are a common injury among the older population. An ideal therapeutic protocol has yet to be developed, and numerous clinical trials are being conducted to find the best therapeutic approach. The purpose of this study is to evaluate the current body of knowledge available via interventional clinical trials. Methods: In December 2022, interventional clinical trials relating to PHFs on Clinicaltrials.gov were screened. Trial characteristics included duration, status, intervention, phase, outcomes, location, and study design. Publications associated with each trial were searched on PubMed/Medline using the ClinicalTrials.gov registry number. Results: The final dataset comprised 64 trials. The majority was completed (36%), did not have an Food and Drug Administration-defined phase (67%), was randomized (81%), involved a single facility (72%), used a parallel assignment intervention model (80%), and used an open-label approach (45%). Eleven trials were associated with a publication, and the publication rate was 17%. Average enrollment was 86 participants, and mean trial duration was 51.4 months. Europe/UK/Russia/Turkey participated in the most trials (70%). Most of the trials were initiated after 2010 (87.5%). Procedure-related interventions (55%) were most common. Disability/function was the most common primary outcome assessed (61%). Conclusions: The low publication rate and the multitude of trials conducted after 2010 highlight the urgency and need for trial results to be published to establish an ideal therapeutic protocol. Since the majority of the trials involved a single institution and an open-label approach, reinforcing blinding and establishing multi-centered trials can improve the validity of the clinical trial results.

Five-Year Mortality Rates Following Elective Shoulder Arthroplasty and Shoulder Arthroplasty for Fracture in Patients Over Age 65.

Background: To effectively counsel patients prior to shoulder arthroplasty, surgeons should understand the overall life trajectory and life expectancy of patients in the context of the patient's shoulder pathology and medical comorbidities. Such an understanding can influence both operative and nonoperative decision-making and implant choices. This study evaluated 5-year mortality following shoulder arthroplasty in patients ≥65 years old and identified associated risk factors. Methods: We utilized Centers for Medicare & Medicaid Services Fee-for-Service inpatient and outpatient claims data to investigate the 5-year mortality rate following shoulder arthroplasty procedures performed from 2014 to 2016. The impact of patient demographics, including fracture diagnosis, year fixed effects, and state fixed effects; patient comorbidities; and hospital-level characteristics on 5-year mortality rates were assessed with use of a Cox proportional hazards regression model. A p value of <0.05 was considered significant. Results: A total of 108,667 shoulder arthroplasty cases (96,104 nonfracture and 12,563 fracture) were examined. The cohort was 62.7% female and 5.8% non-White and had a mean age at surgery of 74.3 years. The mean 5-year mortality rate was 16.6% across all shoulder arthroplasty cases, 14.9% for nonfracture cases, and 29.9% for fracture cases. The trend toward higher mortality in the fracture group compared with the nonfracture group was sustained throughout the 5-year postoperative period, with a fracture diagnosis being associated with a hazard ratio of 1.63 for mortality (p < 0.001). Medical comorbidities were associated with an increased risk of mortality, with liver disease bearing the highest hazard ratio (3.07; p < 0.001), followed by chronic kidney disease (2.59; p < 0.001), chronic obstructive pulmonary disease (1.92; p < 0.001), and congestive heart failure (1.90; p < 0.001). Conclusions: The mean 5-year mortality following shoulder arthroplasty was 16.6%. Patients with a fracture diagnosis had a significantly higher 5-year mortality risk (29.9%) than those with a nonfracture diagnosis (14.9%). Medical comorbidities had the greatest impact on mortality risk, with chronic liver and kidney disease being the most noteworthy. This novel longer-term data can help with patient education and risk stratification prior to undergoing shoulder replacement. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Insertion of a Subacromial Balloon Spacer Can Provide Symptom Relief and Functional Improvement at a Minimum 5-Year Follow-Up in Patients With Massive Irreparable Rotator Cuff Tears.

Purpose: To examine long-term patient-reported outcomes and range of motion in patients with massive irreparable rotator cuff tears (MIRCTs) who underwent subacromial balloon spacer implantation. Methods: A retrospective review of all patients who underwent subacromial balloon placement procedure for MIRCTs at our institution was conducted. Patients with adequate preoperative and postoperative data, with at least 5 years of follow-up, were included in our study. Outcome measures were range of motion (forward elevation), American Shoulder and Elbow Surgeon (ASES) score, and visual analog scale (VAS) score. Independent t test was conducted to check for statistically significant differences between preoperative and postoperative outcome scores, with P < .05 deemed significant. Results: Ten patients were identified: 4 were lost to follow-up beyond 2 years and were excluded. One was converted to an arthroplasty at the 1-year mark and was then lost to follow-up (conversion rate: 16.6%). Five patients had at least 5 years of follow-up after the balloon procedure and were involved in our case series analysis. Mean age was 63.1 years, and mean follow-up was 5.8 years (range, 5-7 years). Preoperatively, mean forward elevation was 110 degrees, mean ASES score was 40.68, and mean VAS score was 6.2. On follow-up, mean forward elevation was 163 degrees (P = .007), mean ASES score was 90.97 (P = .001), and mean VAS score was 0.9 (P = .004). All patients showed significant improvements in all outcome measures, and none had any significant complications. Conclusions: In this study, we found that the use of a subacromial balloon spacer can lead to good outcomes at a minimum 5-year follow-up in patients with MIRCTs. Level of Evidence: Level IV, therapeutic case series.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data.

INTRODUCTION: Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty. METHODS: Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes. RESULTS: A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time (P < 0.001). DISCUSSION: TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued. LEVEL OF EVIDENCE: Level III, therapeutic retrospective cohort study.

Is Arthroscopic Latarjet a Cost-Effective Procedure? A Decision Analysis.

Objectives: Arthroscopic Latarjet for glenohumeral stabilization has emerged as an alternative to the open approach; however, the evidence to date has questioned if this technique delivers improved outcomes. This analysis provides an assessment of the cost and utility associated with arthroscopic versus open Latarjet. Methods: The cost-effectiveness of Latarjet stabilization was modeled over a ten-year period. Institutional cases were reviewed for equipment utilization. Cost data from ambulatory surgical centers was obtained for each piece of equipment used intraoperatively. Based upon prior analyses, the operating room cost was assigned a value of $36.14 per minute. To determine effectiveness, a utility score was derived based upon prior analysis of shoulder stabilization using the EuroQol (EQ) 5D. For reoperations, a utility score of 0.01 was assigned for a single year for revision surgeries for instability and 0.5 for minor procedures. Probability of surgical outcomes and operative time for arthroscopic and open Latarjet were taken from prior studies comparing outcomes of these procedures. Decision-tree analysis utilizing these values was performed. Results: Based upon equipment and operating room costs, arthroscopic Latarjet was found to cost $2,796.87 more than the equivalent open procedure. Analysis of the utility of these procedures were 1.330 and 1.338 quality adjusted life years obtained over the modeled period for arthroscopic versus open Latarjet, respectively. For arthroscopic Latarjet to be cost-equivalent to open Latarjet, surgical time would need to be reduced to 41.5 minutes or the surgical equipment would need to be provided at no expense, while maintaining the same success rates. Conclusion: With nearly identical utility scores favoring open surgery, the added cost associated with arthroscopic Latarjet cannot be supported with available cost and utility data. To provide value, additional benefits such as decreased post-operative narcotic utilization, decreased blood loss, or lower complications of the arthroscopic approach must be demonstrated.

Strategies to Mitigate Bleeding in Shoulder Arthroplasty in the Setting of an Arteriovenous Fistula: A Report of 3 Cases.

CASE: Arteriovenous (AV) fistula in the ipsilateral extremity for hemodialysis presents unique challenges during shoulder arthroplasty. We describe 3 cases of shoulder arthroplasty performed through a deltopectoral approach on the ipsilateral side of an AV fistula. In all cases, the cephalic vein was found to be arterialized with increased diameter and thickness. All procedures were successfully performed without injury to the arterialized cephalic vein. CONCLUSION: This report highlighted strategies to mitigate catastrophic bleeding from an arterialized cephalic vein during shoulder arthroplasty, which includes preoperative cross-matching, expeditious vascular surgery availability, meticulous surgical dissection, and careful retractor placement.

Surgical management of biconcave glenoids: a scoping review.

Biconcave (B2) glenoids, characterized by significant posterior glenoid bone loss and a biconcave wear pattern, are a challenging pathology in shoulder surgery. Significant bone defects present in B2 glenoids increases the risk of complications and rates of failure for operative patients with glenohumeral osteoarthritis. Diagnosing this entity is of pivotal importance, and can be accomplished with imaging and a comprehensive clinical investigation. There are no clear-cut guidelines for management, but options include hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse shoulder arthroplasty. In recent years, modern techniques such as corrective reaming, bone grafts, and the use of augmented components have improved patient outcomes. Educating prospective patients is essential for reaching a shared management decision, setting appropriate expectations, and optimizing prognostic outcomes.

Beyond the joint: Exploring the interplay between mental health and shoulder arthroplasty outcomes.

Considering the fact that mental health illnesses increase with age, and that shoulder arthroplasty procedures are often indicated in the older population, exploring the relationship between mental health and shoulder arthroplasty outcomes can have pivotal implications for shoulder surgeons and patients worldwide. The literature has shown that patients with poor mental health report lower patient-reported outcomes, higher peri-operative complications (such as anemia, infection, delirium, and others), lengthier hospital stays, and higher readmission rates than the normal patient. Employing a holistic approach when managing shoulder arthroplasty patients is necessary for optimizing outcomes and setting up recovery expectations.

Distal Radius Allograft for Glenohumeral Instability: A Novel Osteochondral Allograft Reconstruction Option in the Setting of Glenoid Bone Loss.

BACKGROUND: Distal tibial allograft (DTA) reconstruction for glenoid bone loss is nonanatomic, as it does not match the glenoid radius of curvature (ROC) in the anterior-posterior (AP) plane. The dorsal articular portion of the distal radius has not been previously described as an allograft reconstruction option for glenoid bone loss. PURPOSE: To evaluate distal radius fresh-frozen allograft (DRA) as a potential match for glenoid reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Eighteen fresh-frozen human cadaveric specimens-including 6 shoulder, 6 wrist, and 6 tibia specimens-were used. The ROC and the graft length were measured in the superior-inferior (SI) plane. A 30% defect was created in all glenoid specimens, and both DTAs and DRAs were harvested to assess graft fit after fixation. Computed tomography analysis was used to assess bony ROC and bone mineral density (BMD). RESULTS: The cadaveric specimens had a mean age of 77 years. The mean SI glenoid length was 39.7 mm compared with 36.8 mm for the DRA and 30 mm for the DTA. The ROC in the SI plane was 29 ± 5.3 mm for the glenoid, 37.8 ± 4.9 mm for the DRA, and 24 ± 3.7 mm for the DTA. In the AP plane, the ROC was 39.6 ± 6.6 mm for the glenoid, 30.4 ± 18.6 mm for the DRA, and 126.3 ± 9.5 mm for the DTA. On computed tomography analysis, the ROC in the SI plane was 30.4 ± 1.5 mm for the glenoid, 30.3 ± 5.6 mm for the DRA, and 24.5 ± 9.4 mm for the DTA. In the AP plane, the ROC was 30.8 ± 2 mm for the glenoid, 19.1 ± 2.3 mm for the DRA, and 46.7 ± 21.7 mm for the DTA. The BMD was 226.3 ± 79 Hounsfield units (HU) for the glenoid, 228.5 ± 94.7 HU for the DRA, 235 ± 96.2 HU for the coracoid process, and 235.1 ± 84.6 HU for the DTA. CONCLUSION: Compared with the DTA, the DRA had a greater mean graft length in the SI plane, providing utilization in cases of larger bony defects; the DRA has a more acute ROC in the AP plane (closer to that of the glenoid), providing a greater potential buttress to anterior humeral translation. Compared with currently utilized grafts, the DRA BMD was not significantly diminished. This study presents the DRA as a novel allograft reconstruction option in the setting of anterior glenoid bone loss; further biomechanical and clinical investigation is indicated.

International Medical Graduates in US Orthopedic Residency Programs: A Comprehensive Analysis.

BACKGROUND: This study aims to provide insight regarding the different qualities of international medical graduates (IMGs) involved in US orthopedic residency programs. METHODS: Orthopedic residency programs accredited by the ACGME and listed in the AMA database were screened. Data on program size and location, IMG year of training, the geographic region of IMG's medical schools, their research experiences and number of gap years were included. RESULTS: A total of 167(80.3%) orthopedic residency programs were included. A total of 3838 residents were identified, of which 44 (1.15%) were IMGs. The United Kingdom and Ireland had the highest number of matched IMGs with four (9.1%) each. Massachusetts was the state with the highest number of enrolled IMGs. On average, IMGs had 26.3 publications and joined US orthopedic residency 4.66 years following medical school graduation. CONCLUSION: Despite the many hurdles experienced by IMGs, a decent number succeeds in matching into US orthopedic residency programs each year.

Midterm outcomes of suture anchor fixation for displaced olecranon fractures.

BACKGROUND: Displaced olecranon fractures constitute a challenging problem for elbow surgeons. The purpose of this study is to evaluate the role of suture anchor fixation for treating patients with displaced olecranon fractures. METHODS: A retrospective review was performed for all consecutive patients with displaced olecranon fractures treated with suture anchor fixation with at least 2 years of clinical follow-up. Surgical repair was performed acutely in all cases with nonmetallic suture anchors in a double-row configuration utilizing suture augmentation via the triceps tendon. Osseous union and perioperative complications were uniformly assessed. RESULTS: Suture anchor fixation was performed on 17 patients with displaced olecranon fractures. Functional outcome scores were collected from 12 patients (70.6%). The mean age at the time of surgery was 65.6 years, and the mean follow-up was 5.6 years. Sixteen of 17 patients (94%) achieved osseous union in an acceptable position. No hardware-related complications or fixation failure occurred. Mean postoperative shortened disabilities of the arm, shoulder, and hand (QuickDASH) score was 3.8±6.9, and mean Oxford Elbow Score was 47.5±1.0, with nine patients (75%) achieving a perfect score. CONCLUSIONS: Suture anchor fixation of displaced olecranon fractures resulted in excellent midterm functional outcomes. Additionally, this technique resulted in high rates of osseous union without any hardware-related complications or fixation failures. Level of evidence: IV.

Stemless Reverse Shoulder Arthroplasty.

Since the Food and Drug Administration (FDA) approval nearly two decades ago, the indications for and utilization of reverse shoulder arthroplasty (RSA) have expanded considerably. Stemless RSA designs have been used in Europe since 2005, but have only recently been introduced in domestic Investigational Device Exemption trials. Potential advantages of stemless RSA are similar to those of stemless anatomic total shoulder arthroplasty, which may include fewer shaft-related complications, avoidance of stress shielding, bone preservation, and easier revision surgery. European data support similar outcomes between certain stemless RSA prostheses compared with that of stemmed RSA implants at early and mid-term follow-up. However, long-term outcomes remain to be seen and differences exist between the stemless RSA designs used in Europe and those being studied in domestic clinical trials. An understanding of the potential advantages and disadvantages of stemless RSA, differences between existing designs, and reported clinical outcomes is prudent for the safe and meaningful implementation of this new technology in the United States.

Pyrocarbon hemiarthroplasty and the shoulder: biomechanical and clinical results of an emerging treatment option.

While shoulder hemiarthroplasty is still used to treat young patients with shoulder pathology, the use of this procedure has substantially declined in recent years due to its significant complication profile. Glenoid wear with arthrosis is one of the major postoperative complications following shoulder hemiarthroplasty, and efforts to prevent this complication led many scientists to explore alternative weight-bearing surfaces on arthroplasty implants to decrease joint wear and improve patient outcomes. Pyrolytic carbon, or pyrocarbon, is a material that has better biocompatibility, survivorship, strength, and wear resistance compared to the materials used in traditional shoulder hemiarthroplasty. Pyrocarbon implants have been used in orthopedics for over 50 years; recently, their utility in shoulder hemiarthroplasty has garnered much interest. The purpose behind the use of pyrocarbon in shoulder hemiarthroplasty is to decrease the risk of progressive glenoid wear, especially in young active patients in whom joint preservation is important. Promising survivorship and outcomes have been demonstrated by recent studies, including limited glenoid wear following pyrocarbon hemiarthroplasty. Nevertheless, these clinical studies have been limited to relatively small case series with limited long-term follow-up. Accordingly, additional research and comparative studies need to be conducted in order to properly assess the therapeutic efficacy and value of pyrocarbon hemiarthroplasty.