Glenoid structural bone grafting in reverse total shoulder arthroplasty: clinical and radiographic outcomes.

BACKGROUND: Current options for reconstruction of large glenoid defects in reverse total shoulder arthroplasty (RTSA) include structural bone grafting, use of augmented components, or 3D-printed custom implants. Given the paucity in the literature on structural bone grafts in RTSA, this study reflects our experience on clinical and radiographic outcomes of structural bone grafts used for glenoid defects in RTSA. METHODS: We identified 33 consecutive patients who underwent RTSA using structural bone grafts for glenoid bone loss between 2008 and 2019. Twenty-six patients with a mean clinical follow-up of 4.4 ± 3.9 years and a mean radiographic follow-up of 2.7 ± 3.2 years were included. Patient demographic data, perioperative functional outcomes, radiographic outcomes, complications, and reoperation rates were determined. RESULTS: Between 2008 and 2019, 26 RTSAs were performed using structural autograft or allograft for glenoid defects. There were 20 females (77%) and 6 males (23%), with a mean presenting age of 68 years (range 41-86), mean BMI of 29 (range 21-44), and mean Charlson Comorbidity Index of 3 (range 0-8). There were 19 cases of central glenoid defects, and 7 were combined central and peripheral defects. Structural grafts included humeral head autograft (7), proximal humerus autograft (7), iliac crest autograft (7), distal clavicle autograft (2), and femoral head allograft (3). All 18 revision RTSA cases had simultaneous humeral-sided revision. There was significant postoperative improvement in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores (27.0 ± 12.6 preoperation vs. 59.8 ± 24.1 postoperation; P < .001) and visual analog scale scores (8.1 ± 3.6 preoperation vs. 3.0 ± 3.2 postoperation; P < .001). Range of motion improved significantly for active forward elevation (63° ± 36° preoperation vs. 104° ± 36° postoperation; P < .001) and external rotation (21° ± 20° preoperation vs. 32° ± 23° postoperation, P = .036). Eighty-eight percent of cases (23 of 26) had successful reconstruction of the glenoid, defined as no visible radiolucent lines nor glenoid component migration at final follow-up. The reoperation rate was 19% (5 of 26). Postoperative complications included 2 cases of acromial stress fractures that were treated nonoperatively, for a total complication rate (including reoperation) of 27% (7 of 26 cases). CONCLUSIONS: The use of structural bone autografts and allografts in RTSA was associated with improved outcome scores and range of motion. A reoperation rate of 19% and total complication rate of 27% were reported for these challenging cases. However, 86% of these complications were not related to structural glenoid reconstruction failure. Structural grafts are a reasonable option for glenoid reconstruction in RTSA cases with glenoid bone loss.

High accuracy of intra-articular needle position during anterior landmark guided glenohumeral injections.

OBJECTIVES: Image-guided ultrasound or fluoroscopic glenohumeral injections have high accuracy rates but require training, equipment, cost, and radiation exposure (fluoroscopy). In contrast, landmark-guided glenohumeral injections do not require additional subspecialist referrals or equipment. An optimal technique would be safe and accurate and have few barriers to implementation. The purpose of this study was to define the accuracy of glenohumeral needle placement via an anterior landmark-guided approach as assessed by direct arthroscopic visualization. METHODS: A consecutive series of adult patients undergoing shoulder arthroscopy in the beach chair position were included in this study. Demographic and procedural data were collected. The time required to perform the injection, the precise location of the needle tip, and factors that affected the accuracy of the injection were also assessed. RESULTS: A standardized anterior landmark-guided glenohumeral joint injection was performed in the operating room prior to surgery, and the location of the needle tip was documented by arthroscopic visualization with a low complication profile and few barriers to implementation. A total of 81 patients were enrolled. Successful intra-articular glenohumeral needle placement by sports medicine and shoulder/elbow fellowship-trained orthopedic surgeons was confirmed in 93.8% (76/81) of patients. The average time to complete the procedure was 24.8 â€‹s. There were no patient-related variables associated with nonintra-articular injections in the cohort. CONCLUSIONS: This study demonstrated that the technique of anterior landmark-guided glenohumeral injection has an accuracy of 93.8% and requires less than 30 â€‹s to perform. This method is safe, yields similar accuracy to image-guided procedures, has improved cost and time efficiency, and requires less radiation exposure. No patient-related factors were associated with inaccurate needle placement. Anterior landmark-guided glenohumeral injections may be utilized with confidence by providers in the clinical setting. LEVEL OF EVIDENCE: Level 5. IRB: Approved under Stanford IRB-56323.

No significant difference in risk of prolonged opioid use following outpatient versus inpatient total shoulder arthroplasty: A propensity matched analysis.

Background: The purpose of this investigation was to compare rates of filled opioid prescriptions and prolonged opioid use in opioid naïve patients undergoing total shoulder arthroplasty (TSA) in inpatient versus outpatient settings. Methods: A retrospective cohort study was conducted using a national insurance claims database. Inpatient and outpatient cohorts were created by identifying continuously enrolled, opioid naïve TSA patients. A greedy nearest-neighbor algorithm was used to match baseline demographic characteristics between cohorts with a 1:1 inpatient to outpatient ratio to compare the primary outcomes of filled opioid prescriptions and prolonged opioid use following surgery between cohorts. Results: A total of 11,703 opioid naïve patients (mean age 72.5 ± 8.5 years, 54.5% female, 87.6% inpatient) were included for analysis. After propensity score matching (n = 1447 inpatients; n = 1447 outpatients), outpatient TSA patients were significantly more likely to fill an opioid prescription in the perioperative window compared to inpatients (82.9% versus 71.5%, p < 0.001). No significant differences in prolonged opioid use were detected (5.74% inpatient versus 6.77% outpatient; p = 0.25). Conclusions: Outpatient TSA patients were more likely to fill opioid prescriptions compared to inpatient TSA patients. The quantity of opioids prescribed and rates of prolonged opioid use were similar between the cohorts. Level of evidence: Therapeutic Level III.

Limited Biomechanical Evidence Behind Single Row Versus Double Row Repair of Subscapularis Tears: A Systematic Review.

Purpose: To systematically review the literature for studies investigating the biomechanical properties of constructs used to repair isolated subscapularis tears in time zero human cadaveric studies. Methods: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three electronic databases were searched for studies that reported on the construct technique and biomechanical outcomes for the repair of isolated subscapularis tears in human cadaveric specimens. Ultimate load, gap formation, stiffness, and failure mode were documented. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS) scale. Results: Six articles qualified (104 shoulders [72 single-row, 26 double-row, 6 transosseous]; mean QUACS score 10.5 ± 1) and were analyzed. Studies varied in the number and type of anchors and construct technique (1-2 anchors single-row; 3-4 anchors double-row; bioabsorbable or titanium anchors) and suture(s) used (no. 2 FiberWire or FiberTape), subscapularis tear type (25%, 33%, 50%, or 100% tear), and whether a knotless or knotted fixation was used. In studies that created full-thickness, upper subscapularis tears (Fox-Romeo II/III or Lafosse II), no significant differences were seen in ultimate load, gap formation, and stiffness for knotted versus knotless single-row repair (2 studies) and single-row versus double-row repair (1 study). Double-row repair of complete subscapularis tears demonstrated higher ultimate load, stiffness, and lower gap formation in 1 study. Ultimate load differed between the studies and constructs (single-row: range, 244 N to 678 N; double-row: range 332 N to 508 N, transosseous: 453 N). Suture cutout was the most common mode of failure (59%). Conclusion: Because of the limited number of studies and varying study designs in examining the biomechanical properties of repair constructs used for subscapularis tears, there is inconclusive evidence to determine which construct type is superior for repairing subscapularis tears. Clinical Relevance: Results from biomechanical studies of clinically relevant subscapularis repair constructs are important to guide decision-making for choosing the optimal construct for patients with subscapularis tears.

Outcomes after resection arthroplasty versus permanent antibiotic spacer for salvage treatment of shoulder periprosthetic joint infections: a systematic review and meta-analysis.

BACKGROUND: Although revision to new components is favored after shoulder periprosthetic joint infections (PJIs), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I2 statistic. A P value of .05 was set as significant. RESULTS: The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37-78.5 years, mean Methodological Index for Non-Randomized Studies score 9.6 ± 0.7) were included and analyzed. The pooled infection eradication rate was 82% (72%-89%) after resection arthroplasty and 85% (79%-90%) after permanent antibiotic spacer. The pooled mean forward flexion (71.5° vs. 48.7°; P < .001) and mean American Shoulder and Elbow Surgeons score (53.5 vs. 31.0; P < .001) were significantly higher for patients treated with a permanent antibiotic spacer compared with resection arthroplasty. No significant differences were found for mean external rotation (13.5° vs. 20.5°; P = .07), abduction (58.2° vs. 50.3°; P = .27), or visual analog scale pain (3.7 vs. 3.4; P = .24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 vs. 30.0; P < .001). CONCLUSION: When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.

Arthroscopic Single and Double Row Repair of Isolated and Combined Subscapularis Tears Result in Similar Improvements in Outcomes: A Systematic Review.

PURPOSE: To systematically review the literature to (1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and (2) compare outcomes after single- and double-row subscapularis repair in both of these settings. METHODS: A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis retears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis. RESULTS: The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 ± 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs used single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in 5 studies comparing isolated to combined tears. Subscapularis retear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and retear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (P > .05 for all). CONCLUSION: Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless of whether tears were isolated or combined or if repairs were single or double row. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Pain management in shoulder arthroplasty: a systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically review the literature for randomized controlled trials reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched for Level I-II randomized controlled trials that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, and other modalities. The 2 primary outcome measures were pain level measured on a 0-10 visual analog scale and opioid use. The risk of study bias and methodologic quality were analyzed using The Cochrane Collaboration's Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for visual analog scale pain scores at postsurgical time points and opioid use using a frequentist approach and random-effects model, with heterogeneity quantified using the I2 statistic. Treatments were ranked using the P score, and statistical significance was set at P < .05. RESULTS: The initial search yielded 2391 articles (695 duplicates, 1696 screened, 53 undergoing full-text review). Eighteen articles (1358 shoulders; 51% female patients; mean age range, 65-73.7 years; 4 studies with low risk of bias, 12 with some risk, and 2 with high risk) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) injection (P < .001 for 4 and 8 hours) or local ropivacaine injection (P < .001 for 4 hours and P = .019 for 8 hours) had significantly more pain compared with patients who received either a continuous interscalene block (cISB) or single-shot interscalene block (ssISB). No differences in opioid use (at P < .05) were detected between modalities. The P scores of treatments demonstrated that ssISBs were most favorable at time points < 24 hours, whereas pain at 24 and 48 hours after surgery was best managed with cISBs or a combination of an ssISB with a local LB injection. CONCLUSION: Interscalene blocks are superior to local injections alone at managing pain after TSA. Single-shot interscalene blocks are optimal for reducing early postoperative pain (< 24 hours), whereas pain at 24-48 hours after surgery may be best managed with cISBs or a combination of an ssISB with a local LB injection.

Instability after reverse total shoulder arthroplasty.

BACKGROUND: This study evaluated patients with and without a prosthetic dislocation after reverse total shoulder arthroplasty (RTSA) to identify risk factors for instability. METHODS: Dislocation and nondislocation cohorts were established for analysis in 119 patients who had undergone RTSA at our institution between 2011 and 2014. Preoperative history and parameters pertaining to RTSA design were evaluated for correlation with instability. A logistic regression model was used to analyze independent predictors. RESULTS: Eleven patients (9.2%) demonstrated instability in the early postoperative period. Dislocations occurred at an average of 8 weeks postoperatively (range, 3 days-5 months). The mean follow-up of all patients was 28 months (range, 6-106 months). Postoperative instability was associated with male gender, history of prior open shoulder surgery, and preoperative diagnoses of fracture sequelae, particularly proximal humeral or tuberosity nonunion. Absence of subscapularis repair was an independent predictor of instability. In addition, 5 of the 11 patients (45%) in the instability cohort sustained a second dislocation requiring another operation. CONCLUSIONS: Redislocation after revision surgery for the initial dislocation was an unexpected and alarming finding. Treatment for the initial dislocation event by placement of a thicker polyethylene insert was inadequate in 45% of patients of our cohort and required another revision with a larger glenosphere and thicker humeral inserts. Initial instability after RTSA must be carefully managed, especially in the revision and post-traumatic setting. Exchange to a thicker polyethylene insert only carries a higher risk of recurrent instability.

Are Age and Patient Gender Associated With Different Rates and Magnitudes of Clinical Improvement After Reverse Shoulder Arthroplasty?

BACKGROUND: An improved understanding of how gender differences and the natural aging process are associated with differences in clinical improvement in outcome metric scores and ROM measurements after reverse total shoulder arthroplasty (rTSA) may help physicians establish more accurate patient expectations for reducing postoperative pain and improving function. QUESTIONS/PURPOSES: (1) Is gender associated with differences in rTSA outcome scores like the Simple Shoulder Test (SST), the UCLA Shoulder score, the American Shoulder and Elbow Surgeons (ASES) Shoulder score, the Constant Shoulder score, and the Shoulder Pain and Disability Index (SPADI) and ROM? (2) Is age associated with differences in rTSA outcome scores and ROM? (3) What factors are associated with the combined interaction effect between age and gender? (4) At what time point during recovery does most clinical improvement occur, and when is full improvement reached? METHODS: We quantified and analyzed the outcomes of 660 patients (424 women and 236 men; average age, 72 ± 8 years; range, 43-95 years) with cuff tear arthropathy or osteoarthritis and rotator cuff tear who were treated with rTSA by 13 shoulder surgeons from a longitudinally maintained international database using a linear mixed effects statistical model to evaluate the relationship between clinical improvements and gender and patient age. We used five outcome scoring metrics and four ROM assessments to evaluate clinical outcome differences. RESULTS: When controlling for age, men had better SST scores (mean difference [MD] = 1.41 points [95% confidence interval {CI}, 1.07-1.75], p < 0.001), UCLA scores (MD = 1.76 [95% CI, 1.05-2.47], p < 0.001), Constant scores (MD = 6.70 [95% CI, 4.80-8.59], p < 0.001), ASES scores (MD = 7.58 [95% CI, 5.27-9.89], p < 0.001), SPADI scores (MD = -12.78 [95% CI, -16.28 to -9.28], p < 0.001), abduction (MD = 5.79° [95% CI, 2.74-8.84], p < 0.001), forward flexion (MD = 7.68° [95% CI, 4.15-11.20], p < 0.001), and passive external rotation (MD = 2.81° [95% CI, 0.81-4.8], p = 0.006). When controlling for gender, each 1-year increase in age was associated with an improved ASES score by 0.19 points (95% CI, 0.04-0.34, p = 0.011) and an improved SPADI score by -0.29 points (95% CI, -0.46 to 0.07, p = 0.020). However, each 1-year increase in age was associated with a mean decrease in active abduction by 0.26° (95% CI, -0.46 to 0.07, p = 0.007) and a mean decrease of forward flexion by 0.39° (95% CI, -0.61 to 0.16, p = 0.001). A combined interaction effect between age and gender was found only with active external rotation: in men, younger age was associated with less active external rotation and older age was associated with more active external rotation (ß0 [intercept] = 11.029, ß1 [slope for age variable] = 0.281, p = 0.009). Conversely, women achieved no difference in active external rotation after rTSA, regardless of age at the time of surgery (ß0 [intercept] = 34.135, ß1 [slope for age variable] = -0.069, p = 0.009). Finally, 80% of patients achieved full clinical improvement as defined by a plateau in their outcome metric score and 70% of patients achieved full clinical improvement as defined by a plateau in their ROM measurements by 12 months followup regardless of gender or patient age at the time of surgery with most improvement occurring in the first 6 months after rTSA. CONCLUSIONS: Gender and patient age at the time of surgery were associated with some differences in rTSA outcomes. Men had better outcome scores than did women, and older patients had better outcome scores but smaller improvements in function than did younger patients. These results demonstrate rTSA outcomes differ for men and women and for different patient ages at the time of surgery, knowledge of these differences, and also the timing of improvement plateaus in outcome metric scores and ROM measurements can both improve the effectiveness of patient counseling and better establish accurate patient expectations after rTSA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Rate of Improvement in Clinical Outcomes with Anatomic and Reverse Total Shoulder Arthroplasty.

BACKGROUND: This study quantifies the rate of improvement after anatomic and reverse total shoulder arthroplasty; a better understanding of the rate of improvement associated with each prosthesis type may better establish patient expectations for recovery. METHODS: Prospectively collected data on 1,183 patients who underwent either anatomic total shoulder arthroplasty (n = 505) or reverse total shoulder arthroplasty (n = 678) were collected. The Simple Shoulder Test (SST), University of California at Los Angeles (UCLA) Shoulder, American Shoulder and Elbow Surgeons (ASES), Constant, and Shoulder Pain and Disability Index (SPADI) scores, along with range of motion, were recorded preoperatively and at routine postoperative time points. All included patients had a minimum follow-up of 2 years. The rate of improvement of these outcome measures was quantified for patients who underwent anatomic total shoulder arthroplasty and those who underwent reverse total shoulder arthroplasty to compare recovery over time. RESULTS: In this study, 3,587 visits by 1,183 patients were analyzed and several differences between prosthesis types were noted. Patients who underwent reverse total shoulder arthroplasty experienced larger improvements in the Constant score and active forward flexion, and patients who underwent anatomic total shoulder arthroplasty demonstrated better improvement in external rotation compared with patients who underwent reverse total shoulder arthroplasty at nearly all time points. By 72 months, improvement in flexion and abduction decreased for each prosthesis type, but in particular for reverse total shoulder arthroplasty. Full improvement was achieved by 24 months, although the majority of improvement was achieved in the first 6 months, with all 5 scoring metrics following a similar rate of improvement. The ASES, SPADI, and UCLA Shoulder scores closely mirrored each other in the magnitude of improvement, and the SST score demonstrated the largest improvement and the Constant score demonstrated the smallest improvement for both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty. CONCLUSIONS: Both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty reliably result in improved patient outcomes. However, anatomic total shoulder arthroplasty more reliably improves range of motion, particularly external rotation. Most improvement occurs by 6 months, with some additional improvement up to 2 years for both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty. Although the indications for anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty are substantially different, in addition to the biomechanical differences, the improvement in outcome scores over time can be expected to be very similar. This study is helpful to patients and health-care providers to establish expectations regarding the rate of recovery after total shoulder arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Revision Total Elbow Arthroplasty.

Despite recent technologic advances, total elbow arthroplasty has complication rates higher than that of total joint arthroplasty in other joints. With new antirheumatic treatments, the population receiving total elbow arthroplasty has shifted from patients with rheumatoid arthritis to those with posttraumatic arthritis, further compounding the high complication rate. The most common reasons for revision include infection, aseptic loosening, fracture, and component failure. Common mechanisms of total elbow arthroplasty failure include infection, aseptic loosening, fracture, component failure, and instability. Tension band fixation, allograft struts with cerclage wire, and/or plate and screw constructs can be used for fracture stabilization.

Treatment of Massive Irreparable Rotator Cuff Tears: A Cost-effectiveness Analysis.

Massive irreparable rotator cuff tears cause significant shoulder pain and dysfunction. Physical therapy (PT), arthroscopic debridement with biceps tenotomy (AD-BT), and hemiarthroplasty (HA) are treatments shown to reduce pain and improve quality of life. Reverse total shoulder arthroplasty (RTSA) is a newer surgical treatment option that may offer improved function. A cost-effectiveness analysis of these interventions has never been performed, and no head-to-head comparative effectiveness trials currently exist. A Markov decision analytic model was used to compare RTSA, HA, AD-BT, and PT as treatments for elderly patients with massive irreparable rotator cuff tears. Probabilities for complications, perioperative death, conversion procedures, and reoperations were derived from the literature, and costs were determined by average Medicare reimbursement rates from 2011. Reverse total shoulder arthroplasty yielded the most quality-adjusted life years (QALY) with 7.69, but greater benefits came at higher costs compared with other treatments. Sensitivity analyses showed that PT was the most cost-effective intervention at a health utility of 0.75 or greater (QALY 7.35). The health utility of RTSA was 0.72 or less (QALY 7.48) or RTSA probability of no complications was 0.83 or less (QALY 7.48 at cost of $23,830). Reverse total shoulder arthroplasty yielded benefits at a cost considered good value for money compared with other treatments. Reverse total shoulder arthroplasty is the preferred and most cost-effective treatment option for elderly patients with massive irreparable rotator cuff tears. For patients seeking pain relief without functional gains, AD-BT can be considered a cost-effective and cheaper alternative. The cost-effectiveness analysis approach can help guide clinical practice as well as the policies of health care systems and insurers. [Orthopedics. 2017; 40(1):e65-e76.].

Shoulder Arthroplasty: Key Steps to Improve Outcomes and Minimize Complications.

Advances in shoulder replacement surgery have allowed for the successful treatment of various shoulder conditions. As the elderly population increases and the surgical indications for shoulder replacement surgery continue to expand, the number of shoulder replacements performed annually will continue to increase. Accordingly, the number of complications also will be expected to increase. Successful shoulder replacement outcomes require surgeons to have a thorough understanding of the surgical indications, surgical technique, and potential complications of the procedure. By reviewing the key aspects of shoulder replacement surgery and focusing on the surgical technique and common complications for both anatomic and reverse total shoulder arthroplasty, surgeons can help improve outcomes and minimize complications.

Distribution of Glenoid Implant Options for Correcting Deformities Using a Preoperative Planning Tool.

Preoperative planning tools in shoulder arthroplasty are a recently developing technology with the advantage of being able to clearly assess patient anatomy and deformities before entering the OR. Addressing retroverted glenoids remains one of the most difficult aspects of primary shoulder arthroplasty. In this study, five surgeons were provided with a preoperative planning tool with posterior augmented glenoid implant options (0°, 8°, and 16°) to treat 10 cadaveric cases with a range of versions from 7.8° anteversion to 25.1° retroversion. Surgeons were able to remove less bone using 8° augmented implants over standard non-augmented implants (2.8° reamed vs. 6.4° reamed) and were able to correct each case on average within ± 1.8° of neutral version. Slight glenoid vault perforation was observed in 18% of the plans. Eight degrees posterior augmented implants were used in scans averaging 9.0° retroversion, and 16° posterior augmented implants were used in scans averaging 20.6° retroversion. Results were then compared to 14 preoperative CT scans provided by one of the surgeons in which both 8° and 16° posterior augmented glenoid implants were used in actual patients, showing 8° posterior augmented implants were used in cases averaging 12.3° retroversion, and 16° posterior augmented implants were used in cases averaging 20.7° retroversion. The study shows that surgeons can effectively and predictably use a preoperative planning tool to correct glenoid abnormalities using augmented implant solutions while minimizing both scapular bone removal and vault perforation and maximizing version correction.

Evaluation of Preoperative Implant Placement in Total Shoulder Arthroplasty.

INTRODUCTION: New technology to assist with glenoid placement in shoulder arthroplasty has evolved to include preoperative planning tools and intraoperative guides. These tools provide surgeons with a more complete understanding of glenoid anatomy prior to surgery. However, there have been no studies identifying the information that most influences surgical decision making. Further, there have been few studies that quantify intraoperative identification of scapular landmarks required to execute a preoperative plan. The purpose of this study is to examine the variables that are considered when making a preoperative plan in shoulder arthroplasty. METHODS: The first part of this study was a cadaveric lab in which three surgeons identified the neutral axis in surgical simulation. The second part of the study utilized a preliminary software tool in which surgeons were able to place glenoid implants in a set of CT reconstructions utilizing standard pegged glenoid components. In the third part of the study, surgeons utilized a novel planning software that included the ability to view the 3D reconstructed glenoid in all planes simultaneously and place either standard or augmented glenoid implants. The results of these three studies were compared. RESULTS: The center of the glenoid identified in the cadaver lab was 1.69 mm ± 1.58 mm anterior and 1.99 mm ± 2.49 mm superior to center. The identified neutral axis was tilted 14.2° ± 9.2° superior to the Friedman axis with 11.8° ± 7.9° of retroversion relative to that axis. Using the novel preoperative planning tool, the surgeons placed implants less than 0.5 mm from the center of the glenoid (AP = -0.07 mm ± 0.42 mm, SI = 0.44 mm ± 0.82 mm) with an average retroversion of less than 1° (-0.96° ± 3.04°). CONCLUSION: There was a discernible difference between the neutral axis identified in the cadaveric simulation (aver age of 14.2° superior and 11.8° retroverted) and the implant orientation planned using preoperative software (average of 3.26° superior and 0.96° retroverted). Based on the variability of position and orientation seen cadaverically, it is concluded that additional intraoperative guidance is needed alongside a preoperative plan in order to execute ideal placement of the glenoid component.

Complications of Elbow Trauma.

The elbow is a highly congruent trochoginglymoid joint allowing motion in both flexion-extension and pronosupination across 3 articulations. Therefore, treatment of fractures of the elbow can be technically challenging to manage, even after initial surgery. The posttraumatic elbow is prone to complications such as stiffness associated with heterotopic ossification, instability or subluxation (posterolateral rotatory instability and varus posteromedial instability patterns), and wound complications. This article discusses the pathoanatomy, prevention, and treatment of these complications.

Posterior glenoid wear in total shoulder arthroplasty: eccentric anterior reaming is superior to posterior augment.

BACKGROUND: Uncorrected glenoid retroversion during total shoulder arthroplasty may lead to an increased likelihood of glenoid prosthetic loosening. Augmented glenoid components seek to correct retroversion to address posterior glenoid bone loss, but few biomechanical studies have evaluated their performance. QUESTIONS/PURPOSES: We compared the use of augmented glenoid components with eccentric reaming with standard glenoid components in a posterior glenoid wear model. The primary outcome for biomechanical stability in this model was assessed by (1) implant edge displacement in superior and inferior edge loading at intervals up to 100,000 cycles, with secondary outcomes including (2) implant edge load during superior and inferior translation at intervals up to 100,000 cycles, and (3) incidence of glenoid fracture during implant preparation and after cyclic loading. METHODS: A 12°-posterior glenoid defect was created in 12 composite scapulae, and the specimens were divided in two equal groups. In the posterior augment group, glenoid version was corrected to 8° and an 8°-augmented polyethylene glenoid component was placed. In the eccentric reaming group, anterior glenoid reaming was performed to neutral version and a standard polyethylene glenoid component was placed. Specimens were cyclically loaded in the superoinferior direction to 100,000 cycles. Superior and inferior glenoid edge displacements were recorded. RESULTS: Surviving specimens in the posterior augment group showed greater displacement than the eccentric reaming group of superior (1.01 ± 0.02 [95% CI, 0.89-1.13] versus 0.83 ± 0.10 [95% CI, 0.72-0.94 mm]; mean difference, 0.18 mm; p = 0.025) and inferior markers (1.36 ± 0.05 [95% CI, 1.24-1.48] versus 1.20 ± 0.09 [95% CI, 1.09-1.32 mm]; mean difference, 0.16 mm; p = 0.038) during superior edge loading and greater displacement of the superior marker during inferior edge loading (1.44 ± 0.06 [95% CI, 1.28-1.59] versus 1.16 ± 0.11 [95% CI, 1.02-1.30 mm]; mean difference, 0.28 mm; p = 0.009) at 100,000 cycles. No difference was seen with the inferior marker during inferior edge loading (0.93 ± 0.15 [95% CI, 0.56-1.29] versus 0.78 ± 0.06 [95% CI, 0.70-0.85 mm]; mean difference, 0.15 mm; p = 0.079). No differences in implant edge load were seen during superior and inferior loading. There were no instances of glenoid vault fracture in either group during implant preparation; however, a greater number of specimens in the eccentric reaming group were able to achieve the final 100,000 time without catastrophic fracture than those in the posterior augment group. CONCLUSIONS: When addressing posterior glenoid wear in surrogate scapula models, use of angle-backed augmented glenoid components results in accelerated implant loosening compared with neutral-version glenoid after eccentric reaming, as shown by increased implant edge displacement at analogous times. CLINICAL RELEVANCE: Angle-backed components may introduce shear stress and potentially compromise stability. Additional in vitro and comparative long-term clinical followup studies are needed to further evaluate this component design.

Patient adherence with postoperative restrictions after rotator cuff repair.

HYPOTHESIS: This study aimed to measure self-reported patient adherence to postoperative restrictions after rotator cuff repair, to evaluate correlations between adherence and functional outcome, and to identify possible indicators of poor adherence. We believed that poor adherence would correlate with poor functional outcome. METHODS: Fifty consecutive patients undergoing repair for rotator cuff tears were included and instructed to wear an abduction brace for 6 weeks after surgery. Functional evaluations, including American Shoulder and Elbow Surgeons score, University of California-Los Angeles shoulder score, and Simple Shoulder Test, were made preoperatively and postoperatively. Patients commented on their adherence with a medical adherence measurement questionnaire. RESULTS: Average adherence was 88% (range, 59.2-100). There were no significant correlations between adherence and improvement in American Shoulder and Elbow Surgeons, University of California-Los Angeles, or Simple Shoulder Test scores after rotator cuff repair (P = .06245, .5891, and .7688). Of the patient demographics analyzed, only smoking status had a positive effect on adherence (P = .00432; coefficient, 9.867). All other demographics, including hand dominance, mechanism of injury, repair complexity, comorbidities, living status, employment status, and age, had no significant effect on self-measured adherence to postoperative restrictions (P = .7876, .5889, .6444, .4190, .0609, .4171, .5402). CONCLUSIONS: Patients' self-reported adherence did not correlate with shoulder outcome as measured on any of 3 functional outcome scores.