The Variability of MCID, SCB, PASS, and MOI Thresholds for PROMs in the Reverse Total Shoulder Arthroplasty Literature: A Systematic Review.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) is a common procedure utilized to address degenerative pathologies of the glenohumeral joint and rotator cuff. Increased reliance on patient-reported outcome measures (PROMs) has placed emphasis on the utilization of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), patient acceptable symptom state (PASS), and maximal outcome improvement (MOI) thresholds to assess the clinical efficacy of RTSA. In this study, we systematically reviewed the MCID, SCB, PASS, and MOI thresholds reported for PROMs following RTSA. METHODS: PubMed, Embase, MEDLINE, Cochrane Library, and Google Scholar were queried for articles from Jan. 1, 2000-Aug. 31, 2023 reporting MCID, SCB, PASS, or MOI values for PROMs following RTSA. Patient demographic data, study characteristics, MCID/SCB/PASS/MOI thresholds, and threshold calculation methods were extracted. RESULTS: 141 articles were screened with 39 ultimately included, comprising 11,984 total patients that underwent RTSA. 34 (87%) studies reported MCID thresholds, 20 (51%) reported SCB, 5 (13%) reported PASS, and 2 (5%) reported MOI. 25/39 (64%) studies referenced a previous study when reporting MCID, SCB, PASS, or MOI values, 11 (28%) used an anchor-based method to calculate threshold values, 1 (3%) used a distribution-based method, and 2 (5%) used both anchor and distribution methods. There were 19 newly calculated MCID (11), SCB (5), PASS (1), and MOI (2) thresholds. For five of the six most utilized PROMs (ASES, SST, Constant, UCLA, SPADI), the range of reported MCID values exceeded 50% of the most common threshold. For three of the six, the range of SCB values exceeded 25% of the most common threshold. CONCLUSION: There is substantial variability in the MCID and SCB threshold values reported in the RTSA literature. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for RTSA may allow for improved assessment of PROMs.

Glenosphere Size Does Not Matter in Reverse Total Shoulder Arthroplasty.

Objective There are few studies to date reporting on outcomes following reverse total shoulder arthroplasty with cohorts stratified by glenosphere size. The purpose of this study is to investigate the role that glenosphere size has on postoperative outcomes. Methods Patients who underwent reverse TSA between 1987 with minimum of 2.0 years of follow-up were included. Patients were stratified into two cohorts based on glenosphere size of 36mm or 40mm. Patients' range of motion, patient-reported outcomes, and radiographic variables (glenoid preoperative morphology, scapular notching, humeral loosening) were evaluated. Results All measurements of range of motion measurements with the exception of internal rotation saw significant preoperative to postoperative improvements within each cohort. There were no significant differences in postoperative range of motion, ASES, or VAS pain scores across the two cohorts. Overall, forward elevation improved to 134° ± 16° in the 36mm cohort and 133° ± 14° in the 40mm cohort ( p = 0.47). External rotation improved to 37° ± 13° for 36mm patients and 35° ± 19° for 40mm patients ( p = 0.58). In the 36mm group, internal rotation increased by 1.3 vertebral levels and 2.3 vertebral levels in the 40mm cohort. At final follow-up, the 36mm cohort had a VAS score of 2 ± 2, ASES score of 66 ± 19, and SST score of 6 ± 3. Similarly, the 40mm cohort had a VAS score of 2 ± 3, ASES score of 77 ± 28, and SST score of 9 ± 3. Conclusions Reverse TSA provides sustained improvements in range of motion and shoulder function irrespective of glenosphere size. Level of Evidence III.

Surgical treatment of displaced proximal humerus fractures is associated with decreased 1-year mortality in patients aged 65 years and older: a retrospective study of Medicare patients.

BACKGROUND: Proximal humerus fracture (PHF) is a risk factor for 1-year mortality. This study aimed to determine if surgery is associated with lower mortality compared to nonoperative treatment following PHF in older patients. METHODS: This retrospective cohort study used the Medicare Limited Data set. Patients aged 65 years and older with a PHF diagnosis in 2017-2020 were included. Treatment was classified as nonoperative, open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), or hemiarthroplasty. Multivariable logistic regression models examined (a) predictors of treatment type and (b) the association of treatment type with 1-year mortality, adjusting for patient demographics, comorbidities, frailty, and fracture severity among other variables. A subgroup analysis examined how the relationship between treatment type and 1-year mortality varied based on fracture severity. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are reported. RESULTS: In total, 49,072 patients were included (mean age = 76.6 years, 82.3% female). Most were treated nonoperatively (77.5%), 10.9% underwent ORIF, 10.6% underwent TSA, and 1.0% underwent hemiarthroplasty. Examples of factors associated with receipt of operative (versus nonoperative treatment) included worse fracture severity and lower frailty. The 1-year mortality rate after the initial PHF diagnosis was 11.0% for the nonoperative group, 4.0% for ORIF, 5.2% for TSA, and 6.0% for hemiarthroplasty. Compared to nonoperative treatment, ORIF (aOR 0.55; 95% CI [0.47, 0.64]; P < .001) and TSA (aOR 0.59; 95% CI [0.50, 0.68]; P < .001) were associated with decreased odds of 1-year mortality. In the subgroup analysis, ORIF and TSA were associated with a lower 1-year mortality risk for 2-part and 3-/4-part fractures. CONCLUSIONS: Compared to nonoperative treatment, surgery (particularly TSA and ORIF) was associated with a decreased odds of 1-year mortality. This relationship remained significant for 2-part and 3-/4-part fractures after stratifying by fracture severity.

The Finger, Wrist, and Shoulder are the Most Commonly Injured Areas in Youth Volleyball Players but the Incidence of Injuries Decreased Overall Between 2012 and 2022.

Purpose: To analyze epidemiology, mechanisms, and diagnoses of upper extremity volleyball injuries in youth who present to United States emergency departments. Methods: Data from the National Electronic Injury Surveillance System were analyzed for upper extremity volleyball injuries in patients ≤18 years old from January 1, 2012, to December 31, 2022. Data were collected for body part, diagnosis, mechanism of injury, and disposition. Weighted national estimates were calculated using the hospitals' corresponding statistical sample weights. Linear regressions were used to analyze annual trends. χ2 tests were used to analyze categorical variables. Results: A weighted national estimate of 131,624 upper extremity volleyball-related injuries occurred in the study period. Average age was 13.9 ± 2.3 years. Female patients constituted 77.6% of patients; 99.3% of patients did not require admission. The most common body parts injured were fingers (43.0%), wrists (22.8%), and shoulders (12.2%). The most common identifiable mechanisms of injury were impacts with the floor (19.4%), impacts with the ball (14.7%), and spikes/serves (5.7%). Most common diagnoses were strains/sprains (42.6%) and fractures (19.5%). Most common locations of fracture were fingers (57.4% of all fractures), wrists (16.6%), and lower arms (12.4%). There was a decrease of 544 overall injuries per year (P = .03, 95% confidence interval [CI] -1031 to -58). Female players experienced more contusions/abrasions (16.0% vs 9.9%, P < .001) and strains/sprains (46.1% vs 30.4%, P < .001) compared with male players. Female patients had decreases of 513 overall injuries (P = .01, 95% CI -881 to -144), 349 strains/sprains (P = .002, 95% CI -530 to -168), 102 contusions/abrasions (P = .008, 95% CI 170 to -34), and 92 fractures per year (P = .03, 95% CI -175 to -10). Conclusions: Youth volleyball players are at risk of upper extremity injury, particularly involving the fingers, wrist, and shoulder. Despite increasing national participation in youth volleyball, there is a decreasing incidence of upper extremity injuries. Level of Evidence: Level IV, prognostic case series.

Cemented vs. press-fit humeral stems: a matched cohort analysis at a mean follow-up of 10 years.

BACKGROUND: Although cementation of humeral stems has long been considered the gold standard for anatomic shoulder arthroplasty (aTSA), cementless, or press-fit, fixation offers a relatively cheaper and less demanding alternative, particularly in the setting of a revision procedure. However, this approach has been accompanied by concerns of implant loosening and high rates of radiolucency. In the present study, we performed a propensity-matched comparison of clinical and patient-reported outcomes between cemented and cementless fixation techniques for aTSA. We hypothesized that cemented fixation of the humeral component would have significantly better implant survival while providing comparable functional outcomes at final follow-up. METHODS: This study was a retrospective comparison of 50 shoulders undergoing aTSA: 25 using cemented humeral fixation vs. 25 using press-fit humeral fixation. Patients in the 2 groups were propensity matched according to age, sex, and preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score. Primary outcome measures included range of motion (ROM) (forward elevation, external rotation, internal rotation), patient-reported outcomes (ASES, Simple Shoulder Test [SST], visual analog scale [VAS]), and implant survival. RESULTS: At baseline, the 2 fixation groups were similar in regard to age, sex, body mass index, preoperative ASES score, and surgical indication. Mean follow-up was 11.7 ± 4.95 years in the cemented cohort and 9.13 ± 3.77 years in the press-fit cohort (P = .045). Both groups demonstrated significant improvements postoperatively in all included ROM and patient-reported outcomes. However, press-fit patients reported significantly better VAS, ASES, and SST scores. Mean VAS pain score was 1.1 ± 1.8 in press-fit patients and 3.2 ± 3.0 in cemented patients (P = .005). The mean ASES score was 87.7 ± 12.4 in press-fit patients and 69.5 ± 22.7 in cemented patients (P = .002). Lastly, the mean SST score was 9.8 ± 3.1 in press-fit patients and 7.7 ± 3.7 in cemented patients (P = .040). Both fixation techniques provided lasting implant survivorship with only a single revision operation in each of the cohorts. CONCLUSION: Herein, we provide a propensity-matched, long-term comparison of patients receiving anatomic shoulder arthroplasty stratified according to humeral stem fixation technique. The results of this analysis illustrate that both types of humeral fixation techniques yield durable and significant improvements in shoulder function with similar rates of survival at 10 years of follow-up.

The fragility of statistical findings in the reverse total shoulder arthroplasty literature: a systematic review of randomized controlled trials.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has seen increasing utilization as an effective intervention for a wide variety of shoulder pathologies. The scope and indications for growth are often driven by findings from randomized controlled trials (RCTs) guiding surgical decision-making for RTSA. In this study, we utilized the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to assess the robustness of outcomes reported in RCTs in the RTSA literature. METHODS: PubMed, Embase, and MEDLINE were queried for RCTs (Jan. 1, 2010-Mar. 31, 2023) in the RTSA literature reporting dichotomous outcomes. The FI and rFI were defined as the number of outcome reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI by the sample size of each study. Subgroup analysis was performed based on outcome category. RESULTS: One hundred seventy-six RCTs were screened with 18 studies included. The median FI across 59 total outcomes was 4 (interquartile range [IQR]: 3-5) with an associated FQ of 0.051 (IQR: 0.029-0.065). Thirteen outcomes were statistically significant with a median FI of 3 (IQR: 1-4) and FQ of 0.033 (IQR: 0.012-0.066). Forty-six outcomes were nonsignificant with a median rFI of 4 (IQR: 3-5) and FQ of 0.055 (IQR: 0.032-0.065). The most fragile outcome category was revision/reoperations with a median FI of 2.50 (IQR: 1.00-3.25), followed by clinical score/outcome (median FI: 3.00), complications (median FI: 4.00), "other" (median FI: 4.00), and radiographic findings (median FI: 5.00). Notably, the number of patients lost to follow-up was greater than or equal to the FI for 59% of outcomes. CONCLUSION: The statistical findings in RTSA RCTs are fragile and should be interpreted with caution. Reversal of only a few outcomes, or maintaining postoperative follow-up, may be sufficient to alter significance of study findings. We recommend standardized reporting of P values with FI and FQ metrics to allow clinicians to effectively assess the robustness of study findings.

Subacromial Balloon Spacer Implantation Is a Promising Alternative for Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To provide an overview of the existing literature on subacromial balloon spacers for the treatment of massive irreparable rotator cuff tears, in an effort to inform surgeons of the procedure's clinical effectiveness. METHODS: The PubMed, Scopus, and Ovid EMBASE databases were queried to identify studies evaluating the clinical, radiographic, and patient-reported outcomes of patients indicated for subacromial balloon spacer implantation. The following datapoints were extracted: study demographics, patient baseline characteristics, and postoperative outcomes of interest. Outcomes were evaluated at baseline and at the longest available follow-up period. RESULTS: A total 766 patients were included among 22 included studies, with an average follow-up of 27.54 months. Improvements were seen for all clinical and patient-reported outcomes: forward elevation (ranging from 9.20 to 90.00° improvement), external rotation (ranging from 2.00 to 22.00°), abduction (ranging from 14.00 to 95.00°), Total Constant Score (ranging from 7.70 to 50.00), American Shoulder and Elbow Surgeons score (ranging from 24.60 to 59.84), Oxford Shoulder Score (ranging from 7.20 to 22.20), and pain score (ranging from 3.57 to 6.50). Minimal differences were seen in acromiohumeral interval (ranging from -2.00 to 1.27). Reoperation and complication rates ranged from 0% to 33% and 0% to 19.64%, respectively. CONCLUSIONS: The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. Of note, minimal change in acromiohumeral interval was seen on postoperative radiography, and wide variations in complication and reoperation rates were reported across studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Mid-term outcomes following reverse total shoulder arthroplasty.

PURPOSE: The utilization of reverse total shoulder arthroplasty now exceeds the incidence of anatomic shoulder arthroplasty. Previous mid-to-long-term studies on rTSA have reported a decrease in shoulder function as follow-up increased. The purpose of this study was to provide data on mid-term outcomes and implant survival in a series focusing on reverse total shoulder arthroplasty. MATERIALS AND METHODS: Demographic information such as age at surgery, revision surgery status, BMI, and smoking status were recorded. The clinical endpoints measured in this study were range of motion scores (forward elevation, external rotation, internal rotation) and patient reported outcomes (VAS, ASES, SST). Radiographic variables captured included preoperative glenoid morphology, humeral lucency, and glenoid loosening. RESULTS: Fifty-six shoulders were included in this study. The overall mean age at surgery was 72.5 ± 7.2 years with an average follow-up time of 6.8 ± 3.5 years. The mean BMI was 28.1 ± 5.5. All measurements of range of motion saw significant and sustained improvements. Overall, forward elevation improved from 82° preoperatively to 133° postoperatively (p < 0.01). External rotation improved from 23° preoperatively to 36° (p < 0.01), while internal rotation improved from L3 to L1 (p = 0.05). ASES scores improved from 31 preoperatively to 70 postoperatively (p < 0.01). SST scores improved from 2 preoperatively to 7 (p < 0.01). VAS pain index scores improved from 6 to 2 following surgery (p < 0.01). Postoperative scapular notching was seen in 18 patients at final follow-up. Glenoid loosening was seen in 3 shoulders. Humeral loosening was seen in 18 shoulders. Tuberosity resorption was seen in 8 shoulders. The 5 year survival estimate was 98%, and the 10 year survival estimate was 83%. CONCLUSION: In this series, we found that rTSA provides mid-term improvements in range of motion in patients while reducing pain levels. When considered together, this demonstrates that most patients undergoing rTSA can have excellent use of their shoulder from age at surgery to end-of-life.

The 50 most-cited articles in reverse shoulder arthroplasty.

Background: Citation analyses have been used to understand the impact that a group of publications has on its field. As the techniques and indications of reverse total shoulder arthroplasty (RTSA) continue to expand, it is important to identify articles that can orient readers to the history, evolution, and current status of the body of RTSA literature. The purpose of this study was to identify and analyze the 50 most-cited articles related to RTSA. Methods: Various Boolean queries were searched on the Clarivate Analytics Web of Science. Information collected included author name, publication year, country of origin, journal name, article type, total number of citations, and level of evidence. Results: Top 50 most-cited articles amassed a total of 10,521 citations. The most-cited article was cited a total of 766 times. The most common study designs were case series (28) and cohort studies (9). Authors from the United States (24) contributed the most to included papers, followed by France (19) and Switzerland (8). Discussion: The most-cited articles on RTSA are expert opinions, case studies, and cohort studies published by American authors. As RTSA continues to grow over the next decade, studies with higher levels-of-evidence may overtake articles included in this analysis.

Improved functional, radiographic and patient-reported outcomes at midterm follow-up for shoulder arthroplasty patients 75 years and older.

Background: Current discussion centers around the appropriateness of shoulder arthroplasty in elderly patients, and whether anatomic and reverse total shoulder arthroplasty yield acceptable results in this population. The purpose of this study was to examine midterm outcomes in patients 75 years and older who underwent either procedure. Methods: A retrospective review was performed on patients who underwent anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) between 2000 and 2018. Inclusion criteria was patient age ≥75 years at time of surgery and ≥1 years postoperative follow-up. Primary outcomes were differences in Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, and range of motion. A secondary outcome was revision surgery. Results: 22 patients who underwent aTSA and 17 patients who underwent rTSA were included. Mean age at surgery was 79 and 80 in the aTSA and rTSA groups, respectively. Mean postoperative follow-up was 6.6 years across both cohorts. Anatomic TSA patients experienced improvements in VAS (7 preop vs. 1 postop; p < 0.001), ASES (16 vs. 75; p < 0.001), and SST (2 vs. 8; p < 0.001) scores. Reverse TSA patients also experienced improvements in VAS (7 vs. 1; p < 0.001), ASES (29 vs. 74; p < 0.001), and SST (1 vs. 7; p < 0.001) scores. Anatomic TSA patients experienced improved external rotation (17° vs. 53°; p < 0.001), forward elevation (108° vs. 155°; p < 0.001), and internal rotation (L5 vs. T10; p < 0.001). Reverse TSA patients experienced improved forward elevation (52° vs. 126°; p < 0.001). 21 aTSA patients (100%) and 16 rTSA patients (94%) experienced survival free from revision. 100% of aTSA and rTSA patients experienced survival free from loosening. Conclusion: Both aTSA and rTSA can be performed in the elderly population with acceptable midterm outcomes, suggesting that implant survival and patient satisfaction have the potential to endure through the end of life. Level of evidence: IV.

Evaluating the effects of age on the long-term functional outcomes following anatomic total shoulder arthroplasty.

BACKGROUND: In the past decade, the number of anatomic total shoulder arthroplasty (aTSA) procedures has steadily increased. Patients over 65 years of age comprise the vast majority of recipients, and outcomes have been well documented; however, patients are opting for definitive surgical treatment at younger ages.We aim to report on the effects of age on the long-term clinical outcomes following aTSA. METHODS: Among the patients who underwent TSA, 119 shoulders were retrospectively analyzed. Preoperative and postoperative clinical outcome data were collected. Linear regression analysis (univariate and multivariate) was conducted to evaluate the associations of clinical outcomes with age. Kaplan-Meier curves and Cox regression analyses were performed to evaluate implant survival. RESULTS: At final follow-up, patients of all ages undergoing aTSA experienced significant and sustained improvements in all primary outcome measures compared with preoperative values. Based on multivariate analysis, age at the time of surgery was a significant predictor of postoperative outcomes. Excellent implant survival was observed over the course of this study, and Cox regression survival analysis indicated age and sex to not be associated with an increased risk of implant failure. CONCLUSIONS: When controlling for sex and follow-up duration, older age was associated with significantly better patient-reported outcome measures. Despite this difference, we noted no significant effects on range of motion or implant survival. Level of evidence: IV.

Does humeral fixation technique affect long-term outcomes of total shoulder arthroplasty?

BACKGROUND: For anatomic total arthroscopic repair, cementless humeral fixation has recently gained popularity. However, few studies have compared clinical, radiographic, and patient-reported outcomes between cemented and press-fit humeral fixation, and none have performed follow-up for longer than 5 years. In this study, we compared long-term postoperative outcomes in patients receiving a cemented versus press-fit humeral stem anatomic arthroscopic repair. METHODS: This study retrospectively analyzed 169 shoulders that required primary anatomic total shoulder arthroplasty (aTSA). Shoulders were stratified by humeral stem fixation technique: cementation or press-fit. Data were collected pre- and postoperatively. Primary outcome measures included range of motion, patient reported outcomes, and radiographic measures. RESULTS: One hundred thirty-eight cemented humeral stems and 31 press-fit stems were included. Significant improvements in range of motion were seen in all aTSA patients with no significant differences between final cemented and press-fit stems (forward elevation: P=0.12, external rotation: P=0.60, and internal rotation: P=0.77). Patient reported outcome metrics also exhibited sustained improvement through final follow-up. However, at final follow-up, the press-fit stem cohort had significantly better overall scores when compared to the cemented cohort (visual analog score: P=0.04, American Shoulder and Elbow Surgeon Score: P<0.01, Simple Shoulder Test score: P=0.03). Humeral radiolucency was noted in two cemented implants and one press-fit implant. No significant differences in implant survival were observed between the two cohorts (P=0.75). CONCLUSIONS: In this series, we found that irrespective of humeral fixation technique, aTSA significantly improves shoulder function. However, within this cohort, press-fit stems provided significantly better outcomes than cemented stems in terms of patient reported outcome scores. Level of evidence: III.

The Impact of COVID-19 on the Timing of Rotator Cuff Repair and Method of Postoperative Follow-up.

Objective Rotator cuff repair (RCR) is one of the most common arthroscopic procedures. Our investigation aims to quantify the impact that the COVID-19 pandemic had on RCR, specifically on patients with acute, traumatic injuries. Methods Institutional records were queried to identify patients who underwent arthroscopic RCR between March 1 st to October 31 st of both 2019 and 2020. Patient demographic, preoperative, perioperative, and postoperative data were collected from electronic medical records. Inferential statistics were used to analyze data. Results Totals of 72 and of 60 patients were identified in 2019 and in 2020, respectively. Patients in 2019 experienced shorter lengths of time from MRI to surgery (62.7 ± 70.5 days versus 115.7 ± 151.0 days; p = 0.01). Magnetic resonance imaging (MRI) scans showed a smaller average degree of retraction in 2019 (2.1 ± 1.3 cm versus 2.6 ± 1.2 cm; p = 0.05) but no difference in anterior to posterior tear size between years (1.6 ± 1.0 cm versus 1.8 ± 1.0 cm; p = 0.17). Less patients in 2019 had a telehealth postoperative consultation with their operating surgeon compared with 2020 (0.0% versus 10.0%; p = 0.009). No significant changes in complications (0.0% versus 0.0%; p > 0.999), readmission (0.0% versus 0.0%; p > 0.999), or revision rates (5.6% versus 0.0%; p = 0.13) were observed. Conclusion From 2019 to 2020, there were no significant differences in patient demographics or major comorbidities. Our data suggests that even though the time from MRI to surgery was delayed in 2020 and telemedicine appointments were necessary, RCR was still performed in a timely manner and with no significant changes in early complications. Level of Evidence III.

Superior migration of the humeral head does not significantly affect outcomes at an average of 11 years after total shoulder arthroplasty.

BACKGROUND: Superior migration of the humeral head has been linked with rotator cuff dysfunction and glenoid loosening after total shoulder arthroplasty (TSA). We aimed to determine if superior migration was associated with poor shoulder function following anatomic TSA at long-term follow-up. METHODS: In this retrospective cohort study, we reviewed patients undergoing TSA by a single surgeon at an urban, academic institution. To study the effect of superior migration on TSA outcomes, we stratified the cohort by ≥ and <7 mm of acromiohumeral interval (AHI) and compared range of motion and patient reported outcomes (PROs). Clinical variables included preoperative and postoperative forward elevation (FE), internal rotation, external rotation, visual analog scale, American Shoulder and Elbow Surgeons shoulder score, and Simple Shoulder Text score. Radiographic variables included immediate postoperative and long-term follow-up AHI, lateral humeral offset, and glenoid loosening scores. RESULTS: After applying exclusion criteria, 121 TSAs were included. The mean age was 63.9 ± 9.5 years, and 66 surgeries (55%) were in male patients. The mean follow-up for our cohort was 11.2 years (range, 5-26 years). Nine shoulders underwent revision surgery. All range of motion and PROs improved significantly from preoperative to the most recent postoperative follow-up. The mean AHI immediately following surgery was 10.9 ± 4.1 mm, while the mean AHI at most recent follow-up was 8.4 ± 3.5 mm. Glenoid loosening was observed in 29 (23.8%) shoulders at the most recent follow-up appointment. Although AHI correlated weakly with FE (r = 0.252; P = .006), we did not observe a clear threshold of migration which led to degraded function. Importantly, glenoid loosening was not related to AHI at long-term follow-up (P = .631). None of FE, internal rotation, external rotation, visual analog scale, American Shoulder and Elbow Surgeons shoulder score, Simple Shoulder Text, or revisions were significantly different between patients with ≥ and <7 mm of AHI. CONCLUSION: Our results suggest that anatomic TSA provides durable improvements to pain, function, and PROs despite changes to the AHI.

The Impact of COVID-19 Redeployment on an Orthopedic Surgery Department at a Tertiary Care Medical Center in New York City.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic resulted in new, non-orthopedic roles for many members of our New York City based orthopedic department, including redeployment to medicine wards, emergency departments, and intensive care units. The purpose of this study was to determine if certain areas of redeployment predisposed individuals to higher likelihood of positive diagnostic or serologic testing for COVID-19. METHODS: In this study, attendings, residents, and phy-sician assistants within our orthopedic department were surveyed to determine their roles during the COVID-19 pandemic and whether they were tested via diagnostic or serologic methods for detecting COVID-19. Additionally, symptoms and missed days of work were reported. RESULTS: No significant association between redeployment site and rate of positive COVID-19 diagnostic (p = 0.91) or serologic (p = 0.38) testing was detected. Sixty individuals responded to the survey, with 88.3% of respondents rede-ployed during the pandemic. Nearly half (n = 28) of those redeployed experienced at least one COVID-19 related symptom. Two respondents had a positive diagnostic test, and 10 had a positive serologic test. CONCLUSIONS: Area of redeployment during the COVID-19 pandemic is not associated with an increased risk of subse-quently having a positive diagnostic or serologic COVID-19 test.

The Impact of COVID-19 on the Timing of Rotator Cuff Repair and Method of Postoperative Follow-up / Impacto da COVID-19 no momento de reparo do manguito rotador e método de acompanhamento pós-operatório

Abstract Objective Rotator cuff repair (RCR) is one of the most common arthroscopic procedures. Our investigation aims to quantify the impact that the COVID-19 pandemic had on RCR, specifically on patients with acute, traumatic injuries. Methods Institutional records were queried to identify patients who underwent arthroscopic RCR between March 1st to October 31st of both 2019 and 2020. Patient demographic, preoperative, perioperative, and postoperative data were collected from electronic medical records. Inferential statistics were used to analyze data. Results Totals of 72 and of 60 patients were identified in 2019 and in 2020, respectively. Patients in 2019 experienced shorter lengths of time from MRI to surgery (62.7 ± 70.5 days versus 115.7 ± 151.0 days; p = 0.01). Magnetic resonance imaging (MRI) scans showed a smaller average degree of retraction in 2019 (2.1 ± 1.3 cm versus 2.6 ± 1.2 cm; p = 0.05) butnodifference in anterior toposterior tear size between years (1.6 ± 1.0 cm versus 1.8 ± 1.0 cm; p = 0.17). Less patients in 2019 had a tele-health postoperative consultation with their operating surgeon compared with 2020 (0.0% versus 10.0%; p = 0.009). No significant changes in complications (0.0% versus 0.0%; p > 0.999), readmission (0.0% versus 0.0%; p > 0.999), or revision rates (5.6% versus 0.0%; p = 0.13) were observed. Conclusion From 2019 to 2020, there were no significant differences in patient demographics or major comorbidities. Our data suggests that even though the time from MRI to surgery was delayed in 2020 and telemedicine appointments were necessary, RCR was still performed in a time in early complications. Level of Evidence III.

Resumo Objetivo Oreparodomanguitorotador (RMR) é um dos procedimentos artroscópi-cos maiscomuns. Nossapesquisavisaquantificar o impacto da pandemia de COVID-19 sobre o RMR, especificamente em pacientes com lesões agudas e traumáticas. Métodos Os prontuários institucionais foram consultados para identificação de pacientes submetidos ao RMR artroscópico entre 1° de março e 31 de outubro de 2019 e de 2020. Dados demográficos, pré-operatórios, perioperatórios e pós-operatórios dos pacientes foram coletados de prontuários eletrônicos. Os dados foram analisados por estatística inferencial. Resultados Totais de 72 ede60pacientes foramidentificados em 2019 e 2020, respectivamente. Os pacientes de 2019 apresentaram menor intervalo entre a ressonância magnética (RM) e a cirurgia (62,7 ± 70,5 dias versus 115,7 ± 151,0 dias; p = 0,01). Os exames de RM mostraram menor grau médio de retração em 2019 (2,1 ± 1,3 cm versus 2,6 ± 1,2 cm; p = 0,05), mas nenhuma diferença foi observada na extensão anteroposterior da laceração entre os anos (1,6 ± 1,0 cm versus 1,8 ± 1,0 cm; p = 0,17).Em 2019,o número de pacientes atendidos por seus cirurgiões em consultas pós-operatórias por telemedicina foi menor em comparação com 2020 (0,0% versus 10,0%; p = 0,009). Não foram observadas alterações significativas nas taxas de complicação (0,0% versus 0,0%; p > 0,999), de readmissão (0,0% versus 0,0%; p > 0,999) ou de revisão (5,6% versus 0,0%; p = 0,13). Conclusão Não houve diferenças significativas nos dados demográficos dos pacientes ou nas principais comorbidades entre 2019 e 2020. Nossos dados sugerem que, embora o intervalo entre a RM e a cirurgia tenha sido maior em 2020 e tenha havido necessidade de consultas por telemedicina, o RMR ainda foi realizado em tempo hábil e sem alterações significativas nas complicações precoces. Nível de Evidência III.

The fragility of statistical findings in distal biceps tendon repairs: a systematic review of randomized controlled trials.

BACKGROUND: The purpose of this present study was to perform a fragility analysis to assess the robustness of randomized controlled trials (RCTs) evaluating the distal biceps tendon repairs. We hypothesize that the dichotomous outcomes will be statistically fragile, and higher fragility will exist among statistically significant outcomes comparable to other orthopedic specialties. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), randomized controlled trials from 4 orthopedic journals indexed on PubMed from 2000 to 2022 reporting dichotomous measures relating to distal biceps tendon repairs were included. The fragility index (FI) of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The fragility quotient (FQ) was calculated by dividing each fragility index by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ. RESULTS: Of the 1038 articles screened, 7 RCTs containing 24 dichotomous outcomes were included for analysis. The fragility index and fragility quotient of all outcomes was 6.5 (IQR 4-9) and 0.077 (IQR 0.031-0.123), respectively. However, statistically significant outcomes had a fragility index and fragility quotient of 2 (IQR 2-7) and 0.036 (IQR 0.025-0.091), respectively. The average number of patients lost to follow-up was 2.7 patients, with 28.6% of the included studies reporting loss to follow-up (LTF) greater than or equal to 6.5. CONCLUSIONS: The literature surrounding distal biceps tendon repair may not be as stable as previously thought and presents a similar fragility index to other orthopedic subspecialties. We therefore recommend triple reporting the P value, fragility index, and fragility quotient to aid in the interpretation of clinical findings reported in biceps tendon repair literature.

Arthroscopically Assisted Tensionable Cerclage Reconstruction of an Acromioclavicular Separation With Combined Fixation of the Coracoclavicular and Acromioclavicular Ligaments.

A variety of surgical techniques are currently available to manage high-grade acromioclavicular (AC) separations, including hook plates/wires, nonanatomic ligament reconstruction, and anatomic cerclage with or without biological augmentation. Traditional reconstructions focused on the coracoclavicular ligaments alone and often were associated with high rates of recurrent deformity. Biomechanical and clinical data have suggested that additional fixation of the AC ligaments is beneficial. This Technical Note describes an arthroscopically assisted approach for combined reconstruction of the coracoclavicular and AC ligaments with a tensionable cerclage.

Effect of COVID-19 on Shoulder Arthroplasty at a Tertiary Care Medical Center in New York City.

Objective The COVID-19 pandemic led to an unprecedented pause in elective surgeries, including shoulder arthroplasty. We sought to determine whether clinical and/or demographic differences would be seen between patients who presented for shoulder arthroplasty during the pandemic compared with the previous year (2019). Methods Institutional records were queried for patients who underwent shoulder replacement between March 1 and July 1 of 2019 and 2020. Demographics, range of motion, surgical duration, hospitalization time, discharge disposition, and postoperative management were analyzed. Results The mean duration of surgery was 160 ± 50 minutes in 2020 and 179 ± 54 minutes in 2019 ( p = 0.13). The mean hospitalization time was 36 ± 13 hours in 2020 and 51 ± 40 hours in 2019 ( p = 0.04). In 2019, 96% of the patients participated in physical therapy, while 71% did it in 2020 ( p = 0.003). A total of 100% of the 2019 patients and 86% of the 2020 patients participated in an in-person postoperative follow-up ( p = 0.006). The 2019 patients reported for an office visit on average 14 ± 11 days after surgery; the 2020 patients waited 25 ± 25 days to return for a follow-up ( p = 0.10). Range of motion, age, American Society of Anesthesiologists (ASA) scores, and complication rates did not differ between the cohorts. Conclusion Patients presenting for surgery during the initial phase of the pandemic were demographically and clinically similar to 2019 patients. However, the length of stay was significantly reduced during the COVID-19 pandemic. Postoperative follow-up and physical therapy were delayed in 2020, but this did not lead to differences in complication or readmission rates compared with those of the 2019 cohort. Level of Evidence III.

Effect of COVID-19 on Shoulder Arthroplasty at a Tertiary Care Medical Center in New York City / Efeito da COVID-19 na artroplastia de ombro em um centro médico terciário na cidade de Nova York

Abstract Objective The COVID-19 pandemic led to an unprecedented pause in elective surgeries, including shoulder arthroplasty. We sought to determine whether clinical and/or demographic differences would be seen between patients who presented for shoulder arthroplasty during the pandemic compared with the previous year (2019). Methods Institutional records were queried for patients who underwent shoulder replacement between March 1 and July 1 of 2019 and 2020. Demographics, range of motion, surgical duration, hospitalization time, discharge disposition, and postoperative management were analyzed. Results The mean duration of surgery was 160 ± 50 minutes in 2020 and 179 ± 54 minutes in 2019 (p= 0.13). The mean hospitalization time was 36 ± 13 hours in 2020 and 51 ± 40 hours in 2019 (p= 0.04). In 2019, 96% of the patients participated in physical therapy, while 71% did it in 2020 (p= 0.003). A total of 100% of the 2019 patients and 86% of the 2020 patients participated in an in-person postoperative follow-up (p= 0.006). The 2019 patients reported for an office visit on average 14 ± 11 days after surgery; the 2020 patients waited 25 ± 25 days to return for a follow-up (p= 0.10). Range of motion, age, American Society of Anesthesiologists (ASA) scores, and complication rates did not differ between the cohorts. Conclusion Patients presenting for surgery during the initial phase of the pandemic were demographically and clinically similar to 2019 patients. However, the length of stay was significantly reduced during the COVID-19 pandemic. Postoperative follow-up and physical therapy were delayed in 2020, but this did not lead to differences in complication or readmission rates compared with those of the 2019 cohort. Level of EvidenceIII.

Resumo Objetivo A pandemia de COVID-19 causou uma pausa sem precedentes em cirurgias eletivas, inclusive artroplastia de ombro. Procuramos determinar as possíveis diferenças clínicas e/ou demográficas entre os pacientes que realizaram artroplastia de ombro durante a pandemia em comparação com o ano anterior (2019). Métodos Os registros institucionais foram consultados para obtenção de informações sobre pacientes submetidos a artroplastia de ombro entre 1° de março a 1° de julho de 2019 e 2020. Dados demográficos, amplitude de movimento, duração da cirurgia, tempo de hospitalização, condições à alta e manejo pós-operatório foram analisados. Resultados O tempo médio de cirurgia foi de 160 ± 50 minutos em 2020 e de 179 ± 54 minutos em 2019 (p= 0,13). O tempo médio de internação foi de 36 ± 13 horas em 2020 e de 51 ± 40 horas em 2019 (p= 0,04). Em 2019, 96% dos pacientes fizeram fisioterapia, enquanto 71% o fizeram em 2020 (p= 0,003). Todos os pacientes de 2019 e 86% dos pacientes de 2020 participaram do acompanhamento pós-operatório presencial (p= 0,006). Os pacientes de 2019 retornaram para a consulta médica em média 14 ± 11 dias após a cirurgia; os pacientes de 2020 retornaram para o acompanhamento em 25 ± 25 dias (p= 0,10). A amplitude de movimento, a idade, a pontuação da American Society of Anesthesiologists (ASA, na sigla em inglês) e as taxas de complicações não diferiram entre as coortes. Conclusão Os pacientes submetidos a cirurgia na fase inicial da pandemia eram demográfica e clinicamente semelhantes aos pacientes de 2019. No entanto, o tempo de internação diminuiu de forma significativa durante a pandemia de COVID-19. O acompanhamento pós-operatório e a fisioterapia foram adiados em 2020, mas isso não levou a diferenças nas taxas de complicações ou de reinternações em comparação às da coorte de 2019. Nível de EvidênciaIII.