Reaching Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient-Acceptable Symptomatic State for Patient-Reported Outcome Measures following Arthroscopic Rotator Cuff Repair Does Not Correlate with Patient Satisfaction.

Purpose: Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) serve as metrics to gauge orthopedic treatment efficacy based on anchoring questions that do not account for a patient's satisfaction with their surgical outcome. This study evaluates if reaching MCID, SCB, or PASS values for American Shoulder and Elbow Surgeons score (ASES), Single Alpha Numeric Evaluation (SANE), Simple Shoulder Test (SST), and Visual Analog Score (VAS) for pain following arthroscopic rotator cuff repair (RCR) correlates with overall patient satisfaction. Methods: This was a single-institution, retrospective study of patients who underwent RCR from 2015 to 2019. Pre-operative and 2 year postoperative ASES, SANE, SST, and VAS scores were recorded. Patients underwent a survey to assess: (1) what is your overall satisfaction with your surgical outcome? (scale 1 to 10); (2) if you could go back in time, would you undergo this operation again? (yes/no); (3) for the same condition, would you recommend this operation to a friend or family member? (yes/no). Spearman correlation coefficients were run to assess relationship between reaching MCID, SCB, or PASS and satisfaction. Results: Ninety-two patients were included. Mean preoperative ASES was 51.1 ± 16.9, SANE was 43.3 ± 20.9, SST was 5.4 ± 2.9, and VAS was 4.6 ± 2.1. Mean 2 year ASES was 83.9 ± 18.5, SANE was 81.7 ± 27.0, SST was 9.8 ± 3.2, and VAS was 1.4 ± 1.9. Mean patient satisfaction was 9.0 ± 1.9; 89 (96.7%) patients would undergo surgery again and recommend surgery. Correlation for reaching PASS for SANE and satisfaction was moderate. Correlation coefficients were very weak for all other outcome metrics. Conclusions: Reaching MCID, SCB, and PASS in ASES, SANE, SST, or VAS following RCR did not correlate with a patient's overall satisfaction or willingness to undergo surgery again or recommend surgery. Further investigation into the statistical credibility and overall clinical value of MCID, SCB, and PASS is necessary.

Low acromial insufficiency fracture rate in reverse shoulder arthroplasty with distal clavicle excision.

Background: This study investigated the rate of acromial insufficiency fractures (AIF) in patients undergoing reverse shoulder arthroplasty (RSA) with concomitant distal clavicle excision (DCE). Methods: Patients who underwent primary RSA with DCE by a single surgeon from 2010 to 2021 were identified. Exclusion criteria included revision RSA, RSA for fracture, or cases utilizing an augmented baseplate or bone graft. AIF was defined as a radiographically proven acromion or scapular spine fracture. Pain without an identifiable fracture on imaging was defined as an acromial insufficiency reaction. Patient demographics, implant information, and radiograph measurements were compared between patients with and without acromial pathology. Results: One hundred and seventy-five patients were included. Mean age was 72.8 years, and 67% of patients were female. There were 3/174 acromial insufficiency fractures (1.7%). AIF occurred at a mean of 9.3 months after surgery. Twelve patients had insufficiency reactions (6.9%). Patients with acromial pathology were more likely to be female (p = .003) and have a diagnosis of osteoporosis (p = .047) and inflammatory arthritis (p = .049). There was no significant difference between groups in terms of other factors. Conclusion: The AIF rate in patients who underwent RSA with DCE was 1.7%. These findings suggest that DCE in the setting of RSA may have a protective role against AIF.

Humeral stem loosening is not always prosthetic joint infection.

BACKGROUND: Aseptic humeral stem loosening is an uncommon complication of shoulder arthroplasty, and its presence has been considered a highly specific predictor of prosthetic joint infection (PJI). Literature on aseptic humeral stem loosening is sparse. The primary purpose of this study was to determine the rate of aseptic humeral loosening in revision shoulder arthroplasty. Secondarily, we sought to identify predictors of septic and aseptic humeral loosening. METHODS: Our institutional revision shoulder arthroplasty database was reviewed. Inclusion criteria were patients with humeral stem loosening as indicated in the operative report. Patient demographics, index surgery and indication, revision surgery and indication, and operative data were recorded. Charts were manually reviewed, and PJI scores were calculated using the International Consensus Meeting scoring criteria. International Consensus Meeting classifications of PJI "unlikely" and "possible" were considered aseptic, and PJI "probable" and "definite" were considered septic. Statistical analysis was performed to determine associations between the abovementioned variables and aseptic humeral loosening. RESULTS: Forty-six patients with 48 shoulders were included in our analysis. Ten cases (21%) were classified as definite PJI, 13 cases (27%) were classified as probable PJI, 4 cases (8%) were classified as possible PJI, and 21 cases (44%) were classified as PJI unlikely. On analysis of stem design, there were no statistically significant associations with aseptic loosening; although, a lack of proximal porous ingrowth surface trended toward higher rates of aseptic loosening in all patients and in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) subgroup analyses. In the index RTSA subgroup, aseptic loosening was associated with female sex (P = .005). Seventeen of 39 shoulders (44%) that underwent either index ATSA or RTSA demonstrated concomitant glenoid loosening. The absence of glenoid loosening was associated with aseptic humeral loosening in index ATSA and RTSA (P < .001). CONCLUSION: Fifty-two % of revision shoulder arthroplasty cases with humeral loosening performed at our institution were aseptic. There appear to be distinct demographic and radiographic factors that are more commonly associated with aseptic as opposed to septic humeral loosening. Our data demonstrate that demographic predictors of aseptic loosening of RTSA include female sex. The absence of glenoid component loosening is associated with aseptic humeral loosening and concomitant glenoid loosening is associated with septic humeral loosening. Understanding of these factors can guide the preoperative index of suspicion for PJI in the setting of humeral stem loosening.

Management of proximal humerus bone loss with allograft prosthetic composite technique in shoulder arthroplasty.

BACKGROUND: Proximal humerus bone loss in shoulder arthroplasty is a difficult problem with limited treatment options. It most commonly occurs in the setting of a previously failed shoulder arthroplasty; however, it is occasionally encountered in cases of primary shoulder arthroplasty. Reconstruction of the proximal humerus is essential for soft tissue tension for implant stability and maximizing function. The purpose of this study was to analyze the clinical and functional outcomes of the allograft prosthetic composite (APC) technique for the management of proximal humeral bone loss in shoulder arthroplasty. METHODS: A retrospective review was performed of all patients who underwent primary or revision shoulder arthroplasty using an APC technique with a reverse shoulder arthroplasty prosthesis for the management of proximal humerus bone loss. Data collected included demographic variables, previous shoulder surgeries, indication for APC, type of allograft utilized, fixation technique, and reoperation and revision rates. Patients were contacted by phone and/or email survey to obtain the latest patient-reported functional outcome scores. RESULTS: We identified 14 patients who underwent shoulder arthroplasty using the APC technique with a reverse shoulder arthroplasty prosthesis. One (7.1%) was performed as a primary arthroplasty, and 13 (92.9%) were performed as revision arthroplasties. The indications for APC were instability (21.4%), periprosthetic fracture (21.4%), periprosthetic joint infection (14.3%), humeral component loosening (14.3%), rotator cuff failure (14.3%), fracture sequelae (7.1%), and failed hemiarthroplasty (7.1%). In terms of allograft type, 10 (71.4%) were performed with proximal femur allograft and 4 (28.6%) with proximal humerus allograft. There were 6 patients (42.9%) who sustained postoperative complications, 5 patients (35.7%) had instability, and 1 (7.1%) patient had postoperative wound drainage. All patients with a complication required a revision arthroplasty. CONCLUSION: The APC technique used to address proximal humerus bone loss in shoulder arthroplasty has a high complication rate with fair patient-reported functional outcome scores. Most of the postoperative complications and reoperations are related to implant instability.

Elliptical Humeral Head Implants in Anatomic Total Shoulder Arthroplasty.

Humeral implants for anatomic total shoulder arthroplasty and hemiarthroplasty have typically used spherical humeral heads that have a uniform diameter and radius of curvature. However, the native humeral head has a more elliptical morphology, which has spurred interest in nonspherical implant designs. Cadaveric studies indicate that the native humeral head diameter is 10% longer in the superior-inferior plane than the anterior-posterior plane and has a radius of curvature that is approximately 8% greater. An elliptical implant that more closely replicates native anatomy may allow for more accurate coverage of the humeral resection surface with less implant overhang and risk of overstuffing. Biomechanical evidence suggests that an elliptical implant yields glenohumeral kinematics that mimic the native joint, and early clinical results are promising. As clinical research continues to emerge, it will become clearer whether encouraging cadaveric, biomechanical, and early clinical data translates to meaningful sustained improvements in patient outcomes.

Hematoma Following Shoulder Arthroplasty: Incidence, Management, and Outcomes.

Background: A paucity of data regarding the implications of postoperative hematoma formation on outcomes after shoulder arthroplasty exists. Previous studies on major joint arthroplasty have associated postoperative hematoma formation with high rates of prosthetic joint infection (PJI) and reoperation. Methods: A total of 6,421 shoulder arthroplasty cases were retrospectively reviewed from an institutional database (5,941 primary cases, 480 revision) between December 2008 and July 2017. Patients who developed a postoperative hematoma were identified through direct chart review. Cases with a history of shoulder infection treated with explant and antibiotic spacer placement were excluded. Demographics, surgical characteristics, treatment course, and outcomes were collected. Results: Hematoma occurred in 105 (1.6%; 105/6421) cases within the first three postoperative weeks and was more common following revision (3.3%; 16/480) compared to primary cases (1.5 %; 89/5941; P=0.002). Overall, postoperative shoulder hematoma was successfully managed with nonoperative treatment in 87% of cases via observation (62%, 62/105) and aspiration (25%, 26/105). A total of 14 patients (0.22%, 14/6421) underwent reoperation for hematoma. Eight patients (7.6%, 8/105) that required reoperation for hematoma were diagnosed with PJI. Conclusion: Postoperative hematoma is a complication of shoulder arthroplasty. While many postoperative hematomas can be managed without operative intervention, this analysis reiterates the association between hematoma formation and the development of PJI.

Complications after operative treatment of high-grade acromioclavicular injuries.

BACKGROUND: Treatment of Rockwood type III-V acromioclavicular (AC) joint injuries remains controversial. Numerous reconstruction techniques have been proposed. The purpose of this study was to describe the complication profile in a large cohort of patients who underwent surgical management of AC joint separations using a variety of reconstruction strategies. METHODS: All patients who underwent surgery for AC joint injuries from 2013 to 2019 at a single institution were identified. Chart review was performed to capture patient demographics, radiographic measurements, operative techniques, postoperative complications, and revision surgery. Structural failure was defined as a radiographic loss of reduction of greater than 50% when comparing immediate and final postoperative imaging. Logistic regression analysis was performed to identify risk factors for complications and revision surgery. RESULTS: Of the 279 patients included in the study, 66 (24%) had type III separations, 20 (7%) type IV, and 193 (69%) type V. Fifty-three percent underwent surgery acutely (<6 weeks of injury), and 40% were chronic (>3 months). A total of 252 of the 279 surgeries (90%) were performed open and 27 (10%) were arthroscopically assisted. Allograft was used in 164 of 279 (59%) cases. Specific operative techniques (with or without allograft) included hook plating (1%), modified Weaver Dunn (16%), cortical button fixation (18%), and suture fixation (65%). At mean 28-week follow-up, 108 complications were identified in 97 patients (35%). Complications were identified at mean 20 ± 21 weeks. Sixty-nine structural failures (25%) were identified. Persistent AC joint pain requiring injection, clavicle fracture, adhesive capsulitis, and hardware complications were the other most common complications. Twenty-one patients (8%) underwent unplanned revision surgery at mean 38 ± 28 weeks after the index procedure, with the most common indication for structural failure, hardware complications, or fracture of the clavicle or coracoid. Patients who had surgery after 6 weeks from injury had a significantly greater risk of having a complication (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.34-7.77, P = .009) and a significantly greater risk of having structural failure (OR 2.65, 95% CI 1.38-5.28, P = .004). Patients who had an arthroscopic technique had a greater risk of structural failure (P = .002). Complications, structural failure, and revision surgery were not significantly correlated with use of allograft or specific operative techniques. CONCLUSION: Surgical management of AC joint injuries is associated with a relatively high complication profile. Loss of reduction in the postoperative period is common. However, the revision surgery rate is low. These findings are important for patient preoperative counseling.

Anatomic shoulder arthroplasty in Walch type C glenoid deformity: mid- to long-term outcomes.

BACKGROUND: Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity. METHODS: This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. RESULTS: In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again. DISCUSSION: Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity.

Patients With Mild Osteoarthritis Are Less Likely to Achieve a Clinically Important Improvement in Pain or Function After Anatomic Total Shoulder Arthroplasty.

BACKGROUND: The severity of glenohumeral osteoarthritis (OA) as demonstrated by preoperative radiographs and patient-reported pain plays an important role in the indication for anatomic total shoulder arthroplasty (aTSA). In hip and knee research, data about the effect of the severity of preoperative radiographic OA on the outcome of total joint arthroplasty have been mixed. For shoulder replacement, we are unsure of the effects of radiographic severity on outcomes. QUESTIONS/PURPOSES: This study investigated whether the preoperative radiographic severity of glenohumeral OA is associated with improvement in pain and function after aTSA. We asked, (1) does the severity of glenohumeral OA correlate with improvement in patient-reported outcomes after TSA (delta American Shoulder and Elbow Surgeons score [postoperative-preoperative], delta Single Assessment Numeric Evaluation, delta Simple Shoulder Test, and delta VAS)? (2) Is having mild osteoarthritis associated with not meeting the minimum clinically important differences in preoperative and postoperative American Shoulder and Elbow Surgeons scores? METHODS: An institutional query of patients who underwent aTSA for OA was performed between January 2015 and December 2018. A total of 1035 patients were eligible; however, only patients with adequate preoperative radiographs and patient-reported outcome measures collected preoperatively and at a minimum of 2 years postoperatively were included. Patients with proximal humerus fractures, inflammatory arthropathy, cuff tear arthropathy, prior ipsilateral rotator cuff repair, brachial plexus injury or neuromuscular disorder, workers compensation, periprosthetic joint infection, or revision surgery within 2 years were excluded. Patient characteristics, comorbidities, and prior shoulder surgery were recorded. The severity of OA was classified based on the modified Samilson-Prieto and Walch classification. The association between Samilson-Prieto grade and patient-reported outcome measures (American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and VAS score) was evaluated. Radiographic characteristics, patient demographics, comorbidities, and prior surgery were also evaluated for the potential risk of not achieving improvement in the minimum clinically important difference (16.1) with respect to the American Shoulder and Elbow Surgeons score. The American Shoulder and Elbow Surgeons score is scored 0 to 100, with higher scores representing less pain and better function. A total of 206 patients (20% of those eligible) with a mean follow-up of 2.3 years were included. Twenty-three patients had Samilson-Prieto Grade I, 38 had Grade II, 57 had Grade III, and 88 had Grade IV. RESULTS: There were no differences in improvements (delta) between the groups and between patient-reported outcome scores (American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and VAS). Compared with patients with more severe osteoarthritis (Samilson-Prieto Grades II, III, and IV), a higher proportion of patients with less severe osteoarthritis (Grade I) did not exceed the minimum clinical important difference for the American Shoulder and Elbow Surgeons score (22% [five of 23] versus 4% [seven of 183]; odds ratio 0.14 [95% confidence interval 0.04 to 0.520]; p = 0.006). CONCLUSION: The improvement in patient-reported outcome measure scores was similar regardless of radiographic severity after aTSA. Surgeons should use caution when recommending surgery to patients with less severe OA because a higher percentage did not improve, based on the minimum clinically important difference. LEVEL OF EVIDENCE: Level III, therapeutic study.

Factors associated with functional improvement after posteriorly augmented total shoulder arthroplasty.

BACKGROUND: Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study was to identify preoperative and postoperative factors that impact range of motion (ROM) and function after augmented TSA in patients with type B2 or B3 glenoid morphology. METHODS: This was a retrospective review of all patients who underwent TSA with a step-type augmentation performed by a single surgeon between 2009 and 2018. Patients with Walch type B2 or B3 glenoids were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE) score, and visual analog scale pain score. Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and midglenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to ROM and functional outcome scores. RESULTS: Fifty patients (mean age, 68.1 ± 8.0 years) with a mean follow-up period of 42.0 months (range, 24-106 months) were included. Glenoid morphology included type B2 glenoids in 41 patients and type B3 glenoids in 9. One patient had center-peg osteolysis, and 1 patient had glenoid component loosening. Average preoperative FE, ER, and IR were 110°, 21°, and S1, respectively. Average postoperative FE, ER, and IR were 155°, 42°, and L1, respectively. The mean postoperative visual analog scale score was 0.5 ± 0.8, and the mean SANE score was 94.5 ± 5.6. Type B3 glenoids were associated with better postoperative IR compared with type B2 glenoids (T10 vs. L1, P = .024), with no other differences in ROM between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative ROM. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with ROM in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r = -0.448, P = .006). CONCLUSION: Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative ROM and function showed no clinically important associations with preoperative or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented TSAs, except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

Lesser Tuberosity Osteotomy Combined with Anteroinferior Capsulectomy for Anatomic Shoulder Arthroplasty.

Adequate subscapularis tendon mobilization and glenoid exposure are critical to a successful anatomic total shoulder arthroplasty. A lesser tuberosity osteotomy allows for direct bone-to-bone healing while maintaining the strong tendon-to-bone attachment of the subscapularis tendon insertion. Excision of the typically thickened and contracted anteroinferior capsule in osteoarthritic shoulders can help mobilize the subscapularis, theoretically allowing for optimal soft-tissue balance, decreased tension on the subscapularis repair, improved glenoid exposure, and anatomic repair. In this Technical Note and accompanying video, we describe our technique for lesser tuberosity osteotomy with anteroinferior capsulectomy for anatomic total shoulder arthroplasty. This technique reliably and reproducibly produces good results in terms of glenoid exposure, soft-tissue balance, and postoperative subscapularis function.

Total shoulder arthroplasty using an inlay glenoid component for glenoid deficiency: mid- to long-term follow-up of a previously published cohort.

BACKGROUND: The short-term results of total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon in patients with glenoid bone loss have previously been reported. The purpose of this study was to investigate the mid- to long-term clinical and radiographic outcomes of these patients. METHODS: We identified a cohort of patients who underwent total shoulder arthroplasty with an inlay glenoid component performed by a single surgeon between 2010 and 2019 for severe glenoid dysplasia and/or glenoid bone loss. Patients with a minimum of 2 years' follow-up were evaluated regarding preoperative and postoperative range of motion, radiographic findings, visual analog scale pain scores, and Single Assessment Numeric Evaluation scores. RESULTS: Overall, 39 shoulders in 33 patients were treated with an inlay glenoid component for severe glenoid bone loss. Four patients were lost to follow-up, and 1 patient died with a well-functioning implant in place. The final cohort included 34 shoulders in 28 patients (46.4% female patients [13 of 28] and 53.6% male patients [15 of 28]) with a mean age of 66.9 years (range, 58-81 years) and mean follow-up period of 68.3 months. Of the 34 cases, 5 were revision cases. One patient died following 2-year follow-up. Of the shoulders, 10 were classified as Walch type A2, 4 were classified as Walch type B3, and 15 were classified as Walch type C; 5 shoulders were unable to be classified. We observed statistically significant increases in range of motion (forward elevation, 38.1° [P < .001]; external rotation, 18.8° [P < .001]) and improvement in the Single Assessment Numeric Evaluation score (from 26.6 to 81.0, P < .001). Two patients underwent conversion to reverse shoulder arthroplasty at 2.2 and 1.7 years postoperatively. CONCLUSION: Inlay glenoid components provide a low rate of revision and improved clinical and functional outcomes at mid- to long-term follow-up.

Outcomes of instability after reverse shoulder arthroplasty: reoperation and persistent instability are common.

HYPOTHESIS: Although risk factors for instability after reverse shoulder arthroplasty (RSA) have been extensively studied, the outcomes of patients who experience instability are unknown. The purpose of this study was to evaluate functional outcomes in patients with instability after RSA. METHODS: We retrospectively identified patients with instability after RSA with a minimum of 2 years' follow-up from an institutional database. Baseline data were recorded, and all patients we contacted to obtain clinical outcome scores. Patients who required revision surgery and those treated successfully with closed reduction were compared. RESULTS: Fifty patients were included. Of these patients, 40 (80%) required revision surgery whereas 10 (20%) were treated successfully with closed reduction. At an average follow-up of 63.7 months (range, 24-123 months), outcome scores did not differ between groups. Patients who required revision surgery were more likely to have undergone previous shoulder surgery, prior to their index arthroplasty (P = .031). Seventeen patients (42.5%) reported recurrent instability following revision surgery, and 14 (35.0%) required additional revision surgery. Ultimately, stability was never achieved in 7 of 50 patients (14%) after their index instability event. CONCLUSION: Although instability after RSA can commonly be corrected with reasonable functional results, multiple procedures may be needed and some patients may experience persistent instability.

Postoperative stiffness after reverse total shoulder arthroplasty.

Purpose: The purpose of this study was to evaluate the rate and risk factors for stiffness after reverse shoulder arthroplasty and the ramifications on the patient-reported outcomes. Method: A consecutive series of patients who underwent reverse shoulder arthroplasty were prospectively followed for one year. Passive range of motion was measured preoperatively and at regular intervals postoperatively. Patients with passive forward elevation of less than 100° or passive external rotation of less than 30° were defined as stiff. Radiographic parameters and postoperative patient-reported outcome scores were collected. Results: Seventy-six patients were available for review. The prevalence of postoperative stiffness following reverse shoulder arthroplasty was 47% at three months, 31% at six months, and 25% at one year. Preoperative shoulder stiffness was associated with three-month postoperative stiffness only. In patients with one-year stiffness, smaller (p = 0.03) and less lateralized glenospheres (p = 0.024) were more common. Stiffness was not associated with one-year patient-reported outcome scores. Conclusion: Stiffness is common after reverse shoulder arthroplasty and often improves at one-year after surgery. Implant design and selection may be important determinants of passive range of motion. While stiffness does not appear to influence patient-reported outcome scores, one of four patients will potentially have stiffness one year following reverse shoulder arthroplasty.Level of evidence: Level III; retrospective study.

Mid- to long-term outcomes of augmented and nonaugmented anatomic shoulder arthroplasty in Walch B3 glenoids.

BACKGROUND: In cases of severe osteoarthritis, posterior glenoid wear leads to acquired retroversion of the glenoid. Surgical treatment of glenoids with acquired retroversion and posterior humeral subluxation with anatomic total shoulder arthroplasty (aTSA) is controversial. The purpose of this study was to determine mid- to long-term outcomes and reoperation rates of augmented and nonaugmented aTSA for treatment of glenohumeral osteoarthritis with Walch B3 glenoid deformity. METHODS: This observational cohort study reviewed patients with a Walch B3 glenoid undergoing aTSA at a single institution between 2007 and 2014. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 6 years postoperatively. Outcome measures collected included the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score and Single Alpha Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgery on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. RESULTS: Thirty-nine patients met inclusion criteria, and thirty-five (89.7%) were able to be contacted for final outcomes evaluation. Mean follow-up was 8.7 years (range 6-13) after surgery. Sixteen patients were treated with an augmented glenoid component, and 19 patients were treated with a standard glenoid component. Of those with standard components, all were partially corrected with asymmetric reaming. At final follow-up, there were no statistically significant differences between those with augmented and standard glenoid components for mean ASES score (93.3 vs. 85.7, P = .217), ASES pain score (47.2 vs. 41.6, P = .161), SANE score (87.8 vs. 86.0, P = .692), and percentage patient satisfaction (95.6% vs. 96.8%, P = .735), forward elevation (148° vs. 149°, P = .852), or external rotation (36° vs. 39°, P = .202). No patient in either group had undergone revision surgery of the operative shoulder over the study period and all patients stated that they would undergo the same surgery again. DISCUSSION: Both augmented and standard aTSA can provide satisfactory and sustained improvements in patient-reported outcomes in patients with acquired glenoid retroversion due to glenohumeral osteoarthritis. Despite a trend toward alternative treatment options, anatomic shoulder arthroplasty should remain a surgical consideration even in the setting of a Walch B3 glenoid deformity.

Glenoid Radiolucent Lines in Anatomic Total Shoulder Arthroplasty are Unaffected by Thrombin Glenoid Preparation.

BACKGROUND: Modern glenoid cementing techniques for anatomic total shoulder arthroplasty has improved the ability to achieve a stable cement mantle, but the efficacy of adjunctive agents in glenoid preparation is unclear. The purpose of this study is to compare the early radiolucency rates of glenoids prepared with and without thrombin. METHODS: We identified patients between January 2017 and February 2019 undergoing primary anatomic TSA using two glenoid types. Group A glenoids had a cemented central peg without peripheral peg cementation, and Group B glenoids had cemented peripheral pegs without central peg cementation. The first postoperative radiograph was assessed for radiolucent lines. All patients had the same glenoid preparation except some had the addition of thrombin as a preparation agent. RESULTS: We identified 83 Group A glenoids with and 63 without thrombin glenoid preparation, and109 Group B glenoids with and 48 without thrombin preparation. All Group A glenoids had no radiolucent lines and 5 (3%) Group B glenoids had radiolucent lines. Use of thrombin showed no difference in early radiolucencies (p=1.00) in either Group. CONCLUSION: The addition of thrombin as a preparation agent had no effect on early glenoid radiolucent lines in anatomic TSA, and its routine use should be reconsidered.

Spacers for life: high mortality rate associated with definitive treatment of shoulder periprosthetic infection with permanent antibiotic spacer.

BACKGROUND: Periprosthetic joint infection following shoulder arthroplasty represents a challenging problem for orthopedic surgeons. Although recent studies have supported 2-stage exchanges, this treatment choice may not be appropriate for all patients. Definitive antibiotic spacer placement represents one treatment strategy with limited reported outcomes in the literature. The purpose of this study was to investigate the mortality rate and functional outcomes associated with definitive spacer placement. METHODS: A retrospective chart review identified 17 patients who were treated with definitive antibiotic spacer placement (18 spacers) and were followed up for a minimum of 2 years after surgery. The mortality rate over the study period was determined. Demographic information, clinical course, patient-reported outcomes (American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, and Veterans RAND 12 [VR-12] score), infection parameters as defined by International Consensus Meeting criteria, radiographic evaluation findings, and rotator cuff integrity at the time of spacer placement were collected. RESULTS: Seventeen patients underwent treatment with retained antibiotic spacers at a mean age of 62.4 years (range, 50-73 years). Ten patients were women, and the mean body mass index was 30.5 (range, 22.9-39.9). Spacer placement occurred at a mean of 6.1 years (range, 0.48-14.9 years) following index arthroplasty. Five patients required spacer exchange. The most common organisms were Cutibacterium acnes (6) and methicillin-sensitive Staphylococcus aureus (6); in addition, methicillin-resistant S aureus (2), coagulase-negative Staphylococcus (2), Serratia marcescens (1), gram-positive cocci (1), Enterobacter faecalis (1), Enterobacter cloacae (1), diphtheroids (1), and an infection with negative culture findings (1) were observed. The mortality rate was 52.9% (9 of 17 patients). Among the 8 surviving patients, the mean American Shoulder and Elbow Surgeons score was 33.9 (range, 13.3-80.0), the mean Single Assessment Numeric Evaluation score was 35.6 (range, 0.0-80.0), the mean VR-12 mental score was 57.2 (range, 36.6-66.9), and the mean VR-12 physical score was 37.1 (range, 21.7-64.0) at a mean of 4.7 years (range, 2.0-8.8 years). CONCLUSION: Definitive antibiotic spacer placement is an acceptable method to treat infection in medically frail patients who have a high mortality risk. Spacer exchange may be necessary because of persistent infection, and functional results are poor.

Complications Associated With Intravenous Antibiotic Treatment for Cutibacterium acnes Periprosthetic Shoulder Infection.

Whether positive Cutibacterium acnes cultures during revision shoulder arthroplasty represent true periprosthetic joint infection (PJI), deep tissue inoculant, or laboratory contaminant is a point of substantial controversy. The purpose of this study was to review complications of intravenous antibiotics used for treatment of presumed C acnes shoulder PJI. A study population of 26 patients treated for C acnes PJI with a minimum follow-up of 2 years after operative treatment was established. Complication occurrence and severity were obtained through chart review and phone survey. Sixteen (61.5%) patients experienced a therapeutic complication. Twelve (46.2%) patients experienced a total of 47 antibiotic-associated adverse effects and 10 (38.5%) patients experienced 11 total peripherally inserted central catheter line-associated complications. Female sex carried an increased risk for severe complications (relative risk, 3.3; 95% CI, 1.2-9.5; P=.024). Treatment duration of greater than 6 weeks was a significant predictor for the total number of complications experienced [F(1,23)=5.361; P=.030; adjusted R2=0.189]. Age older than 65 years, treatment duration greater than 6 weeks, and female sex were significant predictors for the number of severe complications [F(3,21)=3.249; P=.042; adjusted R2=0.219]. Treating C acnes infection with intravenous antibiotics carries a substantial risk of adverse events, highlighting the importance of accurate diagnosis of shoulder PJI. Further investigations into the efficacy and safety profile of oral antibiotics for shoulder PJI are necessary. [Orthopedics. 2021;44(3):e422-e426.].

Three-dimensional measures of posterior bone loss and retroversion in Walch B2 glenoids predict the need for an augmented anatomic glenoid component.

HYPOTHESIS: The purpose of this study is to evaluate whether the amount of measured posterior bone loss on 2- and 3-dimensional (2D and 3D) imaging of Walch B2 glenoids can reliably predict the plan for an augmented anatomic glenoid component. METHODS: Patients with Walch B2 glenoids and preoperative computed tomography (CT) scans were retrospectively identified. 2D axial CT scans were reviewed and posterior bone loss was measured by 3 independent reviewers. Images were then formatted into BluePrint (Wright Medical) preoperative planning software. The same 3 reviewers again measured posterior bone loss on 3D imaging. Additionally, all cases were planned with BluePrint software. An augment was used when the following criteria were unable to be satisfied with standard implants: <10° retroversion, <10° superior inclination, ≥90% backside contact, <2 mm medial reaming, and ≤1 peg perforation. RESULTS: Forty-two patients were included in the final analysis with a mean age of 63.1 ± 6.3 years. As measured by BluePrint, the mean retroversion was 23° ± 7° (range = 9°-40°), the mean superior inclination was 5° ± 6° (range = -9° to 22°), and the mean posterior subluxation was 80% ± 17% (range = 41%-95%). The mean 2D bone loss measurements (3.5 ± 1.6 mm) were significantly lower than the mean 3D bone loss (4.0 ± 1.8 mm) measurements (P = .03). There was substantial agreement between reviewers on both 2D and 3D measurements with an interclass correlation of 0.815 (95% confidence interval [CI] 0.714-0.889, P < .001) and an interclass correlation of 0.802 (95% CI 0.683-0.884, P < .001), respectively. Augments were used in 73.8%, 63.4%, and 63.4% of cases by reviewers 1, 2, and 3, respectively, with moderate agreement with a Fleiss kappa of 0.592 (95% CI 0.416-0.769, P < .001). Augment size was moderately, positively correlated with the amount of bone loss on 3D imaging but not with 2D imaging. After multivariate logistic regression, both 3D bone loss and retroversion were found to be predictive for a plan to use an augment. CONCLUSION: Planning for a posterior augment in Walch B2 glenoids is better predicted with 3D imaging than with 2D imaging, as 2D imaging may underestimate posterior bone loss. Additionally, use of a larger augment size is moderately correlated with posterior bone loss on 3D imaging but not 2D imaging. Standard 2D imaging may be limited in cases of posterior bone loss, and 3D imaging may be beneficial for preoperative planning in Walch B2 glenoids.