Impact of opioid dependence on outcomes following total shoulder arthroplasty.

INTRODUCTION: The opioid epidemic is a well-established problem encountered in orthopedic surgery in the United States. Evidence in lower extremity total joint arthroplasty and spine surgery suggests a link between chronic opioid use and increased expense and rates of surgical complications. The purpose of this study was to study the impact of opioid dependence (OD) on the short-term outcomes following primary total shoulder arthroplasty (TSA). METHODS: A total of 58,975 patients undergoing primary anatomic and reverse TSA were identified using the National Readmission Database from 2015 to 2019. Preoperative opioid dependence status was used to divide patients into 2 cohorts, with 2089 patients being chronic opioid users or having opioid use disorders. Preoperative demographic and comorbidity data, postoperative outcomes, cost of admission, total hospital length of stay (LOS), and discharge status were compared between the 2 groups. Multivariate analysis was conducted to control for the influence of independent risk factors other than OD on postoperative outcomes. RESULTS: Compared to nonopioid-dependent patients, OD patients undergoing TSA had higher odds of postoperative complications including any complications within 180 days (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3-1.7), readmission within 180 days (OR 1.2, 95% CI 1.1-1.5), revision within 180 days (OR 1.7, 95% CI 1.4-2.1), dislocation (OR 1.9, 95% CI 1.3-2.9), bleeding (OR 3.7, 95% CI 1.5-9.4), and gastrointestinal complication (OR 14, 95% CI 4.3-48). Total cost ($20,741 vs. $19,643), LOS (1.8 ± 1.8 days vs. 1.6 ± 1.7 days), and likelihood for discharge to another facility or home with home health care (18 vs. 16% and 23% vs. 21%, respectively) were higher in patients with OD. CONCLUSION: Preoperative opioid dependence was associated with higher odds of postoperative complications, rates of readmission and revision, costs, and health care utilization following TSA. Efforts focused on mitigating this modifiable behavioral risk factor may lead to better outcomes, lower complications, and decreased associated costs.

Discharge with Home Health Care is Associated with Increased Complications, Readmission, and Mortality Following Total Shoulder Arthroplasty.

INTRODUCTION: Patients undergoing primary anatomic and reverse total shoulder arthroplasty (TSA) are often discharged with home health care (HHC) to provide access to at-home services and facilitate postoperative recovery and continued medical management. The purpose of this study is to evaluate the short-term postoperative outcomes of patients following primary TSA discharged with HHC, including medical and surgical complications, total cost of care, and total hospital length of stay (LOS). METHODS: The Nationwide Readmissions Database (NRD) was reviewed for patients who underwent elective primary TSA between 2016 to 2020 for a retrospective cohort analysis. Patients were stratified by discharge status following the inpatient admission, with 32,497 patients discharged with HHC and 116,402 patients discharged routinely with self-care. Patient demographics, preoperative medical comorbidities, postoperative medical and surgical complications within 180 days, cost of admission, and total hospital length of stay (LOS) were compared between the two discharge groups using Chi-squared analyses. Further multivariate analysis was conducted to control for independent prognosticators on the effect of HHC on postoperative outcomes. RESULTS: Discharge with HHC was correlated with significantly increased rates of all-cause medical complications (OR 1.6, p < 0.001), surgical site infection (SSI) (OR 2.8, p < 0.001), hospital readmission (OR 1.3, p < 0.001), and death (OR 2.1, p < 0.001) within 180 days of primary TSA. Multivariate analysis suggests these correlations are independent risk factors and not due to patient demographics or preoperative medical comorbidities. While discharge with HHC was found to be associated with increased hospital LOS (1.8 vs. 1.3 days, p < 0.001), there were no significant observed differences in cost of care. CONCLUSION: This study demonstrates that discharge with HHC compared to routine discharge while accounting for several preoperative comorbidities and demographic variables is associated with increased medical complications, SSI, readmission, and death within 180 days of TSA, but no increase in overall patient cost. These findings suggest HHC disposition status can serve as a prognosticator for postoperative complications and can help guide clinician decision making when determining appropriate surgical candidacy.

Predictive factors influencing internal rotation following reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) is increasingly used as a treatment modality for various pathologies. The purpose of this review is to identify preoperative risk factors associated with loss of internal rotation (IR) after RTSA. METHODS: A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Ovid MEDLINE, Ovid Embase, and Scopus were queried. The inclusion criteria were as follows: articles in English language, minimum 1-year follow-up postoperatively, study published after 2012, a minimum of 10 patients in a series, RTSA surgery for any indication, and explicitly reported IR. The exclusion criteria were as follows: articles whose full text was unavailable or that were unable to be translated to English language, a follow-up of less than 1 year, case reports or series of less than 10 cases, review articles, studies in which tendon transfers were performed at the time of surgery, procedures that were not RTSA, and studies in which the range of motion in IR was not reported. RESULTS: The search yielded 3792 titles, and 1497 duplicate records were removed before screening. Ultimately, 16 studies met the inclusion criteria with a total of 5124 patients who underwent RTSA. Three studies found that poor preoperative functional IR served as a significant risk factor for poor postoperative IR. Eight studies addressed the impact of subscapularis, with 4 reporting no difference in IR based on subscapularis repair and 4 reporting significant improvements with subscapularis repair. Among studies with sufficient power, BMI was found to be inversely correlated with degree of IR after RTSA. Preoperative opioid use was found to negatively affect IR. Other studies showed that glenoid retroversion, component lateralization, and individualized component positioning affected postoperative IR. CONCLUSIONS: This study found that preoperative IR, individualized implant version, preoperative opioid use, increased body mass index and increased glenoid lateralization were all found to have a significant impact on IR after RTSA. Studies that analyzed the impact of subscapularis repair reported conflicting results.

Outcomes following Humeral Head Autograft Glenoid Reconstruction in Primary Reverse Total Shoulder Arthroplasty.

BACKGROUND: Patients with severe glenoid bone loss are at increased risk for poor implant fixation, scapular notching, dislocation, joint kinematic disturbances, and prosthetic failure following reverse total shoulder arthroplasty (rTSA). Glenoid bone grafting has proven useful when performing rTSA in patients with inadequate glenoid bone stock, although the current literature is limited. The purpose of this study is to evaluate clinical outcomes in patients with significant glenoid deformity undergoing primary rTSA with one-stage glenoid reconstruction using a humeral head autograft. METHODS: A database of prospectively enrolled patients was reviewed to identify patients who underwent primary rTSA with humeral head autograft (n=40) between 2008 and 2020 by six high-volume shoulder arthroplasty surgeons with minimum two-year follow-up. Variables studied included demographics, medical comorbidities, range of motion (ROM), Constant score, American Shoulder and Elbow Surgeons (ASES) score, pain score, patient satisfaction, glenoid deformity, revisions and complications. Preoperative glenoid deformity was characterized using glenoid version and beta-angles, measured on computed tomography (CT). Improvement at final follow-up was compared to a matched control group of 120 standard primary rTSA patients. Following the post hoc Bonferroni correction, an adjusted alpha value of 0.004 was used to define statistical significance. RESULTS: Forty patients were included with a mean follow-up of 5.3 (range, 2.0-13.2) years. Patients exhibited a mean preoperative glenoid retroversion and beta-angle of 29° and 80°, respectively. At final follow-up, patients who received a graft exhibited lower mean scores for active external rotation (25° vs. 39°; p = 0.001) in comparison to those who did not receive a graft. No differences were observed in active abduction (p = 0.029), active forward elevation (p = 0.009), active internal rotation (p = 0.147), passive external rotation (p = 0.082), Global Shoulder Function score (p = 0.157), Constant score (p = 0.036), ASES score (p = 0.009), or pain score (p = 0.186) between groups. Seven patients (17.5%) exhibited complications of which the most common being aseptic glenoid loosening (15%). CONCLUSION: This study demonstrates that patients undergoing primary rTSA with autogenous humeral head autograft for severe glenoid deficiency experience postoperative improvements in ROM and functional outcome scores that exceeded the minimal clinically important difference and substantial clinical benefit but inferior to matched controls. This suggests that glenoid reconstruction using a resected humeral head autograft is an effective strategy when conducting primary rTSA in patients with significant glenoid deformity.

Delayed elective total shoulder arthroplasty: causes and eventual outcomes.

PURPOSE: The purpose of this study is to identify risk factors for delays in planned total shoulder arthroplasty (TSA) and determine the perioperative outcomes of TSAs that experienced a delay. METHODS: The American College of Surgeons National Quality Improvement Program (NSQIP) database was queried from 2006 to 2019 for primary TSA. Delayed TSA was defined as surgery that occurred greater than one day after hospital admission. Patient demographics, comorbidities, and post-operative complications were collected and compared; the incidence of delayed TSA was analyzed. RESULTS: The delayed patients were older, had a higher BMI, a higher rate of recent prior major surgery, and more comorbidities. Delayed patients had higher rates of postoperative complications, return to the OR, and 30-day readmission. Between 2006 and 2019, the rate of delayed TSA decreased. CONCLUSION: Surgeons should take care to ensure that patients with comorbidities undergo thorough preoperative clearance to prevent same-day cancellations and postoperative complications.

Patient outcomes after revision total shoulder arthroplasty in an inpatient vs. outpatient setting.

BACKGROUND: Total shoulder arthroplasty (TSA) is becoming an increasingly common surgical procedure for numerous shoulder conditions. The incidence of revision TSA is increasing because of the increase in primary TSA and the increased utilization of TSA in younger patients. Conducting revision TSA as an outpatient procedure would be beneficial in limiting expenditure and resource allocation but must show a similar complication profile compared to inpatient revision TSA in order to justify its clinical value. The purpose of this study is to compare the outcomes of outpatient revision TSA to inpatient revision TSA and outpatient primary TSA. METHODS: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2010-2019 to identify all patients who underwent revision TSA (n = 1456) in either an inpatient or outpatient setting, as well as patients who underwent primary TSA in an outpatient setting (n = 2630). Relevant demographic characteristics were compared between the outpatient revision group and both the inpatient revision and outpatient primary groups. Postoperative complications, readmission, and reoperation rates were also compared between the groups. RESULTS: Patients undergoing inpatient revision TSA exhibited increased rates of preoperative hypertension (P = .013) and had increased prevalence of severe American Society of Anesthesiologists classification (P = .021) compared to patients undergoing outpatient revision TSA. Patients undergoing outpatient revision TSA were significantly more likely to experience complications (P < .001), have longer surgical times (P < .001), and undergo readmission (P = .006) and reoperation (P = .049) compared to patients undergoing outpatient primary TSA. There was no significant increase in rates of overall complication, readmission, or reoperation between patients undergoing revision TSA in an outpatient vs. an inpatient setting. CONCLUSION: Outpatient revision TSA has higher complication rates, readmission, and reoperation rates compared to outpatient primary TSA, similar to previous findings when comparing revision and primary TSA done as an inpatient. However, there was no increased risk of complications, readmission, or reoperation for outpatient revision TSA compared to inpatient revision TSA. Outpatient revision TSA should be considered by orthopedic surgeons in patients who are medically healthy to undergo the procedure as an outpatient surgery.

How using body mass index cutoffs to determine eligibility for total shoulder arthroplasty affects health care disparities.

BACKGROUND: The prevalence of obesity in the United States is continuously rising and is associated with increased morbidity, mortality, and health care costs. Body mass index (BMI) has been used as a risk stratification and counseling tool for patients undergoing total joint arthroplasty in an effort to focus on outcome-driven care. Although the use of BMI cutoffs may have benefits in minimizing complications when selecting patients for total shoulder arthroplasty (TSA), it may impact access to care for some patient populations and further increase disparities. The purpose of this study is to determine the implications of using BMI cutoffs on the eligibility for TSA among different ethnic and gender patient populations. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify 20,872 patients who underwent anatomic and reverse TSA between 2015 and 2019. Patient demographics, including age, sex, race and ethnicity, and BMI, were compared between eligible and ineligible patients based on BMI for 5 cutoff values: 30, 35, 40, 45, and 50 kg/m2. RESULTS: Of the total patient population studied, the mean age was 69 years, 55% were female, and the mean BMI was 31 kg/m2. For all BMI subgroups, there were more ineligible than eligible patients who were female or Black (P < .001). The relative rate of eligibility for Black patients was lower in each BMI cutoff group, whereas the relative rate of eligibility for White and Asian patients was higher for each group. There were more eligible than ineligible Asian patients for BMI cutoffs of 30 and 35 kg/m2 (both P < .001), and there were no differences in eligibility and ineligibility in Hispanic patients (P > .05). Furthermore, White patients were more eligible than ineligible for all BMI cutoff groups (P < .001). CONCLUSIONS: Enforcing BMI cutoffs for access to TSA may limit the procedure for female or Black patients for all BMI cutoffs, thus furthering the health care disparities these populations already face. However, there are more eligible than ineligible White patients for all BMI cutoff groups, which indicates a disparity in the access to TSA based on sex and race. Physicians may inadvertently increase health care disparities observed in TSA if they use BMI as the sole risk stratification tool for patients, even though BMI has been known to increase complications after TSA. Moreover, orthopedic surgeons should only use BMI as one of many factors in a more holistic process when determining if a patient should undergo TSA.

Aseptic glenoid baseplate loosening after reverse total shoulder arthroplasty with a single prosthesis.

BACKGROUND: Early reverse total shoulder arthroplasty (rTSA) designs had high failure rates, mainly from loosening of the glenoid baseplate. The purpose of this study was to determine the incidence of aseptic glenoid baseplate loosening after primary rTSA using a contemporary medialized glenoid-lateralized humerus system and identify significant risk factors associated with loosening. METHODS: A total of 7162 patients underwent primary rTSA with a single-platform rTSA system between April 2007 and August 2021; of these primary rTSA patients, 3127 with a minimum 2-year follow-up period were identified. Patients with aseptic glenoid baseplate loosening were compared with all other primary rTSA patients without loosening. Univariate and multivariate analyses were performed to compare these cohorts and identify the demographic characteristics, comorbidities, operative parameters, and implant characteristics associated aseptic glenoid loosening after rTSA. Odds ratios (ORs) were calculated for each significant risk factor and for multiple combinations of risk factors. RESULTS: Irrespective of minimum follow-up, 53 of 7162 primary rTSA shoulders (31 female and 22 male shoulders) experienced aseptic glenoid loosening, for an overall rate of 0.74%. At latest (2-year minimum) follow-up, 30 of 3127 patients experienced aseptic glenoid loosening and showed significantly lower clinical scores, function, and active range of motion and higher pain scores than patients without loosening. Univariate analysis identified rheumatoid arthritis (P = .029; OR, 2.74) and diabetes (P = .028; OR, 1.84) as significant risk factors for aseptic glenoid loosening after rTSA, and multivariate analysis identified Walch glenoid types B2 (P = .002; OR, 4.513) and B3 (P = .002; OR, 14.804), use of expanded lateralized glenospheres (P = .025; OR, 2.57), and use of augmented baseplates (P = .001; OR, 2.50) as significant risk factors. CONCLUSION: The incidence of aseptic glenoid baseplate loosening was 0.74% for the evaluated medialized glenoid-lateralized humerus rTSA system. Numerous risk factors for aseptic loosening were identified, including rheumatoid arthritis, diabetes, Walch type B2 and B3 glenoids, posteriorly-superiorly augmented baseplates, and expanded lateralized glenospheres. Finally, analysis of multiple combinations of risk factors identified patients and implant configurations with the greatest risk of aseptic glenoid loosening.

Does glenohumeral offset affect clinical outcomes in a lateralized reverse total shoulder arthroplasty?

BACKGROUND: Reverse total shoulder arthroplasty (rTSA) exhibits high rates of success and low complication rates. rTSA has undergone numerous design adaptations over recent years, and lateralization of implant components provides theoretical and biomechanical benefits in stability and range of motion (ROM) as well as decreased rates of notching. However, the magnitude of implant lateralization and its effect on these outcomes is less well understood. The purpose of this study was to evaluate how increasing glenohumeral offset affects outcomes after rTSA, specifically in a lateralized humerus + medialized glenoid implant model. METHODS: Primary rTSA using a lateralized humeral + medialized glenoid implant model performed at a single academic institution between 2012 and 2018 were retrospectively reviewed. Patient-reported outcome (PRO) parameters and clinical outcomes including ROM were evaluated both pre- and postoperatively. Pre- and postoperative radiographs were analyzed for measurement of glenohumeral offset, defined as the acromial-tuberosity offset (ATO) distance on the anteroposterior radiograph. RESULTS: A total of 130 rTSAs were included in the analysis, with a mean follow-up of 35 mo. The mean postoperative absolute ATO was 16 mm, and the mean delta ATO (difference from pre- to postoperatively) was 4.6 mm further lateralized. Among all study patients, improvements in all ROM parameters and all PROs were observed from pre- to postoperative assessments. When assessing for the effects of lateralization on these outcomes, multivariate analysis failed to reveal a significant effect from the absolute postoperative ATO or the delta ATO on any outcome parameter. CONCLUSIONS: rTSA using a lateralized humeral + medialized glenoid implant model exhibits excellent clinical outcomes in ROM and PROs. However, the magnitude of lateralization as measured radiographically by the ATO did not significantly affect these outcomes; patients exhibited universally good outcomes irrespective of the degree of offset restoration.

American Shoulder and Elbow Surgeons SLAP/Biceps Anchor Study Group evidence review: pathoanatomy and diagnosis in clinically significant labral injuries.

Glenoid superior biceps-labral pathology diagnosis, treatment, and outcomes are an evolving area of shoulder surgery. Historically, described as superior labrum anterior posterior (SLAP) tears, these lesions were identified as a source of pain in throwing athletes. Diagnosis and treatments applied to these SLAP lesions resulted in less than optimal outcomes in some patients and a prevailing sense of confusion. The purpose of this paper is to perform a reappraisal of the anatomy, examination, imaging, and diagnosis by the American Shoulder and Elbow Surgeons/SLAP biceps study group. We sought to capture emerging concepts and suggest a more unified approach to evaluation and identify specific needs for future research.

Impact of COVID-19 on clinical outcomes following total shoulder arthroplasty.

Background: The coronavirus (COVID-19) pandemic has introduced patient stressors and changes to perioperative protocols in total shoulder arthroplasty (TSA). The purpose of this study is to evaluate the short-term effects of the COVID-19 pandemic on various patient outcomes and satisfaction following elective TSA. Methods: A retrospective review was performed on 147 patients who underwent primary TSA at a single institution between June 2019 and December 2020. Patients were divided into 2 cohorts: pre-COVID (June 2019-March 2020; n = 74) and post-COVID (April 2020-December 2020; n = 73). No elective TSA were performed between 10 March 2020 and 23 April 2020 at our institution. Data were collected prospectively both pre- and postoperatively. Range of motion (ROM) testing included active abduction, internal rotation, and external rotation. Patient reported outcome measures (PROMs) included global shoulder function, Simple Shoulder Test, American Shoulder and Elbow Surgeons, Visual Analog Scale pain scoring systems, and patient satisfaction. ROM and PROMs were compared at preoperative, 3-month follow-up, and 12-month follow-up intervals. Operative time, length of stay (LOS), 90-day readmission, and 90-day reoperation were also compared. Results: There were no differences in baseline patient characteristics. The operative time, LOS, home discharge rate, readmission, and reoperation did not differ between groups. For both cohorts, the PROMs and ROM improved at each follow-up visit postoperatively. While preoperative abduction, internal rotation, and external rotation were significantly greater in the post-COVID group, all ROM measures were similar at 3-month and 12-month follow-up visits. There was no difference in pain, global function, Simple Shoulder Test, American Shoulder and Elbow Surgeons, or patient satisfaction between groups at all time intervals. Conclusions: Patients undergoing elective TSA amidst the COVID-19 pandemic demonstrate excellent PROMs, ROM, and high satisfaction up to 12-months postoperatively that are comparable to pre-pandemic standards. Operative time, LOS, discharge destination, as well as 90-day readmission and reoperation rates were not impacted by the pandemic. Patients can expect similar outcomes for TSA when comparing pre-COVID to post-COVID as the pandemic continues.

Three-dimensional finite element modeling of glenoid bone loss and baseplate fixation in reverse total shoulder arthroplasty.

Background: Posterior glenoid bone loss is frequently observed in patients with osteoarthritis undergoing reverse total shoulder arthroplasty. Glenoid bone loss can reduce the baseplate back support area and the number of screws for fixation. The purpose of this study is to determine how initial baseplate fixation is affected by biomechanical factors introduced by glenoid bone loss such as reduced baseplate back support area and reduced screw number using three-dimensional finite element analysis. Methods: Computerized tomography images of a healthy shoulder were selected and segmented to obtain the solid geometry. Solid models were generated with 100%, 75%, 67%, 50%, and 25% glenoid baseplate back support. With these geometries, two groups of finite element models were then built. In the bone loss areas, screws were maintained in one group of models but were removed in the other group of models. 750N compressive loading was applied along the direction parallel to the scapula axis. Maximum von Mises stress and maximum micromotion between the bone and implant were recorded and evaluated for each glenoid bone model. Results: In the group of models where all screws remained in place, the maximum stress and maximum micromotion between the bone and implant exhibited minimal variation. The maximum stresses were 21.10MPa and the maximum micromotions were between 2-3 µm. However, in the group of models removing screws in the bone loss areas, maximum stress increased from 20MPa to 45MPa and maximum micromotion increased from 2 µm to 85 µm as the backside support area decreased from 100% to 25%. Discussion: In conclusion, this three-dimensional finite element analysis study demonstrates that initial fixation can be achieved with approximately 1/3 posterior glenoid bone deficiency even without screw placement in the area of bone loss. Glenoid bone loss affects baseplate fixation mainly by reducing the screw numbers for fixation. If screws can be placed in the bone loss area, the decreased baseplate back support area will not result in increased stresses or micromotion leading to baseplate failure. This study suggests that surgeons should consider applying screws to the bone loss area if the remaining bone is able to hold the screw. Level of evidence: Computer Modeling Study.

Shoulder arthroplasty after prior anterior shoulder instability surgery: a matched cohort analysis.

PURPOSE: To evaluate the effect of prior anterior shoulder instability surgery (SIS) on the outcomes and complications of primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA). METHODS: Between 2007 and 2018, 38 primary total shoulder arthroplasties (TSA) (22 aTSA and 16 rTSA) with a prior SIS and a minimum of 2 years of follow-up were identified. This cohort was matched 1:3 based on age, sex, body mass index, year of surgery, and dominant shoulder. aTSA and rTSA were matched to patients with primary osteoarthritis (OA) and rotator cuff tear arthropathy (CTA), respectively. RESULTS: TSA produced similar postoperative pain, ROM, patient-reported outcome measures, complications, and revisions in those with prior SIS vs. controls. aTSA with prior SIS demonstrated worse final postoperative abduction (116° vs. 133°; P = 0.046) and abduction improvement (24° vs. 47°; P = 0.034) compared to OA controls. Both aTSA and rTSA with prior SIS demonstrated significant improvements from baseline across all metrics, with no significant differences between the groups. aTSA and rTSA with prior SIS demonstrated no differences to controls in complications (4.6% vs. 6.1%; P = .786 and 0% vs. 6.3%. P = .183) or revisions (4.6% vs. 4.6%; P = .999 and 0% vs. 4.2%; P = .279). CONCLUSIONS: TSA after prior SIS surgery can improve both pain and function without adversely increasing the rates of complications or revision surgery. When compared to patients without prior SIS, aTSA demonstrated worse abduction; however, all other functional differences remained statistically similar. LEVEL OF EVIDENCE: III; Retrospective Cohort Comparison; Treatment Study.

Assessing the hospital volume-outcome relationship in total elbow arthroplasty.

BACKGROUND: Total elbow arthroplasty (TEA) is an effective intervention for multiple elbow disorders including complex fracture in elderly patients, post-traumatic arthropathy, inflammatory arthropathy, and distal humeral nonunion. Given its known therapeutic value and low utilization rate, an investigation into the thresholds for TEA institutional volume-outcome relationships is warranted. The purpose of this study was to identify TEA volume thresholds that serve as predictors of institutional outcomes including complications, readmissions, revisions, cost of care, length of stay (LOS), and non-home discharge. We hypothesized that increased institutional volume would be associated with decreased 90-day adverse outcomes and resource utilization. METHODS: The Nationwide Readmission Database was queried from 2010 to 2017 to identify all cases of TEA. Hospital volume was calculated using a unique hospital identifier and divided into quartiles. Outcomes such as complications, readmissions, revisions, cost of care, LOS, and non-home discharge were then analyzed by quartile. The same outcomes were assessed via stratum-specific likelihood ratio (SSLR) analysis to define volume strata among institutions. RESULTS: SSLR analysis defined statistically significant hospital volume categories for each 90-day outcome. The volume category with the lowest complication rate was ≥21 TEAs per year (5.6%). The volume categories with the lowest readmission rates were 1-3 TEAs per year (4.7%) and ≥18 TEAs per year (9.2%). Revision rates were lowest in the volume categories of 1-5 TEAs per year (0.1%) and ≥18 TEAs per year (0.1%). Hospitals with ≥21 TEAs per year had the lowest cost of care and the highest rate of extended LOS (>2 days). SSLR analysis showed that non-home discharges decreased in a stepwise manner as volume increased. The lowest non-home discharge rate was associated with the volume category of ≥22 TEAs per year (20.3%). CONCLUSION: This study defines TEA volume strata for institutional outcomes. The highest TEA volume strata were associated with the lowest rates of 90-day complications, revisions, and non-home discharges and the lowest cost of care. This trend is likely attributable to the benefits of high-volume institutional experience and standardized patient-care processes.

Clinical and radiographic outcomes following reverse total shoulder arthroplasty in patients 60 years of age and younger.

BACKGROUND: Although initially indicated for use in older patients, reverse total shoulder arthroplasty (rTSA) is being increasingly used in younger patients. The purpose of this study is to compare the clinical and radiographic outcomes of patients aged <60 years to those aged 60-79 years following primary rTSA. METHODS: 154 patients aged <60 years and 1763 patients aged 60-79 years were identified from an international multi-institutional Western Institutional Review Board-approved registry with a minimum 2 years' follow-up. All patients were evaluated and scored preoperatively and at latest follow-up using 5 outcome scoring metrics and 4 active range of motion (ROM) measurements. RESULTS: Patients aged <60 years were more often male (P = .023), had a higher body mass index (P = .001), higher rates of previous surgery (57% vs. 27%, P < .001), higher rates of post-traumatic arthritis (11% vs. 5%, P < .001) and inflammatory arthropathy (13% vs. 4%, P < .001), and lower rates of rotator cuff tear arthropathy (25% vs. 38%, P = .006). There were no differences in ROM between the groups but patients aged <60 years had significantly lower function and outcome metric scores and higher pain scores at latest follow-up. Adverse event rates were similar between the 2 groups, but patients aged <60 years were more likely to require revision (5.2% vs. 1.8%, P = .004). Patients aged <60 years also had lower satisfaction scores (much better/better 86% vs. 92%, P = .006). CONCLUSION: At a mean follow-up of 47 months, primary rTSA patients aged <60 years had worse clinical outcomes compared with those aged 60-79 years, with lower outcome scores, increased pain, lower function scores, and less patient satisfaction. Patients aged <60 years had higher rates of previous surgery, inflammatory arthropathy, and post-traumatic arthritis, whereas those aged 60-79 years had higher rates of rotator cuff tear arthropathy. Although complications were similar, younger patients had 3 times the risk of revision rTSA.

Clinical and radiographic outcomes after reverse total shoulder arthroplasty in patients 80 years of age and older.

BACKGROUND: Previous studies have found less favorable outcomes for patients aged 80 years and older after primary reverse total shoulder arthroplasty (rTSA). However, they are based on small sample sizes with no control group for comparison. The purpose of this study is to compare the clinical, functional, and radiographic outcomes after primary rTSA in patients aged 80 years and older with a younger cohort of patients aged 60-79 years. METHODS: Patients undergoing primary rTSA between 2004 and 2018 were identified within a multi-institutional database with a minimum of 2 years of follow-up. All patients received the same platform prosthesis. Patients were divided into 2 groups based on age: 80 years and older (n = 369) and 60-79 years (n = 1764). Statistical analyses were performed to compare the 2 age cohorts based on pre- and postoperative function and range of motion (ROM) scores, adverse event rates, pain scores, and patient satisfaction. RESULTS: Patients aged 80 years and older had lower preoperative functional and ROM scores relative to patients aged 60-79 years. The differences observed in active abduction, active forward elevation, and Constant scores exceed the minimal clinically important difference (MCID). The evaluation of function and ROM at latest follow-up showed that patients in both age cohorts had significant improvements that exceeded both the MCID and substantial clinical benefit, but older patients still scored lower relative to younger patients, with the differences in active abduction and Constant scores exceeding the MCID. Despite the lower scores observed in older patients, both groups report similar satisfaction (93% in older patients vs. 92% in younger patients, P = .379). There were no differences between the 2 age cohorts with regard to humeral radiolucent lines (9.2% vs. 8.7%, P = .765), scapular notching (11.0% vs. 10.3%, P = .727), adverse events (3.5% vs. 3.3%, P = .863), and revisions (0.8% vs. 1.8%, P = .188). CONCLUSIONS: Patients aged 80 years and older can expect significant improvements in function and ROM after primary rTSA, with satisfaction similar to that of patients aged 60-79 years. Patients in both age cohorts have similar rates of adverse events and revisions, and the rates observed in patients 80 years and older are much lower than what has previously been reported in the literature. rTSA in patients age 80 years and older is a beneficial surgery with outcomes similar to those found in younger patients, and age should not be a limiting factor when considering rTSA.

Variability and reliability of 2-dimensional vs. 3-dimensional glenoid version measurements with 3-dimensional preoperative planning software.

BACKGROUND: Preoperative planning for total shoulder arthroplasty (TSA) may change according to the measured degree of glenoid version. Both 2-dimensional (2D) and 3-dimensional (3D) computed tomographic (CT) scans are used to measure glenoid version, with no consensus on which method is more accurate. However, it is generally accepted that 3D measurements are more reliable, yet most 3D reconstruction software currently in clinical use have never been directly compared to 2D. The purpose of this study is to directly compare 2D and 3D glenoid version measurements and determine the differences between the two. METHODS: CT scans were performed preoperatively on 315 shoulders undergoing either anatomic or reverse TSA. 2D measurements of glenoid version were obtained manually using the Friedman method, whereas 3D measurements were obtained using the Equinoxe Planning Application (Exactech Inc.) 3D-reconstruction software. Negative version values indicate retroversion, whereas positive values indicate anteversion. Two observers collected the 2D measurements 2 separate times, and intra- and interobserver measurements were calculated. Groups were compared for variability using intraclass correlation coefficients (ICCs), and for differences in sample means using Student t tests. Additionally, samples were stratified by version value in order to better understand the potential sources of error between measurement techniques. RESULTS: For the 2D measurements, intraobserver variability indicated excellent reproducibility for both observer 1 (ICC = 0.928, 95% confidence interval [CI] 0.911-0.942) and observer 2 (ICC = 0.964, 95% CI 0.955-0.971). Interobserver variability measurements also indicated excellent reproducibility (ICC = 0.915, 95% CI 0.778-0.956). The overall 2D version measurement average (-4.9° ± 10.3°) was significantly less retroverted than the 3D measurement average (-8.4° ± 9.1°) (P < .001), with 3D measurements yielding a more retroverted value 73% of the time. When stratified on the basis of version value with outliers excluded, there was no significant difference in the distribution of high-error samples within the data. DISCUSSION: There was excellent reproducibility between the 2 observers in terms of both intra- and interobserver variability. The 3D measurement techniques were significantly more likely to return a more retroverted measurement, and high-error samples were evenly distributed throughout the data, indicating that there were no discernable trends in the degree of error observed. Shoulder surgeons should be aware that different glenoid version measurement strategies can yield different version measurements, as these can affect preoperative planning and surgeon decision making.

Effects of obesity on clinical and functional outcomes following anatomic and reverse total shoulder arthroplasty.

BACKGROUND: Limited data exist regarding the clinical and functional outcomes following primary total shoulder arthroplasty in obese patients. The purpose of this study is to determine the effects of obesity on the clinical and functional outcomes following primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) in a large patient population with mid-term follow-up. METHODS: Patients in a multi-institutional shoulder registry receiving either primary aTSA (n = 1520) or rTSA (n = 2054) from 2004 to 2018 with a minimum follow-up period of 2 years were studied. All patients received the same single-platform shoulder prosthesis. Study groups were assigned based on implant type (anatomic or reverse), and further stratification was based on patient body mass index (BMI), with obese patients having a BMI ≥ 30 and non-obese patients having a BMI < 30. Patients were evaluated and scored preoperatively and at latest follow-up by use of 5 scoring metrics and range of motion (ROM). RESULTS: The mean follow-up period was 5 years (range, 2-14 years). Obese patients comprised 41% of the aTSA group and 35% of the rTSA group. Significant postoperative improvements in visual analog scale pain scores, ROM, and all 5 scoring metrics occurred in both obese and non-obese patients (P < .05). Obese patients in both groups reported higher preoperative and postoperative visual analog scale pain scores and less preoperative and postoperative ROM compared with non-obese patients. Compared with non-obese patients, obese patients receiving aTSA reported significantly worse postoperative Simple Shoulder Test, Constant-Murley, American Shoulder and Elbow Surgeons, University of California, Los Angeles, and Shoulder Pain and Disability Index scores compared with non-obese patients, and those receiving rTSA reported significantly worse American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index scores (all P < .05). However, these differences did not exceed the minimal clinically important difference or substantial clinical benefit criteria. Radiographic analysis showed that in the rTSA group, obese patients had significantly less postoperative scapular notching and a lower scapular notching grade compared with non-obese patients (P < .05). DISCUSSION: Both non-obese and obese patients can expect clinically significant improvements in pain, motion, and functional outcome scores following both aTSA and rTSA. Obese patients reported significantly more postoperative pain, lower outcome scores, and less ROM compared with non-obese patients after both aTSA and rTSA at a mean follow-up of 5 years. However, statistically significant differences were not found to be clinically significant with respect to established minimal clinically important difference and substantial clinical benefit criteria. Therefore, obese and non-obese patients experience similar clinical outcomes following total shoulder arthroplasty, regardless of BMI. However, obese patients have more comorbidities, greater intraoperative blood loss, and less scapular notching compared with non-obese patients.

Comparing Dermabond PRINEO versus Dermabond or staples for wound closure: a randomized control trial following total shoulder arthroplasty.

BACKGROUND: The method of surgical incision closure after total shoulder arthroplasty is an important factor to consider, as it affects operating room time, procedure cost, cosmetic outcomes, and patient satisfaction. The optimal method of wound management is unknown, but should be cost-effective, reproducible, and provide a reliable clinical result. This study aimed to compare the following wound closure methods after total shoulder arthroplasty: staples, Dermabond, and Dermabond PRINEO. We hypothesized that wound closure time for Dermabond PRINEO would be faster than Dermabond and comparable to that of staples, and Dermabond PRINEO would be more cost-effective than Dermabond and staples, and provide equal or superior closure outcomes to Dermabond and staples. METHODS: A randomized, prospective clinical trial comparing wound closure time and cost for 2 surgeons' traditional technique with that of Dermabond PRINEO was conducted. This study included at least 18 subjects in each group. Surgeon 1's patients were randomized to traditional Dermabond or Dermabond PRINEO, whereas surgeon 2's patients were randomized to staples or Dermabond PRINEO. Cosmetic outcomes and satisfaction scores were collected at 6 weeks and 3 months, postoperatively. Incisions were photographed, at both the 6-week and 3-month visits, and subsequently evaluated by a plastic surgeon blinded to the treatment method. RESULTS: The wound closure time for surgeon 1 was significantly faster for Dermabond PRINEO vs. Dermabond, and surgeon 2 closed significantly faster with staples vs. Dermabond PRINEO. The mean cost of closure was significantly less with Dermabond PRINEO compared with Dermabond, whereas the mean cost of staples was significantly less than Dermabond PRINEO. For both surgeons 1 and 2, there were no significant differences in patient satisfaction at 6 weeks or 3 months. In addition, the wound closure methods did not produce differing cosmetic outcomes. CONCLUSIONS: Although significant, the closing time for each method did not differ by a clinically relevant amount. Staples were the most cost-effective closing method, followed by Dermabond PRINEO. As neither method was superior over the other in terms of patient satisfaction, adverse events, and cosmetic outcomes, cost-effectiveness may be the greatest differentiator between the 3 methods.

Outcomes and complications of primary reverse shoulder arthroplasty with minimum of 2 years' follow-up: a systematic review and meta-analysis.

BACKGROUND: Primary reverse shoulder arthroplasty (rTSA) is an effective treatment option for reducing pain and improving function for patients with rotator cuff tear arthropathy, irreparable rotator cuff tears, glenoid deformity, and other challenging clinical scenarios, including fracture sequelae and revision shoulder arthroplasty. There has been a wide range of reported outcomes and postoperative complication rates reported in the literature. The purpose of this systematic review and meta-analysis is to provide an updated review of the clinical outcomes and complication rates following primary rTSA. METHODS: A systematic review and meta-analysis was performed to evaluate outcomes and complications following primary rTSA according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Demographics, range of motion, patient-reported outcome measures (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant scores), number of complications, and revisions were extracted, recorded, and analyzed from the included articles. RESULTS: Of the 1415 studies screened, 52 studies met the inclusion criteria comprising a total of 5824 shoulders. The mean age at the time of surgery was 72 years (range: 34-93), and the mean follow-up was 3.9 years (range: 2-16). Patients demonstrated a mean improvement of 56° in active flexion, 50° in active abduction, and 14° in active external rotation. Regarding functional outcome scores, rTSA patients demonstrated a mean clinically significant improvement of 37 in Constant score (minimal clinically important difference [MCID] = 5.7) and ASES score (42.0; MCID = 13.6). The overall complication rate for rTSA was 9.4% and revision rate of 2.6%. Complications were further subdivided into major medical complications (0.07%), shoulder- or surgical-related complications (5.3%), and infections (1.2%). The most frequently reported shoulder- or surgical-related complications were scapular notching (14.4%), periprosthetic fracture (0.8%), glenoid loosening (0.7%), and prosthetic dislocation (0.7%). DISCUSSION: Primary rTSA is a safe and reliable procedure with low complication, revision, infection, and scapular notching rates. Additionally, patients demonstrated clinically significant improvements in both range of motion and clinical outcome scores.