The effect of smoking on functional outcomes and implant survival of anatomical total shoulder arthroplasty.

Aims: We sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients. Methods: A retrospective review of a prospectively collected shoulder arthroplasty database was performed between August 1991 and September 2020 to identify patients who underwent primary aTSA. Patients were excluded for preoperative diagnoses of fracture, infection, or oncological disease. Three cohorts were created based on smoking status: non-smokers, former smokers, and current smokers. Outcome scores (American Shoulder and Elbow Surgeons (ASES), Constant-Murley score, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), University of California, Los Angeles activity scale (UCLA)), range of motion (external rotation (ER), forward elevation (FE), internal rotation, abduction), and shoulder strength (ER, FE) evaluated at two- to four-year follow-up were compared between cohorts. Evaluation of revision-free survival was performed using the Kaplan-Meier method to final follow-up. Results: We included 428 primary aTSAs with a mean follow-up of 2.4 years (SD 0.6). Our cohort consisted of 251 non-smokers, 138 former smokers who quit a mean 21 years (SD 14) prior to surgery (25 pack-years (SD 22)), and 39 current smokers (23 pack-years (SD 20)). At two- to four-year follow-up, former smokers had less favourable SPADI, SST, and FE strength compared to non-smokers, and current smokers had less favourable SPADI, SST, ASES score, UCLA score, Constant-Murley score, FE, abduction, and ER strength compared to non-smokers. Non-smokers exhibited higher revision-free survival rates at two, five, eight, and ten years postoperatively compared to former smokers and current smokers, who had similar rates. Conclusion: Our study suggests that smoking has a negative effect on aTSA functional outcomes that may persist even after quitting.

Outcomes of revision versus re-revision reverse total shoulder arthroplasty: A case-control-matched cohort study.

Background: The increasing incidence of reverse total shoulder arthroplasties (RTSA) has led to an increase in revision surgery. We aimed to compare patients undergoing re-revision RTSA to a matched cohort undergoing first-revision RTSA. Methods: A retrospective review of all revision RTSAs was performed at a single institution. Sixteen shoulders that underwent re-revision RTSA were matched 1:3 to shoulders that underwent revision RTSA with a minimum two-year follow-up. Outcome scores including the American Shoulder and Elbow Surgeons Shoulder Score (ASES), Short-Form 12 (SF-12), Shoulder Pain and Disability Index (SPADI), and Simple Shoulder Test (SST) scores, range of motion (ROM), and improvement from preoperative to postoperative outcomes after re-revision RTSA were assessed. Additionally, postoperative outcomes after re-revision RTSA were compared to patients that underwent first revision RTSA and subsequently compared to the minimal clinically important difference (MCID) values for the outcome scores and ROM measurements assessed. Results: Sixteen shoulders that underwent re-revision RTSA and 78 revision RTSAs met the final inclusion criteria to be included in this study. Significant improvement from preoperative to postoperative re-revision RTSA was seen in the ASES score (p = 0.046), SPADI score (p = 0.044), SST (p = 0.008), abduction (p = 0.016), and elevation (p = 0.025), but not the SF-12 score (p = 0.396), external rotation (p = 0.449), or internal rotation (p = 0.451). Outcomes after revision RTSA were found to be superior to outcomes after re-revision RTSA for all outcome scores (ASES p = 0.029, SF-12 p = 0.018, SPADI p = 0.003) except the SST score (p = 0.080) and all ROM measures (p > 0.05 for all). Internal rotation was equivalent postoperatively between both groups. From preoperative to postoperative re-revision RTSA, the mean improvement exceeded the MCID for the SST score, abduction, forward elevation, and external rotation. When comparing postoperative revision RTSA to postoperative re-revision RTSA, the mean difference between revision and re-revision RTSA exceeded the MCID for the SPADI score and external rotation. The complication rate was 19% in shoulders undergoing first revision and 41% in shoulders undergoing re-revision RTSA. Conclusion: Patients undergoing re-revision RTSA receive improvement in clinical outcomes, but do not achieve outcomes comparable to those achieved after first revision RTSA.

The effect of tuberosity healing on functional outcomes after reverse shoulder arthroplasty for proximal humerus fractures: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis compared clinical outcome measures in patients undergoing reverse shoulder arthroplasty (RSA) for proximal humerus fracture (PHF) with healed versus non-healed greater tuberosity (GT). METHODS: We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines querying PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane for studies that stratified results by the GT healing status. Studies that did not attempt to repair the GT were excluded. We extracted and compared clinical outcomes including postoperative forward flexion (FF), external rotation (ER), internal rotation (IR), Constant score, and complications and revision rates. RESULTS: Of the included patients, 295 (78.5%) demonstrated GT healing while 81 did not (21.5%). The healed GT cohort exhibited increased postoperative FF (P < .001), ER (P < .001), IR (P = .006), and Constant score (P = .006) compared to the non-healed GT cohort. The overall dislocation rate was 0.8% with no study differentiating GT status of dislocation cases. CONCLUSION: Healing of the GT after RSA for PHF yields improved postoperative range of motion and strength, whereas patient-reported pain and function were largely not affected by GT healing indicating merit to RSA for PHF regardless of the likelihood of the GT healing.

The effect of socioeconomic status on clinical outcomes and implant survivorship after primary anatomic and reverse total shoulder arthroplasty.

BACKGROUND: Low socioeconomic status has been shown to contribute to poor outcomes in patients undergoing joint replacement surgery. However, there is a paucity of studies investigating shoulder arthroplasty. The purpose of this study was to evaluate the effect of socioeconomic status on baseline and postoperative outcome scores and implant survivorship after anatomic and reverse primary total shoulder arthroplasty (TSA). METHODS: A retrospective review of a prospectively collected single-institution database was performed to identify patients who underwent primary TSA. Zip codes were collected and converted to Area Deprivation Index (ADI) scores. We performed a correlation analysis between national ADI scores and preoperative, postoperative, and preoperative to postoperative improvement in range of motion (ROM), shoulder strength, and functional outcome scores in patients with minimum 2-year follow-up. Patients were additionally grouped into groups according to their national ADI. Achievement of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) and revision-free survivorship were compared between groups. RESULTS: A total of 1148 procedures including 415 anatomic and 733 reverse total shoulder arthroplasties with a mean age of 64 ± 8.2 and 69.9 ± 8.0 years, respectively, were included. The mean follow-up was 6.3 ± 3.6 years for anatomic and 4.9 ± 2.7 years for reverse total shoulder arthroplasty. We identified a weak negative correlation between national ADI and most functional outcome scores and ROM preoperatively (R range 0.07-0.16), postoperatively (R range 0.09-0.14), and preoperative to postoperative improvement (R range 0.01-0.17). Thus, greater area deprivation was weakly associated with poorer function preoperatively, poorer final outcomes, and poorer improvement in outcomes. There was no difference in the proportion of each ADI group achieving MCID, SCB, and PASS in the anatomic total shoulder arthroplasty cohort. However, in the reverse total shoulder arthroplasty cohort, the proportion of patients achieving MCID, SCB, and PASS decreased with greater deprivation. There was no difference in survivorship between ADI groups. CONCLUSIONS: We found a negative effect of low socioeconomic status on baseline and postoperative patient outcomes and ROM; however, the correlations were relatively weak. Patients that reside in socioeconomically deprived areas have poorer functional outcomes before and after TSA and achieve less improvement from surgery. We should strive to identify modifiable factors to improve the success of TSA in socioeconomically deprived areas.

Mitigating the Risk of Instability After Reverse Shoulder Arthroplasty: A Critical Analysis Review of Patient and Surgical Factors.

¼ Instability and dislocation after reverse shoulder arthroplasty may occur in up to 31% of patients.¼ Clinical risk factors for instability include younger age, male sex, increased body mass index, preoperative diagnosis of proximal humerus fracture or rotator cuff pathology, history of instability of the native shoulder or after surgery, and a medical history of Parkinson's disease.¼ Patients with rheumatoid arthritis and decreased proximity to the coracoid may also be at greater risk.¼ In patients at a high risk of instability, surgeons should consider a more lateralized prosthesis (particularly in patients with an incompetent rotator cuff), repairing the subscapularis (particularly when using a medialized prosthesis), and upsizing the glenosphere (>40 mm in male and 38-40 mm in female patients).¼ While potentially useful, less evidence exists for the use of a constrained liner (particularly with a lateralized glenosphere and/or in low-demand patients) and rotating the polyethylene liner posteriorly to avoid impingement.

Reverse Allograft Prosthetic-Composite Versus Endoprosthesis Reconstruction for Massive Proximal Humerus Bone Loss: A Systematic Review and Meta-analysis of Outcomes and Complications.

Background: This systematic review and meta-analysis sought to compare the clinical outcomes after proximal humerus reconstruction with a reverse allograft-prosthetic composite (APC) versus reverse endoprosthesis. Methods: Per PRISMA guidelines, we queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of reverse APC or reverse endoprosthesis reconstruction of the proximal humerus for massive bone loss secondary to tumor, fracture, or failed arthroplasty. We compared postoperative range of motion, outcome scores, and the incidence of complications and revision surgery. Results: Of 259 unique articles, 18 articles were included (267 APC, 260 endoprosthesis). There were no significant differences between the APC and endoprosthesis cohort for postoperative forward elevation (P = .231), external rotation (P = .634), ASES score (P = .420), Constant score (P = .414), MSTS (P = .815), SST (P = .367), or VAS (P = .714). Rate of complications was 15% (31/213) in the APC cohort and 19% (27/144) in the endoprosthesis cohort. The rate of revision surgery was 12% after APC cohort and 7% after endoprosthesis. APC-specific complications included a 10% APC nonunion/malunion/resorption rate and 6% APC fracture/fragmentation rate. Discussion: Reverse APC and endoprosthesis are reasonable options for proximal humerus reconstruction. APC carries additional risks for complications, warranting evaluation of patients' healing capacity and surgeon experience. Level of Evidence: Level IV; Systematic Review. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-024-01248-7.

The Effect of Smoking on Outcomes of Reverse Total Shoulder Arthroplasty.

BACKGROUND: The effect of smoking status on clinical outcomes in reverse total shoulder arthroplasty (rTSA) has not been thoroughly characterized. We sought to compare pain and functional outcomes, complications, and revision-free survivorship between current smokers, former smokers, and non-smokers undergoing primary rTSA. METHODS: We retrospectively reviewed a prospectively-collected shoulder arthroplasty database from 2004-2020 to identify patients who underwent primary rTSA. Three cohorts were created based on smoking status: current smokers, former smokers, and non-smokers. Outcome scores (SPADI, SST, ASES, UCLA, Constant), range of motion (ROM) (external rotation [ER], forward elevation [FE], abduction, internal rotation [IR]) and shoulder strength (ER, FE) evaluated at 2-4-year follow-up were compared between cohorts. The incidence of complication and revision-free implant survivorship were evaluated. RESULTS: We included 676 primary rTSAs, including 38 current smokers (44±47 pack-years), 84 former smokers who quit on average 20±14 years (range: 0.5-57 years) prior to surgery (38±32 pack-years), and 544 non-smokers. At 2-4-year follow-up, current smokers had less favorable SPADI, SST, ASES scores, UCLA scores, and Constant scores compared to former smokers and non-smokers. On multivariable analysis, current smokers had less favorable SPADI, SST, ASES score, UCLA score, and Constant score compared to non-smokers. There were no significant differences between cohorts in complication rate and revision-free survivorship. CONCLUSION: Our data showed that current smokers may have poorer functional outcomes after rTSA compared to former smokers and non-smokers despite the incidence of complications and revision surgery not differing significantly between cohorts.

Survivorship and Clinical Outcomes of Reverse Total Shoulder Arthroplasty in Patients with Large Glenoid Defects Using the Stilting Technique and a Baseplate with Central Ingrowth Cage and Peripheral Locking Screws.

BACKGROUND: Stilting is a novel technique used in reverse shoulder arthroplasty (RSA) in patients with significant glenoid bone loss. This technique utilizes peripheral locking screws placed behind an unseated portion of the baseplate, to transmit forces from the baseplate to the cortical surface of the glenoid, without the need for bone grafting. The stilted screw, once locked, provides a fixed angle point of support for an unseated aspect of a baseplate. The primary advantages of this technique are reduced cost compared to a custom implant and reduced operative time compared to bone grafting. METHODS: We conducted a retrospective, non-randomized, comparative cohort study of 41 patients underwent primary Reverse Shoulder Arthroplasty (RSA) using the Stilting Technique with the Exactech Equinoxe Reverse System (Gainesville, FL, USA) at a single, academic center from the years 2004-2021. Exclusion criteria included age under 18 or over 100, and oncologic or acute fracture RSA indications. Operative data was documented, including implant records, percent baseplate seating, and operative duration. Survivorship was compared among primary stilted-RSA (n=41), bone graft-RSA (n=42), and non-stilted/non-bone grafted RSA (n=1,032) within our institutional shoulder arthroplasty database. A radiographic examination of baseplate failure was also conducted across the study groups. Postoperative functional outcomes were compared in a matched analysis involving patients with a minimum 2-year follow-up between stilted patients and a non-stilted/non-bone grafted control group for primary RSA. RESULTS: All Stilted-RSA cases utilized metal augments and demonstrated a mean baseplate seating of 61% (range 45-75%). For stilted RSAs, survivorship was 100% and 92.6% at 2- and 5-years, compared to 98.3% and 94.6% for non-stilted/non-bone grafted and 96.3% and 79.5% for bone-grafted RSAs (p=0.042). At 5-years, the baseplate-related failure rates were greater in the stilted (7.4%) and the bone-grafted (9.3%) cohorts compared with the non-stilted/non-bone grafted cohort (1.1%, p<0.001). The mean time to baseplate failure was 30 months for stilted RSA. Functional outcomes for primary RSA were statistically similar between stilted and non-stilted patients, including range of motion, Constant, ASES, SST, UCLA, and SPADI scores. CONCLUSION: The stilted-RSA cohort exhibited noninferior revision and baseplate failure rates to that of bone-grafted RSA. This suggests that stilting may be a viable technique for patients undergoing primary RSA with significant glenoid deformity.

Does preoperative forward elevation weakness affect clinical outcomes in anatomic or reverse total shoulder arthroplasty patients with glenohumeral osteoarthritis and intact rotator cuff?

BACKGROUND: This study sought to determine if preoperative forward elevation (FE) weakness affects outcomes of anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) for patients with rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA). METHODS: A retrospective review of a single institution's prospectively collected shoulder arthroplasty database was performed between 2007 and 2020, including 333 aTSAs and 155 rTSAs for primary RCI-GHOA with a minimum 2-year follow-up. Defining preoperative weakness as FE strength ≤4.9 lb (2.2 kg), three cohorts were matched 1:1:1 by age, sex, and follow-up: weak (n=82) to normal aTSAs, weak (n=44) to normal rTSAs, and weak aTSAs (n=61) to weak rTSAs. Compared outcomes included range of motion, outcome scores, and complication and revision rates at latest follow-up. RESULTS: Weak aTSAs and weak rTSAs achieved similar postoperative outcome measures to normal aTSAs and normal rTSAs, respectively (P>0.05). Compared to weak rTSAs, weak aTSAs achieved superior postoperative passive (P=0.006) and active external rotation (ER) (P=0.014) but less favorable postoperative Shoulder Pain and Disability Index (P=0.032), American Shoulder and Elbow Surgeons (P=0.024), and University of California, Los Angeles scores (P=0.008). Weak aTSAs achieved the minimal clinically important difference and substantial clinical benefit at a lower rate for abduction (P=0.045 and P=0.003) and FE (P=0.011 and P=0.001). Weak aTSAs had a higher revision rate (P=0.025) but a similar complication rate (P=0.291) compared to weak rTSAs. CONCLUSIONS: Patients with RCI-GHOA and preoperative FE weakness obtain postoperative outcomes similar to patients with normal preoperative strength after either aTSA or rTSA. Preoperatively, weak aTSAs achieved greater ER but lower rates of clinically relevant improvement in overhead motion compared to weak rTSAs. Level of evidence: III.

Clinical outcomes of over-the-top subscapularis repair in reverse shoulder arthroplasty.

Background: Biomechanical research demonstrates increased subscapularis abduction range of motion (ROM) when the tendon's upper two-thirds is repaired over-the-top of the center of rotation during reverse shoulder arthroplasty (RSA). This study compares the clinical outcomes of patients undergoing RSA with over-the-top subscapularis repair (OTTR) to patients without repair. Methods: We retrospectively reviewed 97 consecutive RSAs with either OTTR of the subscapularis (N = 75) or no repair (N = 22). Repair was attempted in all patients but not performed if the subscapularis could not be brought to the over-the-top position in 20° of external rotation (ER) and 30° of abduction. Improvements in ROM were compared to the minimal clinically important difference for RSA. Results: The mean follow-up was 3.8 ± 1.6 years. Demographics were similar between groups. Preoperatively, patients undergoing repair had greater ER when compared to those without repair (15 ± 16° vs. 5 ± 12°, P = .003). Postoperatively, patients undergoing repair had greater forward elevation (132 ± 21° vs. 126 ± 22°, P = .268) and abduction (114 ± 26° vs. 106 ± 23°, P = .193) with both exceeding the minimal clinically important difference (-2.9° and -1.9°, respectively); however, not statistically significant. Patients with repair were more frequently able to reach the small of their back postoperatively (65% vs. 21%, P = .006) but had less improvement in ER (13 ± 20° vs. 24 ± 20°, P = .028). Postoperative outcome scores, complications, and reoperations were similar between groups. Discussion: OTTR of the subscapularis in RSA had similar ROM and outcome scores compared to no repair, but a significantly larger proportion of patients with repair achieved functional internal rotation to the small of the back. ER limitations seen after conventional repair may also apply to this novel technique, but without a corresponding detrimental effect on forward elevation or abduction.

Anatomic Versus Reverse Total Shoulder Arthroplasty for Primary Osteoarthritis With an Intact Rotator Cuff: A Midterm Comparison of Early Top Performers.

BACKGROUND: Several surgeons state that their best anatomic total shoulder arthroplasty (aTSA) outperforms their best reverse total shoulder arthroplasty (rTSA) when performed for rotator cuff-intact glenohumeral osteoarthritis. We identified the top-performing aTSAs and rTSAs at short-term follow-up and compared their clinical performance at midterm follow-up to validate this common claim. METHODS: A retrospective review of a multicenter shoulder arthroplasty database was conducted. All shoulders undergoing primary aTSA or rTSA for rotator cuff-intact glenohumeral osteoarthritis between 2007 and 2020 were reviewed. Shoulders with a follow-up clinical visit between 2 and 3 years and a clinical follow-up of minimum 5 years were included. Two separate cohorts were identified: patients with a top 20% (1) American Shoulder and Elbow Surgeons (ASES) score and (2) Shoulder Arthroplasty Smart (SAS) score at 2 to 3 years of follow-up. Clinical outcomes including range of motion, outcome scores, and rates of complications and revision surgeries were compared at minimum 5-year follow-up. RESULTS: The ASES score cohort comprised 185 aTSAs (mean age 67 years, 42% female) and 49 rTSAs (mean age 72 years, 45% female). The SAS score cohort comprised 145 aTSAs (mean age 67 years, 59% female) and 42 rTSAs (mean age 71 years, 57% female). Active external rotation (ER) was greater after aTSA at midterm follow-up in both ASES and SAS score cohorts; however, preoperative to postoperative improvement was equivalent. Postoperative ER and SAS scores were greater after aTSA in both cohorts ( P < 0.05); however, no other significant differences in any preoperative or postoperative clinical outcomes were present ( P > 0.05), and patients achieved the minimal clinically important difference and substantial clinical benefit at similar rates for all outcomes. No difference was found in the incidence of complications and revision surgeries between top-performing aTSAs and rTSAs. CONCLUSION: Among top-performing shoulder arthroplasties at early follow-up, aTSA does not appear to outperform rTSA, except superior ER at midterm follow-up. LEVEL OF EVIDENCE: Retrospective comparative cohort study, Level Ⅲ.

Thresholds for diminishing returns in postoperative range of motion after total shoulder arthroplasty.

BACKGROUND: Satisfaction following total shoulder arthroplasty (TSA), which is commonly reported using patient-reported outcome measures (PROMs), is partially dependent upon restoring shoulder range of motion (ROM). We hypothesized there exists a minimum amount of ROM necessary to perform functional tasks queried in PROM questionnaires, beyond which further ROM may provide no further improvement in PROMs. METHODS: A retrospective review of a multicenter international shoulder arthroplasty database was performed between 2004 and 2020 for patients undergoing anatomic or reverse TSA (aTSA, rTSA), with minimum 2-year follow-up. Our primary outcome was to determine the threshold in postoperative active ROM (abduction, forward elevation [FE], external rotation [ER], and internal rotation [IR] score), whereby additional improvement was not associated with additional improvement in PROMs (Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and the Shoulder Pain and Disability Index). For comparison, we also evaluated the Shoulder Arthroplasty Smart (SAS) score, which is not subject to the ceiling effect. RESULTS: We included 4459 TSAs (1802 aTSAs, 2657 rTSAs) with minimum 2-year follow-up (mean, 56 ± 32 months). The threshold in postoperative ROM that were associated with no further improvement were active abduction, 107-113° for PROMs vs. 163° for the SAS score; active FE, 149-162° for PROMs vs. 176° for the SAS score; active ER, 50-52° for PROMs vs. 72° for the SAS score; IR score, 4-5 points for all PROMs vs. 6 points for the SAS score. Out of 3508 TSAs with complete postoperative ROM data, 8.5% achieved or exceeded all ROM thresholds (14.5% aTSAs, 4.8% rTSAs). CONCLUSIONS: Our findings demonstrate that postoperative ROM exceeding 113° of abduction, 162° of FE, 52° of ER, and IR to L1 is associated with minimal additional improvement in PROMs. While individual patient needs vary, the thresholds may provide helpful targets for patients undergoing postoperative rehabilitation.

Challenging the Concept of Statistical Fragility: Is There Any Value Added?

ABSTRACT: Today, well-designed randomized clinical trials (RCTs) are considered the pinnacle of clinical research, and they inform many practices in orthopaedics. When designing these studies, researchers conduct a power analysis, which allows researchers to strike a balance between (1) enrolling enough patients to detect a clinically important treatment effect (i.e., researchers can be confident that the effect is unlikely due to chance) and (2) cost, time, and risk to patients, which come with enrolling an excessive number of patients. Because researchers will have a desire to conduct resource-efficient RCTs and protect patients from harm, many studies report a p value that is close to the threshold for significance. The concept of the fragility index (FI) was introduced as a simple way to interpret RCT findings, but it does not account for RCT design. The adoption of the FI conflicts with researchers' goals of designing efficient RCTs that conserve resources and limit ineffective or harmful treatments to patients. The use of the FI may reflect many clinicians' lack of familiarity with interpreting p values beyond "significant" or "nonsignificant." Instead of inventing new metrics to convey the same information provided by the p value, greater emphasis should be placed on educating clinicians on how to interpret p values and, more broadly, statistics, when reading scientific studies.

Rehabilitation Protocols in Elbow Medial Ulnar Collateral Ligament Injuries: A Systematic Review of Articles Published in the Last 20 Years.

CONTEXT: Elbow medial ulnar collateral ligament (UCL) injuries have become increasingly common in athletes. Despite this, rehabilitation protocols appear to vary drastically, which may explain the clinical equipoise regarding optimal management. OBJECTIVE: This systematic review reports rehabilitation characteristics reported after UCL injuries and compares reported outcomes based on early versus delayed rehabilitation. DATA SOURCES: Our search utilized PubMed/MEDLINE, Embase, Web of Science, and Cochrane to identify all articles on UCL rehabilitation published between January 1, 2002 and October 1, 2022. STUDY SELECTION: Studies in English with ≥5 patients that reported rehabilitation protocols for UCL injuries were evaluated. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Data included sample characteristics, time to achieve physical therapy milestones, outcome scores, and return-to-play (RTP) rate and timing. RESULTS: Our review included 105 articles with a total of 15,928 elbows (98% male; weighted mean age, 23 years; follow-up, 47 months), with 15,077 treated operatively and 851 treated nonoperatively. The weighted mean time patients spent adhering to nonweightbearing status was 42 days. The mean time until patients were given clearance for active range of motion (ROM) 15 days, full ROM 40 days, and elbow strengthening exercises 32 days. The mean time until all restrictions were lifted was 309 days. The mean time to begin a throwing program was 120 days. Across all rehabilitation characteristics, protocols for patients undergoing nonoperative management started patients on rehabilitation earlier. After UCL reconstruction, earlier active ROM (≤14 days), elbow strengthening (≤30 days), no restrictions (≤180 days), and throwing (≤120 days) postoperatively led to earlier RTP without a negative effect on functional outcome scores. CONCLUSION: Current literature provides a spectrum of protocols for elbow UCL rehabilitation, regardless of management. Nonoperative patients began ROM activities, strengthening, and throwing programs sooner than operative patients, and earlier milestones led to earlier RTP.

Tendon transfers in reverse total shoulder arthroplasty: A systematic review and descriptive synthesis of biomechanical studies.

BACKGROUND: The role of tendon transfer and ideal insertion sites to improve axial rotation in reverse total shoulder arthroplasty (RTSA) is debated. We systematically reviewed the available biomechanical evidence to elucidate the ideal tendon transfer and insertion sites for restoration of external and internal rotation in the setting of RTSA and the influence of implant lateralization. PATIENTS AND METHODS: We queried the PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify biomechanical studies examining the application of tendon transfer to augment shoulder external or internal rotation range of motion in the setting of concomitant RTSA. A descriptive synthesis of six included articles was conducted to elucidate trends in the literature. RESULTS: Biomechanics literature demonstrates that increasing humeral-sided lateralization optimized tendon transfers performed for both ER and IR. The optimal latissimus dorsi (LD) transfer site for ER is posterior to the greater tuberosity (adjacent to the teres minor insertion); however, LD transfer to this site results in greater tendon excursion compared to posterodistal insertion site. In a small series with nearly 7-year mean follow-up, the LD transfer demonstrated longevity with all 10 shoulders having>50% ER strength compared to the contralateral native shoulder and a negative Hornblower's at latest follow-up; however, reduced electromyography activity of the transferred LD compared to the native contralateral side was noted. One study found that transfer of the pectoralis major has the greatest potential to restore IR in the setting of lateralized humerus RTSA. CONCLUSION: To restore ER, LD transfer posterior on the greater tuberosity provides optimal biomechanics with functional longevity. The pectoralis major has the greatest potential to restore IR. Future clinical investigation applying the biomechanical principles summarized herein is needed to substantiate the role of tendon transfer in the modern era of lateralized RTSA. LEVEL OF EVIDENCE: IV; systematic review.

A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty.

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.

Impact of Deltoid Computer Tomography Image Data on the Accuracy of Machine Learning Predictions of Clinical Outcomes after Anatomic and Reverse Total Shoulder Arthroplasty.

Background: Despite the importance of the deltoid to shoulder biomechanics, very few studies have quantified the three-dimensional shape, size, or quality of the deltoid muscle, and no studies have correlated these measurements to clinical outcomes after anatomic (aTSA) and/or reverse (rTSA) total shoulder arthroplasty in any statistically/scientifically relevant manner. Methods: Preoperative computer tomography (CT) images from 1057 patients (585 female, 469 male; 799 primary rTSA and 258 primary aTSA) of a single platform shoulder arthroplasty prosthesis (Equinoxe; Exactech, Inc., Gainesville, FL) were analyzed in this study. A machine learning (ML) framework was used to segment the deltoid muscle for 1057 patients and quantify 15 different muscle characteristics, including volumetric (size, shape, etc.) and intensity-based Hounsfield (HU) measurements. These deltoid measurements were correlated to postoperative clinical outcomes and utilized as inputs to train/test ML algorithms used to predict postoperative outcomes at multiple postoperative timepoints (1 year, 2-3 years, and 3-5 years) for aTSA and rTSA. Results: Numerous deltoid muscle measurements were demonstrated to significantly vary with age, gender, prosthesis type, and CT image kernel; notably, normalized deltoid volume and deltoid fatty infiltration were demonstrated to be relevant to preoperative and postoperative clinical outcomes after aTSA and rTSA. Incorporating deltoid image data into the ML models improved clinical outcome prediction accuracy relative to ML algorithms without image data, particularly for the prediction of abduction and forward elevation after aTSA and rTSA. Analyzing ML feature importance facilitated rank-ordering of the deltoid image measurements relevant to aTSA and rTSA clinical outcomes. Specifically, we identified that deltoid shape flatness, normalized deltoid volume, deltoid voxel skewness, and deltoid shape sphericity were the most predictive image-based features used to predict clinical outcomes after aTSA and rTSA. Many of these deltoid measurements were found to be more predictive of aTSA and rTSA postoperative outcomes than patient demographic data, comorbidity data, and diagnosis data. Conclusions: While future work is required to further refine the ML models, which include additional shoulder muscles, like the rotator cuff, our results show promise that the developed ML framework can be used to evolve traditional CT-based preoperative planning software into an evidence-based ML clinical decision support tool.

Reported outcome measures in complex fracture elbow dislocations: a systematic review.

BACKGROUND: Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison. METHODS: A systematic review was performed per Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for nonrandomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded. RESULTS: Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n = 70), extension (n = 62), pronation (n = 68), or supination (n = 67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (n = 69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n = 28 [34%]), the visual analog scale for pain (n = 27 [33%]), QuickDASH score (n = 13 [15.7%]), and Oxford Elbow score (n = 5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P = .313), study type (P = .689), complex fracture pattern (P = .211), or number of elbows included (P = .152). CONCLUSION: There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the Mayo Elbow Performance Score and DASH outcomes measures as well as visual analog scale pain rating scale in future studies to facilitate cross-study comparisons.

The influence of depression on clinical outcomes of total shoulder arthroplasty: a systematic Review.

PURPOSE: Much of the current literature on total shoulder arthroplasty (TSA) has assessed the impact of preoperative medical comorbidities on postoperative clinical outcomes. The literature concerning the impact of psychological disorders such as depression on TSA has increased in popularity in recent years, but there lacks a thorough review of the influence of depression on postoperative pain and functional outcomes. METHODS: We queried PubMed/MEDLINE and identified six clinical studies that evaluated the influence of a psychiatric diagnosis of depression on patient outcomes after TSA. Studies that discussed the impacts of depression on TSA, including PROs or adverse events in adults, were included. Studies focused on other psychologic pathology, non-TSA shoulder treatments, or TSA not for primary osteoarthritis were excluded. Non-clinical studies, systematic reviews, letters to the editor, commentaries, dissertations, books, and book chapters were excluded. RESULTS: Three cohort studies described patient-reported pain and functional outcomes and three database studies assessed the risk of postoperative complications. Cohort studies demonstrated that the prevalence of depression in patients undergoing TSA decreased from preoperatively to 12-months postoperatively. Two studies demonstrated that depression is an independent predictor of less pre- to postoperative improvement in the ASES score at minimum 2-year follow-up; however, one study found the difference between patients with and without depression did not exceed the minimum clinically important difference. Database studies demonstrated that depression was associated with higher rates of blood transfusion (n = 1, OR = 1.8), anemia (n = 1, OR = 1.65), wound infection (n = 2, OR = 1.41-2.09), prosthetic revision (n = 1, OR = 1.92), and length of hospital stay (n = 3, LOS = 2.5-3 days). CONCLUSION: Although patients with a preoperative diagnosis of depression undergoing TSA can achieve satisfactory relief of shoulder pain and restoration of function, they may experience poorer patient-reported outcomes and a higher risk of postoperative adverse events compared to their peers. Surgeons should be cognizant of the influence of depression in their patients to facilitate proper patient selection that maximizes patient satisfaction, function, and minimizes the risk of adverse events following TSA. LEVEL OF EVIDENCE: Level IV.

Planned Glenoid Implant Utilization: A Comparison of Preoperative Planning with and Without Computer-Assisted Navigation.

BACKGROUND: Preoperative planning for anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) is becoming increasingly common. While preoperative planning allows surgeons to determine individualized implant types, utilization of intraoperative navigation improves the accuracy of implant placement and may increase confidence in the preoperative plan. The purpose of this study was to evaluate and compare the rate at which surgeons use a glenoid implant different than their preoperative plan with and without the use of computer navigation. METHODS: A retrospective review of a multicenter prospectively collected shoulder arthroplasty database was conducted between 2016 and 2022. Inclusion criteria were primary aTSA or rTSA with an available preoperative plan and record of the actual implant used. Change in glenoid implant was defined as a deviation in the final implant from the preoperative plan in regard to backside shape (nonaugmented vs augment or differing augment shape). RESULTS: We included 1,915 shoulder arthroplasties (525 aTSA, 1,390 rTSA) performed with preoperative planning and intraoperative navigation and 110 shoulder athroplasties (37 aTSA, 73 rTSA) performed with preoperative planning alone. Overall, the final glenoid implant deviated from the preoperative plan less frequently when intraoperative navigation was used compared with preoperative planning alone (1.9% [n = 36] versus 7.3% [n = 8], P = 0.002). When stratified by procedure, deviation from the preoperative plan occurred significantly less for rTSA when preoperative planning was used with intraoperative navigation versus planning alone (2% [n = 29] versus 11% [n = 8], P < 0.001; OR = 0.17 [95% CI = 0.07 to 0.46]), but not aTSA (1% [n = 7] versus 0% [n = 0], P = 1). Use of intraoperative navigation was independently associated with lower odds of deviation from the preoperative plan on multivariable logistic regression (OR = 0.25 [95% CI = 0.11 to 0.56], P = 0.001). CONCLUSION: Use of intraoperative navigation is associated with increased adherence to the preoperative plan for primary rTSA. Use of navigation may increase surgeon confidence despite known limitations of glenoid visualization during this procedure. This may offer advantages in outpatient surgery centers and smaller hospitals where inventory space may be limited. LEVEL OF EVIDENCE: Ⅲ, retrospective cohort study.