Preoperative COVID-19 Infection Increases Risk for 60-Day Complications Following Total Shoulder Arthroplasty: A Propensity-Matched Analysis.

BACKGROUND: Total shoulder arthroplasty (TSA) is an effective treatment for a wide range of shoulder pathologies. Literature investigating the impact of COVID-19 diagnosis on outcomes following TSA is limited. The objective of this study was to perform a retrospective multi-institutional database analysis to investigate the association between preoperative COVID-19 diagnosis and 60-day complications following TSA. METHODS: We queried the TriNetX database using Current Procedural Terminology (CPT) and the International Classification of Diseases, Tenth Revision (ICD-10) codes for patients who underwent a TSA from January 1, 2018 to July 1, 2023. Patients were categorized by those who had and those who did not have a diagnosis of COVID-19 within 30 days prior to surgery. The cohorts were matched based on age, gender, ethnicity, race, and past medical history. Chi-square analysis was performed to determine the relationship between COVID-19 diagnosis and 60-day postoperative complications including pneumonia, sepsis, emergency department (ED) visit, hospital admission, mortality, periprosthetic fracture, superficial wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), acute myocardial infarction (MI), and revision surgery. The search results identified a total 63,768 patients who met study criteria. Of these patients, 7,118 (11.08%) were diagnosed with COVID-19 within 30 days prior to their TSA procedure. Propensity score matching resulted in 6,982 patients in each of the two cohorts. RESULTS: Patients with a recent COVID-19 diagnosis prior to surgery had 1.96 (P = 0.0005) times the odds of sepsis, 1.42 (P = 0.0032) times the odds of superficial wound infections, 1.42 (P < 0.0001) times the odds of DVT, 1.52 (P = 0.0001) times the odds of PE, 1.10 (P = 0.0249) and 1.79 (P < 0.0001) times the odds of ED visits and hospital admissions, respectively, and 3.10 (P < 0.0001) and 2.87 (P < 0.0001) times the odds of periprosthetic fracture and revision surgery within 60 days of TSA. CONCLUSIONS: Our study suggests an increased risk of sepsis, ED visits, hospital admissions, periprosthetic fracture, superficial wound infection, DVT, PE, and revision surgery in TSA patients with a recent COVID-19 diagnosis. There may be significant benefit to closer monitoring and greater preventive measures to reduce the occurrence of postoperative complications in this setting. In addition, patients may benefit from postponing elective TSA procedures in the setting of a recent COVID-19 infection.

Operative and Nonoperative Treatment of Periprosthetic Humerus Fractures After Shoulder Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Periprosthetic humerus fracture is a relatively rare complication following shoulder arthroplasty. As shoulder arthroplasty volume increases, more periprosthetic fractures are anticipated. Some surgeons routinely operate on humerus shaft fractures adjacent to a humeral stem, while others recommend first-line nonoperative treatment. The purpose of this study was to identify and describe the prevalence of operative and nonoperative treatment options for periprosthetic humerus fractures, their associated outcomes, and complications. Our goal was to provide clinical insights for surgeons on the outcomes and complications associated with various treatment options. METHODS: We performed a systematic review of studies reporting clinical or radiographic outcomes and complications after operative or nonoperative treatment of postoperative periprosthetic humerus fractures following shoulder arthroplasty. Subgroup analysis was conducted for differences in surgical outcomes between open reduction internal fixation (ORIF) and revision arthroplasty. RESULTS: Twenty studies met the inclusion criteria (196 humeri). The mean clinical follow-up period was 2.6 years. Most fractures were Cofield B (42%), followed by C (27%), and A (12%); 19% were not classified. Forty-two percent of index implants were reverse total shoulders, 27% anatomic total shoulders, 16% hemiarthroplasties, and 1% resurfacing; implant design was not reported for 14%. The average time from index procedure to fracture was 2.9 years. One hundred sixty-seven (85%) fractures were treated operatively, 26 (13%) were treated nonoperatively, and 3 (2%) were missing information. Overall complication rate was 46%. Nonoperatively treated fractures had a higher complication rate (69% vs 43%, P = 0.04) and increased risk of malunion (19% vs 1%, P = < 0.001). Nonoperative management failed in 57% of Cofield B fractures. Time to union was shorter in the ORIF group than the revision arthroplasty group (24 weeks vs 30 weeks, P < 0.001). Among operatively treated fractures, revision arthroplasty was associated with more complications (61% vs 25%, P = 0.04) and higher nonunion rates (22% vs 0%, P = 0.008) than ORIF. CONCLUSIONS: Complications may be more frequent than previously understood. With a 70% healing rate, nonoperative management is a viable treatment option, but should be weighed against high risk of complications and need for future procedures, especially in Cofield B fractures. Treatment with ORIF is associated with a higher union rate and fewer complications than revision arthroplasty.

A threshold of lower preoperative mental health is associated with decreased achievement of comfort and capability benchmarks following rotator cuff repair: a retrospective cohort study.

BACKGROUND: Preoperative biomedical patient characteristics are known to affect the time to achievement of clinically significant outcomes (CSOs) following arthroscopic rotator cuff repair (RCR). However, less is known about the association between preoperative mental status and the time to achievement of CSOs. We hypothesize that higher preoperative mental status is associated with faster achievement of CSOs following arthroscopic RCR. METHODS: Patient-reported outcome measures (PROMs) were collected preoperatively and at postoperative intervals up to 2 years. PROMs included pain visual analog scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and Veterans RAND 12-Item Health Survey (VR-12) scores. Threshold values for CSOs were obtained from previous literature. Mean time to achievement of CSOs was calculated using a Kaplan-Meier analysis. A Cox proportional hazards regression analysis was performed to identify preoperative variables associated with earlier achievement of CSOs. RESULTS: Sixty-nine patients with an average age of 59 ± 8 years were included. Patients with higher preoperative mental status, as measured by VR-12 mental component summary (MCS), experienced significantly earlier substantial pain improvement postoperatively (P = .0471). Patients with higher preoperative mental status also achieved CSOs for physical health at earlier time points (P = .0187). Preoperative VR-12 MCS scores ≥ 40 were associated with earlier achievement of CSOs for pain (P = .0005) and physical health (P = .0015). Ninety-eight percent of patients with preoperative MCS scores ≥40 achieved acceptable pain relief at 4.5 months vs. 56% of all other patients at 12.3 months (P = .0001). Patients with preoperative MCS scores ≥40 experienced significantly faster improvement in physical health compared to patients with preoperative MCS scores <40 (P = .0006). CONCLUSIONS: Higher preoperative mental status, especially a preoperative MCS score ≥40, is associated with significantly faster improvement in pain and physical function following arthroscopic RCR. Nearly all patients (98%) with preoperative MCS score ≥40 achieved an acceptable state of pain relief compared with only 56% of patients with preoperative MCS score <40. These findings indicate that a holistic approach with equal consideration of preoperative mental health and rotator cuff pathophysiology is vital to the successful management of rotator cuff tendinopathy.

Superior labrum anterior to posterior (SLAP) repair is associated with increased rate of subsequent rotator cuff diagnoses and revision surgery: a propensity-matched comparison.

BACKGROUND: Surgical management of superior labral anterior to posterior (SLAP) tears remains controversial. Current management utilizes 2 well-established procedures: biceps tenodesis and SLAP repair. This study evaluates the complications associated with arthroscopic SLAP repair vs. an open or arthroscopic biceps tenodesis to further elucidate optimal surgical management. METHODS: In this retrospective cohort study, the TriNetX database was utilized to evaluate patients who underwent repair of SLAP lesions (International Classification of Diseases, Tenth Revision code: S43.43) from May 15, 2003, to May 15, 2023. Three patient cohorts were evaluated: those who underwent arthroscopic SLAP repair (Current Procedural Terminology [CPT] code: 29807), those who underwent arthroscopic biceps tenodesis (CPT code: 29828), and those who underwent open tenodesis of the biceps (CPT code: 23430). Cohorts were propensity matched for type 2 diabetes, nicotine dependence, alcohol-related disorders, body mass index, and demographic factors such as age at event, ethnicity, race, and sex. The outcomes evaluated were disruption of surgical wound, deep vein thrombosis, mononeuropathy of upper limb, shoulder contusion, humeral fracture, sepsis, deceased, acute postoperative pain, revision, shoulder stiffness, and rotator cuff strain. All outcomes were evaluated within 1 year postprocedure. RESULTS: A total of 11,081 arthroscopic SLAP repairs, 9960 arthroscopic biceps tenodesis, and 9420 open biceps tenodesis were matched. Compared with patients who underwent arthroscopic biceps tenodesis, those who underwent arthroscopic SLAP repair were 1.8 times more likely to undergo revision (2.9% vs. 1.6%, P < .0001). Compared with those who underwent open biceps tenodesis, patients who had SLAP repair performed were 1.4 times more likely to undergo revision (3.1% vs. 2.3%, P = .013) and 1.6 times more likely to have a subsequent rotator cuff strain diagnosis (5.1% vs. 3.2%, P = .0002). Compared with patients who underwent SLAP repair, those who underwent arthroscopic biceps tenodesis exhibited 1.3 times more instances of acute postoperative pain (5.2% vs. 4.0%, P = .011). Similarly, open biceps tenodesis exhibited 1.8 times more instances of acute postoperative pain (6.9% vs. 3.8%, P < .0001) and 1.3 times more shoulder stiffness (11.8% vs. 9.0%, P < .0001). CONCLUSION: In the last 20 years, patients who underwent SLAP repair were associated with higher risk of revision surgery and subsequent rotator cuff strain diagnosis. Conversely, patients who underwent biceps tenodesis were associated with higher rates of acute postoperative pain and shoulder stiffness.

Regarding a human costoscapular joint by Prof. Dr. H. von Luschka (1870): A translation.

Knowledge of variant anatomy was important during the time of Dr. Hubert von Luschka (1820-1875) and continues to be of relevance in current practice to prevent medical and surgical errors and to improve patient outcomes. Dr. H. von Luschka described an anatomical variant observed in the left scapula of a 40-year-old male: a connection between the medial superior angle of the scapula, piercing through the serratus posterior muscle to connect via a synovial capsule to the articular surface of the thoracic wall. The clinical relevance of this so-called "Luschka's tubercle" of the shoulder continues to be discussed. This translation is intended to broaden access to this hallmark manuscript to a wide audience of English readers. The introduction places the manuscript in the context of historical and current discussions. Three authors, all proficient in the German and English languages and educated in the anatomy of the shoulder, conducted the translation. The skeletal process that is part of the described joint structure appears similar to what is now called Luschka's tubercle. The full structure, including its connecting parts, are not currently included in anatomical nomenclature. In conclusion, Luschka's text and named tubercle continue to contribute to the discussion of scapulothoracic joint disorders.

Translation of Runge's 1873 publication "On the etiology and treatment of writer's cramp": The first description of "tennis elbow".

This publication by Dr Ferdinand Runge is ubiquitously credited as first to describe the symptoms, pathology, and treatment of patients with lateral epicondylosis (tennis elbow). However, the main focus of his work was to provide insight into causes of writer's cramp and treatments for the condition, elegantly illustrated in four case reports. This work, recently cited as unavailable, is written in German. Given the high frequency of citations in the English literature, it was considered useful to translate it into English to widen access to a broader readership. The purpose of this project was briefly to introduce the life and clinical expertise of Dr. Ferdinand Runge and the content of his work, followed by a translation of the entire manuscript into English. The paper was translated by the three authors using a process of sequential consensus. All are proficient in German and English, with clinical expertise in both topics. A brief reflection is provided to place Dr Runge's observations, clinical reasoning, and contemporaneously available treatments in the context of current thinking about lateral epicondylalgia. Dr. Runge shares his expertise, carefully reporting pertinent examination findings for each case, sharing hypotheses about the etiology of writer's cramp, and using the effectiveness of his applied treatment as confirmation. He concludes that careful evaluation of the patient's activities that hindered writing prior to the onset of the writer's cramp is key to managing this ailment. The topics addressed in this classic work are still thought-provoking.

Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis.

BACKGROUND: Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years. METHODS: We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating. RESULTS: Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01). CONCLUSIONS: This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.

Industry payments to authors of Journal of Shoulder and Elbow Surgery shoulder arthroplasty manuscripts are accurately disclosed by most authors and are not significantly associated with better reported treatment outcomes.

BACKGROUND: Author transparency in disclosing potential conflicts of interest when reporting outcomes for shoulder arthroplasty implants is important. Using the Centers for Medicare & Medicaid Services Open Payments Program (OPP) database, we analyzed articles in the Journal of Shoulder and Elbow Surgery to evaluate (1) discrepancies between the stated conflicts of interest and associated payments recorded in the database, (2) the magnitude and types of payments received, and (3) possible relationships between industry financial support and positive study outcomes. METHODS: Articles reporting clinical outcomes of shoulder arthroplasty from 2016 and 2017 were reviewed. Articles identifying a specific shoulder arthroplasty implant and having at least 1 author based in the United States were included. Payment types, amounts, and sources were extracted from disclosure statements in the manuscript and considered relevant if they were received from the implant manufacturer. Published disclosure statements were compared against the OPP database. Study outcomes demonstrating a clinical benefit were considered "positive." Payments to authors reporting positive outcomes were compared with those reporting nonpositive outcomes. RESULTS: Implant manufacturers provided $16,051,261 to authors of shoulder arthroplasty publications over a 2-year period. Approximately half of senior authors (46%) received royalty payments, more than 90% of which ($14,910,873; 93%) were reported in disclosure statements. Although authors of articles with positive outcomes received greater payments than those reporting nonpositive outcomes, these differences were not statistically significant. CONCLUSION: The majority of author disclosure statements accurately reflected the OPP data. Payments were not significantly associated with positive outcomes reported for the specific implant.

Timely recognition of total elbow and radial head arthroplasty adverse events: an analysis of reports to the US Food and Drug Administration.

BACKGROUND: Recent recalls of several commonly used elbow arthroplasty implants have prompted interest in the modes by which elbow implants fail and the timing of reports of these failures. METHODS: We reviewed the adverse event reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database from 2012 to 2015 regarding elbow arthroplasty to determine the event date and the type of each adverse event. RESULTS: Among 179 total elbow adverse event reports, the most common modes of failure were implant dissociation (23%), loosening (22%), and infection (16%). The most common modes of failure among 58 radial head replacement reports were component dissociation (19%) and linkage screw failure (19%). The percentage distribution of adverse event types differed among different arthroplasty systems and from that reported in published reviews of elbow arthroplasty. Three implant recalls were implemented 2, 5, and 9 years after the first adverse event report in the MAUDE database. For 2 of the recalls, the first reports of the device failures were published 2 and 5 years after the first MAUDE reports. CONCLUSIONS: The MAUDE database is a publicly funded and publicly available means by which surgeons can identify adverse events for the prostheses they use before such information becomes available through journal publication or recall notification. In this study, MAUDE data revealed a higher relative frequency of mechanical dissociation of elbow implants than what has been represented in the literature. Early identification of these adverse events may help surgeons by informing their implant selection and surgical technique.

Clinical effectiveness and safety of the extended humeral head arthroplasty for selected patients with rotator cuff tear arthropathy.

BACKGROUND: Cuff tear arthropathy is commonly managed with a reverse total shoulder arthroplasty (RTSA). A humeral hemiarthroplasty with an extended humeral head may provide a less invasive alternative for selected patients with cuff tear arthropathy if the shoulder has preserved active elevation. Because evidence regarding this procedure is limited, we investigated its safety and efficacy in treating selected patients with cuff tear arthropathy. METHODS: We analyzed the preoperative characteristics, surgical findings, and clinical outcomes for patients selected for extended head hemiarthroplasty. RESULTS: For 42 patients with 2-year follow-up, there were no complications or revisions. The Simple Shoulder Test score improved from a median of 3.0 to 8.0 (P < .001). The median percentage of maximal possible improvement was 50% (P < .001). The percentage of patients able to perform each of the functions of the Simple Shoulder Test was significantly improved; for example, the ability to sleep comfortably increased from 19% to 71%, and the ability to place a coin on the shelf at shoulder level increased from 38% to 86% (P < .001). CONCLUSIONS: There are circumstances in which RTSA is clearly the preferred procedure for cuff tear arthropathy, including pseudoparalysis, anterosuperior escape, and glenohumeral instability; however, in shoulders with preserved active motion and stability of the humeral head provided by an intact coracoacromial arch, the extended head humeral arthroplasty can enable selected patients to realize improved comfort and function without the potential risks of RTSA. Extended humeral head hemiarthroplasty can provide a safe and effective alternative for the management of selected patients with rotator cuff tear arthropathy and preserved active motion.

Prearthroplasty glenohumeral pathoanatomy and its relationship to patient's sex, age, diagnosis, and self-assessed shoulder comfort and function.

BACKGROUND: There is great current interest in characterizing the prearthroplasty glenohumeral pathoanatomy because of its role in guiding surgical technique and its possible effects on arthroplasty outcome. METHODS: We examined 544 patients within 6 weeks before arthroplasty with the goals of characterizing the following: demographic and radiographic characteristics; relationships of the radiographic pathoanatomy to the patient's age, sex, and diagnosis; inter-relationships among glenoid type, glenoid version, and amount of decentering of the humeral head on the glenoid; and relationships of the pathoanatomy to the patient's self-assessed comfort and function. RESULTS: Male patients had a higher frequency of B2 glenoids and a lower frequency of A2 glenoids. The arthritic shoulders of men were more retroverted and had greater amounts of posterior decentering. Patients with types A1 and C glenoids were younger than those with other glenoid types. Shoulders with osteoarthritis were more likely to be type B2 and to be retroverted. Types B2 and C had the greatest degree of retroversion, whereas types B1 and B2 had the greatest amounts of posterior decentering. Shoulders with glenoid types B1 and B2 and those with more decentering did not have worse self-assessed shoulder comfort and function. CONCLUSIONS: Glenohumeral pathoanatomy was found to have previously unreported relationships to the patient's sex, age, and diagnosis. Contrary to what might have been expected, more advanced glenohumeral pathoanatomy (ie, type B glenoids, greater retroversion, greater decentering) was not associated with worse self-assessed shoulder comfort and function.

One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers.

PURPOSE: Clinical shoulder science lacks a benchmark against which the early clinical value of new glenoid components can be compared; such a benchmark may be derived from a multicenter study of patients receiving an established, internationally used design of glenoid component. METHODS: We obtained data from 11 centers on 1270 patients having total shoulder arthroplasty using an all-polyethylene component with a fluted central peg. We analyzed individual patient outcomes at 1 and 2 years after surgery. We compared the improvement for each patient to the minimal clinically important difference (MCID) and calculated each patient's improvement as a percent of maximal possible improvement (MPI). RESULTS: The preoperative scores improved from SST 3 ± 2, ASES 37 ± 15, Constant score 36 ± 16, and Penn score 30 ± 19 to SST 10 ± 2, ASES 90 ± 12, Constant 76 ± 13, and Penn 80 ± 24 (p < 0.001 for each). A high percentage of patients improved by more than the MCID (SST 96%, ASES 98%, Constant 94%, Penn 93%) and obtained improvement of at least 30% of the MPI (SST 95%, ASES 98%, Constant 91%, Penn 87%). The clinical outcomes realized with this glenoid design were not worse for the 41% of shoulders with preoperative type B glenoids or for the 30% of shoulders with more than 15 degrees of glenoid retroversion. CONCLUSIONS: Individual patients from 11 international practices having total shoulder arthroplasty using a basic glenoid component design obtained highly significant clinical outcomes, providing a benchmark against which the early outcomes of new designs can be compared to determine whether they provide increased clinical value.

Quality of internet-based decision aids for shoulder arthritis: what are patients reading?

BACKGROUND: The objective of this study was to assess the source, quality, accuracy, and completeness of Internet-based information for shoulder arthritis. METHODS: A web search was performed using three common Internet search engines and the top 50 sites from each search were analyzed. Information sources were categorized into academic, commercial, non-profit, and physician sites. Information quality was measured using the Health On the Net (HON) Foundation principles, content accuracy by counting factual errors and completeness using a custom template. RESULTS: After removal of duplicates and sites that did not provide an overview of shoulder arthritis, 49 websites remained for analysis. The majority of sites were from commercial (n = 16, 33%) and physician (n = 16, 33%) sources. An additional 12 sites (24%) were from an academic institution and five sites (10%) were from a non-profit organization. Commercial sites had the highest number of errors, with a five-fold likelihood of containing an error compared to an academic site. Non-profit sites had the highest HON scores, with an average of 9.6 points on a 16-point scale. The completeness score was highest for academic sites, with an average score of 19.2 ± 6.7 (maximum score of 49 points); other information sources had lower scores (commercial, 15.2 ± 2.9; non-profit, 18.7 ± 6.8; physician, 16.6 ± 6.3). CONCLUSIONS: Patient information on the Internet regarding shoulder arthritis is of mixed accuracy, quality, and completeness. Surgeons should actively direct patients to higher-quality Internet sources.

The "tipping point" for 931 elective shoulder arthroplasties.

BACKGROUND: A patient with arthritis usually experiences the progression of symptoms over time. At some stage, the patient may decide that the symptoms have reached a level of severity that leads him or her to elect to proceed with joint replacement; we refer to this degree of symptom severity as the "tipping point." Our goal was to study the factors that influenced the tipping point for patients undergoing elective shoulder arthroplasty. METHODS: We analyzed the characteristics of 931 patients undergoing shoulder arthroplasty to determine the factors affecting the tipping point as characterized by the patients' comfort and function at the time they determined their symptoms had progressed to the point when this elective surgery was merited. RESULTS: The preoperative Simple Shoulder Test (SST) score for all patients averaged 3.6 ± 2.7. The average tipping points were different for the ream-and-run procedure (mean SST score, 5.0 ± 2.5), hemiarthroplasty (mean SST score, 3.1 ± 3.3), total shoulder arthroplasty (mean SST score, 3.0 ± 2.4), cuff tear arthropathy arthroplasty (mean SST score, 2.8 ± 2.5), and reverse total shoulder arthroplasty (mean SST score, 1.5 ± 1.8). A number of other factors were significantly associated with a higher tipping point: younger age, better health, male sex, commercial insurance, married, nonuse of narcotics, use of alcohol, and shoulder problem not related to work. CONCLUSIONS: Analysis of the tipping point-the patients' self-assessed comfort and function at the point they decide to undergo shoulder joint replacement-provides a means by which surgeons can understand the factors influencing the indications for these procedures.

Analysis of 4063 complications of shoulder arthroplasty reported to the US Food and Drug Administration from 2012 to 2016.

BACKGROUND: Most of the literature on shoulder arthroplasty failure comes from high-volume centers. These reports tend to exclude the experience of community orthopedic surgeons, who perform most of the shoulder joint replacements. METHODS: We analyzed the failure reports mandated by the US Food and Drug Administration for all hospitals. Each reported event from 2012 to 2016 was characterized by implant, failure mode, and year of surgery. RESULTS: For the 1673 anatomic arthroplasties, the most common failure modes were glenoid component failure (20.4%), rotator cuff/subscapularis tear (15.4%), pain/stiffness (12.9%), dislocation/instability (11.8%), infection (9%), and humeral component loosening (5.1%). For the 2390 reverse arthroplasties, the most common failure modes were dislocation/instability (32%), infection (13.8%), glenosphere-baseplate dissociation (12.2%), failed/loosened baseplate (10.4%), humeral component dissociation/tray fracture (5.5%), difficulty inserting the baseplate (4.8%), and difficulty inserting the glenosphere (4.2%). Although the percentage distribution among the different failure modes was relatively consistent over the years of this study, the percentage distribution of these failure modes differed substantially among different implant manufacturers. CONCLUSIONS: The Food and Drug Administration database reveals modes of shoulder arthroplasty failure that are not emphasized in the published literature, such as rotator cuff tear, infection, and postoperative pain/stiffness for anatomic total shoulder arthroplasty and implant dissociation and baseplate failure for reverse shoulder arthroplasty. Knowledge of these failure modes may help inform surgical technique and implant design in ways that will lower the risk of implant failure in the future.

The utility of international shoulder joint replacement registries and databases: a comparative analytic review of two hundred and sixty one thousand, four hundred and eighty four cases.

PURPOSE: National registries are valuable tools for understanding the results of shoulder arthroplasty across populations. These databases provide an unselected view of shoulder joint replacement within geographical areas that cannot be obtained from case series or prospective studies. They can be particularly helpful in determining which diagnoses, patients, procedures, and prostheses have higher than expected rates of revision. In an attempt to determine the generalizability of registry data, we asked, 'how similar are the patients and procedures among the different national registries?' METHODS: We analyzed national shoulder arthroplasty registries and databases accessed via Internet portals and through a PubMed literature search. RESULTS: Seven national/regional registries and five publications regarding national shoulder arthroplasty data were identified; these sources contained a combined total of 261,484 shoulder arthroplasty cases. The percentages of hemiarthroplasty, anatomic (aTSA) and reverse total shoulders (rTSA), the diagnoses leading to arthroplasty, the mean patient age, and the distribution of patient gender varied significantly among these different databases. CONCLUSION: This study indicates that the indications for and application of shoulder arthroplasty have important geographical variations and that these variations must be considered when comparing outcomes of shoulder arthroplasty from different locations. Without controlling for age, gender, diagnosis and procedure type, the results from one national registry may not be applicable to patients from a different location. In that national data provide the opportunity to reduce costs by identifying implants and procedures with higher failure rates, the funding of registries needs to be free of conflicts of interest.

Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?

BACKGROUND: While glenoid retroversion and posterior humeral head decentering are common preoperative features of severely arthritic glenohumeral joints, the relationship of postoperative glenoid component retroversion to the clinical results of total shoulder arthroplasty (TSA) is unclear. Studies have indicated concern for inferior outcomes when glenoid components are inserted in 15° or more retroversion. QUESTIONS/PURPOSES: In a population of patients undergoing TSA in whom no specific efforts were made to change the version of the glenoid, we asked whether at 2 years after surgery patients having glenoid components implanted in 15° or greater retroversion had (1) less improvement in the Simple Shoulder Test (SST) score and lower SST scores; (2) higher percentages of central peg lucency, higher Lazarus radiolucency grades, higher mean percentages of posterior decentering, and more frequent central peg perforation; or (3) a greater percentage having revision for glenoid component failure compared with patients with glenoid components implanted in less than 15° retroversion. METHODS: Between August 24, 2010 and October 22, 2013, information for 201 TSAs performed using a standard all-polyethylene pegged glenoid component were entered in a longitudinally maintained database. Of these, 171 (85%) patients had SST scores preoperatively and between 18 and 36 months after surgery. Ninety-three of these patients had preoperative radiographs in the database and immediate postoperative radiographs and postoperative radiographs taken in a range of 18 to 30 months after surgery. Twenty-two patients had radiographs that were inadequate for measurement at the preoperative, immediate postoperative, or latest followup time so that they could not be included. These excluded patients did not have substantially different mean age, sex distribution, time of followup, distribution of diagnoses, American Society of Anesthesiologists class, alcohol use, smoking history, BMI, or history of prior surgery from those included in the analysis. Preoperative retroversion measurements were available for 11 (11 shoulders) of the 22 excluded patients. For these 11 shoulders, the mean (± SD) retroversion was 15.8° ± 14.6°, five had less than 15°, and six had more than 15° retroversion. We analyzed the remaining 71 TSAs, comparing the 21 in which the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°) with the 50 in which it was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°). At the 2-year followup (mean ± SD, 2.5 ± 0.6 years; range, 18-36 months), we determined the latest SST scores and preoperative to postoperative improvement in SST scores, the percentage of maximal possible improvement, glenoid component radiolucencies, posterior humeral head decentering, and percentages of shoulders having revision surgery. Radiographic measurements were performed by three orthopaedic surgeons who were not involved in the care of these patients. The primary study endpoint was the preoperative to postoperative improvement in the SST score. RESULTS: With the numbers available, the mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The mean difference in improvement between the two groups was 0.9 (95% CI, - 2.5 to 0.7; p = 0.412). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%). The mean difference between the two groups was 3% (95% CI, - 18% to 12%; p = 0.857). The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, - 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. With the numbers available, the radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4-6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). With the numbers available, the percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids (three of 50; [6%]; p = 0.251). CONCLUSION: In this small series of TSAs, postoperative glenoid retroversion was not associated with inferior clinical results at 2 years after surgery. This suggests that it may be possible to effectively manage arthritic glenohumeral joints without specific attempts to modify glenoid version. Larger, longer-term studies will be necessary to further explore the results of this approach. LEVEL OF EVIDENCE: Level III, therapeutic study.

Is the Simple Shoulder Test a valid outcome instrument for shoulder arthroplasty?

BACKGROUND: The Simple Shoulder Test (SST) is a brief, inexpensive, and widely used patient-reported outcome tool, but it has not been rigorously evaluated for patients having shoulder arthroplasty. The goal of this study was to rigorously evaluate the validity of the SST for outcome assessment in shoulder arthroplasty using a systematic review of the literature and an analysis of its properties in a series of 408 surgical cases. METHODS: SST scores, 36-Item Short Form Health Survey scores, and satisfaction scores were collected preoperatively and 2 years postoperatively. Responsiveness was assessed by comparing preoperative and 2-year postoperative scores. Criterion validity was determined by correlating the SST with the 36-Item Short Form Health Survey. Construct validity was tested through 5 clinical hypotheses regarding satisfaction, comorbidities, insurance status, previous failed surgery, and narcotic use. RESULTS: Scores after arthroplasty improved from 3.9 ± 2.8 to 10.2 ± 2.3 (P < .001). The change in SST correlated strongly with patient satisfaction (P < .001). The SST had large Cohen's d effect sizes and standardized response means. Criterion validity was supported by significant differences between satisfied and unsatisfied patients, those with more severe and less severe comorbidities, those with workers' compensation or Medicaid and other types of insurance, those with and without previous failed shoulder surgery, and those taking and those not taking narcotic pain medication before surgery (P < .005). CONCLUSION: These data combined with a systematic review of the literature demonstrate that the SST is a valid and responsive patient-reported outcome measure for assessing the outcomes of shoulder arthroplasty.

What is a "periprosthetic shoulder infection"? A systematic review of two decades of publications.

PURPOSE: While as many as 50% of revision shoulder arthroplasties are culture positive, a consistent, clinically useful definition of a "periprosthetic shoulder infection" is lacking. We conducted a systematic review of the published literature with respect to (1) the definition of a "periprosthetic shoulder infection", (2) the pre-operative evaluation for possible infection, and (3) the harvesting and culturing of specimens at the time of surgical revision. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified 20 studies concerning infection at the time of revision shoulder arthroplasty. The review was registered in the international Prospective Register of Systematic Reviews. RESULTS: An explicit definition of infection was not present in six studies (27%). Classification systems used for periprosthetic hip and knee infections were used in three studies (14%). Clinical signs and symptoms were used in all definitions, but most studies did not report microbiologic results or culturing practices. CONCLUSIONS: Synthesis of the literature on failed arthroplasties with positive cultures is compromised by lack of standardization, leaving surgeons without secure evidence on which to base diagnostic and treatment decisions. These decisions would be better informed if authors used a consistent approach in the evaluation of failed arthroplasties with respect to the number and source of specimens submitted, the culture technique, the number of specimens that became culture positive, the bacteria identified, and the bacterial load recovered from the shoulder. LEVEL OF EVIDENCE: This was a systematic review of reports of all levels.