Reverse shoulder arthroplasty design-inlay vs. onlay: does it really make a difference?

BACKGROUND: The design of reverse shoulder arthroplasty (RSA) implants has evolved significantly over the past 50 years. Today there are many options available that differ in design of the glenoid and humeral components, fixation methods, sizes, and modularity. With respect to the humeral component, the literature has generally focused on the differences between inlay and onlay designs and the potential impact on outcomes. However, inlay and onlay design represents only one factor of many. METHODS: It is our hypothesis that separating onlay and inlay designs into 2 distinct entities is an oversimplification as there can be a wide overlap of the 2 designs, depending on surgical technique and the implant selected. As such, the differences between inlay and onlay designs should be measured in absolute terms-meaning combined distalization and lateralization. RESULTS: By reviewing the many factors that can contribute to the glenosphere-humerus relationship, the role of inlay and onlay humeral designs as an important distinguishing feature is shown to be limited. Preliminary studies suggest that the amount of distalization and lateralization of the construct may be the most accurate method of describing the differences in the constructs. CONCLUSIONS: Inlay and onlay humeral component design represents only one factor of many that may impact outcomes. A more accurate method of defining specific design and technique factors in RSA is the degree of lateralization and distalization.

Optimal combination of arthroplasty type, fixation method and postoperative rehabilitation protocol for complex proximal humerus fractures in the elderly: A network meta-analysis.

PURPOSE: The purpose of this study was to define the optimal combination of surgical technique and postoperative rehabilitation protocol for elderly patients undergoing either hemiarthroplasty (HA) or reverse total shoulder arthroplasty (rTSA) for acute proximal humerus fracture (PHF) by performing a network meta-analysis of the comparative studies in the literature. METHODS: A systematic review of the literature using PRISMA guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2007-2023. Inclusion criteria were level I-IV studies utilizing primary HA and/or rTSA published in a peer-reviewed journal, that specified whether humeral stems were cemented or noncemented, specified postoperative rehabilitation protocol, reported results of HA and/or rTSA performed for PHF. Early range of motion (ROM) was defined as the initiation of active ROM at ≤3 weeks after surgery. Level of evidence was evaluated based on the criteria by the Oxford Centre for Evidence-Based Medicine. Clinical outcomes were compared using a frequentist approach to network meta-analysis with a random-effects model that was performed using the netmeta package version 0.9-6 in R. RESULTS: A total of 28 studies (1,119 patients) were included with an average age of 74±3.7 and mean follow-up of 32±11.1 months. In the early ROM cohort (Early), the mean time to active ROM was 2.4±0.76 weeks compared to 5.9±1.04 weeks in the delayed ROM cohort (Delayed). Overall, rTSA-Pressfit-Early resulted in statistically superior outcomes including postoperative forward elevation (126±27.5), abduction (116±30.6), internal rotation (5.27±0.74, corresponding to L3-L1), ASES score (71.8±17), tuberosity union (89%), and lowest tuberosity nonunion rate (9.6%) in patients ≥65 years old with acute PHF undergoing shoulder arthroplasty (all p≤0.05). In total there were 277 (14.5%) complications across the cohorts, of which 89/277 (34%) were in the HA-Cement-Delayed cohort. HA-Cement-Delayed resulted in 2-times higher odds of experiencing a complication when compared to rTSA-Cement-Delayed (p=0.005). Conversely, rTSA-Cement-Early cohort followed by rTSA-Pressfit-Early resulted in a total complication rate of 4.7% and 5.4% (OR, 0.30; p=0.01 & OR, 0.42; p=0.05), respectively. The total rate of scapular notching was higher in the cemented rTSA subgroups (16.5%) versus (8.91%) in the press fit rTSA subgroups (p=0.02). CONCLUSION: Our study demonstrates that patients ≥65 years of age, who sustain a 3-or 4-part PHF achieve the most benefit in terms of range of motion, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative range of motion when compared to the mainstream preference-rTSA-Cement-Delayed.

Utility of Superior Augments in Reverse Shoulder Arthroplasty (Exactech, Equinoxe GPS) without Significant Glenoid Deformity.

INTRODUCTION: Superior augment use may help avoid superior tilt while minimizing removal of inferior glenoid bone. Therefore, our goal is to compare superior augments versus no augment baseplates in RSA for patients with rotator cuff dysfunction and no significant superior glenoid erosion. METHODS: A multicenter retrospective analysis of 145 patients who underwent RSA with intraoperative navigation (Exactech, Equinoxe GPS) and three-year follow-up (mean 32-month follow-up, range 20 to 61 months) who had preoperative superior inclination less than 10 degrees and retroversion less than 15 degrees. Patient demographics, radiographic measurements, surgical characteristics, patient-reported outcomes at preoperative and postoperative visit closest to three years, and adverse events at final follow-up were obtained. Operative time, planned inclination, and planned version of the baseplate were obtained. Chi-square test used to compare categorical variables and student t-test used to compare augment and no augment cohorts. RESULTS: The study population consisted of 54 superior augment patients and 91 no augment patients. The augment cohort had lower BMI (27.2 vs. 29.4, p-0.023), higher native superior inclination (5.9 vs. 1.4 degrees, p<0.001). No difference between the augment and no augment cohorts was found regarding age (p=0.643), gender (p=0.314), medical comorbidities (p>0.05), surgical indication (p=0.082), and native glenoid version (p=0.564). The augment cohort had higher internal rotation score (4.6 vs. 3.9, p=0.023), all remaining ROM and PROs preoperatively were not significantly different. At final follow-up, active ROM in all planes was not different between the cohorts. Regarding PROs, the postoperative SAS score was significantly higher (78.0 vs. 73.6, p=0.042), and ASES score trended towards higher (83.6 vs. 77.5, p=0.063) in the augment cohort. The augment cohort had significantly lower proportion of patients planned to have superior baseplate tilt (1.9% vs. 14.3%, p=0.012), and had greater mean inclination correction (6.3 vs. 1.3 degrees, p<0.001), compared to no augment cohort. Adverse events were rare, and there was no significant difference found between the augment and no augment cohorts (5.6% vs. 3.3%, p=0.509). DISCUSSION: Superior augmented baseplate in RSA with minimal superior glenoid erosion is associated with similar ROM and adverse events with somewhat improved postoperative PROs compared to non-augmented baseplates at 3-year follow-up. Additionally, superior augments resulted in a greater proportion of baseplates planned to avoid superior tilt, and trended toward shorter operative times. Further investigation of long-term glenoid baseplate loosening is imperative to fully understand the cost-effectiveness of superior augments in the setting of minimal glenoid deformity.

Stratification of the Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptomatic State after Total Shoulder Arthroplasty by Implant Type, Preoperative Diagnosis, and Sex.

BACKGROUND: Clinical significance, as opposed to statistical significance, has increasingly been utilized to evaluate outcomes after total shoulder arthroplasty (TSA). The purpose of this study was to identify thresholds of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for TSA outcome metrics and determine if these thresholds are influenced by prosthesis type (anatomic or reverse TSA), sex, or preoperative diagnosis. METHODS: A prospectively collected international multicenter database inclusive of 38 surgeons was queried for patients receiving a primary aTSA or rTSA between 2003 and 2021. Prospectively, outcome metrics including ASES, shoulder function score (SFS), SST, UCLA, Constant, VAS Pain, shoulder arthroplasty smart (SAS) score, forward flexion, abduction, external rotation, and internal rotation was recorded preoperatively and at each follow-up. A patient satisfaction question was administered at each follow-up. Anchor-based MCID, SCB, and PASS were calculated as defined previously overall and according to implant type, preoperative diagnosis, and sex. The percentage of patients achieving thresholds was also quantified. RESULTS: A total of 5,851 total shoulder arthroplasties including aTSA (n=2,236) and rTSA (n=3,615) were included in the study cohort. The following were identified as MCID thresholds for the overall (aTSA + rTSA irrespective of diagnosis or sex) cohort: VAS Pain (-1.5), SFS (1.2), SST (2.1), Constant (7.2), ASES (13.9), UCLA (8.2), SPADI (-21.5), and SAS (7.3), Abduction (13°), Forward elevation (16°), External rotation (4°), Internal rotation score (0.2). SCB thresholds for the overall cohort were: VAS Pain (-3.3), SFS (2.9), SST 3.8), Constant (18.9), ASES (33.1), UCLA (12.3), SPADI (-44.7), and SAS (18.2), Abduction (30°), Forward elevation (31°), External rotation (12°), Internal rotation score (0.9). PASS thresholds for the overall cohort were: VAS Pain (0.8), SFS (7.3), SST (9.2), Constant (64.2), ASES (79.5), UCLA (29.5), SPADI (24.7), and SAS (72.5), Abduction (104°), Forward elevation (130°), External rotation (30°), Internal rotation score (3.2). MCID, SCB, and PASS thresholds varied depending on preoperative diagnosis and sex. CONCLUSION: MCID, SCB, and PASS thresholds vary depending on implant type, preoperative diagnosis, and sex. A comprehensive understanding of these differences as well as identification of clinically-relevant thresholds for legacy and novel metrics is essential to assist surgeons in evaluating their patient's outcomes, interpreting the literature, and counseling their patients preoperatively regarding expectations for improvement. Given that PASS thresholds are fragile and vary greatly depending on cohort variability, caution should be exercised in conflating them across different studies.

High Rate of Patient Satisfaction with Either Telemedicine or Traditional Office-Based Follow-Up Visit After Arthroscopic Shoulder Surgery.

Background: The purpose of this study was to determine if any differences exist in patient satisfaction with office-based visits versus telemedicine visits following arthroscopic shoulder surgery. Methods: Patients undergoing shoulder arthroscopy were prospectively enrolled for 1 year. Patient demographic and clinical data (including complication events) and second postoperative visit satisfaction data were recorded and analyzed for statistical significance. Results: Ninety-six (n = 96) patients met inclusion criteria. Fifty-four patients (56.3%) participated in a traditional in-person office visit, and 42 participated in a video visit (43.8%). No significant differences were found between office and video appointments in terms of overall care satisfaction (9.46 ± 0.9 vs. 9.55 ± 1.0, p = 0.67). Females were significantly less satisfied with their second postoperative visit compared with males (8.3 ± 2.3 vs. 9.3 ± 1.5, p = 0.035). Significantly more females would also have preferred a traditional in person office visit compared with males (91% vs. 67%, p = 0.009). Video appointment patients spent significantly more time with their surgeon than office visit patients (57.64 mean rank vs. 41.39 mean rank, p = 0.003). Discussion: Video visit patients required significantly less time overall for their visit and spent significantly more time with their surgeon, although did not demonstrate differences in satisfaction.

Patients aged 50-75 years take longer to achieve the patient acceptable symptom state than patients aged 20-34 years following primary hip arthroscopy for femoroacetabular impingement syndrome.

PURPOSE: Though an increasing number of adults older than 50 years are undergoing hip arthroscopy for treatment of Femoroacetabular Impingement Syndrome (FAIS), it is unclear how their timeline for functional outcome improvement compares to that of younger patients. The purpose of this study was to assess the impact of age on time to achieving the Minimum Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) following primary hip arthroscopy for FAIS. METHODS: A retrospective comparative single-surgeon cohort study of primary hip arthroscopy patients with minimum 2-year follow-up was conducted. Age categories were 20-34 years, 35-49 years, and 50-75 years. All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6-month, 1-year, and 2-year follow-up. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥ 8.2 and ≥ 19.8, respectively. PASS cutoff was set at postoperative mHHS ≥ 74. Time to achievement of each milestone was compared using interval-censored survival analysis. The effect of age was adjusted for Body Mass Index (BMI), sex, and labral repair technique using an interval-censored proportional hazards model. RESULTS: Two hundred eighty-five patients were included in the analysis with 115 (40.4%) aged 20-34 years, 92 (32.3%) aged 35-49 years, and 78 (27.4%) aged 50-75 years. There were no significant differences between groups in time to achievement for the MCID (n.s.) or SCB (n.s.). However, patients in the oldest group had significantly longer time to PASS than those in the youngest group, both in the unadjusted analysis (p = 0.02) and after adjusting for BMI, sex, and labral repair technique (HR 0.68, 95% CI 0.48-0.96, p = 0.03). CONCLUSION: Achievement of the PASS, but not the MCID or SCB, is delayed among FAIS patients aged 50-75 years who undergo primary hip arthroscopy compared to those aged 20-34 years. Older FAIS patients should be counseled appropriately about their longer timeline to achieving hip function comparable to their younger counterparts. LEVEL OF EVIDENCE: III.

International consensus statement on the management of glenohumeral arthritis in patients ≤ 50 years old.

BACKGROUND: The purpose of this study was to implement a modified Delphi technique among a group of experts affiliated with American Shoulder and Elbow Surgeons (ASES) and European Society for Surgery of the Shoulder and Elbow (SECEC) to determine areas of consensus regarding what factors influence their decision to manage a patient surgically and what specific treatment modalities they utilize for patients ≤50 years of age with glenohumeral arthritis. METHODS: The panel of experts comprised 168 shoulder and elbow specialists, 138 ASES and 30 SECEC members. In the first round, an open-ended questionnaire was utilized to solicit features that are important in making decisions regarding treatment. The second round involved ranking the features identified in the first round as to their importance in helping decision making for surgery. The results of round 2 were then utilized and 18 complex surgical cases previously treated by one of the lead authors were provided for the study. One additional case was included to address the management of Cutibacterium acne infection. RESULTS: A total of 159 (95.0%) participants completed the round one survey, 142 (89%) responded to the second and third round surveys. In total 50 individual factors were positively associated with the decision to proceed with surgery. Ten of these were strongly supportive of surgery. Eight out of 18 clinical cases demonstrated > 80% agreement on the surgical treatment modality chosen. Over 90% of respondents chose reverse total shoulder arthroplasty (TSA) to manage pathology when an incompetent rotator cuff was present. Over 90% of respondents managed avascular necrosis with hemiarthroplasty. Over 70% of respondents chose anatomic TSA for inflammatory arthritis with low demand on their shoulder. Overall, 79% of respondents chose a stemless humeral component when a hemiarthroplasty or anatomic TSA was chosen in response to the proposed surgical cases. If arthroscopy was chosen then there was good agreement on 5 core procedures. There was only fair consensus on the approach to C. acnes in patients with glenohumeral osteoarthritis ≤ 50 years of age. CONCLUSION: The optimal treatment of glenohumeral arthritis in patients ≤ 50 years of age remains controversial, and there are many treatment options to consider when responding to the variety of clinical presentations and anatomic pathologies. While physicians and patients engage in the shared decision-making process regarding the final choice for management, this consensus statement serves as a basis for discussion amongst colleagues and between patients and surgeons though it clearly demonstrates that the topic must be further investigated prospectively and with large cohorts.

Impact of mental health on outcomes after total shoulder arthroplasty.

BACKGROUND: Anxiety and depression are the 2 most commonly diagnosed psychiatric disorders in the United States. The effect of these disorders on total shoulder arthroplasty (TSA) outcomes must be appreciated. The purpose of this study was to examine the correlation between a preoperative diagnosis of anxiety and depression and postoperative outcomes after TSA. The secondary goals were to determine whether patients contemporaneously treated with medication for their mental health diagnosis fared better than a cohort treated without medication and to examine the degree to which Patient-Reported Outcomes Measurement Information System Mental Health (PROMIS-MH) scores correlate with patient outcomes. Our hypothesis was that a history of anxiety and/or depression would negatively impact patient outcomes after TSA. METHODS: We performed a retrospective analysis of a prospectively collected cohort at a single institution. Patients undergoing anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) with anxiety and/or depression were identified and compared with a cohort of patients without a mental health diagnosis enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant types, range of motion, adverse events, and clinical outcome metric scores-PROMIS-MH score, American Shoulder and Elbow Surgeons score, Constant score, Shoulder Arthroplasty Smart Score-were recorded. Outcomes between cohorts were analyzed using conventional statistics, as well as stratification by the minimal clinically important difference and substantial clinical benefit thresholds where applicable. RESULTS: The study comprised 218 patients (114 rTSA and 95 aTSA patients) with a diagnosis of either anxiety and/or depression and 378 patients (153 rTSA and 217 aTSA patients) with no history. Although both cohorts achieved the minimal clinically important difference and substantial clinical benefit thresholds for the postoperative American Shoulder and Elbow Surgeons score, the cohort with anxiety and/or depression showed lower postoperative outcome scores (P < .05), higher AE rates, and significantly lower preoperative-to-postoperative differences in all variables when compared with the cohort without anxiety and/or depression. There were no differences in outcome scores after rTSA or aTSA between patients being treated for anxiety and/or depression and those not receiving treatment. The PROMIS-MH score was positively correlated with postoperative outcomes and patient satisfaction. CONCLUSION: This study shows that patients with anxiety and/or depression who underwent TSA had inferior postoperative outcomes and higher rates of AEs compared with a cohort without a mental health diagnosis. In addition, patients taking medication for treatment of depression and/or anxiety did not gain any significant benefit in terms of their postoperative shoulder outcomes or satisfaction rate compared with those with this diagnosis but not taking medication. Additionally, we found that, independent of a patient's underlying shoulder pathology or psychiatric diagnosis, lower PROMIS-MH scores were correlated with worse postoperative outcomes.

Impact of cervical spine pathology on outcomes after total shoulder arthroplasty.

BACKGROUND: Cervical spine pathology can affect the supporting muscles and function of the shoulder and contribute to shoulder and arm pain and hence may impact postoperative outcomes following shoulder arthroplasty. The purpose of this study was to evaluate the impact of a history of cervical spine arthrodesis and its timing, before or after total shoulder arthroplasty (TSA), on the outcomes of TSA. Our hypothesis is that a history of cervical arthrodesis (CA) will negatively impact patient outcomes after shoulder arthroplasty. METHODS: A retrospective analysis was performed on a prospectively collected cohort at a single institution. Anatomic (aTSA) and reverse TSA (rTSA) patients with CA were identified and compared to a cohort of patients without CA (NCA) enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant type, range of motion, adverse events, and clinical outcome metric scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Constant, Shoulder Function score, patient satisfaction) were recorded. Outcomes between cohorts were analyzed using conventional statistics as well as stratification by minimal clinically important difference and substantial clinical benefit (SCB) thresholds where applicable. RESULTS: Of the 573 TSAs evaluated, 48 (20a CA-aTSA and 28 CA-rTSA) had a history of CA and 525 (280 NCA-aTSA and 245 NCA-rTSA) had no history of CA. The CA-TSA (aTSA and rTSA) had lower Constant, ASES, and Shoulder Function scores postoperatively as well as less improvement in active external rotation and an overall lower satisfaction rating (P < .05 for all) compared with NCA-TSA. The adverse event rate in the CA-TSA cohort was higher compared with the NCA-TSA cohort (25% vs. 6.5% [rTSA; P = .004] and 24.5% vs. 11% [aTSA; P = .068]). Optimal cutoff analysis showed that a time from CA to TSA of greater than 1.33 years had a sensitivity of 75.0% and specificity of 75.0% in predicting achievement of SCB for ASES score. CONCLUSION: The current study demonstrates that patients with a history of CA undergoing shoulder arthroplasty results in lower postoperative functional outcomes, lower satisfaction, and higher rates of postoperative adverse events requiring surgical revision when compared to a cohort without a history of CA. Additionally, the current study demonstrates that a time interval of at least 16 months between CA and shoulder arthroplasty optimizes the chances of achieving SCB for ASES score.

Primary versus conversion reverse total shoulder arthroplasty for complex proximal humeral fractures in elderly patients: a retrospective comparative study.

BACKGROUND: The purpose of this study was to compare clinical, implant-related, and patient-reported outcomes of shoulders undergoing conversion to reverse total shoulder arthroplasty (rTSA) following previous open reduction-internal fixation vs. shoulders undergoing rTSA as a primary treatment modality for acute proximal humeral fractures (PHFs) in patients aged ≥65 years. METHODS: We performed a retrospective analysis of a prospectively collected cohort of patients who underwent primary rTSA for PHFs vs. a cohort who underwent conversion arthroplasty with rTSA following fracture repair between 2009 and 2020. Outcomes were assessed preoperatively and at latest follow-up. Demographic characteristics and outcomes were analyzed between cohorts using conventional statistics, as well as stratification by minimal clinically important difference and substantial clinical benefit thresholds where applicable. RESULTS: In total, 406 patients met the study criteria, of whom 322 underwent primary rTSA for PHF and 84 underwent conversion rTSA after failed PHF open reduction-internal fixation. The conversion rTSA cohort was, on average, 7 years younger than the primary rTSA cohort (65 ± 10 years vs. 72 ± 9 years, P < .001). The follow-up periods were similar between the cohorts, with an average of 47.1 months (range, 24-138 months). The percentages of Neer 3-part (41.9% vs. 45.2%) and 4-part (49.1% vs. 46.4%) PHFs were similar (P > .99). The primary rTSA cohort achieved higher forward elevation, external rotation, and patient-reported outcome measurements including Simple Shoulder Test, American Shoulder and Elbow Surgeons, University of California-Los Angeles, Constant, Shoulder Arthroplasty Smart, and Shoulder Pain and Disability Index scores at a minimum of 24 months postoperatively (P < .05 for all). Patient satisfaction was higher in the primary rTSA group than in the conversion rTSA cohort (P = .002). Patient-reported outcome measures uniformly favored the primary rTSA cohort, rising to the level of statistical significance for forward elevation, American Shoulder and Elbow Surgeons score, and Shoulder Pain and Disability Index score (P < .05) relative to substantial clinical benefit. The adverse event rate and revision rate in the conversion rTSA cohort were higher than those in the primary rTSA cohort (26.2% vs. 2.5% [P < .001] and 8.3% vs. 1.6% [P = .001], respectively). At 10 years postoperatively, the revision-free implant survival rate was significantly lower in the conversion cohort compared with the primary cohort (66% vs. 94%, P = .012). Finally, the hazard ratio of revision was 3.69 in the conversion rTSA cohort compared with only 1.0 in the primary rTSA cohort. CONCLUSION: This study demonstrates that elderly patients who undergo rTSA as a conversion procedure following previous osteosynthesis do not fare as well as those treated with rTSA for acute displaced PHFs. Conversion rTSA patients report lower patient satisfaction and have significantly restricted range of shoulder motion, a higher risk of complications, a higher risk of revision, poorer patient-reported outcomes, and a shorter implant survival rate at 10 years compared with patients undergoing acute rTSA.

Augmented baseplates yield optimum outcomes when compared with bone graft augmentation for managing glenoid deformity during reverse total shoulder arthroplasty: a retrospective comparative study.

PURPOSE: The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using glenoid bone grafting (BG rTSA) with primary rTSA using augmented glenoid baseplates (Aug rTSA) with a minimum 2-year follow-up. METHODS: A total of 520 primary rTSA patients treated with 8° posterior glenoid augments (n = 246), 10° superior glenoid augments (n = 97), or combined 10° superior/8° posterior glenoid augments (n = 177) were compared with 47 patients undergoing glenoid bone grafting for glenoid bone insufficiency. The mean follow-up was 37.0(±16) and 53.0(±27) months, respectively. Outcomes were analyzed preoperatively and at the latest follow-up using conventional statistics and stratification by minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds where applicable. Radiographs were analyzed for baseplate failure, and the incidences of postoperative complications and revisions were recorded. RESULTS: The glenoid Aug rTSA cohort had greater improvements in patient-reported outcome measures (PROMs) and range of motion when compared with the BG rTSA group at a minimum of 2-year follow-up, including Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles score, Shoulder Pain and Disability Index score, shoulder function, Shoulder Arthroplasty Smart score, abduction, and external rotation (P < .05). Patient satisfaction was higher in the Aug rTSA group compared with the BG rTSA group (P = .006). The utilization of an augmented glenoid component instead of glenoid bone grafting resulted in approximately 50% less total intraoperative time (P < .001), nearly 33% less intraoperative blood loss volume (P < .001), approximately 3-fold less scapular notching (P < .01), and approximately 8-fold less adverse events requiring revision (P < .01) when compared with the BG rTSA cohort. Aside from SCB for abduction, the Aug rTSA cohort achieved higher rates of exceeding MCID and SCB for every PROM compared with BG rTSA. More specifically, 77.6% and 70.2% of the Aug rTSA achieved SCB for American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index vs. 55% and 48.6% in the BG rTSA, respectively (P = .003 and P = .013). CONCLUSION: The present midterm clinical and radiographic study demonstrates that the utilization of an augmented baseplate for insufficient glenoid bone stock is superior as judged by multiple PROMs and range of motion metrics when compared with bone graft augmentation at minimum 2-year follow-up. In addition, when analyzed according to MCID and SCB thresholds, the use of augmented baseplates outperforms the use of glenoid bone grafting. Complication and revision rates also favor the use of augmented glenoid baseplates over glenoid bone grafting. Long-term clinical and radiographic follow-up is necessary to confirm that these promising midterm results are durable.

In-Office Needle Arthroscopy for the Treatment of Anterior Ankle Impingement Yields High Patient Satisfaction With High Rates of Return to Work and Sport.

PURPOSE: To evaluate the clinical outcomes of in-office needle arthroscopy (IONA) for the treatment of anterior ankle impingement in the office setting and also evaluate patient experience of the IONA procedure. METHODS: A prospectively collected database of 31 patients undergoing IONA for the treatment of anterior ankle impingement between January 2019 and January 2021 was retrospectively reviewed. Inclusion criteria for this study were patients ≥18 years of age, clinical history, physical examination, radiographic imaging, and magnetic resonance imaging findings consistent with anterior ankle impingement for which each patient underwent IONA and had a minimum of 12-month follow-up. Clinical outcomes were evaluated using the following methods preoperatively and at final follow-up: the Foot and Ankle Outcome Scores (FAOS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity domains. A 5-point Likert scale regarding patient satisfaction with their IONA procedure was evaluated at final follow-up. Wilcoxon signed-rank test was performed to compare preoperative and postoperative outcome scores. RESULTS: In total, 31 patients were included in this study, including 18 male and 13 female, with a mean age of 41.7 ± 15.5 years (range, 17-69 years) and mean body mass index of 27.3 ± 5.7 (range, 19.37-41.5). The mean follow-up time was 15.5 ± 4.9 months. The mean postoperative FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life were 79.4 ± 11.9, 82.9 ± 15.3, 83.5 ± 15.4, 71.9 ± 18.5 and 64.3 ± 21.4 at final follow-up respectively. Minimal clinically important difference was achieved by 84% of patients for FAOS pain, 77% for FAOS symptoms, 75% for FAOS Quality of Life, 74% for FAOS sports, 65% for PROMIS Pain Interference, 61% for FAOS Activities of Daily Living, and 42% for PROMIS Pain Intensity. Lastly, 29 patients (94 %) expressed willingness to undergo the same procedure again. CONCLUSIONS: The current study demonstrates that IONA treatment of anterior ankle impingement results in significant pain reduction, a low complication rate and excellent patient reported outcomes with high rates of return to work/sport. Additionally, IONA for anterior ankle impingement leads to high patient satisfaction with a significant willingness to undergo the same procedure again. LEVEL OF EVIDENCE: IV, Case series study.

Joint Hypermobility Is Associated With Increased Risk of Postoperative Iliopsoas Tendinitis After Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: To determine whether increased joint hypermobility, quantified by the Beighton score, is associated with a greater incidence of iliopsoas tendinitis (IPT) in postoperative hip arthroscopy patients treated for femoroacetabular impingement (FAI). METHODS: We conducted a retrospective chart review of patients who underwent hip arthroscopy for labral repair and FAI from 2016 to 2020 for whom at least 12 months of follow-up data were available. The Beighton score was measured by a blinded, independent reviewer. IPT was clinically diagnosed by a sports medicine fellowship-trained orthopaedic surgeon through physical examination. Patients with a diagnosis of IPT were matched at a 1:1 ratio to controls based on age, sex, and body mass index. Demographic characteristics, radiographs and advanced imaging, surgical characteristics, and corticosteroid injection therapy data were obtained via chart review. Statistical analysis was conducted using Mann-Whitney testing and binary logistic regression. RESULTS: Forty patients in whom postoperative IPT developed were identified and matched to 40 control patients in whom postoperative tendinitis did not develop. Increased joint hypermobility, quantified by the Beighton score, was associated with an increased risk of IPT. For each 1-point increase in the Beighton score, there was a 1.69 (95% confidence interval, 1.25-2.29; P < .001) increased odds of IPT development postoperatively. A high (≥4) versus low (<4) Beighton score was associated with an increased likelihood of tendinitis (odds ratio, 9.82; 95% confidence interval, 2.79-34.58; P < .001). However, there was no association between greater Beighton scores and patients' likelihood of receiving a corticosteroid injection (P = .173). CONCLUSIONS: Increased joint hypermobility, quantified by the Beighton score, is associated with an increased risk of IPT developing in the hip arthroscopy postoperative period in patients treated for FAI and labral pathology. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Transosseous-Equivalent/Suture Bridge Arthroscopic Rotator Cuff Repair in Combination With Late Postoperative Mobilization Yield Optimal Outcomes and Retear Rate: A Network Meta-analysis of Randomized Controlled Trials.

PURPOSE: The purpose of this study was to perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature in order to assess the evidence defining the optimal combination of surgical technique single-row repair (SRR), double-row repair (DRR), or transosseous-equivalent/suture bridge (TOE/SB) arthroscopic rotator cuff repair (ARCR) and postoperative rehabilitation (early or late) protocol for ARCR. METHODS: The literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized SSR-early trials (RCTs) comparing SRR vs DRR vs TOE/SB ARCR techniques were included, as well as early vs late postoperative range of motion. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-score. RESULTS: Twenty-eight studies comprising 2,181 total shoulders met the inclusion criteria. TOE/SB-late (odds ratio [OR], 0.19; 95% confidence interval [CI], 0.08-0.46) and DRR-late (OR, 0.25; 95% CI, 0.12-0.52) were found to significantly reduce the rate of retear, with TOE/SB-late resulting in the highest P-score for the American Shoulder and Elbow Surgeons (P-score: 0.7911) score and retear rate (P-score: 0.8725). DRR-early did not result in any significant improvements over the SRR-early group, except in internal rotation. There was no significant difference in forward flexion between groups, with almost equivalent P-scores. Furthermore, TOE/SB-early and TOE/SB-late trended toward worsening external rotation compared with the control. CONCLUSIONS: The current study suggests that rotator cuff repair using the TOE/SB technique and late postoperative mobilization yields the highest functional outcomes and lowest retear rate in the arthroscopic management of symptomatic rotator cuff tears. LEVEL OF EVIDENCE: Level I, meta-analysis of Level I studies.

High Rate of Satisfaction and Return to Play at 5-Year Follow-Up After Arthroscopic Superior-Labrum Anterior-Posterior Repairs.

PURPOSE: The purpose of this study was to evaluate the outcomes of patients 5 years postoperatively following arthroscopic SLAP repair, and to evaluate factors associated with satisfaction. METHODS: A retrospective review of patients who underwent SLAP repair with a minimum of 5-year follow-up was performed. Recurrence, visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, satisfaction, whether they would undergo the same surgery again, and the rate, level and timing of return to play (RTP) were evaluated. Multilinear regression models were used to evaluate factors affecting postoperative satisfaction. RESULTS: Overall, 122 patients who underwent SLAP repair were included, with a mean age of 33.4 years. 81% were males, and 58.2% were participating in sport preoperatively. The mean follow-up was 86.4 ± 14.4 months. At final follow up, the mean satisfaction was 87.7%, and the mean SSV was 82.9. Overall, the rate of RTP was 85.9%, with 64.8% returning at the same level at a mean of 10.5 ± 8 months. Ultimately, 13 (10.7%) patients had a further surgery, including 10 (8.2%) patients that had a biceps tenodesis. VAS during sport (P = .025), SSV (P < .001), and time to RTP (P = .0056), were associated with higher satisfaction. CONCLUSION: There was a high rate of satisfaction at 5-year follow-up, with excellent patient-reported outcomes but with one-tenth of patients requiring revision surgeries. Additionally, while there was an overall high rate of RTP, there was only a modest rate of RTP at their preinjury level, and overhead athletes took longer to RTP. LEVEL OF EVIDENCE: IV, case series.

Open Subpectoral Biceps Tenodesis May Be an Alternative to Arthroscopic Repair for SLAP Tears in Patients Under 30.

PURPOSE: The purpose of the current study is to compare the outcomes of open subpectoral biceps tenodesis (BT) to arthroscopic repair (AR) for SLAP tears in patients under the age of 30 years. METHODS: A retrospective review of patients under the age of 30 years who underwent either isolated BT or AR for a diagnosis of a SLAP tear between 2011 and 2019 was performed. Patients were included if they were >16 years old at the time of surgery, had an isolated SLAP tear involving instability of the biceps-labral anchor (types II-IV), were skeletally mature, and had a minimum follow-up of 12 months. The American Shoulder & Elbow Surgeons score, visual analog scale, Subjective Shoulder Value, patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. A P value of <.05 was considered statistically significant. RESULTS: Our study included 103 patients in total; 29 patients were treated with BT, and 74 were treated with AR. The mean age was 24.8 years, and the mean follow-up duration was 60 months. At final follow-up, there was no difference between treatment groups in any of the functional outcome measures assessed (P > .05). Overall, there was no significant difference in the total rate of RTP (BT: 76.3%, AR: 85%; P = .53), timing of RTP (BT: 8.8 months, AR: 9.4 months; P = .61), and total rate of RTP among overhead athletes (BT: 84.2%, AR: 83.3%; P > .99). Among those undergoing AR, 9 required a revision procedure (11.5%) compared to none treated with BT (P = .11). CONCLUSIONS: In patients under the age of 30 years with a symptomatic isolated SLAP tear, BT may be a reliable alternative to AR. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Six-Month Outcome Scores Predicts Short-Term Outcomes After Hip Arthroscopy.

PURPOSE: To determine whether early patient-reported outcome improvements in the 6 months after surgery are predictive of achieving a patient acceptable symptomatic state (PASS) at 2 years. METHODS: A prospectively collected database was retrospectively reviewed. Inclusion criteria included patients ≥18 years of age, Tönnis grade 0 or 1 changes, radiographic imaging consistent with femoroacetabular impingement or labral pathology, a primary diagnosis of symptomatic femoroacetabular impingement for which they underwent primary hip arthroscopy, and baseline, 6-month, and 2-year modified Harris Hip Score (mHHS) scores. Revision cases were excluded. Receiver operating characteristic curve analysis was conducted to determine whether 6-month change in mHHS was a predictor for achieving PASS at 2 years. RESULTS: There were 173 patients (mean age: 39.8, 61.8% female) included within the study. Patients who do not achieve the minimal clinically important difference (MCID), defined as a change of 8 points in mHHS, by 6 months (n = 21) tended to have significantly lower mHHS scores at 1 year and 2 years compared with those who did (n = 152). Only 52% of patients who did not achieve MCID by 6 months achieved MCID by 2 years (vs 98% for those that did) and only 24% achieved PASS by 2 years (vs 88% that did). Using the MCID as a cutoff for improvement in mHHS at 6 months results in a 96% sensitivity but 47% specificity for predicting PASS achievement at 2 years. Using 24 points of improvement in mHHS as a cutoff at 6 months improves sensitivity and specificity to 81% and 80%, respectively. CONCLUSIONS: Early improvement in mHHS scores is associated with 2-year outcomes. Patients who do not achieve MCID within 6 months of surgery have a high rate of not achieving PASS at 2 years. LEVEL OF EVIDENCE: IV, case series study.

Return to play criteria among shoulder surgeons following shoulder stabilization.

PURPOSE: The purpose of this study was to survey the members of North American and European shoulder surgery and sports medicine societies to evaluate their criteria for deciding when an athlete can safely return to play (RTP) following shoulder stabilization surgery. METHODS: A survey was sent to the members of the American Shoulder and Elbow Surgeons (ASES), American Orthopaedic Society for Sports Medicine (AOSSM), European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), and European Society for Surgery of the Shoulder and the Elbow (SECEC). Surgeons were asked which criteria they used to determine when an athlete can return to play following the arthroscopic Bankart repair and Latarjet procedures, with additional questions on how time from surgery and participation in collision sports affect return. RESULTS: Overall, 317 surgeons responded to the survey. Following arthroscopic Bankart repair, the most common criteria used were time (98.7%), strength (74.8%), and range of motion (70%). The most commonly reported time point was 4 months (43.8%), and the majority used an additional time period, most commonly 2 months (38.2%), before allowing a collision athlete to return to play (75.4%). Interestingly, the addition of a remplissage procedure did not affect decision making regarding RTP in most cases (92.1%). Following the Latarjet procedure, the most common criteria used were time (98.4%), strength (67.5%), and range of motion (65.9%). Less than half reported using imaging to assess for radiographic union before allowing patients to return to play (47%), and the most common modality was plain radiography (80%). The most common time point was 4 months (33.1%), and the majority reported waiting an additional period of time, most commonly by 2 months (25.9%), before allowing a collision athlete to return to play (59.6%). CONCLUSION: Despite the absence of evidence-based guidelines on when athletes can safely return to play following shoulder stabilization surgery, there exists minimal variability in recommendations between North American and European shoulder surgeons. Further research is required to better define criteria for RTP after the arthroscopic Bankart repair and Latarjet procedures.

Remplissage for anterior shoulder instability with Hill-Sachs lesions: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study was to perform a systematic review and meta-analysis of the current evidence in the literature to determine how arthroscopic Bankart repair (ABR) and remplissage compare with ABR alone and the open Latarjet procedure for anterior shoulder instability in patients with concomitant Hill-Sachs lesions. METHODS: A literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies comparing ABR and remplissage vs. ABR alone or the Latarjet procedure for anterior shoulder instability in patients with Hill-Sachs lesions were included. Clinical outcomes were compared, with all statistical analysis performed using Review Manager (version 5.3). P < .05 was considered statistically significant. RESULTS: Twelve clinical trials were included. There was a significant difference between ABR plus remplissage and ABR alone in total recurrence rate (3.2% vs. 16.8%, P < .05) but not the rate of revision due to recurrence (1.7% vs. 8.5%, P = .06). There was no significant difference between the Latarjet procedure and ABR plus remplissage in total recurrence rate (7.0% vs. 9.8%, P = .39), total revision rate (3.7% vs. 5.7%, P = .41), and rate of revision due to recurrence (1.6% vs. 2.1%, P = .79). There was a significantly lower rate of complications with ABR and remplissage compared with the Latarjet procedure (0.5% vs. 8.6%, P = .003). CONCLUSION: In patients with Hill-Sachs lesions and subcritical glenoid bone loss, ABR with remplissage resulted in lower rates of recurrent instability compared with ABR alone while resulting in similar recurrence rates, as well as similar patient-reported outcomes, with lower morbidity and fewer complications, compared with the Latarjet procedure. LEVEL OF EVIDENCE: Level III; Systematic Review.

Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age: A Systematic Review and Network Meta-analysis.

BACKGROUND: Massive irreparable rotator cuff tears (MIRCTs) remain a challenging treatment paradigm, particularly for nonelderly patients without pseudoparalysis or arthritis. PURPOSE: To use a network meta-analysis to analyze comparative studies of surgical treatment options for MIRCTs in patients <70 years of age for several patient-reported outcomes, range of motion (ROM), and acromiohumeral distance (AHD). STUDY DESIGN: Network meta-analysis of comparative studies; Level of evidence, 3. METHODS: A systematic review of the literature, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of the MEDLINE, Embase, and Cochrane Library databases was conducted from 2017 to 2022. Inclusion criteria were (1) clinical comparative studies of MIRCTs (with several study-specific criteria); (2) ≥1 outcome of interest reported on, with standard deviations; (3) minimum 1-year follow-up; and (4) mean age of <70 years for both cohorts, without arthritis or pseudoparalysis. There were 8 treatment arms compared. Outcomes of interest were the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, visual analog scale for pain, AHD, and forward flexion and external rotation ROM. A frequentist approach to network meta-analysis with a random-effects model was performed using the netmeta package Version 0.9-6 in R. RESULTS: A total of 23 studies met the inclusion criteria, with 1178 patients included in the network meta-analysis. There was a mean weighted age of 62.8 years, 568 (48.2%) men, with a mean follow-up of 28.9 months. There were no significant differences between groups in regard to sex (P = .732) or age (P = .469). For the ASES score, InSpace balloon arthroplasty (mean difference [MD], 12.34; 95% CI, 2.18 to 22.50; P = .017), arthroscopic bridging graft (aBG) (MD, 7.07; 95% CI, 0.28 to 13.85; P = .041), and long head of biceps augmented superior capsular reconstruction (BSCR) (MD, 5.16; 95% CI, 1.10 to 9.22; P = .013) resulted in the highest P-scores. For the Constant-Murley score, debridement (MD, 21.03; 95% CI, 8.98 to 33.08; P < .001) and aBG (MD, 6.97; 95% CI, 1.88 to 12.05; P = .007) resulted in the highest P-scores. For AHD, BSCR resulted in the highest P-score (MD, 1.46; 95% CI, 0.45 to 2.48; P = .005). For forward flexion ROM, debridement (MD, 45.77; 95% CI, 25.41 to 66.13; P < .001) resulted in the highest P-score, while RSA resulted in the lowest P-score (MD, -16.70; 95% CI, -31.20 to -2.20; P = .024). CONCLUSION: For patients <70 years with MIRCT without significant arthritis or pseudoparalysis, it appears that graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains, while RSA provides the least benefit in forward flexion.