Analysis of three different reverse shoulder arthroplasty designs for cuff tear arthropathy - the combination of lateralization and distalization provides best mobility.

BACKGROUND: The two major reverse shoulder arthroplasty (RSA) designs are the Grammont design and the lateralized design. Even if the lateralized design is biomechanically favored, the classic Grammont prosthesis continues to be used. Functional and subjective patient scores as well as implant survival described in the literature so far are comparable to the lateralized design. A pure comparison of how the RSA design influences outcome in patients has not yet been determined. The aim of this study was a comparison focused on patients with cuff tear arthropathy (CTA). METHODS: We analyzed registry data from 696 CTA patients prospectively collected between 2012 and 2020 in two specialized orthopedic centers up to 2 years post-RSA with the same follow-up time points (6,12 24 months). Complete teres minor tears were excluded. Three groups were defined: group 1 (inlay, 155° humeral inclination, 36 + 2 mm eccentric glenosphere (n = 50)), group 2 (inlay, 135° humeral inclination, 36 + 4 mm lateralized glenosphere (n = 141)) and group 3 (onlay, 145° humeral inclination, + 3 mm lateralized base plate, 36 + 2 mm eccentric glenosphere (n = 35)) We compared group differences in clinical outcomes (e.g., active and passive range of motion (ROM), abduction strength, Constant-Murley score (CS)), radiographic evaluations of prosthetic position, scapular anatomy and complications using mixed models adjusted for age and sex. RESULTS: The final analysis included 226 patients. The overall adjusted p-value of the CS for all time-points showed no significant difference (p = 0.466). Flexion of group 3 (mean, 155° (SD 13)) was higher than flexion of group 1 (mean, 142° (SD 18) and 2 (mean, 132° (SD 18) (p < 0.001). Values for abduction of group 3 (mean, 145° (SD 23)) were bigger than those of group 1 (mean, 130° (SD 22)) and group 2 (mean, 118° (SD 25)) (p < 0.001). Mean external rotation for group 3 (mean, 41° (SD 23)) and group 2 (mean, 38° (SD 17)) was larger than external rotation of group 1 (mean, 24° (SD 16)) (p < 0.001); a greater proportion of group 2 (78%) and 3 (69%) patients reached L3 level on internal rotation compared to group 1 (44%) (p = 0.003). Prosthesis position measurements were similar, but group 3 had significantly less scapular notching (14%) versus 24% (group 2) and 50% (group 1) (p = 0.001). CONCLUSIONS: Outcome scores of different RSA designs for CTA revealed comparable results. However, CTA patients with a lateralized and distalized RSA configuration were associated with achieving better flexion and abduction with less scapular notching. A better rotation was associated with either of the lateralized RSA designs in comparison with the classic Grammont prosthesis. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Scapulothoracic orientation has a significant influence on the clinical outcome after reverse total shoulder arthroplasty.

BACKGROUND: Computer simulation has indicated a significant effect of scapulothoracic orientation and posture on range of motion (ROM) after reverse total shoulder arthroplasty (RTSA). We analyzed this putative effect on the clinical and radiologic outcome post-RTSA. METHODS: We retrospectively assessed 2-year follow-up data of RTSA patients treated at our clinic between 2008 and 2019. Patients were categorized into posture types A, B, and C based on an established method using scapular internal rotation on preoperative cross-sectional imaging. We compared differences in clinical ROM, pain, Subjective Shoulder Value, Constant Score, Shoulder Pain and Disability Index (SPADI), quality of life (EuroQol-5 Dimensions-5 Level utility index), and radiologic outcomes between posture types using linear regression analyses. RESULTS: Of 681 included patients, 225 had type A posture, 326 type B, and 130 type C. Baseline group characteristics were comparable, although the type C group had a higher proportion of females (60% [A], 64% [B], 80% [C]) with lower abduction strength (0.7 kg [A], 0.6 kg [B], 0.3 kg [C]) and a slightly higher proportion with a Grammont design RTSA (41% [A], 48% [B], 54% [C]). There were significant adjusted differences in mean (±standard deviation) active flexion (A: 137° ± 21°; B: 136° ± 20°; C: 131° ± 19°) and passive flexion (A: 140° ± 19°; B: 138° ± 19°; C: 134° ± 18°), active (A: 127° ± 26°; B: 125° ± 26°; C: 117° ± 27°) and passive abduction (A: 129° ± 24°; B: 128° ± 25°; C: 121° ± 25°), SPADI (A: 81 ± 18; B: 79 ± 20; C: 73 ± 23), and pain (A: 1.2 ± 1.7; B: 1.6 ± 2.2; C: 1.8 ± 2.4) between posture types at 2 years (P ≤ .035). A higher distalization shoulder angle was associated with better abduction in type C patients (P = .016). Type C patients showed a trend toward a higher complication rate (3.9% vs. 1.1% [A], 3.2% [B]) (P = .067). CONCLUSIONS: Type C posture influences the 2-year clinical outcome of RTSA patients in terms of worse flexion, abduction, SPADI, and pain. Scapulothoracic orientation and posture should be considered during the patient selection process, preoperative planning, and implantation of an RTSA.

Patients with rotator cuff tears present a psychological impairment, not only a functional deficit: a systematic review.

INTRODUCTION: Psychological factors impact patients with rotator cuff tears (RCT) in terms of pain level, shoulder function, sleep disturbance, and quality of life (QoL). The aim of this study was to quantify the prevalence of psychological factors in those patients, evaluate their influence on patient-reported outcomes (PROMs), and assess the possible improvement with surgical treatment. METHODS: The literature search was performed on PubMed, Web of Science, Wiley Cochrane Library up to January, 2023. INCLUSION CRITERIA: RCT treated with arthroscopic rotator cuff reconstruction (ARCR), description of psychological variables evaluated with validated questionnaires, descriptions of PROMs. RESULTS: Thirty-nine studies included 7021 patients. Depression was found in eight studies (19.2%), anxiety in 6 (13.0%), sleep disturbance in seven (71.3%), and distress in three studies (26.4%). Studies evaluating the relationship between psychological impairment and pain documented more pain and impaired shoulder function before and after ARCR in patients with altered psychological status. DISCUSSION: An impaired psychological status has an important impact on patients' perception of their disease. RCT patients with psychological alterations often experience more pain and reduced shoulder function, thus having worse QoL. CONCLUSION: This study underlines that psychological impairment largely affects RCT patient condition and treatment outcome, which underlines the importance of a multidisciplinary biopsychosocial intervention to achieve better results.

Clavicular Tunnel Widening After Acromioclavicular Stabilization Shows Implant-Dependent Correlation With Postoperative Loss of Reduction.

PURPOSE: To radiographically describe, quantify, and compare clavicular tunnel widening (cTW) of 2 different types of stabilization devices and investigate a possible correlation between cTW and loss of reduction. METHODS: In a retrospective analysis of single-center registry data, we compared patients who were treated for an acute AC dislocation (Rockwood types III to V) with either the AC Dog Bone (DB) or low-profile AC (LP) repair systems. On 6-week and 6-month postoperative radiographs, we measured clavicle height and tunnel diameter. We calculated the button/clavicle filling (B/C) ratio to quantify how much of the clavicular tunnel height is covered by the low-profile inlet. The association between B/C ratio and the extent of cTW was defined, and we also compared cTW between treatment groups. Reduction of the AC joint was graded as either stable, partially dislocated or dislocated depending on the AC ratio. A 2-sample t-test was used for comparing cTW progression between the 2 groups. For continuous variables between more than 2 groups, the Kruskal-Wallis test was used. RESULTS: Of 65 eligible patients, there were 37 and 28 included in the DB and LP groups, respectively. Overall, cTW was conically shaped with transclavicular widening noted in the DB group and cTW developing strictly inferior to the button in the LP group. For both implants, mean maximal cTW was 7.1 mm and located at the inferior cortex; the B/C ratio was not associated with increased inferior cTW (r = -0.23, P = .248). Only LP patients with complete loss of reduction had significantly increased cTW (P = .049). CONCLUSIONS: Conical-shaped cTW is a common implant-independent phenomenon after AC stabilization using suture-button devices. It occurs only at the suture-bone interface and is less excessive for the LP implant. There is an association between increased cTW and loss of reduction specific to the LP implant only. LEVEL OF EVIDENCE: Level III, therapeutic study.

The V angle compliments radiographic assessment of acute acromioclavicular joint dislocations by differentiating between Rockwood types III versus V and by considering dynamic horizontal translation in coronal radiographs.

PURPOSE: Acromioclavicular joint (ACJ) dislocations are usually graded radiographically according to Rockwood, but differentiation between Rockwood types III and V may be ambiguous. The potentially clinically relevant horizontal instability is barely addressed in coronal radiographs. It was hypothesized that a new radiologic parameter (V angle) would complement ACJ diagnostics on anteroposterior radiographs by differentiating between cases of Rockwood III and V while also considering the aspect of dynamic horizontal translation (DHT). METHODS: Ninety-five patients with acute ACJ dislocations (Rockwood types III and V) were included retrospectively between 2017 and 2020. On anteroposterior views (weightbearing: n = 62, non-weight-bearing: n = 33), the coracoclavicular (CC) distance and the newly introduced V angle for assessing scapular orientation were measured bilaterally. This angle is referenced between the spinal column and a line crossing the superior scapular angle and the crossing point between the supraspinatus fossa and the medial base of the coracoid process, reported as the side-comparative difference (non-injured side *minus* injured side). DHT on Alexander views was divided into stable, partially unstable or completely unstable. RESULTS: The V angle on the injured side alone (mean 50.0°; 95% confidence interval (CI), 48.6°-51.3°) showed no correlation with the side-comparative CC distance [%] (r = - 0.040; n.s.). Thus, the V angle on the non-injured side was considered, displaying a normal distribution (n.s.) with a mean of 58.0° (95% CI, 56.6°-59.4°). The side-comparative V angle showed a correlation with the side-comparative CC distance (r = 0.83; p < 0.001) and was able to differentiate between Rockwood types III (4.7°; 95% CI, 3.9°-5.5°; n = 39) and V (10.3°; 95% CI, 9.7°-11.0°; n = 56) (p < 0.001). A cut-off value of 7° had a 94.6% sensitivity and an 82.1% specificity (area under curve, AUC: 0.954; 95% CI, 0.915-0.994). The side-comparative V angle was greater for cases with complete DHT (8.7°; 95% CI, 7.9°-9.5°; n = 78) than for cases with partial DHT (4.8°; 95% CI, 3.3°-6.3°; n = 16) (p < 0.001). A cut-off value of 5° showed a sensitivity of 84.6% and a specificity of 66.7% (AUC 0.824; 95% CI, 0.725-0.924). CONCLUSION: The scapular-based V angle on anteroposterior radiographs distinguishes between Rockwood types III and V as well as cases with partial or complete DHT. STUDY DESIGN: Diagnostic study. LEVEL OF EVIDENCE: Level II.

In vivo analysis of the circles measurement supports its use in evaluating acromioclavicular joint dislocations.

BACKGROUND: Classification and treatment of acromioclavicular joint (ACJ) dislocations according to the Rockwood classification is controversial. The "circles measurement" on Alexander views was proposed to enable a clear assessment of displacement in ACJ dislocations. However, the method and its ABC classification were introduced on a Sawbones model based on exemplary Rockwood scenarios without soft tissue. This is the first in vivo study to investigate the circles measurement. We aimed to compare this new measurement method with the Rockwood classification and the previously described semiquantitative degree of dynamic horizontal translation (DHT). METHODS: A total of 100 consecutive patients (87 men and 13 women) with acute ACJ dislocations between 2017 and 2020 were included retrospectively. The mean age was 41 years (range, 18-71 years). ACJ dislocations on panoramic stress views were classified according to Rockwood type (type II, n = 8; type IIIA, n = 9; type IIIB, n = 24; type IV, n = 7; and type V, n = 52). On Alexander views, where the hand of the affected arm rested on the contralateral shoulder, the circles measurement and the semiquantitative degree of DHT (none, n = 6; partial, n = 15; or complete, n = 79) were assessed. Convergent and discriminant validity of the circles measurement (including its ABC classification according to displacement) with the coracoclavicular distance and Rockwood types, as well as the semiquantitative degree of DHT, was tested. RESULTS: The circles measurement showed a strong correlation with the coracoclavicular distance according to the Rockwood classification (r = 0.66, P < .001) and differentiated between Rockwood types according to the ABC classification, including types IIIA and IIIB. The circles measurement correlated with the semiquantitative method of assessing DHT (r = 0.61, P < .001). Measurement values were smaller in cases without DHT than in cases with partial DHT (P = .008). Cases with complete DHT had respectively larger measurement values (P < .001). CONCLUSION: In this first in vivo study, the circles measurement allowed differentiation between Rockwood types according to the ABC classification in acute ACJ dislocations with a single measurement and correlated with the semiquantitative degree of DHT. On the basis of these validations of the circles measurement, its use for evaluating ACJ dislocations is recommended.

Subpectoral biceps tenodesis with BicepsButton fixation in the young population: which technique works best?

BACKGROUND: Injuries of the long head of the biceps (LHB) tendon are a prevalent source of anterior shoulder pain and are commonly treated with tenodesis. Not only a stable fixation of the LHB but also anatomic restoration of the length-tension relationship plays a central role in providing satisfactory functional and cosmetic outcomes, especially in young patients. We report the clinical outcomes of 2 different subpectoral tenodesis techniques using unicortical button fixation. METHODS: Patients aged ≤ 50 years who were treated between April 2015 and January 2020 with 1 of the 2 following subpectoral tenodesis techniques were retrospectively selected and enrolled to undergo a follow-up examination at least 2 years after surgery: subpectoral in situ tenodesis followed by resection of the intra-articular portion leaving a residual tendon stump in the bicipital groove (group I) vs. tenotomy followed by resection of the stump and subpectoral tenodesis (group II). Patients who underwent concomitant rotator cuff repair, subsequent shoulder surgery, or contralateral biceps surgery were excluded. Clinical outcomes were evaluated using the LHB score and the Constant-Murley Score (CMS), as well as measurements of isometric elbow flexion and forearm supination strength. Sonographic evaluation included assessment of the integrity of the LHB and tenodesis, examination for signs of inflammation within the sulcus or around the tendon, and measurements of the distalization of the myotendinous junction of the LHB compared with the nonoperative side. RESULTS: A total of 34 patients comprising group I (24 men; mean age at time of surgery, 40.3 years; mean follow-up period, 57.2 months) and 24 patients comprising group II (19 men; mean age at time of surgery, 39.8 years; mean follow-up period, 51.9 months) were evaluated. The total CMS, as well as the scores for each CMS subcategory, did not reveal significant differences between the groups. The overall LHB score was on average 10 points higher in group I (mean, 94 points) than in group II (mean, 84 points) (P = .016). Regarding the LHB score subcategories, group I showed significantly better results for patient-dependent cosmesis (mean, 15 points in group I vs. 12 points in group II; P = .005) and examiner-dependent cosmesis (mean, 14 points in group I vs. 10 points in group II; P = .001). This finding was substantiated by a significantly higher distalization of the myotendinous junction in group II (mean, 3.0 cm in group I vs. 3.8 cm in group II; P = .030). CONCLUSION: This study shows that subpectoral in situ tenodesis of the LHB followed by arthroscopic resection of the intra-articular portion provides higher LHB scores and better cosmetic outcomes compared with proximal intra-articular tenotomy followed by subpectoral tenodesis.

Prognostic factors for the occurrence of post-operative shoulder stiffness after arthroscopic rotator cuff repair: a systematic review.

BACKGROUND: Post-operative shoulder stiffness (POSS) is one of the most frequent complications after arthroscopic rotator cuff repair (ARCR). Factors specifying clinical prediction models for the occurrence of POSS should rely on the literature and expert assessment. Our objective was to map prognostic factors for the occurrence of POSS in patients after an ARCR. METHODS: Longitudinal studies of ARCR reporting prognostic factors for the occurrence of POSS with an endpoint of at least 6 months were included. We systematically searched Embase, Medline, and Scopus for articles published between January 1, 2014 and February 12, 2020 and screened cited and citing literature of eligible records and identified reviews. The risk of bias of included studies and the quality of evidence were assessed using the Quality in Prognosis Studies tool and an adapted Grading of Recommendations, Assessment, Development and Evaluations framework. A database was implemented to report the results of individual studies. The review was registered on PROSPERO (CRD42020199257). RESULTS: Seven cohort studies including 23 257 patients were included after screening 5013 records. POSS prevalence ranged from 0.51 to 8.75% with an endpoint ranging from 6 to 24 months. Due to scarcity of data, no meta-analysis could be performed. Overall risk of bias and quality of evidence was deemed high and low or very low, respectively. Twenty-two potential prognostic factors were identified. Increased age and male sex emerged as protective factors against POSS. Additional factors were reported but do require further analyses to determine their prognostic value. DISCUSSION: Available evidence pointed to male sex and increased age as probable protective factors against POSS after ARCR. To establish a reliable pre-specified set of factors for clinical prediction models, our review results require complementation with an expert's opinion.

Cost-Utility Analysis of Thumb Carpometacarpal Resection Arthroplasty: A Health Economic Study Using Real-World Data.

PURPOSE: Knowledge about the costs and benefits of hand surgical interventions is important for surgeons, payers, and policy makers. Little is known about the cost-effectiveness of surgery for thumb carpometacarpal osteoarthritis. The objective of this study was to examine patients' quality of life and economic costs, with focus on the cost-utility ratio 1 year after surgery for thumb carpometacarpal osteoarthritis compared with that for continued nonsurgical management. METHODS: Patients with thumb carpometacarpal osteoarthritis indicated for resection arthroplasty were included in a prospective study. The quality of life (using European Quality of Life-5 Dimensions-5 Level), direct medical costs, and productivity losses were assessed up to 1 year after surgery. Baseline data at recruitment and costs sustained over 1 year before surgery served as a proxy for nonsurgical management. The total costs to gain 1 extra quality-adjusted life year and the incremental cost-effectiveness ratio were calculated from a health care system and a societal perspective. RESULTS: The mean European Quality of Life-5 Dimensions-5 Level value for 151 included patients improved significantly from 0.69 to 0.88 (after surgery). The productivity loss during the preoperative period was 47% for 49 working patients, which decreased to 26% 1 year after surgery. The total costs increased from US $20,451 in the preoperative year to US $24,374 in the postoperative year. This resulted in an incremental cost-effectiveness ratio of US $25,370 per quality-adjusted life year for surgery compared with that for simulated nonsurgical management. CONCLUSIONS: The calculated incremental cost-effectiveness ratio was clearly below the suggested Swiss threshold of US $92,000, indicating that thumb carpometacarpal surgery is a cost-effective intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analyses II.

Lateralized vs. classic Grammont-style reverse shoulder arthroplasty for cuff deficiency Hamada stage 1-3: does the design make a difference?

BACKGROUND: Reverse shoulder arthroplasty (RSA) with a lateralized design is thought to improve outcomes. Our aim was to compare RSA with the classic Grammont prosthesis against a prosthesis with 135° inclination and a lateralized glenosphere for cuff-deficient shoulders. METHODS: Patients with irreparable massive posterosuperior rotator cuff tear Hamada grade 1-3 underwent RSA and were documented prospectively up to 24 months postsurgery. Comparative RSA groups were "lateralized" (L), with 135° humeral inclination and 36+4-mm lateralized glenosphere (n = 44), and "Grammont" (G), with 155° humeral inclination and 36+2-mm eccentric glenosphere (n = 23). Range of motion including the Apley scratch test, abduction strength, Constant-Murley score (CS), and Shoulder Pain and Disability Index (SPADI) were assessed. Anteroposterior and axial radiographs were evaluated at 24 months, and additional measurements of scapular neck and glenoid anatomy, baseplate and glenosphere position, center of rotation, humeral offset, and lateralization and distalization shoulder angles were made. Linear regression and mixed models adjusted for sex differences and preoperative values were applied. RESULTS: Overall CS and SPADI outcomes were not significantly different between groups (P ≥ .654). For group L, external rotation remained stable up to the 2-year follow-up and was higher than for group G (P = .012 ); a greater proportion of group L patients could reach the lumbar vertebra 3 (L3) (70% vs. 48% in group G) (P = .26). Group G had a higher inferior glenosphere overhang (P = .020) and center of rotation (COR) medialization (P < .001), whereas group L had higher humeral offset (P < .001) and lateralization shoulder angle (P < .001) with a trend toward higher baseplate positioning (P = .045). The rate of scapular notching was 2.9 times higher for group G than group L (P = .001). CONCLUSION: RSA with 135° humeral inclination and a lateralized glenosphere shows similar outcome scores as the classic Grammont design but enables better preservation of external rotation and reduces the rate of scapular notching compared with the classic Grammont design in Hamada 1-3 patients with irreparable posterosuperior tears.

Validity, responsiveness and minimal important change of the EQ-5D-5L in patients after rotator cuff repair, shoulder arthroplasty or thumb carpometacarpal arthroplasty.

PURPOSE: The aim was to investigate the measurement properties of the EQ-5D-5L utility index in patients after arthroscopic rotator cuff repair (RCR), total shoulder arthroplasty (TSA) or thumb carpometacarpal (CMC I) arthroplasty. METHODS: In this prospective study, all patients completed the EQ-5D-5L before surgery and 6 months and 1 year after surgery. In addition, RCR patients completed the Oxford Shoulder Score (OSS), TSA patients completed the Shoulder Pain and Disability Index (SPADI) and CMC I patients completed the brief Michigan Hand Outcomes Questionnaire (brief MHQ) at each designated time point. Construct validity (Pearson's correlation coefficient, r), responsiveness (effect size), minimal important difference (MID), minimal important change (MIC), and floor and ceiling effects of the EQ-5D-5L were determined. To test discriminative ability, EQ-5D-5L utility indices of patients who were in a patient acceptable symptom state (PASS) or not at follow-up were compared using the Mann-Whitney U test. RESULTS: We included 153 RCR, 150 TSA, and 151 CMC I patients. The EQ-5D-5L utility index correlated with the OSS (r = 0.73), SPADI (r = - 0.65) and brief MHQ (r = 0.61). The effect sizes were 1.3 (RCR and CMC I group) and 1.1 (TSA). The MID and MIC ranged from 0.027 to 0.209. Ceiling effects were found. The EQ-5D-5L utility index differed significantly between patients being in a PASS versus patients who were not in a PASS. CONCLUSION: The EQ-5D-5L utility index shows good construct validity, responsiveness and discriminative ability in patients after arthroscopic RCR, TSA and CMC I arthroplasty and is suitable to quantify quality of life. CLINICAL TRIAL REGISTRATION: This auxiliary analysis is part of a primary study that was originally registered at ClinicalTrials.gov (NCT01954433) on October 1, 2013.

Core set of unfavorable events of proximal humerus fracture treatment defined by an international Delphi consensus process.

BACKGROUND: Proximal humerus fracture (PHF) complications, whether following surgery or nonoperative management, require standardization of definitions and documentation for consistent reporting. We aimed to define an international consensus core event set (CES) of clinically-relevant unfavorable events of PHF to be documented in clinical routine practice and research. METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder trauma surgeons selected by survey invitation of AO Trauma members. An organized list of PHF events after nonoperative or operative management was developed and reviewed by panel members using on-line surveys. The proposed core set was revised regarding event groups along with definitions, specifications and timing of occurrence. Consensus was reached with at least a two-third agreement. RESULTS: The PHF consensus panel was composed of 231 clinicians worldwide who responded to at least one of two completed surveys. There was 93% final agreement about three intraoperative local event groups (device, osteochondral, soft tissue). Postoperative or nonoperative event terms and definitions organized into eight groups (device, osteochondral, shoulder instability, fracture-related infection, peripheral neurological, vascular, superficial soft tissue, deep soft tissue) were approved with 96 to 98% agreement. The time period for documentation ranged from 30 days to 24 months after PHF treatment depending on the event group and specification. The resulting consensus was presented on a paper-based PHF CES documentation form. CONCLUSIONS: International consensus was achieved on a core set of local unfavorable events of PHF to foster standardization of complication reporting in clinical research and register documentation. TRIAL REGISTRATION: Not applicable.

Complications Within 6 Months After Arthroscopic Rotator Cuff Repair: Registry-Based Evaluation According to a Core Event Set and Severity Grading.

PURPOSE: To report complications after arthroscopic rotator cuff repairs (ARCRs) in a large patient cohort based on clinical application of a newly defined core event set (CES) and severity grading. METHODS: Consecutive primary ARCRs documented in a local clinical registry between February 2010 and September 2016 were included. Clinicians documented adverse events (AEs) reported until the final, 6-month postoperative follow-up according to the CES. The CES is an organized list of relevant AEs sorted into 3 intraoperative event groups (device, osteochondral, and soft tissue) and 9 postoperative event groups (device, osteochondral, pain, rotator cuff, surgical-site infection, peripheral neurologic, vascular, superficial soft tissue, and deep soft tissue). Severity was determined using an adaptation of the Clavien-Dindo classification. Cumulative complication risks were calculated per event group and stratified by severity and rotator cuff tear extent. RESULTS: A total of 1,661 repairs were documented in 1,594 patients (mean age, 57 years [standard deviation, 9 years]; 38% women); 21% involved partial tears. All events were recorded according to the CES. Intraoperative events occurred in 2.2% of repairs. We identified 329 postoperative events in 307 repairs (305 patients); 93% had 1 AE. The cumulative AE risk at 6 months was 18.5%; AE risks were 21.8% for partial tears, 15.8% for full-thickness single-tendon tears, 18.0% for tears with 2 ruptured tendons, and 25.6% for tears with 3 ruptured tendons. AE risks per event group were as follows: 9.4% for deep soft tissue, with shoulder stiffness (7.6%) being the most common event; 3.4% for persistent or worsening pain; 3.1% for rotator cuff defects; 1.7% for neurologic lesions; 0.8% for surgical-site infection; 0.7% for device; 0.4% for osteochondral; 0.2% for superficial soft tissue, and 0.1% for vascular. Most AEs had severity grades I (160 [49%]) and II (117 [36%]). CONCLUSIONS: Comprehensive local AE documentation according to the CES and severity grading was possible and showed that about one-fifth of ARCRs were affected, mostly by one AE of low severity. Shoulder stiffness was the most frequent event. LEVEL OF EVIDENCE: Level IV, case series.

Cost-utility analysis of total shoulder arthroplasty: a prospective health economic study using real-world data.

BACKGROUND: With increasing health care expenditures, knowledge about the benefit and costs of surgical interventions such as total shoulder arthroplasty (TSA) becomes important for orthopedic surgeons, social insurance programs, and health policy decision makers. We examined the impact of TSA on quality of life (QOL), direct medical costs, and productivity losses and evaluated the cost-utility ratio of TSA compared with ongoing nonoperative management using real-world data. METHODS: Patients with shoulder osteoarthritis and/or rotator cuff tear arthropathy indicated for anatomic or reverse TSA were included in this prospective study. QOL (European Quality of Life 5 Dimensions 5-Level questionnaire) and shoulder function (Constant score; Shoulder Pain and Disability Index; short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and Subjective Shoulder Value) were assessed preoperatively and up to 2 years postoperatively. Health insurance companies provided all-diagnosis direct medical costs for 2018 in Swiss francs (CHF), where 1 CHF was equivalent to US $1.02. Indirect costs were assessed using the Work Productivity and Activity Impairment Questionnaire. Baseline data at recruitment and the total costs of the preoperative year served as a proxy for nonoperative management. The incremental cost-effectiveness ratio (ICER) was calculated as the total costs to gain 1 extra quality-adjusted life-year (QALY) based on both the health care system perspective and societal perspective. The relationship between QOL and shoulder function was assessed by regression analysis. RESULTS: The mean preoperative utility index for the European Quality of Life 5 Dimensions 5-Level questionnaire of 0.68 for a total of 150 patients (mean age, 71 years; 21% working; 58% women) increased to 0.89 and 0.87 at 1 and 2 years postoperatively, respectively. Mean direct medical costs were 11,771 CHF (preoperatively), 34,176 CHF (1 year postoperatively), and 11,763 CHF (2 years postoperatively). The ICER was 63,299 CHF/QALY (95% confidence interval, 44,391-82,206 CHF/QALY). The mean productivity losses for 29 working patients decreased from 40,574 CHF per patient (preoperatively) to 26,114 CHF at 1 year postoperatively and 10,310 CHF at 2 years postoperatively. When considering these productivity losses, the ICER was 35,549 CHF/QALY (95% confidence interval, 12,076-59,016 CHF/QALY). QOL was significantly associated with shoulder function (P < .001). CONCLUSION: Using real-world direct medical cost data, we calculated a cost-utility ratio of 63,299 CHF/QALY for TSA in Switzerland, which clearly falls below the often-suggested 100,000-CHF/QALY threshold for acceptable cost-effectiveness. In view of productivity losses, TSA becomes highly cost-effective with an ICER of 35,546 CHF/QALY.

Is limited shoulder abduction associated with poor scapulothoracic mobility after reverse shoulder arthroplasty?

INTRODUCTION: The contribution of the glenohumeral joint to shoulder abduction is acknowledged as an important factor for reverse total shoulder arthroplasty (RTSA) patients. In contrast, the degree of scapulothoracic joint contribution and its relation to RTSA patients with poor to excellent shoulder abduction are unclear. MATERIALS AND METHODS: Twenty-three selectively recruited patients (74 ± 7 years, 11 males) with shoulder abduction ranging from poor to excellent at least 6 months after primary, unilateral RTSA participated in this study. Individual scapulothoracic and glenohumeral contributions at maximum shoulder abduction in the scapular plane were measured using 3D motion capture and correlations between scapulothoracic and glenohumeral contributions to shoulder abduction were assessed. Multiple regression analysis was used to determine the influence of age, body mass index, follow-up period, abduction strength and passive glenohumeral mobility on scapulothoracic and glenohumeral function. RESULTS: Maximum shoulder abduction (range 48°-140°) was not significantly correlated with the scapulothoracic contribution (range 39°-75°, r = 0.40, p = 0.06), but there was a strong and significant correlation with the glenohumeral contribution (range - 9°-83°, r = 0.91, p < 0.001). Abduction strength was strongly associated with glenohumeral (p = 0.006) but not scapulothoracic (p = 0.34) joint contributions. CONCLUSIONS: Limited shoulder abduction is not associated with insufficient scapulothoracic mobility, which rather provides a basic level of function for RTSA patients. Good to excellent shoulder abduction could only be achieved by increasing the glenohumeral contribution that was associated with postoperative abduction strength.

High rate of maintaining self-dependence and low complication rate with a new treatment algorithm for proximal humeral fractures in the elderly population.

BACKGROUND: We modified our treatment algorithm for proximal humeral fractures in elderly patients in 2013 to a more conservative approach avoiding locking plates. This study assesses the impact of this change on patient self-dependence. METHODS: We carried out an observational comparative study including both retrospectively and prospectively collected data. For the former, 147 isolated proximal humeral fracture patients older than 65 years were treated between 2011 and 2013 at our hospital and included in a historical group. The revised treatment algorithm was applied in a similar non-concurrent, comparative patient group (n = 160) prospectively enrolled between 2015 and 2017. The primary outcome was any loss of self-dependence, with secondary outcomes including documentation of shoulder functional scores, quality of life, and adverse events. RESULTS: Historical and prospective patients had similar baseline characteristics. Nonoperative treatment was performed in 53 historical patients (36%) and 83 prospective patients (78%). Prospective patients were 1.6 times less likely to lose some level of self-dependence (risk ratio, 0.62; 95% confidence interval, 0.25-1.5; P = .292), and the local adverse event risk dropped from 12.2% to 5.7% (P = .078). Mean shoulder function and quality of life were similar between the 2 groups. CONCLUSION: By applying our revised algorithm, a higher proportion of elderly patients maintained their premorbid level of self-dependence and returned to their previous social environment.

Short-term safety, function, and quality of life in patients treated with Univers Revers prosthesis: a multicenter 2-year follow-up case series.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has dramatically increased in recent years with the advent of new prosthesis designs regularly entering the market. We define the rate of local complications during the first 2 years after RTSA with the Univers Revers prosthesis and describe the changes in radiologic outcomes, as well as function, pain, satisfaction, and quality of life. METHODS: This multicenter, prospective case series included rotator cuff tear arthropathy patients who underwent RTSA with the Univers Revers. Incidence percentages of complications and pathologic radiographic changes were documented. Mixed-model linear regression was used to examine changes in range of motion, shoulder function (Constant score, Shoulder Pain and Disability Index, Subjective Shoulder Value), and quality of life (EQ-5D-5L [European Quality of Life 5 Dimensions 5 Level] and EQ-VAS [EuroQol Visual Analog Scale]). RESULTS: Of 187 patients, 59.4% were women, and the mean age was 75.3 years (range, 56-91 years). Twenty-five percent of patients had a postoperative complication; 5 complications were severe (2.7%, 5 of 187), whereby 2 were implant related (1.1%; 95% confidence interval [CI], 0.1%-3.8%). The incidence of scapular notching was 10.6% (95% CI, 6.5%-16%). After 2 years, abduction, flexion, and abduction strength improved by 54° (95% CI, 50°-58°), 57° (95% CI, 53°-60°), and 5 kg (95% CI, 4-5 kg), respectively (P < .001), whereas external rotation at 0° (1°; 95% CI, -1° to 3°) did not improve (P = .4). The Constant score improved by 39 (95% CI, 38-41); Shoulder Pain and Disability Index, by 50 (95% CI, 47-52); and Subjective Shoulder Value, by 43 (95% CI, 41-45) (P < .001). Furthermore, the EQ-5D-5L index value improved by 0.31 (95% CI, 0.30-0.33), and the EQ-VAS score improved by 16 (95% CI, 14-18) (P < .001). CONCLUSION: Our case series showed a low complication rate with a consistent clinically relevant and statistically significant improvement across most clinical and patient-reported outcomes for the Univers Revers. Long-term safety requires further investigation.

Re-intervention and revision rates following primary reverse total shoulder arthroplasty - review of a local shoulder arthroplasty registry.

PURPOSE: Our primary aim was to describe the re-intervention and revision rates after primary reverse shoulder arthroplasty (RSA) documented in a local shoulder arthroplasty registry. We also identify the main indication for revision and re-intervention, which may be relevant for patient outcome post-RSA. METHODS: Since July 2006, RSAs are consecutively documented in our clinic registry and prospectively controlled with follow-ups. Any intervention after primary RSA requiring a return to the operating room for any shoulder-related indication was termed a re-intervention. Revisions were defined as surgeries involving any exchange, removal, or addition of at least one component. The study endpoints were survival rates at two, five and ten years follow-up for both definitions. RESULTS: Until July 2017, 63 from a total of 1480 primary RSAs required at least one re-intervention and 33 patients had a revision. Open reduction and internal fixation for fractures around the implant (n = 14) were the predominating indications for re-intervention. The re-intervention rate for instability was 0.5%. For re-interventions, survival rates were 97.7, 95.4 and 90.8% at two, five and ten years, respectively, and the respective rates for revisions were 98.7, 97.5 and 95.3%. CONCLUSION: The revision rate after primary RSA for our patient registry is low. A relevant number of additional interventions were noted that did not require any component revision but may impair the final outcome post-RSA. By only reporting revision rates, the number of post-RSA re-interventions is clearly underestimated. We recommend the documentation of all events leading to any re-intervention in arthroplasty registries.

Treatment options for proximal humeral fractures in the older adults and their implication on personal independence.

BACKGROUND: No consensus exists on the optimal treatment of proximal humeral fractures (PHFx). Uncertainty about surgical treatment in the older adults using locking plates (e.g., PHILOS) has emerged, due to a high number of complications. This study aimed to assess the impact of non-operative versus operative treatment of a PHFx on the level of self-dependence in our older population. METHODS: We included patients aged over 65 years with some level of self-dependence, treated at our hospital between 5/2011 and 4/2013 for isolated PHFx of AO subtypes A2, A3, and B1 for which either non-operative or surgical treatment using a PHILOS plate had been applied. The patients were questioned, examined, or interviewed via phone; AO fracture patterns and treatment were documented as well as level of self-dependence, complications, constant score (CSM), subjective shoulder value (SSV), quality of life (EQ-5D), and shoulder pain and disability index (SPADI). RESULTS: Patients with PHFx of AO subtypes A2, A3, or B1 that were either treated non-operative (n = 50) or operative by insertion of the PHILOS plate (n = 63) were included. Operative-treated patients were 3.3 times as likely to lose some level of independence (95% CI 0.39-28, p = 0.271). Shoulder motion, strength, and functional outcomes tended to be lower in operative-treated patients, with adjusted differences of, - 11 CMS points (95% CI - 23 to 2), - 9 SPADI points (95% CI - 18 to 0), and - 6% in SSV (95% CI - 17 to 5). Quality-of-life EQ-5D utility index was similar in both groups (mean - 0.04; 95% CI - 0.18 to 0.10). CONCLUSION: In our study population, non-operatively treated older adults with an AO type A2, A3, B1 fracture of the proximal humerus tended to have a high chance to return to their premorbid level of independence, compared to patients treated with a locking plate. A change in the treatment algorithm for these PHFx may be carefully considered and further investigated in clinical practice.

Oropharyngeal leak pressure of the LMA Protector™ vs the LMA Supreme™; a prospective, randomized, controlled clinical trial.

BACKGROUND: Clinical characteristics such as oropharyngeal leak pressure (OLP) and ventilation peak pressure are important factors for successful use of supraglottic airway devices in general anaesthesia. We hypothesized that the LMA Protector™ compared to the LMA Supreme™ may develop a higher OLP, which could be of clinical significance. METHODS: Ninety-six patients were randomized to the LMA Protector™ or LMA Supreme™ groups. We measured oropharyngeal leak pressure within 5 minutes after insertion of the supraglottic airway device with a standardized cuff pressure at 60 cm H2 O. Secondary parameters, such as insertion time of the supraglottic airway device, the number of attempts inserting the supraglottic airway device and the gastric tube, volume of gastric contents, and maximum airway pressure, as well as pulse oximetry throughout the operation were measured. Further, blood staining after removal of the supraglottic airway device and postoperative airway morbidity 3 hours after surgery were determined. RESULTS: The mean difference of oropharyngeal leak pressure was 5.2 (95% CI 2.8-7.6), ie, 30.9 (7.4) cmH2 O for the LMA Protector™ vs 25.6 (4.4) cmH2 O for the LMA Supreme™ (P < 0.001; mean(SD)). Similarly, there was a mean difference between OLP and maximal ventilation peak pressure 5.6 (95% CI 3.1-8.2) ie 19.6 (7.7) cmH2 O for the LMA Protector™ vs 14.0 (4.4) cmH2 O for the LMA Supreme™ (P < 0.001). No difference was found between the groups for other secondary parameters, as well as postoperative airway morbidity. CONCLUSION: The LMA Protector™ enabled a higher OLP compared to the LMA Supreme™. This finding may be important for patients requiring a higher peak pressure for sufficient supraglottic airway device ventilation.