The subcoracoid distance is correlated with pain and internal rotation after reverse shoulder arthroplasty.

Background: A proposed etiology of anterior shoulder pain and limited internal rotation after reverse shoulder arthroplasty (RSA) is impingement of the humeral component on the coracoid or conjoint tendon. The primary goal of this study was to investigate radiographic surrogates for potential coracoid or conjoint tendon impingement and their relationship to postoperative pain and internal rotation after RSA. Methods: A retrospective review of a clinical registry was performed to identify patients with (1) primary RSA, (2) minimum 2-year clinical follow-up, and (3) satisfactory postoperative axillary lateral radiographs. The primary radiographic measurement of interest was the subcoracoid distance (SCD), defined as the distance between the posterior aspect of the coracoid and the anterior glenosphere. Additional measurements were as follows: anterior glenosphere overhang, posterior glenosphere overhang, native glenoid width, lateralization of glenosphere relative to the coracoid tip, lateralization shoulder angle, and distalization shoulder angle. The primary clinical outcome of interest was the 2-year postoperative Visual Analog Scale score. Secondary outcomes were (1) internal rotation (IR) defined by spinal level (IRspine), (2) IR at 90 degrees of abduction, (3) American Shoulder and Elbow Surgeons score, (4) forward flexion, and (5) external rotation at 0 degrees of abduction. Linear regression analyses were used to evaluate the relationship of the various radiographic measures on the clinical outcomes of interest. Results: Two hundred seventeen patients were included. There was a statistically significant relationship between the SCD and Visual Analog Scale scores: B = -0.497, P = .047. There was a statistically significant relationship between the SCD and IRspine: B = -1.667, P < .001. Metallic lateralization was also positively associated with improving IRspine; increasing body mass index was negatively associated. There was a statistically significant relationship between the SCD and IR at 90 degrees of abduction: B = 5.844, P = .034. Conclusion: For RSA with a 135° neck shaft angle and lateralized glenoid, the postoperative SCD has a significant association with pain and IR. Decreasing SCD was associated with increased pain and decreased IR, indicating that coracoid or conjoint tendon impingement may be an important and potentially under-recognized etiology of pain and decreased IR following RSA. Further investigations aimed toward identifying a critical SCD to improve pain and IR may allow surgeons to preoperatively plan component position to improve clinical outcomes after RSA.

Anatomic variations of the deltoid muscle insertion: a cadaveric study.

Background: The deltoid is a trisegmented muscle with anterior, middle, and posterior components. While the clinical relevance of the presence of anatomic variations of the deltoid origin and insertion continues to be debated, the architecture of the deltoid muscle is more complex than initially believed. This study aimed to evaluate the gross anatomy of the deltoid muscle insertion by qualitatively and quantitatively characterizing the insertion and location of the deltoid muscle's anterior, middle, and posterior components. This information is valuable to surgeons as it raises awareness of potential variants that could be encountered during surgery, promotes mindfulness of neurovascular proximities, and reduces the likelihood of confusion between adjacent muscle fibers. Methods: Eight nonpaired, fresh-frozen clavicle-to-fingertip cadaveric shoulders were acquired for the study (6 left, 2 right). The average age of the cadavers was 79.5 years (range: 64-92). The standard deltopectoral approach was carried out on all specimens. The planes dividing the anterior, middle, and posterior deltoid were identified and marked. Once complete exposure had been achieved, digital calipers were used to record the size of the deltoid insertion. The specimens were qualitatively assessed to characterize the style of insertion they demonstrated. Results: The average length of the deltoid insertion was 39.45 ± 9.33 mm (n = 8). Six of the eight shoulders demonstrated an insertion style previously characterized in the literature. The remaining two shoulders highlighted an insertion pattern not previously described. Conclusion: The current study demonstrates a novel insertion pattern for the deltoid muscle that has not been previously characterized. This "step-off" insertion pattern shows that the anterior, middle, and posterior tendons are inserted superior-medial, directly on, and inferior-lateral to the deltoid tuberosity and was found in 2/8 of our cadaveric specimens.

Rates of subacromial notching are low following reverse shoulder arthroplasty with a 135° inlay humeral component and a lateralized glenoid.

Background: Lateralization in reverse shoulder arthroplasty (RSA) decreases bony impingement and improves rotational range of motion, but has been theorized to increase the risk of subacromial notching (SaN). The purpose of this study was to evaluate the presence of SaN following RSA and its relationship with lateralization with a 135° inlay humeral component. The secondary purpose was to assess the association of SaN with functional outcomes. Methods: A retrospective review was performed from a multicenter prospectively collected database on patients who underwent primary RSA from 2015 to 2021. All RSAs were performed with a 135° inlay humeral component. SaN was defined as bony erosion with sclerotic margins on the undersurface of the acromion on final follow-up radiographs not present preoperatively. Postoperative implant positioning (inclination, distalization, and lateralization) were evaluated on minimum 1-year postoperative radiographs. Regression analyses were performed on implant and clinical variables to assess for risk factors. A separate analysis was performed to determine the association of SaN with clinical outcomes. Results: SaN was identified in 13 out of 442 shoulders (2.9%). Age, sex, body mass index, smoking status, diabetes mellitus, arm dominance had no relationship with SaN. Neither glenoid sided lateralization nor humeral offset were associated with SaN risk. Other implant characteristics such as distalization, glenosphere size, and postoperative inclination did not influence SaN risk. The presence of SaN did not affect patient-reported outcomes (American Shoulder and Elbow Surgeons: P = .357, Visual Analog Scale: P = .210) or range of motion. Conclusion: The rate of SaN is low and not associated with glenoid or humeral prosthetic lateralization when using a 135° inlay humeral component. When SaN occurs, it is not associated with functional outcomes or range of motion at short-term follow-up.

Dermal Allograft Augmentation for Large and Massive Rotator Cuff Tears and Revisions: A Case Series.

Introduction Arthroscopic advancements have notably improved rotator cuff repair, yet the healing of tendons and retear risks still pose significant challenges, especially with massive and large tears. These larger tears have shown a quadruple increase in retear rate when the tear size grows from 1-3 cm. The prevalent cause of failure, particularly in tears with fatty degeneration, is suture tearing. As such, techniques that enhance tendon healing are pivotal due to their correlation with improved functional outcomes. Dermal allograft augmentation (DAA) is one method that has demonstrated improvements in rotator cuff repair biomechanics, as well as the promotion of vascularization and neotendon formation. This study evaluates the efficacy of DAA in the postoperative healing of large and massive rotator cuff tears, assessed through patient-reported outcomes and functional range of motion. Methods This retrospective study reviewed a single surgeon's database, selecting patients who underwent arthroscopic surgery for full-thickness rotator cuff tears measuring at least 3 cm, or those with maximum stage II fatty infiltration of the supraspinatus or infraspinatus muscle on MRI. We used three validated patient-reported outcome (PRO) measures, American Shoulder and Elbow Surgeon Score (ASES), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST), alongside a range of motion metrics, external rotation (ER), and forward flexion (FF). These were recorded pre-operatively and, at minimum, one year post-operatively, with a standard student t-test employed for comparative analysis. Results Out of 18 total patients, the average age was 61 years, and 83% were male. The cause of injury was mostly traumatic in nature (n=11), with the remainder being chronic (n=7). All three PROs (n=11) demonstrated a statistically significant increase in score including ASES (p=0.003), SANE (p=0.004), and SST (p=0.039). External rotation also significantly improved pre- to post-operative function (46 vs 58, p=0.049). Three patients (17%) suffered from a retear within three months of their rotator cuff repair. Two patients (11%) required a reverse shoulder arthroplasty within a year. Conclusion Our study demonstrated that DAA in rotator cuff repair yielded notable functional and clinical advancements, with a moderately low retear rate as confirmed by ultrasound. These outcomes suggest that DAA is a promising intervention for large and historically difficult rotator cuff tears, offering significant implications for future treatment protocols.

Posteroinferior Glenosphere Positioning is Associated with Improved Range of Motion Following Reverse Shoulder Arthroplasty with a 135° Inlay Humeral Component and Lateralized Glenoid.

BACKGROUND: Optimal glenosphere positioning in a lateralized reverse shoulder arthroplasty (RSA) to maximize functional outcomes has yet to be clearly defined. Center of rotation (COR) measurements have largely relied on AP radiographs which allow assessment of lateralization and inferior position, but ignore scapular Y radiographs which may provide an assessment of posterior and inferior position relative to the acromion. The purpose of this study was to evaluate the COR in the sagittal plane and assess the effect of glenosphere positioning with functional outcomes utilizing a 135° inlay stem with a lateralized glenoid. METHODS: A retrospective review was performed on a prospectively maintained multicenter database on patients who underwent primary RSA from 2015-2021 with a 135° inlay stem. The COR was measured on minimum 2-year postoperative sagittal plain radiographs using a perfect-circle fit method. A perfect circle was made on the glenosphere and the center was marked. From there, four measurements were made: 1) center to the inner cortex of the coracoid, 2) center to the inner cortex of the anterior acromion, 3) center to the inner cortex of the middle acromion, 4) center to the inner cortex of the posterior acromion. Regression analysis was performed to evaluate any association between the position of the COR relative to bony landmarks with functional outcomes. RESULTS: A total of 136 RSAs met the study criteria. There was no relation with any of the distances with outcome scores (ASES, VAS). In regards to range of motion (ROM), each distance had an effect on at least one parameter. The COR to coracoid distance had the broadest association with ROM with improvements in forward flexion (FF), external rotation (ER0), and internal rotation with arm at 90° (IR90) (p = <0.001, 0.031, <0.001; respectively). The COR to coracoid distance was also the only distance to affect the final FF and IR90. For every 1 mm increase in this distance, there was a 1.8° increase in FF and 1.5° increase in IR90 (ß = 1.78; 95% CI 0.85 - 2.72, p = <0.001, ß = 1.53; 95% CI 0.65 - 2.41, p = <0.001; respectively). CONCLUSION: Evaluating the COR following RSA in the sagittal plane suggests that posteroinferior glenosphere position may improve ROM when using a 135° inlay humeral component and a lateralized glenoid.

Stener-like lesion of the lateral meniscus in the setting of a multiligamentous knee injury: A case report.

Traumatic dislocations of the knee can result in significant soft tissue damage including multiligamentous and meniscal knee injury. When a meniscal tear involves the posterior horn, the meniscus loses one of its attachments to the tibia and can become extruded from the joint. Stener-like lesions of the knee have been reported throughout the literature; however, they have been exclusively described as a distal tear of the medial collateral ligament (MCL) lying superficial to the pes anserine tendon which prevents anatomic healing. The purpose of this report is to present a previously unreported unique variant of a lateral meniscus tear in the setting of a MLKI. In this case presentation, the lateral meniscus became extruded superficial to the intact lateral collateral ligament (LCL) resulting in a Stener-like lesion. Corrective recognition of lesions like these and timely surgical intervention is recommended to restore native anatomy and prevent chronic pain, instability, and premature degenerative disease. Level IV, Case report.

Stemless anatomic total shoulder arthroplasty is associated with less early postoperative pain.

Background: Improvements in pain control after shoulder arthroplasty with a reduction in narcotic use continues to be an important postoperative goal. With the increased utilization of stemless anatomic total shoulder arthroplasty (aTSA), it is relevant to compare between stemmed and stemless arthroplasty to assess if there is any association between this implant design change and early postoperative pain. Methods: Patients from a multicenter, prospectively-maintained database who had undergone a stemless aTSA with a minimum of two year clinical follow-up were retrospectively identified. Patients who underwent aTSA with a short stem were identified in the same registry, and matched to the stemless aTSA patients by age, sex and preoperative pain score. The primary study outcome was the Visual Analog Scale pain score. Secondary pain outcomes were the American Shoulder and Elbow Surgeons shoulder pain subscore, Western Ontario Osteoarthritis of the Shoulder physical symptoms subscore, and the Single Assessment Numeric Evaluation score. Finally, the percentage of patients who could sleep on the affected shoulder was assessed for each group. These pain-related clinical outcomes were assessed and compared preoperatively, and postoperatively at 9 weeks, 26 weeks, one year and two years. For all statistical comparisons, P > .05 was considered significant. Results: 124 patients were included in the study; 62 in each group. At 9 weeks after surgery, statistically significantly improved pain control was reported by patients undergoing stemless aTSA, as assessed by the Visual Analog Scale (stemless: 1.5, stemmed: 2.5, P = .001), American Shoulder and Elbow Surgeons pain subscore (stemless: 42.4, stemmed: 37.3, P < .001), Western Ontario Osteoarthritis of the Shoulder Physical Symptoms (stemless: 80.3, stemmed: 73.1, P = .006) and Single Assessment Numeric Evaluation (stemless: 58.1, stemmed: 47.4, P = .011). Patients who underwent a stemless aTSA were significantly more likely to be able to sleep on the affected shoulder at 9 weeks (29% vs. 11%, odds ratio 3.2, 95% confidence interval 1.2-8.4, P = .014). By 26 weeks postoperatively, there were no differences in all pain-specific outcomes. At two years postoperatively, patient-reported outcomes, range of motion, and strength measures were all similar between the two cohorts. Conclusion: Stemless aTSA provides earlier improvement in postoperative shoulder pain compared to matched patients undergoing short-stem aTSA. Additionally, earlier return to sleeping on the affected shoulder was reported in the stemless aTSA group. The majority of these differences dissipate by 26 weeks postoperatively and there were no differences in pain, patient-reported outcomes, range of motion or strength measures between stemless and short-stem aTSA at 2 years postoperatively.

Obesity is associated with improvement in functional outcome but lower internal rotation after reverse shoulder arthroplasty.

Background: The role of obesity as an independent risk factor for increased complications following reverse shoulder arthroplasty (RSA) continues to generate debate. While no standardized body mass index (BMI) cutoff values for shoulder arthroplasty exist, many surgeons are concerned about the potential for poor outcomes and decreased range of motion (ROM) in patients with a high BMI. The purpose of this study was to compare functional outcomes in obese and nonobese patients preoperatively and at short-term follow-up after RSA. Methods: A retrospective review was performed of a prospectively maintained, multicenter database of primary RSAs performed by 14 surgeons between 2015 and 2019 with minimum 2-year follow-up. A total of 245 patients met the study criteria, including 111 obese (BMI >30) and 134 nonobese (BMI <30) patients. Patient-reported outcomes (PROs) as well as ROM measurements were compared between the 2 groups. Results: At baseline, obese patients had significantly lower American Shoulder and Elbow Surgeons (36.6 vs. 42.0, P = .014), Western Ontario Osteoarthritis of the Shoulder scores (33.1 vs. 37.8, P = .043), external rotation at 90° (19° vs. 28°, P = .007), internal rotation (IR) spinal level (L5 vs. L4, P = .002), and belly press strength (P = .003) compared to the nonobese cohort. There were no statistical differences in 2-year outcomes (PROs, ROM, and strength) other than a worse IR (spinal level) in the low BMI group (L4 vs. L3, P = .002). In linear regression analyses controlling for confounding variables, increasing BMI was negatively correlated with preoperative external rotation (B = -0.591, P = .034) and preoperative IR spinal level (B = 0.089, P = .002). Increasing BMI was not correlated with postoperative external rotation at 90° (B = 0.189, P = .490) but was associated with worse postoperative IR by spinal level (B = 0.066, P = .043). Conclusions: Obese patients have greater restrictions in external and internal rotation as well as American Shoulder and Elbow Surgeons and Western Ontario Osteoarthritis of the Shoulder scores at baseline prior to RSA. However, there are no major differences in postoperative PROs or ROM measurements between obese and nonobese patients apart from a worse active IR by spinal level in the obese group (L4 vs. L3, P = .002). This study suggests that an RSA procedure does not need to be restricted solely based on BMI.

Return-to-Golf Rate After Shoulder Arthroplasty: A Systematic Review and Meta-analysis.

Background: With advancements in the technology, techniques, and biomechanical understanding of shoulder arthroplasty, higher rates of postoperative return to various sports have been seen in the past decade. Purpose: To observe the return-to-golf rate after various types of shoulder arthroplasty (anatomic total shoulder arthroplasty [TSA], hemiarthroplasty [HA], and reverse total shoulder arthroplasty [RSA]) and also to review the protocols for return to golf. Study Design: Scoping review; Level of evidence, 4. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in a search of PubMed, JSTOR, Google Scholar, ScienceDirect, and CORE using the keywords "return to sport,""shoulder arthroplasty,""golf,""TSA,""shoulder arthroplasty,""hemiarthroplasty,""reverse shoulder arthroplasty,""RSA,""sports," and "athlete." Of 145 preliminary results, 10 retrospective studies (n = 178 patients) published between 1998 and 2021 were included in the final analysis. Results: The mean patient age was 65 years. Of the 172 patients with reported return-to-sport rates, the mean return-to-golf rate was 75.8% for all types of shoulder arthroplasty. Of these 172 patients, 107 patients were categorized by type of procedure: Anatomic TSA had the highest return-to-golf rate at 77.6% (49/107), followed by HA at 64.3% (14/107) and RSA at 59.1% (44/107). Four studies commented on return to the full 18 holes of golf, with a return-to-sport timeline ranging from 5 to 6 months postoperatively. One study specified the return-to-golf timeline based on the type of shot and reported the mean number of weeks before putting, chipping, and returning to the course as 20, 22, and 27 weeks, respectively. Two studies that reported on golf playing frequency noted an increase from before to 1 year after TSA, from a mean of 1.6 and 0.7 times per week to 2.0 and 1.7 times per week, respectively. Only 1 study, published in 1998, provided a comprehensive return-to-golf protocol. Conclusion: The return-to-golf rate after shoulder arthroplasty was highest after anatomic TSA (78%) compared with HA (64%) and RSA (59%). The most commonly reported duration before returning to a full 18 holes was 5 to 6 months, but patients returned to putting and chipping earlier.

Robert H. Cofield, MD, Award for Best Oral Presentation 2023: Up to 8 mm of glenoid-sided lateralization does not increase the risk of acromial or scapular spine stress fracture following reverse shoulder arthroplasty with a 135° inlay humeral component.

BACKGROUND: Glenoid-sided lateralization in reverse shoulder arthroplasty (RSA) decreases bony impingement and improves rotational range of motion, but has been theorized to increase the risk of acromial or scapular spine fractures (ASFs). The purpose of this study was to assess if glenoid-sided lateralization even up to 8 mm increases the risk for stress fracture following RSA with a 135° inlay humeral component. METHODS: A retrospective review was performed from a multicenter prospectively collected database on patients who underwent primary RSA from 2015 to 2021. All RSAs were performed with a 135° inlay humeral component. Varying amounts of glenoid lateralization were used from 0 to 8 mm. Preoperative radiographs were reviewed for the presence of acromial thinning, acromiohumeral distance (AHD), and inclination. Postoperative implant position (distalization, lateralization, and inclination) as well as the presence of ASF was evaluated on minimum 1-year postoperative radiographs. Regression analyses were performed on component and clinical variables to assess for factors predictive of ASF. RESULTS: Acromial or scapular spine fractures were identified in 26 of 470 shoulders (5.5%). Glenoid-sided lateralization was not associated with ASF risk (P = .890). Furthermore, the incidence of fracture did not vary based on glenoid-sided lateralization (0-2 mm, 7.4%; 4 mm, 5.6%; 6 mm, 4.4%; 8 mm, 6.0%; P > .05 for all comparisons). RSA on the dominant extremity was predictive of fracture (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.20-5.75; P = .037), but there was no relationship between patient age, sex, preoperative acromial thinning, or diagnosis and risk of fracture. Although there was no difference in mean postoperative AHD between groups (P = .443), the pre- to postoperative delta AHD was higher in the stress fracture group (2.0 ± 0.7 cm vs. 1.7 ± 0.7 cm; P = .015). For every centimeter increase in delta AHD, there was a 121% increased risk for fracture (OR 2.21, 95% CI 1.33-3.68; P = .012). Additionally, for every 1-mm increase in inferior glenosphere overhang, there was a 19% increase in fracture risk (P = .025). CONCLUSION: Up to 8 mm of glenoid-sided metallic lateralization does not appear to increase the risk of ASF when combined with a 135° inlay humeral implant. Humeral distalization increases the risk of ASF, particularly when there is a larger change between pre- and postoperative AHD or higher inferior glenosphere overhang. In cases of pronounced preoperative superior humeral migration, it may be a consideration to avoid excessive postoperative distalization, but minimizing bony impingement via glenoid-sided lateralization appears to be safe.

Management of Glenoid Bone Loss in Shoulder Instability: Where We Are in 2023.

The management of glenoid bone loss in shoulder instability can be challenging. Although shoulder instability can often be managed with arthroscopic soft-tissue procedures alone, the extent of glenoid bone loss and bipolar bone defects may require bone augmentation procedures for restoration of stability. In this setting, patient evaluation, examination, treatment options, and surgical pearls are vital. Furthermore, a treatment algorithm is established to guide both indications and the technical application of procedures including Bankart repair with remplissage, Latarjet procedure, and glenoid bone graft options. The limitations, complications, and current research pertinent to each treatment assist in guiding treatment.

Correlation of Joint Space Widening on Valgus Stress Magnetic Resonance Imaging With Level of Play and Innings Pitched in Professional Pitchers.

Background: Previous studies have described various techniques and confirmed the clinical utility of valgus stress radiography and stress ultrasound in overhead athletes. The addition of valgus stress and a high-resolution anatomic assessment of the elbow with magnetic resonance imaging (MRI) in the active throwing position (flexed elbow valgus external rotation [FEVER] view) can add valuable diagnostic or prognostic information in throwing athletes. Purpose/Hypothesis: The purpose of this study was to evaluate findings on MRI and subsequent performance in professional throwing athletes. It was hypothesized that joint space widening in the FEVER view would be predictive of performance and the risk of subsequent injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All pitchers on 2 Major League Baseball teams who consented to participate during their preseason screening in 2019 and 2020 underwent standard and FEVER MRI, and performance data from the following season were recorded, including injuries, mean throwing velocity, number of innings pitched, strikeout percentage, walk percentage, weighted on-base average, and level of play reached (not signed, minor league, or major league). Categorical variables were compared using the Fisher exact test or chi-square test, and continuous variables were compared using the Kruskal-Wallis test, as appropriate. Ordered logistic regression was used to determine the independent factors predicting performance. Results: A total of 91 players underwent preseason imaging, and all players had subsequent performance data available. Multivariate analysis revealed that when controlling for age, mean velocity, history of injuries, presence of symptoms, and history of ulnar collateral ligament reconstruction, increased absolute joint space widening was predictive of a lower level of play (ß = -0.63; P = .042). Univariate analysis demonstrated a significant correlation between relative joint space widening and level of play reached (ß = -0.54; P = .034). Relative joint space widening remained a significant predictor of level of play (ß = -0.87; P = .012) on multivariate analysis. Multivariate analysis also showed that both absolute joint space widening (ß = -13.50; P = .012) and relative joint space widening (ß = -13.60; P = .026) were predictive of the number of innings pitched in the subsequent season. Conclusion: The present study demonstrates that findings on MRI with valgus stress correlated with the level of play reached and number of innings pitched in professional throwing athletes.

Reliability of Current Classification Systems for Periprosthetic Fractures of the Humerus.

OBJECTIVE: Numerous classification systems exist to evaluate periprosthetic humerus fractures, although most are based on limited patient numbers. The Wright and Cofield system is the most widely used classification system. We sought to evaluate the interobserver and intraobserver reliabilities of this system compared with the Unified Classification System (UCS) using the largest patient sample to date. METHODS: This retrospective study identified patients between December 2011 and January 2021 with a periprosthetic fracture of the humerus around the stem of a shoulder arthroplasty component. Three upper extremity fellowship-trained surgeons evaluated all radiographs for stem stability, evidence of preinjury stem loosening, Wright and Cofield classification, UCS classification, and recommended treatment for each case at 2 timepoints separated by 2 months. The kappa statistic for interobserver and intraobserver reliability was calculated. RESULTS: Seventy-six patients were included. There was moderate interobserver (kappa 0.53) and substantial intraobserver (kappa 0.69) agreement when classifying stem stability after fracture. There was moderate interobserver (kappa 0.48) and intraobserver (kappa 0.60) agreement when evaluating for stem loosening before fracture. There was fair interobserver (kappa 0.29) and moderate intraobserver (kappa 0.51) agreement regarding the UCS class. There was moderate interobserver (kappa 0.41) and intraobserver (kappa 0.57) agreement regarding the proposed treatment. There was slight interobserver (kappa 0.04) and moderate intraobserver (kappa 0.44) agreement regarding the Wright and Cofield classification. CONCLUSION: The Wright and Cofield system is less reliable than the UCS classification. A more reliable and clinically relevant classification system is needed to standardize discussion of periprosthetic proximal humerus fractures.

Physician Professional Fees Are Declining and Inpatient and Outpatient Facility Fees Are Increasing for Orthopaedic Procedures in the United States.

PURPOSE: To examine the trends in physician professional fees and inpatient and outpatient facility fees in orthopaedic surgery in the United States. METHODS: Physician professional fees and inpatient and outpatient facility fees were tracked from 2008 to 2021 for the most common orthopaedic procedures in each orthopaedic subspecialty. Using common procedure codes for physician and outpatient procedures and Medicare severity diagnosis related group codes for inpatient procedures, the Medicare Physician Fee Schedules were used to obtain the national payment amounts for physician professional fees and inpatient and outpatient facility fees. Trends in fees were tracked over time after adjustment for inflation. RESULTS: From 2008 to 2021, physician professional fees decreased by an average of 20%, whereas inpatient facility fees increased by 15%, and outpatient facility fees increased by 72%. The orthopaedic subspecialty with the largest decrease in physician professional fees was oncology, with an average decrease of 23.5%, followed by general orthopaedics (23.1%), and sports medicine (22.8%). The largest increase in outpatient facility fees was seen in the subspecialties of general orthopaedics (149.8%), spine (130.1%), and trauma (123.0%). CONCLUSIONS: Over the past 13 years, physician professional fees for the most common orthopaedic procedures have declined while inpatient and outpatient facility fees have increased. Understanding these changes is important to the practice of orthopaedic surgery in the United States. LEVEL OF EVIDENCE: IV, economic.

Stemless components lead to improved radiographic restoration of humeral head anatomy compared with short-stemmed components in total shoulder arthroplasty.

BACKGROUND: Restoring the native center of rotation (COR) in total shoulder arthroplasty (TSA) has been shown to improve postsurgical function, subjective outcomes, and implant longevity. The primary purpose of this study was to compare postoperative radiographic restoration of the humeral COR between short-stem and stemless humeral implants by evaluating the mean COR shift between the 2 techniques. Secondary outcomes evaluated were comparisons of COR shift outliers, humeral head implant thickness and diameter, direction of COR shift, and neck-shaft angle (NSA). METHODS: This study was a multicenter retrospective comparative study using a consecutive series of primary anatomic TSA patients who received either a short-stem or stemless humeral implant. Radiographically, COR and NSA were measured by 2 fellowship-trained surgeons using the best-fit circle technique on immediate postoperative Grashey radiographs. RESULTS: A total of 229 patients formed the final cohort for analysis that included 89 short stems and 140 stemless components. The mean COR shift for short stems was 2.7 mm (±1.4 mm) compared with 2.1 mm (±0.9 mm) for stemless implants (P < .001). The percentage of short-stem implant patients with a >2 mm COR difference from native was 66.0% (n = 62) compared with 47.4% (n = 64) for stemless (P = .006). The percentage of short-stem patients with a >4 mm COR difference from native was 17.0% (n = 16) compared with 3.0% (n = 4) for stemless (P < .001). The mean humeral implant head thickness for short stems was 18.7 ± 2.2 mm compared with 17.2 ± 1.3 mm for stemless implants (P < .001). The mean humeral head diameter for short stems was 48.7 ± 4.4 mm compared with 45.5 ± 3.5 mm for stemless implants (P < .001). The NSA for the short-stem cohort was 136.7° (±3.6°) compared with 133.5° (±6.0°) for stemless (P < .001). CONCLUSIONS: Stemless prostheses placed during TSA achieved improved restoration of humeral head COR and were less likely to have significant COR outliers compared with short-stem implants.

Patient reported outcomes and ranges of motion after reverse total shoulder arthroplasty with and without subscapularis repair.

Background: In performing reverse total shoulder arthroplasty (rTSA), the role of repairing the subscapularis has been debated. Our objective was to determine the effect of subscapularis repair following rTSA on postoperative shoulder ranges of motion and patient reported outcome scores (PROs). Methods: A prospective registry was reviewed to establish a cohort of primary rTSA patients with a 135-degree humeral implant, with a minimum of 2 years of follow-up. Variables collected included demographics, subscapularis repair information, diagnosis, glenosphere size, and glenoid lateralization information. Outcomes collected were range of motion measurements, subscapularis strength, and multiple generic and shoulder PROs. Multivariable linear regression models were created to predict these 2-year outcomes. Results: The 143-patient cohort had a mean age of 69 years with 68% of patients undergoing subscapularis repair. After adjustment in the multivariable models, whether the subscapularis was repaired did not significantly predict a 2-year forward elevation, external rotation, internal rotation, subscapularis strength, Western Ontario Osteoarthritis of the Shoulder score, VR-12 scores, Constant Score, or American Shoulder and Elbow Surgeons Shoulder Scores. Increased glenoid lateralization significantly predicted greater internal rotation, higher VR-12 physical score, and higher Constant Score. There were no dislocations in either group. Conclusions: After adjusting for patient and implant factors, subscapularis repair was not associated with a 2-year postoperative range of motion, strength, or any PROs suggesting that repairing the subscapularis may not affect functional outcome. Increased glenoid lateralization through the baseplate and glenosphere independently predicted better internal rotation, VR-12 physical score, and Constant Scores indicating a benefit to lateralization during rTSA.

No difference in range of motion in reverse total shoulder arthroplasty using standard or constrained liners: a matched cohort study.

Background: Prosthetic instability is one of the most common short-term complications following reverse total shoulder arthroplasty (RTSA). Numerous strategies exist to attempt to mitigate this complication, including utilization of constrained polyethylene humeral liners. A concern of constrained humeral liners is that they may come at the expense of restricted rotational range of motion (ROM). The purpose of the present study is to compare range of ROM and patient-reported outcomes (PROs), and satisfaction among matched cohorts using constrained vs. unconstrained liners after RTSA. Methods: A multicenter shoulder arthroplasty registry was retrospectively reviewed to identify patients with two-year clinical follow-up after RTSA with constrained liners used at the surgeon's discretion. All patients had the same inlay humeral prosthesis with a 135° neck shaft angle. This study cohort was matched 1:2 to control patients who underwent RTSA with standard liners based on age, sex, total glenoid-sided lateralization, glenosphere diameter, and surgery performed on the dominant arm. Improvement in PROs and ROM was compared between groups. Results: Twenty-two patients were identified who underwent RTSA with a constrained humeral liner; these were compared to 44 matched patients with standard liners. The groups were found to have no notable differences in demographics, baseline PROs and ROM. At two years postoperatively, both cohorts demonstrated improvements in all PROs without statistically significant differences between the two groups. There were no differences between groups in improvement in any ROM measure, including forward flexion (constrained: 54°, standard: 57°, P = .771), external rotation at the side (constrained: 42°, standard: 41°, P = .906) or internal rotation at 90° of abduction (constrained: 24°, standard: 20°, P = .587). Conclusions: For an inlay humeral prosthesis with a 135° neck shaft angle, utilization of a constrained liner for RTSA demonstrates no significant difference in ROM or PROs compared to a well-matched cohort of patients who underwent RTSA with a standard polyethylene humeral liner. These are reassuring data for using constrained liners when there is intraoperative concern for prosthetic instability.

Arthroscopic Management of Stiffness and Anterior Shoulder Pain Following Reverse Shoulder Arthroplasty.

Arthroscopy following shoulder arthroplasty has primarily been described as a diagnostic tool in the setting of unexplained pain. However, this tool also can be used to potentially manage postoperative stiffness and pain following reverse shoulder arthroplasty. This Technical Note provides a stepwise approach to assessing and addressing limitations in range of motion as well as causes of postoperative impingement following reverse shoulder arthroplasty.

A ratio estimating glenoid bone loss.

Background: Estimating glenoid bone loss when assessing the unstable shoulder can be challenging. The aim of this article was to describe a simple derived ratio to estimate glenoid bone loss. Methods: When the glenoid is damaged and bone is damaged because of instability, the anterior aspect of the glenoid loses its normal curvature and becomes flattened. In geometry, this represents a chord. There are 3 assumptions for the calculations: (1) the lower glenoid is a circle; (2) there is a relationship between the glenoid height and the diameter of the glenoid circle; and (3) the length of the measured bone loss of the glenoid is a chord. Two measurements are required: glenoid height and length of the glenoid defect. The calculations involved in the ratio are reviewed. Results: If the ratio of the length of the bone defect to the glenoid height is 0.5 (otherwise, 50% of the height), the estimated bone loss is 12%. Conclusion: Glenoid bone loss can be estimated by measuring the length of the glenoid and the length of the defect.

A 135° short inlay humeral stem leads to comparable radiographic and clinical outcomes compared with a standard-length stem for reverse shoulder arthroplasty.

Background: Humeral stem length in reverse total shoulder arthroplasty (RTSA) has decreased in recent years in an attempt to preserve more bone and facilitate stem removal in the revision setting. The purpose of this study was to compare the clinical and radiographic outcomes of a short- to standard-length stem RTSA. The authors hypothesized that there would be no difference in radiographic or clinical outcomes at short-term follow-up. Methods: Patients who underwent RTSA using a press-fit standard- or short-length humeral component with a consistent geometry (Univers Revers, or Revers Apex; Arthrex, Inc., Naples, FL, USA) were evaluated in a multicenter retrospective review. The minimum clinical follow-up was 2 years. Immediate postoperative radiographs were used to assess initial alignment and filling ratios. In addition, radiographs at 2 years were evaluated for signs of stress shielding and/or loosening. Clinical outcome scores and range of motion were evaluated at the final follow-up and compared between groups. Results: A total of 220 patients with short-stem RTSA and 357 patients with standard-length stem RTSA were analyzed. There was no difference in baseline function between short- and standard-length stem patients. Patients in the short stem group had higher postoperative American Shoulder and Elbow Surgeons (84.6 vs. 80.8; P = .014) and Western Ontario Osteoarthritis of the Shoulder (86.5 vs. 82.7; P = .025). Patients in the short stem group also had greater postoperative active forward flexion (139° vs. 132°; P = .003) and internal rotation with the arm at 90° of abduction (43° vs. 32°; P < .001) than patients in the standard-length group. Radiographically, there was a higher metaphyseal (P = .049) and diaphyseal (P < .001) fill ratio in the short stem group, although there was no difference in postoperative alignment, radiographic signs of loosening, or revision for loosening between groups (all P > .05). Conclusion: A short inlay stem leads to comparable radiographic findings and revision-free survival compared with a standard-length stem when placed with a press-fit technique for RTSA. Clinical outcomes are also equivalent or slightly improved with a short stem compared with a standard-length stem.