Predictors of dislocations after reverse shoulder arthroplasty: a study by the ASES complications of RSA multicenter research group.

BACKGROUND: Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants. METHODS: A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA. RESULTS: We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001). CONCLUSION: The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA.

Risk factors of acromial and scapular spine stress fractures differ by indication: a study by the ASES Complications of Reverse Shoulder Arthroplasty Multicenter Research Group.

BACKGROUND: Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status. METHODS: Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis. RESULTS: Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort. CONCLUSION: Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons.

Arthroscopic scapulothoracic bursectomy with and without superomedial angle scapuloplasty: a comparison of patient-reported outcomes.

BACKGROUND: Operative treatment of scapulothoracic bursitis most commonly comprises arthroscopic scapulothoracic bursectomy with or without partial superomedial angle scapuloplasty. There is currently no consensus regarding whether or when scapuloplasty should be performed. Prior studies are limited to small case series, and optimal surgical indications are not yet established. The purposes of this study were (1) to retrospectively review patient-reported outcomes of arthroscopic treatment of scapulothoracic bursitis and (2) to compare outcomes between scapulothoracic bursectomy alone and bursectomy with scapuloplasty. We hypothesized that bursectomy with scapuloplasty would provide superior pain relief and functional improvement. MATERIALS AND METHODS: All cases of scapulothoracic débridement with or without scapuloplasty completed at a single academic center from 2007 through August 2020 were reviewed. Patient demographic characteristics, symptomatology data, physical examination findings, and corticosteroid injection response data were collected from the electronic medical record. Visual analog scale pain, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Single Assessment Numeric Evaluation scores were collected. Comparisons between the group undergoing bursectomy alone and the group undergoing bursectomy with scapuloplasty were made using the Student t test for continuous variables and the Fisher exact test for categorical variables. RESULTS: Thirty patients underwent scapulothoracic bursectomy alone, and 38 patients underwent bursectomy with scapuloplasty. Final follow-up data were available for 56 of 68 cases (82%). Final postoperative visual analog scale pain scores (3.4 ± 2.2 and 2.8 ± 2.2, respectively; P = .351), American Shoulder and Elbow Surgeons scores (75.8 ± 17.7 and 76.5 ± 22.5, respectively; P = .895), and Simple Shoulder Test scores (8.8 ± 2.3 and 9.5 ± 2.8, respectively; P = .340) were similar between the bursectomy-alone and bursectomy-with-scapuloplasty groups. CONCLUSION: Both arthroscopic scapulothoracic bursectomy alone and bursectomy with scapuloplasty are effective treatments for scapulothoracic bursitis. Operative time is shorter without scapuloplasty. In this retrospective series, these procedures showed similar outcomes regarding shoulder function, pain, surgical complications, and rates of subsequent shoulder surgery. Further studies with a focus on 3-dimensional scapular morphology may help optimize patient selection for each of these procedures.

Prospective Evaluation of Pain Flares and Time Until Pain Relief Following Musculoskeletal Corticosteroid Injections.

BACKGROUND: Corticosteroid injections are used ubiquitously within musculoskeletal medicine. One of the most common side effects is a postinjection pain flare, though little is known regarding this phenomenon. HYPOTHESIS: Some risk factors are related to postinjection pain flare following an ultrasound-guided corticosteroid injection. STUDY DESIGN: Prospective clinical research study. LEVEL OF EVIDENCE: Level 2. METHODS: Patients undergoing ultrasound-guided corticosteroid injections in an academic orthopaedic and sports medicine clinic were approached to participate. Patients completed a survey immediately following their injection and again 2 weeks later, asking them about their pain and side effects. A postinjection pain flare was defined as an increase in pain, as defined by the patient. RESULTS: A total of 140 patients completed the entirety of the study, with 29 (20.7%) patients reporting a flare of pain. There was a significant effect of younger age on the development of a pain flare after the injection, estimated as 5.5% decreased odds of developing a flare per year of age (P < 0.01). Gender, injection location, body mass index (BMI), preinjection pain, and corticosteroid type had no contributing effect. When patients obtained relief following the corticosteroid injection, 60.4% had improved pain within 3 days, whereas over 93.7% obtained relief within a week. CONCLUSION: Pain flares seem to affect approximately 1 in 5 patients. With increasing age, the likelihood of postinjection pain flare becomes less likely. Sex, injection location, BMI, preinjection pain, and corticosteroid type do not seem to significantly relate to an increase in pain following injection. CLINICAL RELEVANCE: Corticosteroid injections are common procedures in the orthopaedic and sports medicine settings. Younger patients can be counseled on the higher likelihood of a pain flare following a corticosteroid injection.

Is ultrasound-guided hip aspiration more successful than fluoroscopic-guided aspiration in diagnosing prosthetic joint infection?

Introduction: aspiration of total hip arthroplasty (THA) is commonly performed to assist in the diagnosis of prosthetic joint infection (PJI). This study aimed to determine whether fluoroscopic- or ultrasound- guided hip aspiration differs in the ability to acquire synovial fluid and in the accuracy of diagnosing infection. Methods: all THA aspirations performed between 2014 and 2021 at our institution were retrospectively identified. Aspirations were classified as successful or dry. If successful, the volume of fluid obtained was recorded. The sensitivity and specificity of hip aspiration in identifying PJI were calculated with four methods: (1) culture results excluding saline lavage, (2) culture results including saline lavage, (3) 2018 Musculoskeletal Infection Society (MSIS) International Consensus Meeting (ICM) criteria, and (4) 2021 European Bone and Joint Infection Society (EBJIS) criteria. Analyses were performed using Student's t test or Wilcoxon rank sum for continuous variables and chi-squared or Fisher's exact test for categorical variables. Results: 290 aspirations were included (155 fluoroscopic-guided and 135 ultrasound-guided). Success of aspiration (>0.5 mL) was more common in the ultrasound cohort (69 %) than fluoroscopy (53 %) (p<0.0055). When successful, more volume was obtained in the ultrasound cohort (mean 13.1 mL vs. 10.0 mL; p=0.0002). Ultrasound-guided aspiration was more sensitive than fluoroscopy in diagnosing PJI using culture results excluding saline lavage (85 % vs. 73 %; p=0.03), culture results including saline lavage (85 % vs. 69 %; p=0.001), 2018 MSIS-ICM criteria (77 % vs. 52 %; p=0.02), and 2021 EBJIS criteria (87 % vs. 65 %; p=0.02). Ultrasound-guided aspiration was more specific than fluoroscopy in diagnosing PJI using 2021 EBJIS criteria (100 % vs. 96 %; p=0.001). Conclusions: ultrasound-guided aspiration is more frequently successful and yields more fluid than fluoroscopic-guided aspiration of THA. Ultrasound-guided aspiration is more sensitive in diagnosing PJI than fluoroscopy using culture data, 2018 MSIS-ICM criteria, and 2021 EBJIS criteria.

Revision Reverse Total Shoulder Arthroplasty With Pectoralis Major Transfer for Anterior Deltoid Deficiency: A Case Report.

CASE: A 70-year-old male patient presented with anterior deltoid weakness from Parsonage-Turner neuropathy status post failed nerve transfer and a failed total shoulder arthroplasty with pseudoparalysis. The patient underwent revision to a reverse total shoulder arthroplasty with concomitant pectoralis major transfer to substitute for the anterior deltoid. An excellent functional result was attained as early as 6 weeks after surgery. CONCLUSION: Pectoralis major transfer can be an effective treatment option for isolated anterior deltoid insufficiency, even in the setting of a reverse total shoulder arthroplasty.

Significant Factors of High Performance Outcomes for Tibial Plafond Fractures.

BACKGROUND: Limited research exists about high performance postsurgical tibial plafond fractures. This study aimed to identify aspects of the plafond fracture injury and care associated with "high performance" based on Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) scores. METHODS: Tibial plafond fracture patients with minimum 12-month follow-up treated at a level 1 trauma center from 2006 to 2019 were categorized into high (top 25%) vs average-low (AL) (bottom 75%) performers based on PROMIS PF scores. Demographics and fracture characteristics of high and AL performers were compared. Variables with a P value less than .1 were used in stepwise logistic regressions. RESULTS: The final cohort of 198 patients was divided into high (n=51) and AL (n=147) performers based on PF scores. The mean PF scores for the high and AL groups were 58 (SD=5.3) and 41.9 (SD=6.5), respectively. The mean PROMIS Pain Interference scores for the high performers and AL were 43.3 (SD=4.9) and 56.8 (SD=8.6) (P < .001), respectively. FAAM activities of daily living (high 95.4 [SD=5.5] vs AL 70.4 [SD=19.8], P < .001) and FAAM sports (high 76.8 [SD=21.3] vs AL 27.3 [SD=28.9], P < .001) subscale scores were significantly greater in the high-performing group. Sex, age, marital status, and diabetes were nonsignificant factors in univariate analysis. Significant demographic factors associated with high performance from univariate analysis were Caucasian race, private insurance, no tobacco use, lower body mass index (BMI), and mechanism of injury. Patients with fracture characteristics of OTA 43C (complete articular) fractures, bone loss, open fractures, or nonexcellent reduction were significantly less likely to be high performers. Additionally, less than excellent reductions were more common in more complex fracture patterns. Multivariable regression modeling showed that higher BMI, OTA/AO 43-C (complete articular) fracture classification, and open fracture were significant independent risk factors for reducing likelihood of high performance. CONCLUSION: Significant independent factors associated with high performance after tibial plafond fracture are lower BMI, closed fracture, and OTA/AO 43-B (partial articular) fracture.

Syndesmotic Injury in Tibial Plafond Fractures Is Associated With Worse Patient Outcomes.

OBJECTIVES: To present long-term patient-reported outcomes of tibial plafond fractures with and without concomitant ankle syndesmotic injury. DESIGN: Retrospective cohort study. SETTING: Academic Level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred ninety-seven patients with tibial plafond fractures (OTA/AO 43-B and 43-C) treated with definitive surgical fixation were contacted by telephone or email to obtain patient-reported outcome scores at a minimum follow-up of 1 year. Of those contacted, 148 (75%) had an intact syndesmosis, whereas 49 (25%) experienced a syndesmotic injury. INTERVENTION: The intervention involved open reduction internal fixation of the tibial plafond with syndesmosis repair when indicated. MAIN OUTCOME MEASUREMENT: The main outcome measurement included patient-reported ankle pain and function using Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and physical function (PF). RESULTS: The cohort including patients with syndesmotic injury had significantly more open fractures (syndesmotic injury = 39%, no syndesmotic injury = 16%, P = 0.001), higher rates of end-stage reconstruction (syndesmotic injury = 27%, no syndesmotic injury = 10%, P = 0.004), and worse PROMIS PF (syndesmotic injury = 42.5 [SD = 8.0], no syndesmotic injury = 47.1 [SD = 9.6], P = 0.045) scores at final follow-up when compared with the cohort comprising patients with no syndesmotic injury. Patients with syndesmotic injury trended toward higher rates of postoperative infection, but this association was not statistically significant. There was no difference between the groups in nonunion or PROMIS pain interference scores. CONCLUSION: Patients with a tibial plafond fracture and concomitant syndesmotic injury had significantly worse PROMIS PF scores, more end-stage ankle reconstructions, and more open fractures. Syndesmotic injury in the setting of tibial plafond fractures portends worse patient outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Anesthetic Relief Correspond to Future Pain Relief?: A Prospective Trial Examining Future Pain Relief for Ultrasound-Guided Corticosteroid-Anesthetic Injections.

OBJECTIVES: The aim of the study was to prospectively evaluate the association between immediate pain relief from injections of local anesthetic with corticosteroid and subsequent pain relief up to 3 mos. The secondary aim was to examine the time until subjective pain relief after these injections. DESIGN: This was a single-center, prospective study of patients undergoing ultrasound-guided corticosteroid injections for musculoskeletal pain. Subjects completed follow-up surveys at 2 wks, 1 mo, and 3 mos postinjections. χ 2 tests and sensitivity analysis were used to examine the primary outcome, at least 50% relief from the injection. Regression modeling examined the effects of demographic and injection-related variables on outcome measures. RESULTS: A total of 132 patients were enrolled (55% female, mean age 52 yrs). Response rates were 87.1% at 2 wks and 77.2% at 3 mos. The positive likelihood ratios from 50% initial pain relief ranged from 1.22 to 1.29 at the three time points, whereas the negative likelihood ratios ranged from 0.54 to 0.63. More than 75% of participants reported subjective pain relief by day 4 after injection. CONCLUSIONS: The predictive value of immediate pain relief for subsequent longer-term pain relief from corticosteroid-anesthetic injections is not particularly high. Most patients will obtain pain relief within 4 days of a corticosteroid injection.

Acromial and glenoid morphology in glenohumeral osteoarthritis: a three-dimensional analysis.

BACKGROUND: The purpose of this study was to determine the association between glenohumeral osteoarthritis (GHOA) and three-dimensional acromial and glenoid morphology. METHODS: In this retrospective study, we compared computed tomographic studies of three groups of scapulae: normal healthy, mild GHOA (Samilson-Prieto grade 1), and severe GHOA (Samilson-Prieto grade 3). All scans were segmented to create three-dimensional reconstructions. From these models, critical shoulder angle and acromial offset were measured, as normalized to scapular height. The coronal plane inclination of the glenoid was measured using a glenoid sphere-fit method. Reliability was confirmed via intraclass correlation coefficients > 0.75. RESULTS: Eighty scapulae were included: 30 normal, 20 mild GHOA, and 30 severe GHOA. There were no differences in acromial offset between the normal group and either the mild-GHOA group or the severe-GHOA group. The severe-GHOA group had a smaller critical shoulder angle than either the normal (30 ± 5° vs. 34 ± 4°, P = .003) or mild-GHOA groups (34 ± 4°, P = .020), but the normal and mild-GHOA groups did not differ (P = .965). The severe-GHOA group had more inferiorly inclined glenoids than either the normal (7 ± 6° vs. 12 ± 5°, P = .002) or mild-GHOA groups (14 ± 5°, P ≤ .001), but the normal and mild-GHOA groups did not differ (P = .281). CONCLUSION: Normal and severe-GHOA shoulders differ in critical shoulder angle and glenoid inclination but not acromial offset. The lack of a difference in critical shoulder angle or inferior inclination between mild-GHOA and normal groups calls into question whether inclination and critical shoulder angle differences predate severe GHOA.