Cemented Versus Uncemented Reverse Shoulder Arthroplasty Treatment of Proximal Humerus Fractures: National Shoulder Arthroplasty Data from Türkiye.

Background: This study evaluated national trends in cemented and uncemented reverse shoulder arthroplasty (RSA) for proximal humerus fractures using a comprehensive national surgical database. This study aimed to compare RSA used in the treatment of proximal humerus fractures with the literature and to determine the country's trend. Methods: A cross-sectional study was conducted using the health records of individuals aged ≥ 18 years who underwent RSA for proximal humerus fractures between 2016 and 2022. Patients were divided into cemented and uncemented groups, and demographic data (age, sex), duration of hospital stay, transfusions, revisions, mortality, and Charlson Comorbidity Index (CCI) scores were analyzed. Results: A total of 618 cemented RSA and 1,364 uncemented RSA procedures were reviewed. Patients who underwent cemented RSA were significantly older than those who had uncemented RSA (p = 0.002). Transfusion rates were higher in the cemented RSA group (p = 0.006). The frequency of revision surgery was 6.1%. Younger age and male sex were associated with revision (p < 0.001). CCI scores were higher among transfused patients than non-transfused patients (p < 0.001). The incidence of cemented RSA was 11.7% and 49% in 2016 and 2022, respectively. Differences were found among hospital types and geographical regions. Conclusions: While cemented RSA has been gaining attention and increased application in recent years for proximal humerus fractures, uncemented RSA still predominates. The choice between these 2 methods is largely influenced by regional and hospital-level factors. The type of RSA and high CCI scores were found to have no significant impact on the risk of surgical revision.

The 100 Most Impactful Articles on Total Shoulder Arthroplasty: An Altmetric Analysis.

Background: To use the top 100 articles pertaining to total shoulder arthroplasty (TSA) to understand the impact that social media platforms have on the dissemination of shoulder research while highlighting bibliometric factors associated with Altmetric Attention Score (AAS) to offer insight into the impact that social media platforms have on the dissemination, attention, and citation of shoulder research publications. Methods: In June 2023, the Altmetric database was searched using the following PubMed MeSH terms: "total shoulder arthroplasty" or "TSA." Articles with the highest AAS were screened to exclude other topics unrelated to TSA. The top 100 articles that met inclusion criteria were used in the final analysis. Bibliometric factors pertaining to each study were collected for further analysis of article characteristics in accordance with prior studies. Results: The Altmetric Database query yielded 1,283 studies. After applying our inclusion criteria, the top 118 articles with the highest AAS were identified. The mean AAS was 29.14 ± 42.35, with a range of 13 to 402. The included articles represented 27 journals, with 70 articles attributed to 2 journals: Journal of Shoulder and Elbow Surgery (JSES; 43%) and the Journal of Bone and Joint Surgery (JBJS; 16%). There was a significant increase in AAS for the presence of a conflict of interest (p = 0.042) and open access status (p < 0.01), but no association between the score and citation rate (p > 0.05). Conclusions: Top articles on TSA, as defined by high AAS, mostly comprise original clinical research performed in the United States or Europe. The presence of a conflict of interest and open access status is associated with an increase in AAS, but there was no association between AAS score and citation rate.

International trends in shoulder replacement: a meta-analysis from 11 public joint registers.

BACKGROUND AND PURPOSE: International variation exists in the types of shoulder replacement used for treatment of specific diseases. Implant choice continues to evolve without high-quality evidence. Our aim was to evaluate trends in incidence rates of shoulder replacement and assess any recent changes in practice between countries by using registry data. METHODS: Patient characteristics, indication and year of surgery, type of replacement, and collection methods of patient-reported outcomes (PROMs) was extracted from 11 public joint registries. Meta-analyses examined use of reverse total shoulder replacement (RTSR) for osteoarthritis, cuff tear arthropathy, and acute fracture; use of anatomical total shoulder replacement (TSR) for osteoarthritis; and use of humeral hemiarthroplasty for fracture. RESULTS: The annual growth rate of shoulder replacements performed is 6-15% (2011-2019). The use of RTSR has almost doubled (93%). RTSR is now universally performed for cuff tear arthropathy (97.3%, 95% confidence interval [CI] 96.0-98.1). Its use for avascular necrosis, trauma, and inflammatory arthropathy is increasing. The use of RTSR was similar (43.1%, CI 30.0-57.2) versus TSR (44.7%, CI 31.1-59.1) for osteoarthritis. The types of PROMs used, collection time points, and response rates lack standardization. COVID-19 had a varying inter-registry impact on incidence rates. CONCLUSION: The incidence of shoulder replacements has grown. Use of RTSR has increased for all disease indications despite limited high-quality evidence driving this change in indications outside of cuff arthropathy. Consequently, less variation is observed in international practice. Existing differences now relate to use of newer implant types and methodology of PROMs collection, which prevents international comparison and outcome analysis.

Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty.

BACKGROUND: Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients. AIMS: The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years. METHODS: A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes. RESULTS: Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed. CONCLUSIONS: There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.

Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting?

BACKGROUND: In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database. METHODS: White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities. RESULTS: A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673). CONCLUSION: Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.

Gender differences among shoulder arthroplasty surgeons: past, present, and future.

BACKGROUND: Reducing differences in the gender representation of shoulder arthroplasty surgeons may help optimize patient care. This work aimed to determine (1) the current gender distribution of surgeons performing shoulder arthroplasty, (2) how gender relates to practice patterns among shoulder arthroplasty surgeons, and (3) how gender distribution has been changing over time. METHODS: The Medicare Provider Utilization and Payment Data for the years 2012-2020 were used to identify orthopedic surgeons performing anatomic and reverse total shoulder arthroplasty (Current Procedural Terminology code 23472). The data set provides self-reported gender, credentials, National Provider Identifier, annual volume of all procedures (based on Current Procedural Terminology codes) that were performed ≥11 times in the calendar year, and location for all included providers. The data set was linked to the Medicare Physician Compare data set using National Provider Identifiers to determine hospital affiliations, year of medical school graduation, and graduating medical school. All included hospitals were queried to determine academic status (affiliated orthopedic residency or fellowship program). The American Shoulder and Elbow Surgeons (ASES) directory was reviewed to determine the gender breakdown of current members. RESULTS: The number of surgeons performing ≥11 shoulder arthroplasties annually increased from 821 (13 women [1.6%]) in 2012 to 1840 (53 women [2.9%], P = .05) in 2019. One female surgeon ranked in the top 100 surgeons by shoulder arthroplasty volume in 2012 and in 2020. Female surgeons graduated more recently from medical school (mean, 2005) compared with male surgeons (mean, 1997; P < .001). About 10% of female surgeons (10.8%, 12 of 111) and male surgeons (9.1%, 229 of 2528) practiced at hospitals with orthopedic residents (P = .50). Female surgeons performing shoulder arthroplasty were less likely than male surgeons to perform total knee arthroplasty (29.4% vs. 54.1%, P < .001) and total hip arthroplasty (12.6% vs. 34.7%, P < .001). There were 86 female members of ASES (6.7%, 86 of 1275), with a significant difference in the proportion of women in differing membership categories (P = .017). DISCUSSION AND CONCLUSION: A diverse cohort of high-volume shoulder replacement surgeons is integral to delivering high-quality shoulder arthroplasty. Currently, the proportion of women performing high-volume shoulder replacement in the United States is small, with little improvement in recent years. However, women performing shoulder arthroplasty are younger and are often involved in academic practices, and the membership of ASES is increasingly female. Continued efforts to promote orthopedics-and to mentor female residents and medical students interested in shoulder surgery-may bring real change to the gender differences among shoulder replacement surgeons over the coming years.

Lateralización y distalización objetiva en prótesis reversa de lateralización glenoidea / Lateralization and distalization in reverse shoulder arthroplasty

Introducción: la artroplastia reversa de hombro (RSA, por su nombre en inglés) con un centro de rotación lateralizado ha demostrado reducir las tasas de notching, restaurar el contorno del hombro y mejorar la rotación externa. La lateralización puede lograrse desde el componente glenoideo o desde el vástago humeral. Boutsadis et al. describieron dos mediciones angulares en radiografías postoperatorias para determinar objetivamente la lateralización y la distalización en la RSA: el ángulo de lateralización del hombro (LSA, por su nombre en inglés) y el ángulo de distalización del hombro (DSA, por su nombre en inglés). Estas mediciones son reproducibles y se correlacionan con los resultados funcionales y la amplitud de movimiento. La prótesis DJO (DJO Surgical, Austin, TX, EE. UU.) presenta una glenosfera con centro de rotación lateralizado, con un ángulo cuello-eje de 135°. Este implante ha dado resultados clínicos satisfactorios en los estudios de seguimiento a medio y largo plazo. Hasta la fecha, no se ha descripto la medición objetiva de los índices de lateralización y su asociación con la amplitud de movimiento postoperatorio mediante LSA y DSA en este tipo de implante. Materiales y métodos: se realizó una revisión retrospectiva de las artroplastias inversas de hombro efectuadas en una única institución por un único cirujano de hombro formado en la especialidad (autor principal) entre enero de 2014 y abril de 2021. Se incluyeron los pacientes que se sometieron a una RSA por artropatía del manguito rotador o por osteoartritis glenohumeral primaria con un implante lateralizado en el lado de la glenoides y un ángulo cuello-eje de 135°. En todos los pacientes se obtuvo una radiografía postoperatoria para evaluar las medidas radiográficas de la LSA y la DSA. Las radiografías fueron revisadas de manera independiente por tres autores y se evaluó la concordancia entre los examinadores. Resultados: un total de treinta y nueve pacientes cumplieron los criterios de inclusión. Su edad media fue de 77.5 años, y la distribución por sexos fue de un 74.3% de mujeres. La mediana final de rotación externa activa fue de 26° y la mediana final de flexión activa hacia adelante fue de 125°. El análisis radiográfico realizado por los tres revisores dio como resultado un ángulo de lateralización con un punto de corte de 93° (73° ­ 118°) y un ángulo de distalización con un punto de corte de 40° (15° ­ 65°). El coeficiente de correlación entre los tres evaluadores para el ángulo de lateralización fue de 0.59 y para el ángulo de distalización fue de 0.79.Discusión: el principal hallazgo de esta investigación es que un implante RSA con lateralización glenoidea proporciona una lateralización objetiva con LSA de 93° y una distalización con DSA de 40°. Estos resultados cumplen el rango ideal para la restauración óptima del movimiento. Las mediciones radiográficas postoperatorias de la lateralización y la distalización para este tipo de implante son reproducibles entre diferentes observadores. Nivel de Evidencia: IV

Introduction: reverse shoulder arthroplasty (RSA) with a lateralized center of rotation has proven to reduce notching rates, restore shoulder contour and improve external rotation. Lateralization can be achieved from the glenoid component or from the humeral stem. Boutsadis et al. described two angular measurements on postoperative radiographs to objectively determine lateralization and distalization in RSA: the lateralization shoulder angle (LSA) and the distalization shoulder angle (DSA). These measurements are reproducible, and they correlate with functional outcomes and range of motion. The DJO prosthesis (DJO Surgical, Austin, TX, USA) features a lateralized center of rotation glenosphere, with a neck-shaft angle of 135°. This implant has yielded satisfactory clinical outcomes in the medium, and long term follow-up studies. To date, objective measurement of lateralization rates and their association postoperative range of motion using LSA and DSA has not been described in this type of implant.Materials and methods: a retrospective review was performed of reverse shoulder arthroplasties performed in a single institution by a single fellowship trained shoulder surgeon (senior author) between January 2014 and April 2021. Patients were included if they underwent a RSA for rotator cuff arthropathy or primary glenohumeral osteoarthritis with a glenoid-side lateralized implant and a 135° neck-shaft angle. In all patients, a postoperative X-ray was obtained in order to evaluate the radiographic measurements of LSA and DSA. Radiographs were independently reviewed by three authors and the agreement between the examiners was assessed.Results: a total of thirty-nine patients met the inclusion criteria. Their average age was 77.5 years, the sex distribution was 74.3% female patients. Final median active external rotation was 26° and final median active forward flexion was 125°. The radiographic analysis performed by the three reviewers resulted in a lateralization angle with a cut-off point of 93° (73° ­ 118°) and a distalization angle with a cut-off point of 40° (15° ­ 65°). The correlation coefficient between the three evaluators for the lateralization angle was 0.59and for the distalization angle was 0.79.Discussion: the main finding of this research is that an RSA implant with glenoid-side lateralization provides an objective lateralization with LSA of 93° and a distalization with DSA of 40°. These results met the ideal range for optimal restoration of motion. Postoperative radiographic lateralization and distalization measurements for this type of implant are reproducible between different observers. Level of Evidence: IV

Total Shoulder Arthroplasty Is Cost-Effective Compared with Hemiarthroplasty: A Real-World Economic Evaluation.

BACKGROUND: Although outcome studies generally demonstrate the superiority of a total shoulder arthroplasty (TSA) over a hemiarthroplasty (HA), comparative cost-effectiveness has not been well studied. From a publicly funded health-care system's perspective, this study compared the costs and quality-adjusted life-years (QALYs) in patients who underwent TSA with those in patients who underwent HA. METHODS: We conducted a cost-utility analysis using a Markov model to simulate the costs and QALYs for patients undergoing either TSA or HA over a lifetime horizon to account for costs and medically important events over the patient lifetime. Subgroup analyses by age groups (≤50 or >50 years) were performed. A series of sensitivity analyses were performed to assess robustness of study findings. The results were presented in 2019 U.S. dollars. RESULTS: TSA was dominant as it was less costly ($115,785 compared with $118,501) and more effective (10.21 compared with 8.47 QALYs) than HA over a lifetime horizon. Changes to health utility values after TSA and HA had the largest impact on the cost-effectiveness findings. At a willingness-to-pay (WTP) threshold of $50,000 per QALY gained, HA was not found to be cost-effective. The probability that TSA was cost-effective was 100%. CONCLUSIONS: Based on a WTP of $50,000 per QALY gained, from the perspective of Canada's publicly funded health-care system, TSA was found to be cost-effective in all patients, including those ≤50 years of age, compared with HA. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff: A Concise 5-Year Follow-up of a Previous Report.

LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The rate of 2nd revision for shoulder arthroplasty as analyzed by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).

Background and purpose - The increase in shoulder arthroplasty may lead to a burden of revision surgery. This study compared the rate of (2nd) revision following aseptic 1st revision shoulder arthroplasty, considering the type of primary, and the class and type of the revision.Patients and methods - All aseptic 1st revisions of primary total reverse shoulder arthroplasty (rTSA group) and of primary total stemmed and stemless total shoulder arthroplasty (non-rTSA group) procedures reported to our national registry between April 2004 to December 2018 were included. The rate of 2nd revision was determined using Kaplan-Meier estimates and comparisons were made using Cox proportional hazards models.Results - There was an increased risk of 2nd revision in the 1st month only for the rTSA group (n = 700) compared with the non-rTSA group (n = 991); hazard ratio (HR) = 4.8 (95% CI 2.2-9). The cumulative percentage of 2nd revisions (CPR) was 24% in the rTSA group and 20% in the non-rTSA group at 8 years. There was an increased risk of 2nd revision for the type (cup vs. head) HR = 2.2 (CI 1.2-4.2), but not class of revision for the rTSA group. Minor (> 3 months) vs. major class revision, and humeral revision vs. all other revision types were second revision risk factors for the non-rTSA group.Interpretation - The CPR of revision shoulder arthroplasty was > 20% at 8 years and was influenced by the type of primary, the class, and the type of revision. The most common reasons for 2nd revision were instability/dislocation, loosening, and infection.

Identifying surgeon and institutional drivers of cost in total shoulder arthroplasty: a multicenter study.

BACKGROUND: Despite rapid increases in the demand for total shoulder arthroplasty, data describing cost trends are scarce. We aim to (1) describe variation in the cost of shoulder arthroplasty performed by different surgeons at multiple hospitals and (2) determine the driving factors of such variation. METHODS: A standardized, highly accurate cost accounting method, time-driven activity-based costing, was used to determine the cost of 1571 shoulder arthroplasties performed by 12 surgeons at 4 high-volume institutions between 2016 and 2018. Costs were broken down into supply costs (including implant price and consumables) and personnel costs, including physician fees. Cost parameters were compared with total cost for surgical episodes and case volume. RESULTS: Across 4 institutions and 12 surgeons, surgeon volume and hospital volume did not correlate with episode-of-care cost. Average cost per case of each institution varied by factors of 1.6 (P = .47) and 1.7 (P = .06) for anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA), respectively. Implant (56% and 62%, respectively) and personnel costs from check-in through the operating room (21% and 17%, respectively) represented the highest percentages of cost and highly correlated with the cost of the episode of care for TSA and RSA. CONCLUSIONS: Variation in episode-of-care total costs for both TSA and RSA had no association with hospital or surgeon case volume at 4 high-volume institutions but was driven primarily by variation in implant and personnel costs through the operating room. This analysis does not address medium- or long-term costs.

Administration of tranexamic acid during total shoulder arthroplasty is not associated with increased risk of complications in patients with a history of thrombotic events.

INTRODUCTION: Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion risk in various orthopedic surgeries including shoulder arthroplasty. However, concerns still exist regarding its use in patients with a history of thrombotic events. Using national claims data, we aimed to study the safety of TXA administration in shoulder arthroplasty patients with a history of thrombotic events. METHODS: We used retrospective national claims data (Premier Healthcare) on 71,174 patients who underwent a total or reverse shoulder arthroplasty between 2010 and 2016. TXA use was evaluated specifically within a subgroup of patients with a history of thrombotic events such as myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke. Studied outcomes were blood transfusion need, complications (including acute renal failure, new onset myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke), and cost and length of hospitalization. Mixed-effects models measured the association between TXA use and outcomes, separately in patients with and without a history of thrombotic events. Odds ratios (OR) or percent change for continuous outcomes with 95% confidence intervals (CI) were reported. RESULTS: Overall, TXA was used in 13.7% (n = 9735) of patients, whereas 10.5% (n = 7475) of patients had a history of a thrombotic event. After adjustment for relevant covariates, TXA use (compared with no TXA use) in patients without a history of thrombotic events was associated with decreased odds of blood transfusions (OR, 0.48; CI, 0.24-0.98; P = .0444), whereas no increased odds for complications were observed (OR, 0.83; CI, 0.40-1.76; P = .6354). Similar results were observed in patients with a history of thrombotic events. Moreover, in this subgroup, TXA use was associated with a slight reduction in hospitalization cost (-8.9% CI: -13.1%; -4.6%; P < .0001; group median $18,830). CONCLUSIONS: Among shoulder arthroplasty patients, TXA use was not associated with increased complication odds, independent of a history of thrombotic events. These findings are in support of wider TXA use.

Comparison of complication types and rates associated with anatomic and reverse total shoulder arthroplasty.

BACKGROUND: Complications after anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty can be devastating to a patient's quality of life and require revisions that are costly to both the patient and the health care system. The purpose of this study is to determine the types, incidence, and timing of complications following aTSA and rTSA using an international database of patients who received a single-platform total shoulder arthroplasty system, in order to quantify the types of failure modes and the differences that occur between aTSA and rTSA. METHODS: A total of 2224 aTSA (male-female, 1090:1134) and 4158 rTSA (male-female, 1478:2680) patients were enrolled in an international database of primary shoulder arthroplasty performed by 40 different surgeons in the United States and Europe. Adverse events and revisions reported for these 6382 patients were analyzed to identify the most common failure modes associated for both aTSA and rTSA. RESULTS: For the 2224 aTSA patients, 239 adverse events were reported for a complication rate of 10.7% and 124 revisions for a revision rate of 5.6%. The top 3 complications for aTSA were rotator cuff tear/subscapularis failure (n = 69; complication rate = 3.1%, revision rate = 1.9%), aseptic glenoid loosening (n = 55; complication rate = 2.5%, revision rate = 1.9%), and infection (n = 28; complication rate = 1.3%, revision rate = 0.8%). For the 4158 rTSA patients, 372 adverse events were reported for a complication rate of 8.9% and 104 revisions for a revision rate of 2.5%. The top 3 complications for rTSA were acromial/scapular fracture/pain (n = 102; complication rate = 2.5%, revision rate = 0.0%), instability (n = 60; complication rate = 1.4%, revision rate = 1.0%), and pain (n = 49; complication rate = 1.2%, revision rate = 0.2%). CONCLUSIONS: This large database analysis quantified complication and revision rates for aTSA and rTSA. We found aTSA and rTSA complication rates of 10.7% and 8.9%, respectively; with revision surgery rates of 5.6% and 2.5%, respectively. The 2 most common complications for each prosthesis type (aTSA: subscapularis/rotator cuff tears, aseptic glenoid loosening; rTSA: acromial/scapular fractures, instability) were unique to each device. The rate of infection was similar for both. Future prosthesis and technique development should work to mitigate these common complication types in order to reduce their rate of occurrence.

Predictors of Long-term Opioid Use After Elective Primary Total Shoulder Arthroplasty.

Opioids are prescribed routinely for pain after total shoulder arthroplasty (TSA). This study was designed to characterize opioid use after elective primary TSA and identify predictors of long-term postoperative opioid use. The authors used the MarketScan administrative claims database to identify 5676 adults who underwent elective primary TSA between 2010 and 2015 and had 1 year or more of continuous insurance enrollment, including prescription drug coverage, postoperatively. Long-term postoperative opioid use was defined as filling prescriptions totaling a 120-day or greater supply during the 3- to 12-month postoperative period. The authors performed univariate regression analysis with age, sex, US region, anatomic or reverse TSA, anxiety, chronic obstructive pulmonary disease, congestive heart failure, depression, diabetes, history of drug abuse, hypertension, obesity, osteoporosis, history of myocardial infarction, and current tobacco use. Variables that were significant at P<.05 were included in multivariate logistic regression. Overall, 16% of patients had long-term postoperative opioid use, which was strongly predicted by the multivariate model (area under the curve, 0.77; P<.001). The strongest predictors in the multivariate analysis were preoperative opioid use (odds ratio [OR], 4.7; 95% CI, 4.0-5.5), history of drug abuse (OR, 2.5; 95% CI, 1.3-4.9), depression (OR, 1.9; 95% CI, 1.6-2.3), anxiety (OR, 1.4; 95% CI, 1.2-1.7), surgery performed in the Western United States (OR, 1.8; 95% CI, 1.3-2.4), and reverse TSA (OR, 1.5; 95% CI, 1.2-1.8). Most patients do not have long-term opioid use after elective primary TSA. Strong predictors of long-term postoperative opioid use are preoperative opioid use, history of drug abuse, depression, anxiety, reverse TSA, and surgery performed in the Western United States. [Orthopedics. 2021;44(1):58-63.].

The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty.

BACKGROUND: There remains a paucity of epidemiologic data from recent years on the incidence of shoulder arthroplasty. We aimed to examine the recent trends and predict future projections of hemiarthroplasty (HA), anatomic (aTSA), and reverse shoulder arthroplasty (RSA), as well as compare these predictions to those for total hip (THA) and knee arthroplasty (TKA). METHODS: The National Inpatient Sample was queried from 2011 to 2017 for HA, aTSA, and RSA, as well as TKA and THA. Linear and Poisson regression was performed to project annual procedural incidence and volume to the year 2025. RESULTS: Between 2011 and 2017, the number of primary shoulder arthroplasties increased by 103.7%. In particular, RSA increased by 191.3%, with 63,845 RSAs performed in 2017. All projection models demonstrated significant increases in shoulder arthroplasty volume and incidence from 2017 to 2025. By 2025, the linear model predicts that shoulder arthroplasty volume will increase by 67.2% to 174,810 procedures whereas the Poisson model predicts a 235.2% increase, to 350,558 procedures by 2025. These growth rate projections outpace those of THA and TKA. CONCLUSIONS: The number of shoulder arthroplasties has been increasing in recent years, largely because of the exponential increases in RSA. The overall incidence is increasing at a greater rate than TKA or THA, with projections continuing to rise over the next decade. These data and projections can be used by policy makers and hospitals to drive initiatives aimed at meeting these projected future demands.

The use of tobacco is a modifiable risk factor for poor outcomes and readmissions after shoulder arthroplasty.

AIMS: The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA. METHODS: Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors. RESULTS: A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively. CONCLUSION: Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA. Cite this article: Bone Joint J 2020;102-B(11):1549-1554.

The value of artificial neural networks for predicting length of stay, discharge disposition, and inpatient costs after anatomic and reverse shoulder arthroplasty.

HYPOTHESIS/PURPOSE: The objective is to develop and validate an artificial intelligence model, specifically an artificial neural network (ANN), to predict length of stay (LOS), discharge disposition, and inpatient charges for primary anatomic total (aTSA), reverse total (rTSA), and hemi- (HSA) shoulder arthroplasty to establish internal validity in predicting patient-specific value metrics. METHODS: Using data from the National Inpatient Sample between 2003 and 2014, 4 different ANN models to predict LOS, discharge disposition, and inpatient costs using 39 preoperative variables were developed based on diagnosis and arthroplasty type: primary chronic/degenerative aTSA, primary chronic/degenerative rTSA, primary traumatic/acute rTSA, and primary acute/traumatic HSA. Models were also combined into diagnosis type only. Outcome metrics included accuracy and area under the curve (AUC) for a receiver operating characteristic curve. RESULTS: A total of 111,147 patients undergoing primary shoulder replacement were included. The machine learning algorithm predicting the overall chronic/degenerative conditions model (aTSA, rTSA) achieved accuracies of 76.5%, 91.8%, and 73.1% for total cost, LOS, and disposition, respectively; AUCs were 0.75, 0.89, and 0.77 for total cost, LOS, and disposition, respectively. The overall acute/traumatic conditions model (rTSA, HSA) had accuracies of 70.3%, 79.1%, and 72.0% and AUCs of 0.72, 0.78, and 0.79 for total cost, LOS, and discharge disposition, respectively. CONCLUSION: Our ANN demonstrated fair to good accuracy and reliability for predicting inpatient cost, LOS, and discharge disposition in shoulder arthroplasty for both chronic/degenerative and acute/traumatic conditions. Machine learning has the potential to preoperatively predict costs, LOS, and disposition using patient-specific data for expectation management between health care providers, patients, and payers.

Cost analysis and complication profile of primary shoulder arthroplasty at a high-volume institution.

BACKGROUND: Paralleling the increased utilization of shoulder arthroplasty, bundled-payment reimbursement is becoming increasingly common. An understanding of the costs of each element of care and detailed information on the frequency of and reasons for readmission and reoperation are keys to developing bundled-payment initiatives. The purpose of this study was to perform a comprehensive analysis of complications, readmission rates, and costs of primary shoulder arthroplasty at a high-volume institution. METHODS: Between 2012 and 2016, 2 shoulder surgeons from a single institution performed 1794 consecutive primary shoulder arthroplasties: 636 anatomic total shoulder arthroplasties (TSAs), 1081 reverse shoulder arthroplasties (RSAs), and 77 hemiarthroplasties. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation. RESULTS: The 90-day complication, reoperation, and readmission rates were 2.3%, 0.6%, and 1.8%, respectively. The 90-day readmission risk was higher among patients with an American Society of Anesthesiologists score of 3 or greater; a 1-unit increase in the American Society of Anesthesiologists score was associated with a $429 increase in index cost. Of the hospital readmissions, 10 were directly related to the index arthroplasty whereas 21 were not. The median standardized costs were as follows: preoperative evaluation, $481; index surgical hospitalization, $15,758; and postoperative care, $183. The median standardized costs for index surgical hospitalization were different for each procedure: TSA, $14,010; RSA, $16,741; and hemiarthroplasty, $12,709. CONCLUSION: In this study, primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. The median standardized costs inclusive of preoperative workup and 90-day postoperative recovery were $14,675 and $17,407 for TSA and RSA, respectively.

Therapeutic postoperative anticoagulation is a risk factor for wound complications, infection, and revision after shoulder arthroplasty.

BACKGROUND: The purpose of the present study was to examine the relationship between postoperative therapeutic anticoagulation, wound complications, infection, and revision. METHODS: Using a national insurance database from 2007 to 2016, patients who underwent shoulder arthroplasty with an indication for postoperative therapeutic anticoagulation in the case of atrial fibrillation or acute postoperative venous thromboembolism were identified. Those with a prescription for a therapeutic anticoagulant within 2 weeks of surgery were identified and compared with controls without postoperative therapeutic anticoagulant prescriptions. Wound complications and postoperative infection at 3 and 6 months, and revision shoulder arthroplasty at 6 months and all time points were then compared in the database using a multivariable logistic regression analysis. RESULTS: A total of 17,272 patients were included, including 684 patients who received therapeutic anticoagulation and 16,588 controls. Patients receiving therapeutic anticoagulation experienced increased wound complications at 3 months (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.0-4.6, P < .0001) and 6 months (OR 2.5, 95% CI 1.7-3.8, P < .0001). Patients receiving therapeutic anticoagulation also experienced increased rates of wound infection at 3 months (OR 1.5, 95% CI 1.1-2.0, P = .007) and 6 months (OR 1.8, 95% CI 1.4-2.3, P < .0001). Finally, patients receiving therapeutic anticoagulation experienced increased rates of revision surgery at 6 months (OR 1.8, 95% CI 1.3-2.5, P = .0003) and within 9 years (OR 1.5, 95% CI 1.1-2.0, P = .007). CONCLUSIONS: Wound complications and revision rates in patients undergoing shoulder arthroplasty who require postoperative therapeutic anticoagulation are significantly elevated compared with controls.

Lower operating volume in shoulder arthroplasty is associated with increased revision rates in the early postoperative period: long-term analysis from the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: Improved short-term outcomes have been demonstrated with higher surgical volume in shoulder arthroplasty. There is however, little data regarding long-term outcomes. METHOD: Revision data from the Australian Orthopaedic Association National Joint Replacement Registry from 2004-2017 was analyzed according to 3 selected surgeon volume thresholds: <10, 10-20, and >20 shoulder arthroplasty cases per surgeon, per year. RESULTS: There was a significantly higher rate of revision for stemmed total shoulder arthroplasty (TSA) for osteoarthritis (OA) for the <10/yr compared with the >20/yr group for the first 1.5 years only (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.08-1.71, P = .009). For reverse total shoulder arthroplasty (rTSA) performed for OA, there was a higher revision rate for the <10/yr compared with the >20/yr group for the first 3 months only (HR 2.58, 95% CI 1.67-3.97, P < .001). In rTSA for cuff arthropathy, there was a significantly higher rate of revision for the <10/yr compared with the >20/yr group throughout the follow-up period (HR 1.66, 95% CI 1.21-2.28, P = .001). There was no significant difference for the primary diagnosis of fracture. CONCLUSION: Lower surgical volume was associated with higher all-cause revision rates in the early postoperative period in TSA and rTSA for OA and throughout the follow-up period in rTSA for cuff arthropathy. Despite increases in the volume of shoulder arthroplasties performed in recent years, more than 78% of surgeons undertake fewer than 10 procedures per year.