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.

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.].

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.

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.

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.

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.

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.

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.

Use and Cost of Reverse Shoulder Arthroplasty Versus Hemiarthroplasty for Acute Proximal Humerus Fractures.

Although reverse total shoulder arthroplasty (RTSA) may outperform hemiarthroplasty (HSA) for acute proximal humerus fractures (PHF), both the RTSA implant and the procedure are more expensive. The goal of this study was to compare the use and longitudinal cost of care for RTSA vs HSA for the treatment of PHF. Patients were selected from a private payer database with a surgical date between 2010 and 2015. The International Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), codes were used to identify patients who underwent RTSA and HSA for PHF. The 1-year cost follow-up was guaranteed. During the study period, a total of 1038 patients underwent RTSA and 1046 patients underwent HSA for the treatment of PHF. A total of 601 patients who underwent RTSA and 431 patients who underwent HSA with at least 1 year of follow-up were matched by age and sex. The average Charlson Comorbidity Index for the RTSA and HSA groups was 4, indicating similar health status. From 2010 to 2015, the use of RTSA increased linearly (R2=0.986), whereas the use of HSA decreased linearly (R2=0.796). The average index admission cost was higher for RTSA than for HSA ($15,263 vs $14,356, respectively; mean difference [MD], $907; 95% confidence interval [CI], $58-$1760; P=.04). At 1 year postoperatively, however, no statistically significant difference was noted in cost (P=.535). The 1-year physical and occupational therapy cost per patient was higher after HSA than after RTSA (MD, $723; CI, $718-$728; P<.001), but no difference was noted in discharge disposition or 1-year revision or readmission rates. The results of this study suggest that despite the higher initial cost of RTSA, the total cost of care in the year after RTSA and HSA is similar. Therefore, RTSA should be considered in the appropriate clinical setting. [Orthopedics. 2020;43(2):119-125.].

Defining the Volume-Outcome Relationship in Reverse Shoulder Arthroplasty: A Nationwide Analysis.

BACKGROUND: As the utilization of reverse total shoulder arthroplasty (RSA) grows, it is increasingly important to examine the relationship between hospital volume and RSA outcomes. We hypothesized that hospitals that perform a higher volume of RSAs would have improved outcomes. We also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA. METHODS: The Nationwide Readmissions Database was queried for patients who had undergone elective RSA from 2011 to 2015. Annual hospital volume and 90-day outcome data were collected, including readmission, revision, complications, hospital length of stay (LOS), supramedian cost, and discharge disposition. SSLR analysis was performed to determine hospital volume cutoffs associated with increased risks for adverse events. Cutoffs generated through SSLR analysis were confirmed via binomial logistic regression. RESULTS: The proportion of patients receiving care at high-volume centers increased from 2011 to 2015. SSLR analysis produced hospital volume cutoffs for each outcome, with higher-volume centers showing improved outcomes. The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year, whereas cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year. SSLR analysis of 90-day readmission produced 3 hospital volume categories (1 to 16, 17 to 69, and ≥70 RSAs/year), each significantly different from each other. These were similar to the strata for 90-day revision (1 to 16, 17 to 53, and ≥54 RSAs/year) and 90-day complications (1 to 9, 10 to 68, and ≥69 RSAs/year). SSLR analysis produced 6 hospital volume categories for cost of care over the median value (1 to 5, 6 to 25, 26 to 47, 48 to 71, 72 to 105, and ≥106 RSAs/year), 5 categories for an extended LOS (1 to 10, 11 to 25, 26 to 59, 60 to 105, and ≥106 RSAs/year), and 4 categories for non-home discharge (1 to 31, 32 to 71, 72 to 105, and ≥106 RSAs/year). CONCLUSIONS: We have defined hospital surgical volumes that maximize outcomes after RSA, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways. This information may be used in future policy decisions to consolidate complex procedures, such as RSA, at high-volume destinations, or to encourage lower-volume institutions to strategize an approach to function as a higher-volume center. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Shoulder arthroplasty for glenohumeral osteoarthritis: results from a comprehensive survey in Belgium and the Netherlands.

The purpose of this survey in Belgium and the Netherlands was to assess treatment variation in glenohumeral osteoarthritis between experienced and less experienced orthopedic surgeons, and to investigate perioperative treatment after shoulder arthroplasty in a large group of orthopedic surgeons. Orthopedic surgeons specialized in shoulder surgery were invited to complete a survey between November 2013 and February 2015. Seventy-one percent of the approached surgeons com-pleted the survey. Less experienced surgeons (< 6 years) and surgeons from the Netherlands find patient characteristics (e.g. smoking p=0.01) more relevant than more experienced surgeons (≥ 6 years) and surgeons from Belgium. Less experienced surgeons will less likely (p=0.001) perform resurfacing arthroplasty compare to experienced surgeons. The less and the experienced surgeons use similar indications for a reverse shoulder arthroplasty regarding age limit and cuff arthropathy without osteoarthritis. Less experienced surgeon will more likely (p=0.003) prescribe a low molecular weight heparin during the hospital stay after a shoulder arthroplasty. In this survey, we found a decrease in the use of resurfacing arthroplasty and a strong increase in the use of reverse shoulder arthroplasty. Besides, there is little consensus concerning pre-operative planning, patient characteristics, surgical technique, and patient reported outcome measures. Level of evidence: IV.

Lower-extremity total joint arthroplasty in shoulder arthroplasty patients: does the order of the lower-extremity total joint arthroplasty matter?

BACKGROUND: As total joint arthroplasty (TJA) utilization increases, arthroplasties of multiple joints in a patient are more common. An understanding of the success of shoulder arthroplasty patients also requiring a lower-extremity (hip or knee) TJA is lacking. We evaluated the following questions: (1) Is there a difference in the revision risk following shoulder arthroplasty in patients who also undergo a lower-extremity TJA compared with those who do not? (2) Does the revision risk differ depending on the sequence of the procedures? METHODS: Patients who underwent elective primary shoulder arthroplasty from 2009 through 2015 were identified using Kaiser Permanente's shoulder arthroplasty registry. Patients with a lower-extremity TJA were identified using the institution's total joint replacement registry. Revision related to the index shoulder was modeled via Cox regression stratified by procedure type and adjusted for confounders. RESULTS: Of the 4751 shoulder arthroplasties identified, 1285 (27.0%) underwent a prior hip and/or knee arthroplasty and 483 (10.2%) underwent a hip and/or knee arthroplasty following the index shoulder arthroplasty. No difference was found in all-cause shoulder revision risk with lower-extremity TJA before (hazard ratio, 1.38; 95% confidence interval, 0.97-1.96) or after (hazard ratio, 1.30; 95% confidence interval, 0.82-2.06) the index shoulder arthroplasty compared with patients who underwent a shoulder arthroplasty only. CONCLUSION: In our study sample, we did not observe shoulder revision surgery risk to be different in patients who also underwent a lower-extremity TJA, regardless of the sequence of the 2 procedures. Future prospective studies should investigate whether the timing of the lower-extremity TJA in relation to the shoulder procedure impacts the latter's success.

Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component.

BACKGROUND: Head-split fractures are a subgroup of proximal humeral fractures in which the fracture line affects the articular surface. Limited data are available regarding outcomes and risk factors for failure following surgical treatment of this rare fracture type. METHODS: Of 45 patients with head-split fractures identified, a total of 30 (67%) were included in this retrospective study, with a mean follow-up of 49 ± 18 months (range, 12 to 83 months). Of those 30, 24 were treated with open reduction and internal fixation (ORIF), 4 with reverse total shoulder arthroplasty (RTSA), and 2 with hemiarthroplasty. Subjective Shoulder Value, Simple Shoulder Test, Constant score, and biplanar radiographs were assessed. Fracture pattern, quality of reduction, eventual complications, revision procedures, and clinical failure (adjusted Constant score < 40) were analyzed, and risk factors for failure were calculated. RESULTS: The overall complication rate was 83% (ORIF: 21 of 24 [88%]; RTSA: 3 of 4 [75%]; and hemiarthroplasty: 1 of 2 [50%]). The most common complications following ORIF were humeral head osteonecrosis (42%), malunion of the lesser tuberosity (33%), and screw protrusion (29%), whereas all complications following RTSA were related to tuberosity problems. Revision was performed in 7 of 24 (29%) of initial ORIF patients, and no revisions were performed in RTSA or hemiarthroplasty patients. Four patients (17%) who underwent primary ORIF underwent conversion to RTSA, and 3 patients (12.5%) had screw removal due to penetration. The overall clinical failure rate was 50% (ORIF: 12 of 24 [50%]; RTSA: 1 of 4 [25%]; and hemiarthroplasty: 2 of 2 [100%]). No significant association was found between preoperative factors and clinical failure. ORIF and primary RTSA showed higher average clinical outcome scores than primary hemiarthroplasty and secondary RTSA. In general, patients who required revision had worse Subjective Shoulder Value (p = 0.014), Simple Shoulder Test (p = 0.028), and adjusted Constant scores (p = 0.069). CONCLUSIONS: Head-split fractures of the humerus treated with ORIF showed high complication and revision rates. RTSA resulted in comparable clinical outcomes and complication rates; however, the complications associated with RTSA were mostly related to tuberosity problems, which in this small series did not require revision. Therefore, RTSA may be the most predictable treatment option for head-split fractures in elderly patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete list of levels of evidence.

Risk factors for opioid use after total shoulder arthroplasty.

HYPOTHESIS: The purpose was to assess opioid use before and after anatomic and reverse total shoulder arthroplasty (TSA) and determine patient factors associated with prolonged postoperative opioid use. METHODS: Patients undergoing primary TSA (anatomic or reverse) were identified within the Humana database from 2007 to 2015. Patients were categorized as opioid-naive patients who did not fill a prescription prior to surgery or those who filled opioid prescriptions within 3 months preoperatively (OU); the OU cohort was subdivided into those filling opioid prescriptions within 1 month preoperatively and those filling opioid prescriptions between 1 and 3 months preoperatively. The incidence of opioid use was evaluated preoperatively and longitudinally tracked for each cohort. Multivariate analysis was used to identify factors associated with opioid use at 12 months after surgery, with statistical significance defined as P < .05. RESULTS: Overall, 12,038 patients (5180 in OU cohort, 43%) underwent primary TSA during the study period. Opioid use declined after the first postoperative month; however, the incidence of opioid use was significantly higher in the OU cohort than in the opioid-naive cohort at 1 year (31.4% vs. 3.1%, P < .0001). Subgroup analysis revealed a similar decline in postoperative opioid use for anatomic and reverse TSA (P < .0001 for both). Multivariate analysis identified chronic preoperative opioid use (ie, filling an opioid prescription between 1 and 3 months prior to surgery) as the strongest risk factor for opioid use at 12 months after anatomic and reverse TSA (P < .0001). CONCLUSION: More than 40% of patients undergoing TSA received opioid medications within 3 months before surgery. Preoperative opioid use, age younger than 65 years, and fibromyalgia were independent risk factors for opioid use 1 year following anatomic and reverse TSA. Chronic preoperative opioid use conferred the highest risk of prolonged postoperative opioid use.