Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial.

BACKGROUND: The benefits of reverse shoulder arthroplasty compared to nonoperative treatment for patients presenting with complex proximal fractures have been rarely explored. The aim of this prospective study was to compare the functional results of reverse shoulder arthroplasty with those of nonsurgical treatment in patients with displaced proximal humeral fractures. METHODS: A multicentric prospective randomized control trial of patients older than 70 years who sustained an acute proximal humeral fracture (3 or 4 parts), with less than 3 weeks of evolution, and had no previous condition or surgery on the affected shoulder was conducted. Patients were randomly assigned to the intervention group (implantation of a reverse shoulder arthroplasty and tuberosities reattachment) or the control group (nonoperative treatment). Functional outcome was assessed using the Constant-Murley score (CMS) at the 1-year follow-up. Complications and reinterventions were considered secondary outcomes. The power of the study relied on the inclusion of 81 patients to recognize a statistically significant difference of 10 points between CMS scores in the groups. Analysis was performed based on the intention to treat principle. RESULTS: Eighty-one patients were randomized to surgical treatment or nonoperative treatment, while 66 patients completed the 1-year follow-up evaluation. There was no significant difference between the groups in terms of age (76.1 yo vs. 77.43 yo, P = .43), sex (81.08% women in the surgical group vs. 84.09% in the nonoperative group, P = .72), or type of fracture according to Neer's classification system (P = .06). At the 1-year follow-up, the group assigned to undergo the intervention had better functional outcomes than the nonoperative treatment group (mean CMS; 61.24, SD: 13.33 vs. mean CMS: 52.44, SD: 16.22, P: .02), with a mean difference of 8.84 points, 95% CI (1.57, 16.11). Two patients in the intervention group (6.5%) suffered major complications (periprosthetic joint infection and axillary nerve palsy). No major complications were observed in the nonoperative group. One patient in the intervention group underwent secondary surgery for a periprosthetic joint infection. CONCLUSIONS: Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. The difference in CMS is close to the clinically significant thresholds, and some harms are associated with the operative treatment.

Plastic waste in major orthopaedic surgical procedures: descriptive and sources of improvement.

PURPOSE: The healthcare industry is a significant contributor to single-use plastic waste, particularly in the operating room (OR). This study aims to assess the volume of plastic waste generated during total hip, knee, and shoulder arthroplasty in the OR and identify areas for improvement. METHOD: A prospective transversal study at a tertiary hospital was conducted. All total knee arthroplasty (TKA), total hip arthroplasty (THA), and reverse shoulder arthroplasty (RSA) from April to July 2021 were included. The weight of plastic used during patient preparation, anaesthesia, and the surgical procedure was recorded. To calculate the environmental impact, a calculator generated by the United States Environmental Protection Agency (U.S. EPA) was used. RESULTS: A total of 68 surgeries were included. The mean weight of plastic used in total was 7.3 kg (SD 0.48), with the highest yielding procedure being TKA. It generated a mean of 7.63 kg (SD 0.28), followed by THA at 7.28 kg (SD 0.43), and RSA at 6.87 kg (SD 0.47). Various scenarios were simulated to evaluate the potential impact of reducing plastic waste. Substituting plastic wrapping with recyclable materials could save 159.6 kg of CO2 emissions per 100 prostheses. Eliminating non-essential equipment and adopting reusable fabric drapes also showed a significant potential. CONCLUSION: The findings highlight the need for environmentally sustainable practices in the OR. In this way, the healthcare sector can contribute to a cleaner and greener world without compromising patient safety.

Are Cutibacterium acnes delivered from skin to deep tissues in primary reverse shoulder arthroplasty? A prospective study.

INTRODUCTION: The objective of this study is to determine whether the deep tissues are inoculated during surgery with the Cutibacterium acnes still present in the skin after the surgical preparation in reverse shoulder arthroplasties. MATERIALS AND METHODS: Prospective study including patients undergoing surgery with reverse shoulder arthroplasty. All the patients received preoperative antibiotic prophylaxis with cefazolin (2 g IV) and the skin was prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. From all the patients, 9 cultures were obtained after the antibiotic was administrated and the skin surgically prepared. The cultures were sent to isolate C. acnes. DNA was extracted from the C. acnes isolated colonies. Isolate nucleotide distances were calculated using the Genome-based distance matrix calculator from the Enveomics collection toolbox. RESULTS: The study included 90 patients. C. acnes was isolated in 24 patients (26.6%) with a total of 61 positive cultures. There were 12 phylotype II, 27 IB and 22 IA. In 9 patients, C. acnes was present in both skin and deep tissues, and they constituted the sample to be studied by means of genomic analysis. In 7 out of the 9 patients, deep tissue samples clustered closer to at least one of its corresponding skin isolates when compared to the other independent bacterial ones. CONCLUSIONS: The C. acnes present in the skin at the beginning of the surgery are the same as those found in the deep tissues at the end of the surgery. This result strengthens the possibility that the C. acnes is delivered from the skin to the deep tissues.

Minimal number of cultures needed to detect Cutibacterium acnes in primary reverse shoulder arthroplasty: a prospective study.

BACKGROUND: The objective of this study was to determine the minimum number of cultures needed to detect Cutibacterium acnes in primary reverse shoulder arthroplasties (RSAs). METHODS: It is a prospective study including 160 primary RSAs. Exclusion criteria included an active infection, an invasive shoulder treatment in the last 6 months before surgery, an Arthro-SCAN or Arthro-MRI in the last 6 months before surgery, previous shoulder surgeries and revision cases. In 90 cases, 11 cultures were obtained. Another 10 cultures were obtained in the other 70 cases (culture 10 was a sterile sponge to detect false positives). To determine the minimum number of cultures needed to detect C acnes, the prevalence of C acnes contamination of the 160 patients included was determined. RESULTS: There were 128 females and 32 males, with a mean age of 74 years. There were 1690 cultures obtained from the 160 primary RSA surgeries, and 132 of them turned out to be positive for C acnes. There were 42 patients with positive cultures. Twenty of them were males and 22 females. When considering the skin and the deep tissue cultures altogether, the prevalence of positive cultures for C acnes was of 26.25%. If only deep tissues cultures were considered, the prevalence of positive cultures for C acnes was of 23.13%. When considering the skin and the deep tissue cultures together, the sensitivity to detect the C acnes is 19% if only 1 culture is obtained, 31% if 2 cultures are obtained, 50% if 3 cultures are obtained, 59.5% if 4 cultures are obtained, 66.7% if 5 cultures are obtained, 73.8% if 6 cultures are obtained, 85.7% if 7 cultures are obtained, and 92.9% if 8 cultures are obtained. When considering only the deep tissue cultures, if only 1 culture is obtained, the sensitivity to detect the C acnes is 24.3%, 40.5% if 2 cultures are obtained, 54.1% if 3 cultures are obtained, 73% if 4 cultures are obtained, 89.2% if 5 cultures are obtained, and 97.3% if 6 or 7 cultures are obtained. DISCUSSION: A minimum number of 8 cultures are needed to detect C acnes in skin. Moreover, a minimum of 6 cultures are needed to detect it in deep tissues when performing an RSA.

Functional outcomes and complications of patients contaminated with Cutibacterium acnes during primary reverse shoulder arthroplasty: study at two- and five-years of follow-up.

PURPOSE: The objective of the study was to compare the functional outcomes and the complication rate of the patients with C. acnes contamination at the end of the primary reverse shoulder arthroplasty (RSA) surgery to those patients without C. acnes contamination. METHOD: A total of 162 patients were included. In all cases, skin and deep tissue cultures were obtained. A molecular typing characterization of the C. acnes strains was performed. Functional outcomes were assessed with the Constant score at the two and five year follow-up and all complications were also recorded. RESULTS: A total of 1380 cultures were obtained from the 162 primary RSA surgeries. Of those, 96 turned out to be positive for C. acnes. There were 25 patients with positive cultures for C. acnes. The overall postoperative Constant score was not significantly different between those patients having C. acnes-positive cultures and those with negative cultures at the two and five year follow-up (59.2 vs. 59.6 at two years, p 0.870, and 59.5 vs. 62.4 at five years, p 0.360). Patients with positive cultures presented a higher complication rate (p 0.001) with two infections, one revision surgery, and one dislocation. CONCLUSION: Patients ending up with C. acnes-positive cultures after primary shoulder arthroplasty surgery do not have worse clinical outcomes when compared to patients having negative cultures, but a greater number of complications were found in those patients with C. acnes-positive cultures.

Are Cutibacterium acnes present at the end of primary shoulder prosthetic surgeries responsible for infection? Prospective study.

The purpose of this study was to investigate if the C. acnes present at the end of a primary shoulder arthroplasty could be responsible for shoulder arthroplasty infection. Prospective study includes patients undergoing primary shoulder arthroplasty from January 2015 until December 2018. From all the patients included, 5 to 12 tissue samples were obtained and were specifically cultured to detect the presence of C. acnes. DNA was extracted from the C acnes isolated colonies and Whole Genome Sequencing (WGS) analysis was done. A cohort of 156 patients was finally included. In twenty-seven patients, the C. acnes was present at the end of the primary surgery. Two of these patients developed a C. acnes periprosthetic shoulder infection at 6 and 4 months after the primary surgery. WGS of C. acnes isolated colonies showed that all the revision-surgery isolates clustered near to the corresponding primary-surgery isolates compared to the other independent bacterial colonies. (99.89% of similarity). C. acnes present at the end of the primary surgery can be the cause of early or delayed periprosthetic joint infections in shoulder arthroplasty.

Positioning of the metaglene in reverse shoulder arthroplasty: deltopectoral versus anterosuperior approach: a prospective randomized trial.

BACKGROUND: The primary objective of this study was to determine whether there are differences in metaglene positioning related to the approach used (deltopectoral vs. anterosuperior) in primary reverse shoulder prosthesis (reverse shoulder arthroplasty) implantation. The hypothesis was that there would be no differences in metaglene positioning between the 2 approaches. METHODS: A prospective randomized trial was designed to evaluate metaglene positioning in primary reverse shoulder arthroplasty. The patients included were allocated to either the deltopectoral approach (group I) or the anterosuperior approach (group II). Glenosphere overhang and glenosphere tilt were assessed using the methods described by Lévigne et al, Simovitch et al, and Kempton et al, and the beta angle was assessed as described by Maurer et al. The functional outcome was assessed with the Constant score at 2 years' follow-up. Scapular notch development and complication rates were also recorded. RESULTS: A total of 98 patients (77 women and 21 men) were randomized and allocated to group I (49 patients) or group II (49 patients). The mean age of the patients was 74.4 years (standard deviation, 6.3 years). Glenosphere overhang did not show significant differences between groups (6.5 mm in group I vs. 6.1 mm in group II by the Lévigne method, P = .482; 2.2 mm in group I vs. 2.1 mm in group II by the Simovitch method, P = .08). Glenosphere tilt was significantly different between groups (94.6° in group I vs. 86.8° in group II by the Lévigne method, P < .001; 125.9° in group I vs. 119.4° in group II by the Kempton method, P = .002). This was also the case for the prosthesis-scapular neck angle (94.6° in group I vs. 86.8° in group II, P < .001). Moreover, the postoperative beta angle was significantly different between groups (78.6° in group I vs. 73.8° in group II, P = .001). No significant differences were noted in terms of functional outcomes as measured with the Constant score (P = .16). No significant differences between groups were noted relative to scapular notch development and the overall complication rate. DISCUSSION: The deltopectoral and anterosuperior approaches do not differ relative to the craniocaudal positioning of the metaglene, but a slight superior tilt can be expected when using the anterosuperior approach. Both approaches yield comparable functional outcomes, scapular notch development, and complication rates at 2 years' follow-up.

Opinion leaders in the medical community attract more attention than randomized controlled trials in shoulder surgery.

PURPOSE: The objective of this study was to determine whether opinion leaders in the medical community attract more attention than randomized controlled trials (RCT) in shoulder surgery. METHODS: A PubMed search to retrieve all therapeutic and diagnosis RCT shoulder studies was carried out. Three opinion leaders were chosen from among the last ten presidents of the European Shoulder and Elbow Society based on the number of publications. Their studies were also retrieved from PubMed. The metrics of the studies were determined through ResearchGate and Web of Science. The year of publication, impact factor of the journal, level of evidence, number of citations, number of reads, research interest, and reported conflicts of interest were recorded for every study. RESULTS: Two-hundred forty-five shoulder RCTs and 236 opinion leader studies met the inclusion criteria. The opinion leader studies were read significantly more times than the RCTs (p = 0.04). The mean impact factor for RCT studies was 2.84 (SD 3.9) while it was of 1.99 (SD1.14) in the opinion leader group (p < 0.001). Most of the studies of the opinion leaders were level IV (73.3%), while only 6.3% of their papers were categorized as levels I-II. Conflict of interest was present in 19.6% of the RCTs and in 32.2% of the opinion leader studies (p < 0.001). CONCLUSION: The medical community pays more attention to opinion leader studies in shoulder surgery than to RCT studies even though RCTs are published in higher impact factor journals and opinion leader studies are mainly level IV evidence studies.

Non-medical patient-related factor influence in proximal humeral fracture outcomes: a multicentric study.

PURPOSE: Age, sex, and type of fracture have traditionally been described as prognostic factors for proximal humeral fractures (PHFs). Some non-medical patient-related factors may play a role in the outcome. This paper evaluates the association of comorbidities and socioeconomic factors with clinical outcomes for PHF. METHODS: A total of 217 patients with PHF were evaluated according to Neer's classification with X-ray. Comorbidities were assessed through the Charlson comorbidity index and, non-medical patient-related factors were determined with a 52-item questionnaire concerning personal behaviors such as social activities, family support, economic solvency, and leisure-time activities. The clinical outcome was assessed with the Constant-Murley Score (CMS), with a minimum 1-year follow-up. The minimal clinically relevant difference for the CMS was set at 10 points. A multivariable analysis was performed to adjust for comorbidities and non-medical patient-related factors, such as age, sex, fracture classification, and treatment. RESULTS: One hundred and eighty-three patients completed the initial research protocol, while 126 of them completed the 1-year follow-up. The mean age was 71.6 years (SD ± 13.3), and 79.3% of the patients were women. In the bivariable analysis, age and comorbidities were correlated with the CMS (correlation coefficient: - 0.34 [- 0.49, 0.17] and 0.35 [0.18, 0.50], respectively), as well as non-medical patient-related factors and the fracture pattern (p value ANOVA < 0.001). In the multivariable regression model, the effects of considering oneself socially active, without economic problems, and self-sufficient were associated with a higher CMS than the effect of the fracture pattern (beta coefficient: 11.69 [6.09-17.30], 15.54 [8.32-22.75], and 10.61 [3.34-17.88], respectively). CONCLUSION: Socioeconomic status had a higher impact on functional outcomes than fracture pattern in patients with PHF.

Can small glenospheres with eccentricity reduce scapular notching as effectively as large glenospheres without eccentricity? A prospective randomized study.

BACKGROUND: The objective of this study was to analyze whether small glenospheres with eccentricity were comparable to large glenospheres in scapular notch development. METHODS: This prospective randomized study included 82 patients who had undergone a reverse shoulder arthroplasty with a 2-year follow-up period. After randomization, 43 patients were allocated to receive a 42-mm glenosphere and 39 patients were allocated to receive a 38-mm glenosphere with 2 mm of eccentricity. Scapular notch development was defined after examination of an anteroposterior radiograph at the end of follow-up. Functional outcomes were recorded using the Constant score before surgery and at the end of follow-up. RESULTS: Scapular notch development was present in 16.6% of patients who received a 42-mm glenosphere and 34.2% of patients who received a 38-mm eccentric glenosphere. No significant difference was found between the groups with the number of cases available (P = .07). Functional outcomes significantly increased from preoperatively to postoperatively in both groups, with no significant difference found between them (P = .77). The mean glenosphere overhang measure was 6.3 mm in patients with a 42-mm glenosphere and 6.0 mm in those with a 38-mm eccentric glenosphere (P = .68). No significant differences were noted between patients with a scapular notch and patients without a scapular notch in terms of functional outcomes. DISCUSSION: Small glenospheres with eccentricity fared slightly worse than large glenospheres regarding scapular notch development, even though no significant differences were noted. Functional outcomes were comparable between the 2 designs.

Sonication in shoulder surgery: is it necessary?

PURPOSE: The objective of the present study was to determine whether sonication yields greater sensitivity when compared with the traditional tissue culture in detecting peri-implant infections in shoulder surgery. METHODS: It is a retrospective study that includes 99 shoulder surgeries with implants explanted. The inclusion criteria required at least four tissue cultures, sonication of the material explanted, and a minimum follow-up of two years. Patients were classified according to the definition of periprosthetic shoulder infection of the 2018 International Consensus Meeting on Orthopedic Infections. The classifications are definitive infection, probable infection, possible infection, and unlikely infection. RESULTS: Among the 99 surgical procedures, 31 were considered definitive infections, 11 possible/probable infections, and 57 unlikely infections. Considering the cases with a definitive infection, the sensitivity of the tissue culture was 87.09% and the sensitivity of sonication stood at 80.64% (p = 0.406). Analyzing the cases with a definitive infection and those having a possible/probable infection together and comparing them with those with unlikely infection, the sensitivity of sonication was 80.4% and the sensitivity of the tissue culture came to 91.4%. The specificity of the sonication was 98.1% and the specificity of the tissue culture was 99.6%. CONCLUSION: The sensitivity of sonication in shoulder surgery (80.64%) is not superior to the sensitivity of the tissue culture (87.09%). Specificity remains high with both methods, being 98.1% in the sonication group and 99.6% in the tissue culture. Sonication brings no benefit to the detection of shoulder per-implant infections.

Cutibacterium acnes in primary reverse shoulder arthroplasty: from skin to deep layers.

BACKGROUND: The aim of this study was to determine the presence of Cutibacterium acnes (formerly Propionibacterium acnes) on the skin and in deep tissue in a real clinical scenario of primary reverse shoulder arthroplasty. METHODS: This prospective study included 90 primary reverse shoulder arthroplasties, and 12 cultures were obtained from each patient. Each sample was homogenized and used to inoculate PolyVitex (bioMérieux, Marcy-l'Etoile, France) agar and Schaedler (bioMérieux) agar plates. The same procedure was also followed with a thioglycolate broth. Culture was considered positive for C acnes when 2 or more colonies were observed. Total DNA from C acnes isolates was extracted using the InstaGene Matrix (Bio-Rad Laboratories, Hercules, CA, USA) method. The phylotype was determined, and single-locus sequence typing was done on all isolates. RESULTS: We obtained 1080 tissue cultures from the 90 patients included, and 62 of those tissue cultures (5.7%) were positive for C acnes. There were 22 C acnes-positive tissue cultures before prosthesis implantation and 40 after implantation. C acnes was isolated in 17 patients (18.8%). We sent 38 positive samples for blinded phylotyping, single-locus sequence typing, and multi-locus sequence typing type determination. Many of the clusters isolated belonged to phylotype IB and clonal complex (CC) 36 or phylotype II and CC53. DISCUSSION: In the real scenario of patients undergoing primary reverse shoulder arthroplasty using antibiotic prophylaxis and standard preoperative skin preparation with chlorhexidine, C acnes was isolated in the deep layers of 18.8% of the patients. The C acnes K1 and K2 subtypes (belonging to phylotype II and CC53), reported to be commonly involved in prosthetic joint infection, were usually isolated.

Serum C-reactive protein in patients undergoing elective shoulder arthroplasty. Prospective study.

BACKGROUND: The objective of the study was to determine the normalization curve of the serum C-reactive protein (CRP) in elective shoulder arthroplasty. METHODS: A prospective study including 58 consecutive patients who had undergone elective shoulder arthroplasty. Forty-one patients had received a Reverse Shoulder Arthroplasty, 13 a Total Shoulder Arthroplasty and 4 a Hemiarthroplasty. Based on a pilot study, blood samples to determine CRP values were obtained at baseline (1 h before surgery), on the 1st, 2nd, 6th, 8th and 14th postoperative days. All the patients included presented no postoperative complications during inpatient stay or any re-admission during the three months after surgery. RESULTS: Mean CRP values showed a rapid increase on the 1st postoperative day (7-fold higher than the baseline in cuff tear arthropathy, 11-fold higher in primary osteoarthritis, 1-fold higher in acute fracture) and reached a peak on the 2nd postoperative day (14-fold higher than the baseline in cuff tear arthropathy, 24-fold higher in primary osteoarthritis and 2-fold higher in acute fracture). After the 2nd postoperative day CRP values began to slowly decrease reaching the normal range in the 14th postoperative day. CONCLUSIONS: Serum CRP levels after elective shoulder arthroplasty rapidly increase to reach a maximum peak after the 2nd surgery day and then slowly decrease to return to normality on the 14th day. Knowing the normalization curve of CRP can be a helpful tool to help in the diagnosis of acute infections in elective shoulder arthroplasty.

A vast majority of preliminary reports published in the shoulder literature are not followed by long-time follow-up studies - a literature review.

INTRODUCTION: The aim of paper is to check how many preliminary reports (PR) reach a long-term publication (LT), and analyse differences in outcomes and complications between them. METHODS: A literature search was performed to identify shoulder preliminary or early reports. Fifty one papers fulfilled criteria and were categorized for paper topic. Bibliographic searches were undertaken to find LT on the topic from the same author or research group. Outcomes and complications reported in PR were recorded and compared to those reported in LT. RESULTS: Ten out of 51 PR (19.61 %) were followed by a LT with minimum follow-up of five years, by the same authors. Complication and reintervention rate were higher in the LT compared to PR (p < 0.05). Results published on PR were better than results published on LT even though these differences did not reach significance (p = 0.08). DISCUSSION: PR may represent the fastest way to spread new findings. However, concerns regarding short-term follow-up, small sample size bias and decrease in outcomes over time can discourage promising preliminary results. CONCLUSIONS: The vast majority of preliminary reports never reached a LT follow-up paper. Preliminary reports underestimate complications and tend to overestimate outcomes.

The minimal clinically important difference for function and strength in patients undergoing reverse shoulder arthroplasty.

HYPOTHESIS: Despite a statistically significant improvement in functional scores after receiving a reverse shoulder arthroplasty (RSA) in a cuff-deficient shoulder, not all patients perceive a minimal clinically important difference (MCID) in every functional domain of the score. METHODS: This was a prospective longitudinal study including 60 consecutive patients with a cuff-deficient shoulder treated with a RSA. The Constant score was recorded before surgery and at a 1-year follow-up assessment. At the 1-year follow-up, all patients also filled out a 15-item anchor questionnaire to assess their perception of change in their overall function, forward elevation, lateral rotation, internal rotation, and strength to determine the MCID. RESULTS: The mean Constant score was 30.1 (standard deviation, 10.7) before surgery and was 58.4 (standard deviation, 16.2) at the 1-year follow-up, with statistically significant improvement (P < .001). A statistically significant improvement was found in the domains of forward elevation (P < .001), lateral rotation (P < .001), and strength (P < .001) except for internal rotation (P = .15). The MCID for overall function, forward elevation, lateral rotation, internal rotation, and strength in the Constant score increased by 8, 6, 2, 2, and 11.5 points, respectively; only 46.7%, 20%, 50%, 45.8%, and 33.3% of the patients, respectively, exceeded the MCID on each domain after surgery. CONCLUSIONS: A statistically significant improvement in the Constant score is expected after receiving an RSA in a cuff-deficient shoulder, but a considerable number of patients do not reach the MCID in the function and strength domains. A small improvement in rotation is perceived to be beneficial by patients, whereas large improvements in forward elevation are required for the improvement to be perceived to be beneficial.

Influence of glenosphere size on the development of scapular notching: a prospective randomized study.

HYPOTHESIS: The objective of the study was to evaluate the development of scapular notching in reverse shoulder arthroplasty by comparing larger glenospheres (42 mm) with smaller glenospheres (38 mm). METHODS: This was a prospective randomized study of 81 patients who had undergone reverse shoulder arthroplasty with a 2-year follow-up. Patients were randomized to receive either a 42-mm glenosphere (38 patients) or a 38-mm glenosphere (43 patients). Scapular notching development was assessed with an anteroposterior radiograph at the end of the follow-up. Functional outcome was assessed with the Constant score before surgery and at the end of follow-up. An independent blinded observer carried out radiologic and clinical assessments. RESULTS: Scapular notching was present in 48.8% of the patients receiving a 38-mm glenosphere and in 12.1% of the patients receiving one of 42 mm, with significant differences between both (P < .001). No significant differences were noted between the 2 glenosphere size groups in terms of the total Constant score. Patients with a 42-mm glenosphere had a mean glenoid-glenosphere overhang of 6.1 mm, whereas patients with a 38-mm glenosphere had one of 4.2 mm, with significant differences between them (P < .001). No significant differences in the total Constant score were found between the patients whether they had scapular notching or not. CONCLUSION: Bigger glenospheres (42 mm) significantly reduce development of scapular notching compared with smaller glenospheres (38 mm). Glenosphere size has no significant influence on functional outcomes measured with the Constant score.

Does fracture of the dominant shoulder have any effect on functional and quality of life outcome compared with the nondominant shoulder?

HYPOTHESIS: Proximal humeral fractures involving the dominant arm are not predisposed to worsen the functional outcome and the quality of life compared with proximal humeral fractures of the nondominant arm. METHODS: This was a retrospective study including 179 consecutive proximal humeral fractures divided into 2 groups: fractures involving the dominant arm (n = 97) and fractures involving the nondominant arm (n = 82). Both groups were prospectively assessed for 2 years, and at the end of the follow-up, all patients underwent functional assessment by Constant score and quality of life assessment through the 36-Item Short Form Health Survey (SF-36). RESULTS: At the 2-year follow-up, the mean Constant score of the whole series was 65.5 (64.1 in the dominant group and 66.8 in the nondominant group). No significant differences were noted between groups in the total Constant score or among any of the items of the Constant score (total Constant score, P = .43; pain, P = .63; activities of daily living, P = .70; forward elevation, P = .57; abduction, P = .52; lateral rotation; P = .90; internal rotation, P = .32; and strength, P = .24). The mean physical component summary score of the SF-36 at the 2-year follow-up was 40.8 (39.7 in the dominant group and 41.9 in the nondominant group). The mean mental component summary score of the SF-36 at the 2-year follow-up was 43.5 (44.2 in the dominant group and 42.7 in the nondominant group). No significant differences were noted between groups in any item of the SF-36 (physical component summary score, P = .29; mental component summary score, P = .51). CONCLUSION: No significant difference could be found relating to dominance in functional outcome and in the quality of life perception in proximal humeral fractures. Dominance of the affected shoulder has no influence and should not be used to make treatment decisions.

Patients Lost to Follow-up in Shoulder Arthroplasty: Descriptive Characteristics and Reasons.

BACKGROUND: The purpose of this study was to determine the number of patients lost to follow-up yearly in shoulder arthroplasty and investigate the characteristics of the patients lost to follow-up that may differ from those not lost to follow-up. METHODS: All shoulder arthroplasties performed from January 2008 to December 2014 were retrospectively reviewed. The number of patients lost to follow-up was determined yearly. Independent variables included age, sex, body mass index (BMI), diagnosis, type of prostheses, living condition, smoking, alcohol intake, American Society of Anesthesiologists (ASA) score, in-hospital length, surgery length, living area, preoperative Constant score, last Constant score available, and complications. Number of deaths was recorded. RESULTS: This study included 251 patients. There was an accumulation of 86 patients (34.3%) lost to follow-up after a maximum of 8 years. During the first year, 9.9% of the patients were lost to follow-up, 18.3% in the second year, 25.1% in the third year, 28.7% in the fourth year, 31.5% in the fifth year, 33.9% in the sixth year, and 34.3% in the seventh year. Patients with severe obesity had 2.44 times greater risk of being lost to follow-up (hazard ratio [HR], 2.44; p < 0.001). Elderly patients were also at higher risk (HR, 1.05; p < 0.001). Increases in the ASA score raised the risk of being lost (HR, 1.93; p < 0.001). Patients with complications had a lower risk (43%) of being lost (HR, 0.57; p = 0.018) at the 8-year follow-up. At the 2-year follow-up, the patients with acute fractures and fracture sequelae had a higher risk of being lost to follow-up (HR, 2.44; p = 0.002), and the patients with complications were not significantly different from those without complications (HR, 0.54; p = 0.12). CONCLUSIONS: The longer the follow-up in shoulder arthroplasty, the greater the number of patients lost to follow-up, reaching 34.3% by the seventh year. Patients lost to follow-up were not random in shoulder arthroplasty: older patients, severely obese patients, and those with higher ASA scores were at higher risk of being lost to follow-up, but reasons for being lost to follow-up changed through time and depending on when they were assessed.

One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures: A Prospective Randomized Trial.

BACKGROUND: There is no consensus on the duration of immobilization for nonoperatively treated proximal humeral fractures (PHFs). The main objective of the study was to determine the differences in pain between PHFs that were treated nonoperatively with 3-week immobilization and those treated with 1-week immobilization. METHODS: A prospective randomized trial was designed to evaluate whether the immobilization time frame (1-week immobilization [group I] versus 3-week immobilization [group II]) for nonoperatively treated PHFs had any influence on pain and functional outcomes. Pain was assessed using a 10-cm visual analog scale (VAS) that was administrated 1 week after the fracture, at 3 weeks, and then at the 3, 6, 12, and 24-month follow-up. The functional outcome was evaluated using the Constant score. To assess the functional disability of the shoulder, a self-reported shoulder-specific questionnaire, the Simple Shoulder Test (SST), was used. The Constant score and the SST were recorded at the 3, 6, 12, and 24-month follow-up. Complications and secondary displacement were also recorded. RESULTS: One hundred and forty-three patients were randomized, and 111 (88 females and 23 males) who had been allocated to group I (55 patients) or group II (56 patients) were included in the final analysis. The mean age of the patients was 70.4 years (range, 42 to 94 years). No significant differences were found between the 2 groups in terms of pain as measured with the VAS at any time point (1 week [5.9 versus 5.6; p = 0.648], 3 weeks [4.8 versus 4.1; p = 0.059], 3 months [1.9 versus 2.4; p = 0.372], 6 months [1.0 versus 1.2; p = 0.605], 1 year [0.65 versus 0.66; p = 0.718], and 2 years [0.63 versus 0.31; p = 0.381]). No significant differences were found in the Constant score or SST score at any time point. No significant differences were noted in the complication rate. CONCLUSIONS: Short and long periods of immobilization yield similar results for nonoperatively treated PHFs, independent of the fracture pattern. These fractures can be successfully managed with a short immobilization period of 1 week in order to not compromise patients' independence for an overly extended period. LEVEL OF EVIDENCE: Randomized controlled trial Level II. See Instructions for Authors for a complete description of levels of evidence.

Assessment of radiolucent lines in cemented shoulder hemi-arthroplasties: study of concordance and reproducibility.

We report on the concordance and reproducibility of the evaluation of radiolucent lines in the humeral component of shoulder arthroplasty. Thirty-two shoulder prostheses were assessed independently, on two occasions, by five observers. The level of inter- and intra-observer agreement was calculated using the kappa statistic. Intra-observer agreement: the overall kappa values ranged from 0 to 0.6, meaning poor, fair and moderate agreement levels. Inter-observer agreement: when the anteroposterior (AP) views were analysed, the values obtained for the bone-cement interface ranged from 0.290 to 0.539, meaning a poor-to-moderate agreement. For the cement-implant interface, the values ranged from 0.064 to 0.684, meaning a poor-to-good agreement. When radiolucent lines of the humeral component were analysed, inter-observer agreement proved to be as low as that obtained when total hip or knee components were analysed. Intra-observer agreement showed better results.