The effect of subscapularis repair in reverse total shoulder arthroplasty depends on the design of the implant: a comparative study with a minimum 2-year follow-up.

INTRODUCTION: The role of the subscapularis (Ssc) tendon does not yet have a well-defined role in RSA. The purpose of the present study was to evaluate if the repair of the Ssc in RSA improves overall clinical and radiographic results and if it has the same results using a medialized design humeral stem compared to a lateralized design. METHODS: Eighty-four consecutive patients undergoing RSA were retrospectively analyzed. Nine patients were lost at FU. Two implants with similar glenosphere design and different stem design (medialized and lateralized) were used. The Ssc was repaired in case of good quality of the fibers and reducibility without tension intraoperatively. Patients were divided into four groups for data analysis depending on whether they had received a medialized or lateralized design and Ssc repair or not. Patients were reviewed at an average follow-up of 40.8 ± 13.1 months. Clinical outcome measures included Active range of motion (ROM), strength, visual analog scale (VAS), Constant-Murley score (CMS), and the American Shoulder and Elbow Surgeons score (ASES). Radiographic evaluation at final follow-up was performed to assess scapular notching, stress shielding, and radiolucent lines. RESULTS: No statistically significant clinical differences (p > 0.05) emerged between Lat/Ssc+ and Lat/Ssc-. Conversely, the patients belonging to the Med/Ssc- group reported statistically worse (p < 0.05) results than the Med/Ssc + group in terms of VAS, ASES and CMS. Statistically worse (p < .05) results in the Med/Ssc- group than in the Med/Ssc + were found also in active ROM achieved in FE, ABD, ER1 and ER2, and in the strength obtained in FE, ABD and ER2. Scapular notching was reported in 3 shoulders (15.7%) in Lat/Ssc+ group and in 7 shoulders (50%) in Lat/Ssc- group, while it was reported in 4 shoulders (14.2%) in Med/Ssc + group and in 6 shoulders (42.8%) in Med/Ssc- group. Stress shielding was observed in 6 cases in Lat/Ssc+ group (31.6%), in 8 cases in Lat/Ssc- group (57.1%), in 3 cases (10.7%) in Med/Ssc + group and 4 cases in Med/Ssc- group (28.6%). CONCLUSIONS: Patients undergoing RSA show clinical improvements at mid-term follow-up with a low rate of complications, regardless of the use of a medialized or a lateralized humeral stem design. Ssc repair is associated with better functional outcomes in the cohort of medialized stem, while it did not yield significant differences in the cohort of lateralized stem. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Comparison; Treatment Study.

Comparative study of 145° onlay curved stem versus 155° inlay straight stem reverse shoulder arthroplasty: clinical and radiographic results with a minimum 2-year follow-up.

BACKGROUND: Lateralized onlay reverse shoulder arthroplasty (RSA) is designed to ensure better clinical functional recovery and lower rate of complications compared with Grammont medialized inlay RSA. The purpose of the present study was to compare the clinical and radiographic outcomes between these 2 different designs. METHODS: Eighty-five consecutive patients who underwent RSA were retrospectively analyzed. Nine patients were lost to follow-up, 34 received a curved onlay with a 145° neck-shaft angle (Ascend Flex group), and 42 received a long straight inlay stem with a 155° neck-shaft angle (Delta Xtend group). Patients were reviewed at an average follow-up of 46.8 ± 13.2 months (Ascend Flex group) and 36 ± 10.8 months (Delta Xtend group). Clinical outcome measures included active range of motion, strength, visual analog scale, Constant-Murley score, and the American Shoulder and Elbow Surgeons score. Radiographic evaluation at the final follow-up was performed to assess scapular notching, stress shielding, acromial or scapular fractures, heterotopic ossification, and radiolucent lines or implant loosening. RESULTS: No differences emerged between the 2 groups in terms of visual analog scale, American Shoulder and Elbow Surgeons and Constant-Murley scores, pain, function, strength, mobility, active forward elevation, active internal rotation, active external rotation at 0° and 90° of abduction, abduction, forward elevation, and external rotation strength (P = n.s.). Statistically superior active abduction was observed in the Delta Xtend group (P = .0017). Scapular notching was observed in 12 shoulders (35.2%) in the Ascend Flex group (a grade 1) and in 10 shoulders (23.8%) in the Delta Xtend group (P = n.s.). No differences emerged between the 2 groups in terms of humeral or glenoid radiolucency (P = n.s.). Higher rate of humeral stress shielding rate was observed in the Ascend flex cohort (P = n.s.). CONCLUSIONS: No statistically significant difference emerged between the 145° onlay curved stem vs. the 155° inlay straight stem according to most of the evaluated parameters. Statistically superior active abduction was observed in the 155° group although it did not affect patients' satisfaction.

Patient satisfaction and clinical outcomes of reverse shoulder arthroplasty: a minimum of 10 years' follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has been shown to reliably improve pain and functional outcomes for multiple pathologies. Despite its increasing use in the United States since its introduction in 2004, few studies have investigated long-term outcomes of this procedure. This information is vital in many ways, including durability of functional outcomes, complication profiles, and implant survivorship. METHODS: Our prospectively collected shoulder arthroplasty registry included 471 patients who had undergone RSA prior to December 31, 2010, by a single surgeon at a high-volume shoulder arthroplasty center. The study sample included 94 patients with a minimum of 10 years' follow-up, and we evaluated the indications for RSA, complications, pain, Single Assessment Numeric Evaluation (SANE), and patient satisfaction on these patients at baseline, 2-5 years, and 10 or more years of follow-up. Prosthesis survivorship was determined by Kaplan-Meier survival analysis performed with revision for any reason as the end point for all 471 patients in the study period regardless of follow-up interval. RESULTS: The 93 patients with at least 10 years of follow-up were 63% female (60) and 37% male (34), with an average age of 66±10 years at the time of RSA. There were 70 (75%) primary RSAs and 23 (25%) revision RSAs. Patient-reported outcome measures at 10 years or more included a current pain rating averaging 2±3 on a 0-10 scale and Single Assessment Numeric Evaluation (SANE) of 73±28. There was no deterioration in function or pain from midterm to long-term follow-up, as the SANE and pain score changed by less than the minimal clinically important difference or improved in 87% and 90% of patients, respectively. Overall, patients were satisfied with the RSA procedure, with 52 (56%) very satisfied, 24 (26%) satisfied, 13 (14%) dissatisfied, and 4 (4%) very dissatisfied. For the subset of 68 patients who were contacted for follow-up, 64 (94%) would have the procedure again and 4 (6%) would not. Kaplan-Meier prosthesis survival rate for all 471 RSA patients was 88% (95% confidence interval [CI] 84%-92%) at 5 years and 81% (95% CI 74%-86%) at 10 years. CONCLUSIONS: This study presents the largest American cohort of Grammont design RSA at a minimum 10-year follow-up. Although RSA provided clinically significant and durable improvements in pain and function, the complication and revision rates were higher than prior reports. Despite this, the vast majority of patients were satisfied and would have the procedure again.

Anatomic and reverse shoulder arthroplasty in patients 70 years of age and older: a comparison cohort at early to midterm follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has gained popularity in elderly patients because of its limited reliance on rotator cuff function and high survivorship rates. However, although there are theoretical advantages of RSA over anatomic total shoulder arthroplasty (TSA) in elderly patients, there is little data to guide surgeons on implant selection in this population. METHODS: Patients were identified from our prospectively collected shoulder arthroplasty registry. We included patients between the age of 50 and 89 years who underwent primary TSA for osteoarthritis with intact rotator cuff or primary RSA for cuff tear arthropathy. The minimum and mean clinical follow-up was 2 and 3.1±1.3 years, respectively. Four patient groups were formed for analysis: (1) TSA age 50-69 years (n=274), (2) TSA age 70-89 years (n=208), (3) RSA age 50-69 years (n=81), and (4) RSA age 70-89 years (n=104). We evaluated age group differences in pain, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, patient satisfaction, complications, and revisions. RESULTS: All groups showed significant improvements from preoperative to final follow-up for all outcome measures (P < .001). Visual analog scale for pain average score decreased from 5.8 preoperatively to 1.1, with no significant differences between groups (TSA P = .180; RSA P = .103). Final ASES scores and improvement from preoperative ASES score between the age groups were not significantly different (TSA P = .520; RSA P = .065). There were no significant differences in outcomes between TSA in patients older than 70 years vs. patients younger than 70 years (all P > .05); however, older RSA patients reported better function during activities of daily living (P = .020) than their younger counterparts. Patients undergoing TSA had a lower revision rate of 3.9% compared with 8.1% in the RSA group (P = .043). CONCLUSIONS: TSA and RSA are reliable procedures for patients older than 70 years, and have comparable results to their respective patient cohorts younger than 70 years. Although some surgeons anecdotally advocate for RSA in patients older than 70 years with primary osteoarthritis and an intact rotator cuff, we found no difference in outcomes for TSA based on our age cutoff. Given satisfactory results following TSA in patients 70 years of age and older, we do not routinely perform RSA for primary osteoarthritis with an intact rotator cuff solely based on age. Further studies and longer follow-up are needed to determine the optimal implant selection for elderly patients with primary osteoarthritis.

A localized laminar flow device decreases airborne particulates during shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Although the rate of periprosthetic joint infection following shoulder arthroplasty is low, it is a morbid and costly complication. Airborne particulates have long been recognized as a potential source of wound contamination, and operating room-mounted and smaller localized laminar airflow devices have been developed to minimize airborne particulates. This randomized controlled trial evaluated the effectiveness of a localized laminar flow device in reducing the intrusion of ambient airborne particles and bacteria into the surgery site during shoulder arthroplasty as measured by overall particle counts and colony-forming units (CFUs). METHODS: Patients undergoing primary anatomic or reverse shoulder arthroplasty were eligible for participation. After providing informed consent, patients were randomly assigned to the Air Barrier System (ABS) group or control group. For all patients, the ABS was placed on the surgical field; however, it was only turned on by the technician for those randomized to the ABS. Study participants, surgeons, and surgical staff were blinded to group assignment. Bacterial CFUs were collected from within 5 cm of the surgical wound every 10 minutes, whereas airborne particulates were collected every minute. Poisson regression models were used to determine whether differences existed in CFUs and particulate counts between the ABS and control groups. RESULTS: A total of 43 patients were randomized into the ABS (n = 21) or control (n = 22) group. Surgical time (P = .53) and the average staff count (P = .16) in the operating room did not differ between groups. Poisson regression showed that the ABS group had significantly lower CFUs (ß = -0.583, P < .001) along with surgical time and particulates with a diameter ≥ 5 µm. Staff count and particulates with a diameter < 5 µm were not significant predictors of CFUs. Infection was not a primary outcome; however, no postoperative infections have been reported in either study group with a minimum of 1-year follow-up for all patients. DISCUSSION: This double-blinded, randomized trial demonstrated that a localized laminar flow device dramatically reduced the count of CFUs in the air directly above the wound and beneath the ABS (adjusted for the number of operating room personnel and surgical time). The use of the device was not associated with a longer case duration; however, some additional setup time was required prior to surgical incision to place the device. Further study is required to determine the clinical implications of this finding-specifically, whether such devices result in lower rates of periprosthetic joint infection after shoulder arthroplasty.

Early to midterm outcomes of anatomic shoulder arthroplasty performed on dysplastic glenoids.

BACKGROUND: Treatment of primary osteoarthritis with glenoid dysplasia or Walch type C glenoids remains controversial. There is scant literature available on patient outcomes after anatomic shoulder arthroplasty in patients with Walch type C glenoids. The purpose of this study was to evaluate the outcomes of total shoulder arthroplasty (TSA) for Walch type C dysplastic glenoids with standard (nonaugmented) glenoid components compared with TSA for glenoids with concentric wear and minimal erosion (Walch type A1). We hypothesized that TSA performed for Walch type C dysplastic glenoids with standard glenoid components can reliably produce successful results at short- to midterm follow-up. METHODS: We identified all patients who had primary anatomic TSA performed for osteoarthritis in a prospective shoulder arthroplasty registry collected from 2004 to the present time. Twenty-nine patients met inclusion criteria of a preoperative Walch type C dysplastic glenoid, treatment with TSA using standard (nonaugmented) glenoid components, and a minimum of 2-year clinical follow-up. A matched cohort of 58 patients with a type A1 glenoid and minimum of 2-year clinical follow-up for anatomic shoulder arthroplasty served as the control group. The American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), patient satisfaction, complications, and revisions were evaluated in both cohorts. RESULTS: The mean follow-up for this study was 4.5 years (standard deviation, 2.6 years; range, 2-10 years). Baseline measures were not significantly different between the Walch type C dysplastic group and the matched type A1 cohort (all P > .05). Both groups showed significant improvements in ASES, ASES pain, and SANE scores from baseline to the final follow-up (all P < .001). The Walch type C group had no significant differences in ASES score (P = .118), ASES pain (P = .730), or SANE score (P = .168) compared with the matched type A1 cohort. The complication rate of patients with a type C glenoid was 14% (4 of 29) with a 7% (2 of 29) revision rate. Similarly, the complication rate for the A1 matched cohort was 17% (10 of 58) with a 12% (7 of 58) revision rate. Both groups had high patient satisfaction without statistical differences (P = .549). In addition, there were no differences in the rate of radiographic lucencies or Lazarus scores (P = .222). CONCLUSIONS: Anatomic TSA reliably produced clinically significant improvements in pain and function and similar short- to midterm outcomes in patients with Walch type C dysplastic glenoids compared with patients with type A1 glenoids. Anatomic TSA with standard (nonaugmented) glenoid components should remain an option in patients with Walch type C dysplastic glenoids despite emerging treatment options including augmented glenoid components and reverse TSA.

Reliability of the modified Walch classification for advanced glenohumeral osteoarthritis using 3-dimensional computed tomography analysis: a study of the ASES B2 Glenoid Multicenter Research Group.

BACKGROUND: Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group. METHODS: Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories. RESULTS: Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87). DISCUSSION: Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.

Outcomes of anatomic shoulder arthroplasty performed on B2 vs. A1 type glenoids.

BACKGROUND: Glenoid component malpositioning and glenoid component retroversion have been associated with higher rates of radiolucencies, raising concerns about its implications on glenoid loosening and ultimate failure of anatomic total shoulder arthroplasty (TSA). Although there is literature regarding the relative advantages of techniques to address posterior glenoid bone loss, we are not aware of studies comparing outcomes of TSA on these challenging Walch type B2 glenoids vs. more common A1 glenoids. The purpose of this study is to compare outcomes of TSA performed on A1 glenoids and B2 glenoids treated with asymmetric glenoid reaming. METHODS: We identified 1045 shoulders that had primary TSAs performed for osteoarthritis in a prospective shoulder arthroplasty registry. Two hundred eighty-nine shoulders met inclusion criteria of a preoperative Walch type A1 (178) or B2 (111) glenoid morphology, treatment with TSA, asymmetric reaming in the B2 group, and a minimum of 2-year clinical and radiographic follow-up. Postoperative radiographs were assessed for lucencies, and patient-reported outcome measures were collected at all follow-up visits. RESULTS: Follow-up averaged 40 ± 15 months for all patients, and more men presented with a B2 glenoid (80 of 111; 72%) compared with A1 (101 of 178; 57%) (P = .009). Age at surgery (P = .166), dominant-sided surgery (P = .281), body mass index (P = .501), smoking (P = .155), preoperative opioid use (P = .154), and diabetes (P = .331) were not significantly different between groups. Both groups had similar Constant Strength scores preoperatively (A1: 4.7 ± 7.1, and B2: 4.3 ± 7.3) but the B2 group improved significantly more at final follow-up (A1: 10.3 ± 6.2 vs. B2: 12.7 ± 6.7, P = .005). The Total Constant score was also significantly better at follow-up in the B2 glenoid group (P = .039). All other Constant subscales, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numerical Evaluation (SANE) measures showed significant improvement preoperatively to final follow-up (all P <.001) but there were no significant differences between the A1 and B2 glenoid groups (all P > .05). A similar proportion of patients rated their satisfaction as either very satisfied or satisfied between the A1 (160; 90%) and B2 (100; 90%) (P = .613). Lazarus scores were also similar between the A1 and B2 groups (P = .952) as were the rates of humeral radiolucent lines (P = .749) and humeral osteolysis (P = .507). CONCLUSIONS: Although patients with B2 glenoids may present a more technically challenging anatomic total shoulder arthroplasty, treatment with concurrent asymmetric glenoid reaming produced similar, successful clinical and radiographic early to midterm outcomes for patients undergoing TSA compared with A1 glenoids. Additional follow-up on this cohort will be important to confirm the durability of these early results.

The impact of fellowship type on trends and complications following total shoulder arthroplasty for osteoarthrosis by recently trained board-eligible orthopedic surgeons.

BACKGROUND: Total shoulder arthroplasty (TSA) with an anatomic or reverse prosthesis is a commonly used and successful treatment option for many degenerative shoulder conditions. There is an increasing trend toward fellowship training and subspecialization in newly trained orthopedic surgeons. The literature also suggests that subspecialization and high volume are associated with better clinical outcomes. The purpose of this study was to evaluate the effects of fellowship training on the trends and outcomes of TSA in board-eligible orthopedic surgeons. METHODS: The American Board of Orthopaedic Surgery database was used to identify primary TSA cases performed for osteoarthrosis submitted by American Board of Orthopaedic Surgery Part II Board Certification candidates. Candidates were grouped based on fellowship training and subspecialty examination being taken. Groups were analyzed with analysis of variance and Bonferroni post hoc analysis to evaluate significant differences between groups for a number of candidates, cases per candidate, and patient age/sex. Differences in complications, reoperations, and readmissions were statistically evaluated with χ2 tests and multivariate logistic regression analysis. RESULTS: From 2010 to 2017, 854 candidates performed at least 1 primary TSA (anatomic or reverse) after a diagnosis of osteoarthritis and 2720 submitted cases met inclusion criteria. Candidates completing a Shoulder fellowship performed significantly more TSAs per candidate compared with all other groups (Shoulder = 8.0 ± 6.2, Sports Medicine = 2.4 ± 2.1, Hand and Upper Extremity = 2.9 ± 2.9, General Orthopedics = 2.4 ± 2.3, P < .001). The Shoulder fellowship group had significantly lower complication rates (17.9%) as compared with the Sports Medicine fellowship (23.7%, P = .008) and Hand and Upper Extremity fellowship (25.0%, P = .008) groups. CONCLUSIONS: Shoulder fellowship-trained surgeons performed significantly more TSAs per year than other groups, with a lower complication rate when compared with other fellowship-trained candidates. Fellowship type had no effect on reoperation or readmission rates.

Outcomes of total shoulder arthroplasty for instability arthropathy with a prior coracoid transfer procedure: a retrospective review and matched cohort.

BACKGROUND: Many surgeons are concerned about reports of increased complications, worse outcomes, and early failures in patients undergoing anatomic total shoulder arthroplasty after coracoid transfer. The purpose of this study was to evaluate minimum 2-year outcomes following anatomic total shoulder arthroplasty for instability arthropathy with a prior coracoid transfer procedure and compare them with a matched cohort of patients undergoing total shoulder arthroplasty for primary osteoarthritis. METHODS: We identified 11 primary anatomic total shoulder arthroplasties performed by a single surgeon for instability arthropathy with a prior coracoid transfer procedure with a minimum of 2 years' follow-up (mean, 58 ± 35 months). A matched cohort of 33 patients with a total shoulder arthroplasty for primary osteoarthritis served as the control group. The American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, patient satisfaction, complications, and revisions were evaluated in both cohorts. RESULTS: The coracoid transfer cohort showed no difference in the final ASES score (88 vs. 82, P = .166) or SANE score (85 vs. 67, P = .120) vs. the matched cohort. The postoperative ASES pain score (45 vs. 41, P = .004) was higher in the coracoid transfer cohort, but the mean improvement from preoperative to postoperative values for the ASES score (P = .954), ASES pain score (P = .183), and SANE score (P = .293) was no different between cohorts. Both cohorts had high patient satisfaction without a statistically significant difference (P = .784). CONCLUSION: At early- to mid-term follow-up, total shoulder arthroplasty performed after a coracoid transfer demonstrated similar results to total shoulder arthroplasty performed for primary osteoarthritis. Longer follow-up and larger patient cohorts will provide further insights and highlight any potential differences in outcomes or revision rates.

Editorial Commentary: Arthroscopic Latarjet: An Analysis of Outcomes and Complications Through its Learning Curve.

The arthroscopic Latarjet has been proposed in the past decade to reduce the rate of bone block malpositioning, decrease soft-tissue damage associated with open approach, and possibly decrease intraoperative complications. Several recent studies have reported similar or even superior results with arthroscopic Latarjet compared with those achieved with open technique. However, arthroscopic Latarjet is known to be more technically demanding and some feel that it should be performed by expert shoulder surgeons with advanced arthroscopic skills. Surgical innovations should be adopted when they have potential advantages for patients. Despite the initial challenges and learning curve of arthroscopic Latarjet, experience and technical skills may reduce the rate of intraoperative complications for this technically demanding procedure.

Clinical and radiographic outcomes after total shoulder arthroplasty with an anatomic press-fit short stem.

BACKGROUND: There is limited information assessing outcomes after total shoulder arthroplasty (TSA) with a press-fit short stem. The purpose of this study was to evaluate early clinical and radiographic outcomes and complications after TSA with an anatomic press-fit short stem. METHODS: We identified 118 TSAs completed with press-fit short stem and minimum 2-year follow-up; 85 of these patients had a grit-blasted (GB) short stem placed, whereas 33 patients had short stems with proximal porous coating (PPC). Shoulder function scores, active mobility measurements, and radiographs were assessed. RESULTS: The average age at surgery was 66.7 years, with average follow-up of 3 years. Significant improvements were noted for all shoulder function scores and active mobility measurements from the preoperative state to final follow-up (P < .001). There was no stem loosening in any patients with minimum 2-year follow-up; however, 3 female patients with GB stems had gross loosening of their humeral components before 1 year, 2 requiring revision. Radiolucent lines around the humeral component were found in 5.9% without evidence of loosening. Osseous resorption at the medial cortex was noted in 9.3%. Of patients with PPC stems, no patients were observed to have radiolucent lines compared with 8.2% in the GB group (P = .09). CONCLUSION: TSAs with anatomic press-fit short stem showed significant clinical improvements from the preoperative state to final short-term follow-up, with few complications and minimal radiographic changes. Lack of PPC may contribute to early loosening in patients with poor bone quality. The authors now use a short stem with PPC.

Radiographic comparison of finned, cementless central pegged glenoid component and conventional cemented pegged glenoid component in total shoulder arthroplasty: a prospective randomized study.

BACKGROUND: Radiographic lucency of the glenoid component remains a problem after cement fixation in primary total shoulder arthroplasty. Glenoid component design likely contributes to rates of glenoid lucency. The purpose of this study was to prospectively compare radiographic lucency between a finned, cementless central pegged glenoid component (CL component) and a conventional cemented pegged glenoid component (P component) on immediate postoperative and minimum 2-year follow-up radiographs. METHODS: Fifty-four patients undergoing total shoulder arthroplasty were prospectively randomized to receive an all-polyethylene CL component or a conventional all-polyethylene P component. Three raters graded glenoid lucency and bone interdigitation on immediate postoperative and latest follow-up radiographs. Patients who had undergone revision surgery or had died before evaluation were excluded. Minimum 2-year follow-up was required for inclusion of radiographic evaluation. RESULTS: Fifty patients met inclusion criteria; 42 patients (84%; 20 CL and 22 P) were available for follow-up with the original glenoid implant in place. The mean follow-up duration was 35 months (24-64 months). There were no significant differences in glenoid radiolucency between CL (1/20 [5%]) and P (2/22 [9%]) components at last follow-up (P = .999). Five patients (25%) in the CL group had bone interdigitation. No instances of aseptic glenoid loosening occurred. CONCLUSION: There were no significant differences in the rate of glenoid lucency between the 2 groups at immediate or an average 35-month follow-up. Both techniques appear to be viable options for initial glenoid component fixation, with CL components allowing possible osseointegration, imparting potential long-term stability.

Treatment of Symptomatic Acromioclavicular Joint Instability by a Docking Technique: Clinical Indications, Surgical Technique, and Outcomes.

PURPOSE: To report functional and objective outcomes resulting from surgical treatment of patients with symptomatic type III through V acromioclavicular (AC) joint injury by use of a modification of the anatomic AC joint reconstruction developed by Carofino and Mazzocca. METHODS: The study included all patients treated in 2009-2014 who presented with a history of direct trauma to the shoulder; deformity of the AC joint on clinical examination; radiographic findings that would classify the injury as a Rockwood type III, IV, or V injury; AC joint instability on clinical examination; and self-reported deficits of arm function on initial presentation, in whom a comprehensive and directed nonoperative program failed. The surgical procedure used an allograft with reinforcing internal sutures passed around the coracoid and through anatomically positioned clavicular holes for the coracoclavicular (CC) ligaments, used a docking technique for reconstruction of the superior AC ligaments, and included repair of the native AC ligaments. Outcomes were reported for patients with a minimum follow-up period of 1.5 years. Outcome measurements included dynamic-static stability evaluation and Disabilities of the Arm, Shoulder and Hand (DASH) scores. RESULTS: The study included 15 patients with 15 affected shoulders. The postsurgical follow-up period averaged 3 years (range, 1.5-5 years). Postoperatively, one patient showed loss of reduction after a fall. All others showed 2-dimensional radiographic stability and 3-dimensional dynamic clinical stability. Static radiographic measurement of the CC distance at discharge averaged 0.93 cm compared with 2.7 cm on initial examination (P < .0001). Patient-reported outcomes at an average of 3 years' follow-up showed a DASH score of 13 compared with a preoperative DASH score of 51 (P < .0001). CONCLUSIONS: This study confirms that anatomic CC ligament reconstruction and repair or reconstruction of the AC ligaments help restore arm function as shown by the patient-specific and clinical outcome metrics. These results were achieved by correction of the deformity, which in turn allowed for the obtainment of static and dynamic stability. LEVEL OF EVIDENCE: Level IV.

Radiographic and clinical comparison of pegged and keeled glenoid components using modern cementing techniques: midterm results of a prospective randomized study.

BACKGROUND: Glenoid component loosening remains a significant issue after anatomic shoulder arthroplasty. Pegged glenoid components have shown better lucency rates than keeled components in the short term; however, midterm to long-term results have not fully been determined. We previously reported early outcomes of the current randomized controlled group of patients, with higher glenoid lucency rates in those with a keeled glenoid. The purpose of this study was to evaluate the radiographic and clinical outcomes of these components at minimum 5-year follow-up. METHODS: Fifty-nine total shoulder arthroplasties were performed in patients with primary glenohumeral osteoarthritis. Patients were randomized to receive either a pegged or keeled glenoid component. Three raters graded radiographic glenoid lucencies. Clinical outcome scores and active mobility outcomes were collected preoperatively and at yearly postoperative appointments. RESULTS: Of the 46 shoulders meeting the inclusion criteria, 38 (82.6%) were available for minimum 5-year radiographic follow-up. After an average of 7.9 years, radiographic lucency was present in 100% of pegged and 91% of keeled components (P = .617). Grade 4 or 5 lucency was present in 44% of pegged and 36% of keeled components (P = .743). There were no differences in clinical outcome scores or active mobility outcomes between shoulders with pegged and keeled components at last follow-up. Within the initial cohort, 20% of the keeled shoulders (6 of 30) and 7% of the pegged shoulders (2 of 29) underwent revision surgery (P = .263). Kaplan-Meier analysis showed no significant difference in survival rates between groups (P = .560). CONCLUSION: At an average 7.9-year follow-up, non-ingrowth, all-polyethylene pegged glenoid implants are equivalent to keeled implants with respect to radiolucency, clinical outcomes, and need for revision surgery.

Reverse Shoulder Arthroplasty for Trauma: When, Where, and How.

Reverse shoulder arthroplasty has become increasingly popular for the treatment of complex shoulder injuries, including proximal humerus fractures and fixed glenohumeral dislocation, in the elderly population. The early to midterm results of reverse shoulder arthroplasty for the treatment of proximal humerus fractures are promising compared with the results of unconstrained humeral head replacement, and patients may have more predictable improvement with less dependence on bone healing and rehabilitation. However, long-term follow-up is needed, and surgeons must be familiar with various complications that are specific to reverse shoulder arthroplasty. To achieve optimal patient outcomes for the management of traumatic shoulder injuries, surgeons must have a comprehensive understanding of the current implant options, indications, and surgical techniques for reverse shoulder arthroplasty.

Comparison of satisfied and dissatisfied patients 2 to 5 years after anatomic total shoulder arthroplasty.

BACKGROUND: With an increasingly large number of patients undergoing total shoulder arthroplasty (TSA) combined with increased requirements for public reporting of patient outcomes, there is a greater need to better understand the underlying factors related to patient satisfaction. The purpose of this study was to compare patient demographics, nonorthopedic comorbidities, patient-reported outcome scores, and range of motion of patients who reported being either satisfied or dissatisfied with their procedure at midterm follow-up. METHODS: We identified 234 primary TSAs performed by a single surgeon for glenohumeral osteoarthritis with a minimum 2-year follow-up in a prospective shoulder arthroplasty registry. American Shoulder and Elbow Surgeons (ASES) score, patient satisfaction, and active forward flexion, abduction, and external rotation at 0° of flexion-abduction were assessed before and after TSA. RESULTS: Of the 234 patients, 207 (88.5%) were satisfied with their procedure. Dissatisfied patients had significantly lower ASES scores both before and after surgery (P < .001) as well as a significantly lower preoperative to postoperative change in ASES score (P < .001). Similarly, dissatisfied patients demonstrated significantly lower changes in active forward flexion (P = .004), abduction (P = .02), and external rotation (P = .03). Patients with ASES score changes <12 points were 19 times more likely to be dissatisfied after TSA (95% confidence interval, 4.4-81.4; P = .0001). CONCLUSION: Dissatisfied patients had significantly lower improvements in pain, function, and range of motion. Furthermore, a change in ASES score <12 points was associated with a 19-fold increase in the risk of being dissatisfied after TSA.

Preoperative opioid use associated with worse outcomes after anatomic shoulder arthroplasty.

BACKGROUND: Preoperative opioid use has been associated with worse clinical outcomes after orthopedic surgery. The purpose of this study was to evaluate the impact of preoperative opioid use on outcomes and patient satisfaction after anatomic total shoulder arthroplasty (TSA). METHODS: We identified 224 TSAs performed for primary glenohumeral joint osteoarthritis with 2- to 5-year follow-up in a prospective shoulder arthroplasty registry. Sixty patients with a history of preoperative opioid use for shoulder pain were compared with a control group of 164 patients. Patient-reported outcome measurements, range of motion measurements, and patient satisfaction were assessed preoperatively and at most recent follow-up. RESULTS: Preoperative opioid use was associated with significantly worse preoperative patient-reported outcome scores for nearly all outcome measures. Both groups significantly improved on all outcome scores and range of motion measurements from preoperative to most recent follow-up; however, the nonopioid group had significantly better postoperative outcome scores. There was a statistical difference between the 2 groups regarding the number of satisfied patients, with 80% satisfied in the opioid group (48 of 60 patients) compared with 91% satisfied in the nonopioid group (149 of 164 patients) (P = .03). CONCLUSION: Patients with a history of preoperative opioid use can achieve significant improvements in patient-reported outcome measurements and patient satisfaction after anatomic TSA for primary glenohumeral joint arthritis. However, patients with preoperative opioid use have a significantly lower preoperative baseline and achieve significantly lower final outcome scores after TSA compared with patients without a history of preoperative opioid use.

Preoperative opioid use and outcomes after reverse shoulder arthroplasty.

BACKGROUND: The potential adverse effect of preoperative opioid use on outcomes after reverse shoulder arthroplasty (RSA) has not been investigated. The purpose of this study was to evaluate outcomes after RSA in patients with a history of preoperative opioid use and compare them with a control group without a history of preoperative opioid use. METHODS: Sixty-eight RSAs performed for rotator cuff tear arthropathy (CTA) with a minimum of 2 years of follow-up were identified in a prospective shoulder arthroplasty registry. Thirty-two patients with a history of preoperative opioid use for shoulder pain were compared with a control group of 36 patients who did not use opioids preoperatively. Shoulder function scores and range of motion measurements were assessed preoperatively and at the final follow-up. RESULTS: No differences were noted between the 2 groups in age, gender, duration of follow-up, depression, smoking, chronic back pain, diabetes, heart disease, or body mass index. Preoperative opioid use was associated with significantly lower preoperative shoulder function scores. Both groups significantly improved on all shoulder function scores and for range of motion measurements from the preoperative to the final follow-up assessment; however, the nonopioid group had significantly better outcomes. The magnitude of change between the groups from preoperatively to the final follow-up was nearly identical. CONCLUSIONS: Improvements can be expected in patients with a history of preoperative opioid use; however, patients with preoperative opioid use have a lower preoperative baseline and should not expect to reach the same peak outcome scores after RSA as patients without a history of preoperative opioid use.

Workers' compensation claims and outcomes after reverse shoulder arthroplasty.

BACKGROUND: The effect of workers' compensation claims on outcomes after reverse shoulder arthroplasty (RSA) has not been investigated. The purpose of this study was to evaluate outcomes after RSA in patients with a workers' compensation claim and to compare them with a control group without a workers' compensation claim. METHODS: We identified 14 primary RSAs completed in patients with a workers' compensation claim and a minimum of 2 years of follow-up in a prospective shoulder arthroplasty registry. Fourteen patients without a workers' compensation claim served as the age-, gender-, and diagnosis-matched control group. The Constant score, the American Shoulder and Elbow Surgeons score, the Western Ontario Osteoarthritis of the Shoulder Index, the Single Assessment Numeric Evaluation score, mobility, and the patient's satisfaction were assessed for both groups preoperatively and at final follow-up. RESULTS: There were no differences between the groups regarding patient demographics, duration of follow-up, complications, preoperative shoulder function scores, or preoperative mobility (P > .05). Both groups significantly improved on all shoulder function scores and for mobility from preoperative to final follow-up (all P < .001); however, the workers' compensation group had significantly worse Constant (P = .002), American Shoulder and Elbow Surgeons (P = .003), and Western Ontario Osteoarthritis of the Shoulder Index (P = .001) scores. Only 57% of the workers' compensation group reported that they were satisfied or very satisfied at final follow-up compared with 93% in the control group. The workers' compensation group had a lower return to work rate (14.2% vs 41.7%), but this did not reach statistical significance (P = .117). CONCLUSION: Patients with a workers' compensation claim had significant improvements after RSA, but they achieved significantly worse outcomes compared with the control group.