Regional variations in surgical training may influence where physicians establish clinical practice. In the competitive field of shoulder and elbow surgery, the impact of training location on practice patterns remains unclear. As shoulder arthroplasty volumes continue to rise and rotator cuff disease remains a common musculoskeletal complaint among older patients, equitable access to trained shoulder specialists is paramount. A deeper understanding of these trends may help identify regions that better train and retain subspecialists and inform strategies to improve geographic and gender representation. This study included shoulder and elbow surgeons identified through the American Shoulder and Elbow Surgeons database. Training and practice locations-medical school, residency, fellowship, and current employment were categorized using U.S. Census regions (Northeast, South, Midwest, West, international). Residency programs were also ranked according to the top 25 orthopedic hospitals listed in U.S. News & World Report. Publicly available sources were used to collect demographic and professional data. Descriptive statistics and chi-square analyses assessed geographic retention, and subgroup analyses evaluated differences by gender. A total of 752 shoulder and elbow surgeons were identified: 50 (6.6%) were female and 702 (93.4%) were male. Surgeons were significantly more likely to practice in the same region where they completed residency (range: 44.1%-77.0%, P < .001), medical school (36.8%-70.4%, P < .001), and to a lesser extent, fellowship (21.9%-68.7%, P < .001). In the Northeast, retention following residency (77.0%) and fellowship (68.7%) was especially high (P < .001). In contrast, fellowship retention in the Midwest was the lowest (21.9%, P = .002). Female surgeons were more likely to remain in the Northeast after fellowship (32.0% vs. 20.2% for males, P = .048). In comparison, male surgeons were significantly more likely to remain in the Midwest after residency (10.5% vs. 0%, P = .016). Female representation was highest in the Northeast (9.1%) and lowest in the West (0.7%), though these regional differences did not reach statistical significance (P > .05). Geographic retention among shoulder and elbow surgeons was highest following residency and medical school and lowest after fellowship, where retention varied widely by region. The Northeast consistently demonstrated the highest retention across training stages, whereas the Midwest had the lowest retention after fellowship. Sex-based differences were also observed, with greater retention of female surgeons in the Northeast after fellowship and no female retention in the Midwest after residency. These findings highlight consistent regional and sex-based differences in geographic retention across training stages.
Although os acromiale is often noted on preoperative imaging in patients undergoing reverse total shoulder arthroplasty (rTSA), its clinical significance is ill-defined. The purpose of this study was to compare the clinical outcomes in shoulders with an os acromiale undergoing rTSA with a matched control group. We conducted a retrospective review of a prospectively collected shoulder arthroplasty database for patients who underwent primary rTSA with a minimum 2-year clinical follow-up. Preoperative imaging studies taken within 6 months of surgery were assessed for an os acromiale. Sixty-four shoulders with os acromiale were identified and were matched in a ratio of 1:5 to a control group (n = 320) based on age (within 3 years), sex (exact), preoperative diagnosis, preoperative forward elevation (within 5°) and American Shoulder and Elbow Surgeons score (within five points). Clinical outcome scores, shoulder strength, and active range of motion assessed preoperatively and at latest follow-up as well as the incidence of complications were compared between cohorts. Outcomes of meso- and meta-acromion were grouped and compared with preacromion shoulders. The incidence of os acromiale was 9.7% (64/663) in our institution. Of these, 55% (n = 34) were preacromion, 38% (n = 24) were mesoacromion, and 8% (n = 5) were meta-acromion. No statistically significant differences were found in any outcome score, shoulder strength, or range of motion measures between shoulders with os acromiale and matched controls. Similar proportions of each cohort achieved a clinically significant benefit (minimal clinically important difference/substantial clinical benefit) for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, constant score, abduction, forward flexion, external rotation, and internal rotation. Shoulders with os acromiale had a similar overall complication rate compared with matched controls (14% vs. 12%; P = 0.658). No statistical difference in outcomes were observed between the pre- and meso-/meta-acromion shoulders. Patients with os acromiale undergoing rTSA have similar postoperative functional outcomes and pain relief compared with matched controls. Ⅲ, Retrospective Matched Cohort Study.
Restoring elbow flexion is a focus in treating brachial plexus injuries (BPI), aiming for anti-gravity strength (mBMRC grade ≥3). However, patients with flail or subluxated glenohumeral (GH) joints may struggle to achieve adequate strength due to energy lost stabilizing the GH joint. This study evaluates whether glenohumeral arthrodesis (GHA) can improve elbow flexion in BPI patients with prior failed elbow reconstruction and identifies preoperative factors affecting outcomes. A retrospective review of adult BPI patients with prior elbow flexion reconstruction who later underwent GHA was conducted. Inclusion criteria were patients with preoperative mBMRC grade <3. Demographics, BPI level, prior surgeries, motion, and mBMRC grade were collected. Primary outcome was change in elbow flexion strength. Secondary outcomes included changes in elbow motion and total arc of motion. Statistical analyses were performed to assess changes from pre- to postoperative and identify factors affecting outcomes. Sixteen patients (mean age 40 years) were included, with a mean follow-up of 55 weeks. Significant postoperative improvements were noted in elbow flexion motion, total arc of motion, and mBMRC elbow flexion grade. Preoperative elbow flexion strength was inversely correlated with postoperative strength and arc of motion. Four patients did not achieve antigravity strength, with only two failing to improve post-GHA. Increased age was a risk factor for failure to improve elbow flexion. In conclusion, glenohumeral arthrodesis improves elbow flexion strength and range of motion in BPI patients with prior failed elbow reconstruction. GHA should be considered for patients with flail shoulders and inadequate strength following previous elbow surgery.
Modern anatomic total shoulder glenoid implants must achieve sound fixation, low rate of revision, and ease of conversion to a reverse shoulder replacement should the clinical need arise. This study presents the medium term follow-up of a consecutive series of patients being treated for primary glenohumeral joint osteoarthritis with a hybrid convertible glenoid implant. This was a retrospective review of a prospective series of patients treated with an anatomic total shoulder replacement with the SMR TT Hybrid Glenoid Implant (LimaCoporate, San Daniele del Friuli). The inclusion criterion was a minimum of 5 years follow-up. Patients were excluded from this review if they had less than 5 years of follow-up. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons score and the Oxford Shoulder Score, while range of motion was measured using a goniometer. Standardized Grashey and axillary radiographs were analyzed for evidence of implant loosening or component failure. Forty-two consecutive aTSA performed in 41 patients who received an SMR TT Hybrid Glenoid at a single center between August 2017 and June 2020. There were 24 female patients, and mean age was 68 years (standard deviation: ±8). The mean follow-up duration was 69 months (standard deviation: ±13). The mean pre-operative and post-operative American Shoulder and Elbow Surgeons scores were 27 ± 12 and 87 ± 15, respectively (P< .001). The mean pre-operative and post-operative Oxford Shoulder Score scores were 20 ± 7 and 44 ± 5, respectively (P< .001). There were significant improvements in range of motion, with mean forward flexion increasing from 71 ± 35 to 144 ± 25 and abduction 68 ± 34 to 134 ± 30 (P< .001). Radiographically, 11% showed radiolucent lines affecting the glenoid and 24% affecting the humerus, all asymptomatic. There were no cases of component failure. One patient was revised to a reverse total shoulder arthroplasty for subscapularis failure secondary to trauma. Our study demonstrates that patients treated with an anatomic total shoulder arthroplasty with SMR TT Hybrid Glenoid had excellent clinical and radiological outcomes at a minimum of 5-year follow-up.
Reverse shoulder arthroplasty is considered for displaced geriatric proximal humerus fractures (PHFs). This study compared clinical and radiographic outcomes of "Grammont-style" medialized and contemporary lateralized implants, hypothesizing that contemporary implants yield greater range of motion and tuberosity healing. This retrospective single-institution case series reviewed 74 shoulders (74 patients) treated for acute PHFs from 2008-2020. Patients received a medialized reverse shoulder arthroplasty (M-rTSA) (Delta Xtend; n = 31) or lateralized reverse shoulder arthroplasty (L-rTSA) prosthesis (ReUnion RFX; n = 43). Outcomes included visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, and range of motion. Tuberosity healing was classified radiographically as anatomic, malunion, nonunion, partial migration, or resorption. The mean follow-up was 34.2 and 19.9 months for the M-rTSA and L-rTSA groups, respectively, with no significant demographic differences. L-rTSA shoulders demonstrated greater external rotation (45° vs. 31°; P = .02). Healing rates of 48% and 86% were observed for M-rTSA and L-rTSA shoulders, respectively. There were no significant differences in forward elevation, complications, or American Shoulder and Elbow Surgeons or pain scores. Anatomic tuberosity healing was associated with better rotation and pain scores. Lateralized implants were associated with improved tuberosity healing and external rotation compared to Grammont-style implants for acute PHFs. Tuberosity healing was correlated with better clinical outcomes.
Reports of equivalent patient-reported outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) have contributed to a continued preference of rTSA. Although many surgeons believe that the best aTSA outcome can outperform the best rTSA outcome, this has not yet been demonstrated in the literature. The purpose of this study is to investigate the outcome characteristics of aTSA and rTSA patients who perceive that their shoulder is close to normal, with the hypothesis that aTSA patients will outperform rTSA patients. A retrospective query of our institution's data repository from 2006 to 2021 identified primary anatomic and rTSA patients with minimum 2-year follow-up and who have achieved a "new normal," defined as a most recent Single Assessment Numeric Evaluation score ≥95. aTSA and rTSA patients were compared based on patient-reported outcome measures, range of motion, and satisfaction. Specific patient-reported outcome measure questions representative of higher functional demands were analyzed, and a subset analysis of patients treated for osteoarthritis with an intact rotator cuff was performed. The query identified 849 aTSA and 745 rTSA patients with minimum 2-year follow-up. Of these, 40% (337) of aTSA and 26% (193) of rTSA patients reached a Single Assessment Numeric Evaluation score ≥95 at most recent follow-up. aTSA significantly outperformed rTSA in total American Shoulder and Elbow Surgeons score (P < .001); ability to reach a high shelf (P < .001), lift 10 pounds (P < .001), and perform usual work and usual sport (P < .001); total Simple Shoulder Test score (P < .001); ability to lift 8 pounds and carry 20 pounds (P < .001); and range of motion including clinician measured elevation, abduction, external rotation, and internal rotation (P < .001). A subanalysis among patients treated for osteoarthritis with an intact rotator cuff produced similar results, with aTSA patients outperforming rTSA patients in many higher demand functions. aTSA patients have a 40% chance of perceiving their shoulder as normal. Among shoulder arthroplasty patients who perceive their shoulder as normal, aTSA patients outperform rTSA patients with better motion and greater ability to return to work, return to sport, and perform higher demand activities without difficulty.
Background and objective Golf is a popular recreational activity among older adults, many of whom develop shoulder pathology requiring surgical intervention. Despite increasing interest in return-to-sport outcomes, comparative data on return to golf following shoulder arthroscopy versus shoulder arthroplasty remain limited. This study aims to compare return-to-golf outcomes, patient satisfaction, and functional recovery between patients undergoing shoulder arthroscopy and those undergoing shoulder arthroplasty. This is a retrospective cohort study and represents level III evidence. Methods A retrospective comparative study was performed on 71 recreational golfers, including 46 (64.8%) who underwent arthroscopy and 25 (35.2%) who underwent arthroplasty. Pre- and postoperative assessments included range of motion (ROM) and patient-reported outcome measures (PROMs). The PROMs included the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS), and subjective shoulder value (SSV). Golf-specific outcomes included return timelines, satisfaction, and performance. Paired t-tests assessed within-group changes, and independent t-tests evaluated between-group differences. Results Both groups demonstrated significant improvements in ASES, VAS, and SSV scores (all p < 0.001). Forward flexion and external rotation improved more in the arthroplasty group (p = 0.001 and p = 0.030), while internal rotation did not significantly improve in either group. The mean time to resume putting, chipping, and driving was 5.8 ± 3.1 months, 6.2 ± 3.0 months, and 7.4 ± 2.9 months, respectively, with no significant differences between groups (putting, p = 0.890; chipping, p = 0.894; driving, p = 0.990). At 12 months, 57 of 71 patients (80.3%) had returned to golf (p = 0.970), and 65 of 71 patients (91.5%) reported being satisfied or very satisfied. Conclusion Recreational golfers undergoing either shoulder arthroscopy or arthroplasty experience significant functional improvements and high return-to-golf rates. Surgical technique was not associated with differences in return timelines, satisfaction, or golf-specific performance. These findings may guide patient expectations and support shared decision-making in surgical planning.
To describe a novel reconstructive technique for bidirectional elbow instability using a cylindrical ligament retention device in the distal humerus and toothed metal plates for graft fixation to the proximal ulna and to report early outcomes in the first four patients treated with this technique. Patients who underwent this procedure exhibited either preoperative or anticipated intraoperative bidirectional elbow instability. Preoperative, postoperative, and intraoperative examination findings were obtained. All patients were stabilized with this bilateral ligament reconstruction. Three patients required an interposition arthroplasty. One patient, who underwent interposition arthroplasty, required use of his operated arm for transfers, which necessitated an external fixator that was removed at 6 weeks. Despite subsequent splinting, he developed lateral widening on examination at 12 weeks after surgery and underwent a revision, which became infected requiring the removal of both the ligament reconstruction and interposition arthroplasty. The mean preoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 73.3and Mayo Elbow Performance Score was 26.3. After surgery, in the three patients who remained stable, the mean Quick Disabilities of the Arm, Shoulder, and Hand score improved to 51 at 3 months and the mean Mayo Elbow Performance Score improved to 85 at 3 months. Three patients have remained stable at their elbow status post bilateral ligament reconstruction. One patient developed elbow subluxation and had a second procedure performed, which led to an infection and removal of all hardware. A contraindication to this procedure may be need for early force application to the elbow in the postoperative period. Future patients will clarify the clinical utility of this bilateral ligament reconstruction. Therapeutic IV.
Acromial stress fractures can occur after reverse total shoulder arthroplasty (rTSA). We performed this study to assess the incidence, risk factors, characteristics, and outcome of acromial stress fractures and reactions after rTSA. We determined the incidence of acromial stress fractures and reactions in a cohort of patients who underwent rTSA, and assessed risk factors using a case-control design. Each patient who developed an acromial stress fracture or reaction after rTSA (case) was matched by date of rTSA with 2 patients who did not develop acromial stress fractures/reactions after rTSA (control subjects); univariate and multivariable analyses were performed to identify risk factors. Characteristics of acromial stress fractures/reactions are described. Outcomes were compared between cases and control subjects. The incidence of acromial stress fracture/reaction after rTSA was 11% (24/220 rTSAs). Acromial stress fractures/reactions occurred at a median time of 5.5 months after rTSA (range: 20 days-118 months) and most were fractures (18/24, 75%). Using a multivariable analysis, we found 2 factors to be independently associated with the occurrence of an acromial stress fracture/reaction after rTSA: corticosteroids use (adjusted OR: 9.6, 95% confidence interval: 1.1-86.1, P = .04) and previous shoulder surgery (adjusted OR: 7.2, 95% confidence interval: 1.4-36.6, P = .02). In this cohort, in which the management was exclusively conservative, the occurrence of post-rTSA acromial stress fracture/reaction was associated with a significantly worse functional outcome at last follow-up visit, as compared with control subjects. This was illustrated by significantly lower American Shoulder and Elbow Surgeons Shoulder score, higher Shoulder Pain and Disability Index and Disabilities of the Arm, Shoulder and Hand scores, and worse forward elevation and internal rotation as compared with control patients who did not develop acromial stress fracture/reaction after rTSA. In our Australian cohort, acromial stress fractures/reactions were relatively common after rTSA, and independently associated with corticosteroids use and previous shoulder surgery. The occurrence of acromial stress fracture/reaction was associated with a significantly worse functional outcome, as compared with patients who do not develop this complication after rTSA.
Reverse total shoulder arthroplasty (rTSA) is the preferred surgical treatment for non-reconstructible 7 proximal humerus fractures in the elderly population. The most common classification for 8 these fractures is the Neer classification. A more recent system is the Mayo-Fundación Jiménez 9 Díaz (Mayo-FJD) classification, which has demonstrated higher intraobserver and interobserver 10 reliability compared to the Neer system. However, their predictive utility remains unclear. The study consisted of a retrospective analysis of prospectively collected data from 40 patients treated for isolated proximal humerus fractures with rTSA by a shoulder and elbow fellowship-trained orthopedic surgeon between 2010 and 2020. Data collection included demographic information, post-operative range of motion, pain, and patient-reported outcome measures including the Simple Shoulder Test, the University of California Los Angeles score, the American Shoulder and Elbow Surgeons, and Constant Murley scores, among others. The 9 categories of the Mayo-FJD were organized into 3 groups: isolated tuberosity fractures-greater tuberosity or lesser tuberosity; humeral head compromising fractures-varus posteromedial (VPM), valgus impacted, head split (HS), head dislocation (HD), and head impression (VPM, valgus lateral, HS, HD, and head impaction); and surgical neck (SN) fractures-SN and disengaged neck (SN and DN). The t-test and the Kruskal-Wallis test were utilized to compare the outcomes for each fracture pattern between the 2 classifications. The final cohort consisted of 13 2-part fractures (35.1%), 19 3-part fractures (51.4%), and 5 4-part fractures (13.5%) by the Neer classification, and there were 6 VPM (16.2%), 13 valgus lateral (35.1%), 3 HS (8.1%), 2 HD (5.4%), and 13 DN (35.1%) by the Mayo-FJD classification. Patients in the SN/DN group had increased pain with touching the back of their necks (P = .045) as well as decreased Simple Shoulder Test (P = .023) and University of California Los Angeles scores (P = .018) when compared to humeral head compromising fractures. Our findings suggest that fractures about the SN, specifically the DN fractures, may be associated with higher levels of pain and poorer shoulder function following rTSA. However, future studies should include a larger cohort of patients with complete subtype representation to verify our conclusion.
There are some major controversies surrounding the use and longevity of pyrocarbon interposition shoulder arthroplasty (PISA). The objective of this study was to investigate the long-term survival and outcomes (minimum 10-year) following PISA for osteoarthritis (OA) in young and active patients. This was a retrospective review of prospectively collected data of patients who underwent PISA (InSpyre; Tornier-Stryker) for OA between 2009 and 2012. Arthroplasty survival was known for 71 patients followed longitudinally for a minimum of 10 years. The clinical and radiologic outcomes were assessed in 62 patients (62 shoulders) reviewed with radiographs. The mean age at surgery was 60 years (range, 23-72 years), and 31 shoulders (50%) underwent prior surgery before PISA. The diagnosis was primary osteoarthritis (POA = 29), post-traumatic osteoarthritis (PTOA = 23), and postinstability osterarthritis (PIOA = 10). Clinical failure was defined as repeat surgical intervention involving prosthesis revision. Clinical outcomes were assessed with the Constant score (CS) and Subjective Shoulder Value (SSV). The mean duration of follow-up was 11 ± 0.6 years (range, 10-14 years). Overall, the survival rate was 90% (95% confidence interval [CI] 82.8-96.8) at 5 years and 87% (95% CI 79-94.8) at a 10-year follow-up. Survival was 100% in PTOA (type 1 fracture sequelae) and in PIOA as well as 95% in primary OA with type A glenoid. Revision surgery was significantly higher in biconcave (type B2) glenoid (44%) compared with concentric (type A) glenoid (2%), respectively (P = .002). Among the 7 patients who were revised to reverse shoulder arthroplasty, 5 had painful glenoid erosion and 2 had bipolar (glenoid and humeral) erosion with thinning and finally fracture of the greater tuberosity. Two shoulders with glenohumeral erosion were associated with secondary rotator cuff tears (1 supraspinatus and 1 subscapularis tear). The mean time to revision and revision was 4 ± 1.7 years. Glenoid wear was more often superior (81%) than central (19%), P < .001. For those shoulders not revised, the mean CS and SSV significantly increased from 39 ± 14 to 70 ± 14 points and 34% ± 15% to 75% ± 17%, respectively (P < .001). PISA is an efficient and durable surgical procedure for the treatment of young and active patients with post-traumatic OA, postinstability OA, and primary OA with concentric (type A) glenoid erosion, but not for those with biconcave (type B2) glenoid. Biconcave (type B2) glenoid and subscapularis tear or insufficiency are risk factors for failure and revision.
Glenoid bone loss is commonly encountered at the time of revision reverse shoulder arthroplasty (rTSA). The ipsilateral distal clavicle has been considered as one possible source of autograft if needed at the time of revision rTSA. The purpose of this study was to determine the outcome of ipsilateral distal clavicle autograft (IDCA) at the time of revision rTSA with particular attention to survival of the glenoid baseplate. Between 2017 and 2023, 20 consecutive revision rTSAs were performed at a single institution using IDCA augmentation of glenoid defects. The mean age at the time of surgery was 74 ± 12 years. Failed prostheses revised included 13 anatomic total shoulder arthroplasties and 7 failed rTSAs. According to the Kocsis classification, pre-operative bone loss was considered stage 2 in 12 shoulders and stage 3 in 8 shoulders. Intraoperatively, 15 patients had central bone defects and 5 patients had combined bone loss using Antuña classification. Clinical assessment was performed pre-operatively and post-operatively for pain, subjective, and objective scores. Radiographic evaluation analyzed the position of the glenoid component as well as radiographic evidence of graft incorporation and loosening. The mean follow-up time was 44 ± 12 months. Mean visual analog scale scores for pain decreased 7 pre-operatively to 1 at most recent follow-up (P < .001). Active elevation and external rotation were improved as well (active elevation = 89° pre-operatively vs. 111° at most recent follow-up [P < .01]; external rotation = 22 pre-operatively degrees vs. 32° at most recent follow-up [P < .01]). Constant scores, American Shoulder and Elbow Surgeons scores, and subjective shoulder values also improved from pre-operatively to most recent (34 points vs. 58 points, P < .001 for Constant scores; 31 points vs. 65 points, P < .001 for American Shoulder and Elbow Surgeons scores; 30% vs. 64% for subjective shoulder values, P < .001). Two revisions were performed for recurrence of infection. One additional shoulder underwent irrigation and débridement with implant retention and one shoulder underwent closed reduction of a dislocation. For the 18 shoulders with no re-revision for infection, IDCA appeared radiographically incorporated, and there was no evidence of glenoid loosening. At mid-term follow-up, IDCA provided a reliable option for moderate glenoid bone loss encountered at the time of revision rTSA. A major benefit of IDCA is availability from the same surgical site of the revision procedure, even if pre-operative assessment underestimated bone loss. These results need to be confirmed in a larger sample size and with longer follow-up.
Primary glenohumeral osteoarthritis in young patients poses challenging treatment decisions. Arthroplasty options have different failure profiles and implant survivorship patterns. This registry study aims to analyze the cumulative per cent revision (CPR) rate of different types of arthroplasties conducted for primary osteoarthritis in patients below 55 years of age. This comparative observational national registry study included all shoulder arthroplasty for osteoarthritis in patients below 55 years of age undertaken between January 1st, 2005, and December 31st, 2022. Partial hemi resurfacing and hemi stemless procedures were excluded. The CPR was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazard models adjusted for gender. Reasons for revision of each type of arthroplasty and cumulative incidence of revision diagnoses were analyzed. Two thousand one-hundred eleven primary shoulder arthroplasties were compared. Glenoid erosion is the predominant cause of revision for humeral resurfacing (29.8%) and hemiarthroplasty (35.5%). Instability is the predominant cause of revision for stemmed anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), while loosening is the predominant cause of revision for stemless aTSA. The 6-year CPR is 12.8% for humeral resurfacing, 14.1% for hemiarthroplasty, 12.4% for stemmed (aTSA), 7.0% for stemless aTSA, and 6.5% for rTSA. Stemmed aTSA had a higher revision rate than rTSA (entire period HR = 2.04 (95% confidence interval 1.16, 3.57), P = .012). In contrast, the revision rate of stemless aTSA was not different from rTSA (HR = 1.05 (95% confidence interval 0.51, 2.19), P = .889). Males outnumber females for all shoulder arthroplasty categories. rTSA and stemless aTSA are viable options in young patients with primary osteoarthritis. Their short-to-medium term revision rates are comparable to those of older patients and lower than those associated with humeral resurfacing, hemiarthroplasty, and stemmed aTSA. In the predominantly male patient population below the age of 55, reverse shoulder arthroplasty and stemless aTSA have a lower short-term revision risk than stemmed aTSA.
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Stemless implants were introduced to prevent some of the stem-related complications associated with the total shoulder arthroplasty. Although general requirements for receiving these implants include good bone quality conditions, little knowledge exists about how bone quality affects implant performance. The goal of this study was to evaluate the influence of age-induced changes in bone density, as a metric of bone quality, in the primary stability of five anatomic stemless shoulder implants using three-dimensional finite element (FE) models. The implant designs considered were based on the Global Icon, Sidus, Simpliciti, SMR, and Inhance stemless implants. Shoulder arthroplasties were virtually simulated in Solidworks. The density distributions of 20 subjects from two age groups, 20-40 and 60-80 years old, were retrieved from medical image data and integrated into three-dimensional FE models of a single humerus geometry, developed in Abaqus, to avoid confounding factors associated with geometric characteristics. For the designs which do not have a solid collar covering the entire bone surface, ie, the Sidus, Simpliciti, SMR, and Inhance implants, contact and noncontact conditions between the humeral head component and bone were considered. Primary stability was evaluated through the assessment of micromotions at the bone-implant interface considering eight load cases related to rehabilitation activities and demanding tasks. Three research variables, considering 20 μm, 50 μm, and 150 μm as thresholds for osseointegration, were used for a statistical analysis of the results. The decreased bone density registered for the 60-80 age group led to larger micromotions at the bone-implant interface when compared to the 20-40 age group. The Global Icon-based and Inhance-based designs were the least sensitive to bone density, whereas the Sidus-based design was the most sensitive to bone density. The establishment of contact between the humeral head component and bone for the implants that do not have a solid collar led to decreased micromotions. Although the age-induced decline in bone density led to increased micromotions in the FE models, some stemless shoulder implants presented good overall performance regardless of the osseointegration threshold considered, suggesting that age alone may not be a contraindication to anatomic total shoulder arthroplasty. If only primary stability is considered, the results suggested superior performance for the Global Icon-based and Inhance-based designs. Moreover, the humeral head component should contact the resected bone surface when feasible. Further investigation is necessary to combine these results with the long-term performance of the implants and allow more precise recommendations.
The Pennsylvania Shoulder Score is a common patient-reported measure of shoulder pain, function, and satisfaction. Cross-cultural adaptation is essential for non-English-speaking populations. This prospective cross-sectional validation of the Arabic Pennsylvania Shoulder Score (PSS-AR) followed translation and cultural adaptation steps. Adults ≥18 years with shoulder pain/dysfunction were recruited from two outpatient clinics. Participants completed the PSS-AR (Pain 0-30; Satisfaction 0-10; Function 0-60; Total = sum, higher = better) and Arabic Simple Shoulder Test (SST-AR; 0-100). Readability was assessed using Automatic Arabic Readability Index (AARI). Stable participants repeated PSS-AR after 5-10 days. 219 patients participated; 102 stable individuals completed retesting. AARI showed readability levels of grade 5.24 for PSS-AR and 2.92 for SST-AR, below the recommended sixth-grade threshold. Function showed excellent internal consistency (Cronbach's α=0.96). Exploratory factor analysis supported essential mono-dimensionality: Factor 1 explained 54.90% of variance (factor 2 + 5.19%; cumulative 60.09%) with loadings 0.47-0.85. Convergent validity with SST-AR was strong (Spearman ρ: Total 0.792, function 0.788, pain 0.538; all p < 0.0001). Test-retest reliability was excellent: ICC(2,1) = 0.95 (95% confidence interval 0.93-0.97). Mean change was minimal (Δ=-0.47 ± 9.36) without systematic shift (F = 0.09, p = 0.76). SEM was 4.98; MDC individual=13.80 and MDC_group=1.37. The PSS-AR is reliable, valid, and culturally appropriate for Arabic-speaking patients.
Reverse total shoulder arthroplasty (RTSA) is a well-established replacement strategy to treat irreparable massive rotator cuff tears and cuff tear arthropathy. In patients with forward (FF) deficits combined with a loss of external rotation (ER), RSA with latissimus dorsi transfer (LDT), which was initially used for brachial plexopathies, has been addressed to restore both functional deficits. The aim of the study is to assess mid-term clinical and radiological outcomes of concomitant RSA with LDT in patients with significant preoperative external rotation lag greater than 30 degrees without pseudoparalysis. We hypothesized that RTSA with concomitant isolated LDT can effectively improve ER range of motion (ROM) and ER lag postoperatively. Our final case series included 26 patients who underwent RTSA concomitant with isolated LDT out of 341 RTSA's from July 2014 to July 2023. Inclusion criteria were (1) ER lag greater than 30 degrees and Goutallier grade greater than 3 in infrapinatus and teres minor muscle on preoperative MRI (Goutallier in J Shoulder Elbow Surg 12:550-554, 2003), (2) ROM in FF greater than 90 degrees, (3) diagnosis of massive irreparable rotator cuff tears and cuff tear arthropathy, according to Hamada classification (Hamada in Clinical Orthopaedics Related Res 469:2450-2460, 2011), and (4) a minimum postoperative follow-up of 2 years. Clinical outcome measures, which were evaluated preoperatively, postoperative 6 month, 12 month, and annually thereafter, were range of motion, muscle strength, visual analogue scale (VAS), Constant-Murley score, and American Shoulder and Elbow Society (ASES) score as well as complications. Radiologic outcomes measures included preoperative Hamada grade and Goutallier grades. The study was consisted of 10 male and 16 female patients, with an average follow-up of 5 years (range, 27 to 150 months). Preoperative range of motion showed FF 136', ER 28', internal rotation T9, and abduction 127'; in addition, ER lag was 32.6' at side and 26.2' at 90' abduction. Mean Goutallier grades of infraspinatus and teres minor were 3.9 and 3.7, respectively. Postoperative outcomes revealed that active range of ER did not significantly increase over time but that the degree of ER lag at side and at 90' abduction both showed statistically significant improvement at their final follow-up. Furthermore, the VAS and clinical scores, including ASES and Constant scores, all showed significant improvement at the final follow-up although muscle power including ER, belly press, lift off showed no improvement. In conclusion, the RTSA with isolated LDT in patients with irreparable massive rotator cuff tears with significant ER lag but without pseudoparalysis showed that ER lag was significantly improved postoperatively and remained stable through the mid-term follow-up without loss of IR. Regardless of prosthesis designs, LDT was able to restore functional ROM in ER and did not sacrifice its function in internal rotation in a combination with RSA. Case Series, Level IV.
The articular surface angle of the elbow (ie, valgus/varus alignment) could affect how traumatic forces are distributed through the ulnohumeral joint, potentially influencing coronoid fracture types. This study hypothesizes that an angle toward varus would be associated with coronoid fractures involving the anteromedial facet (O'Driscoll type 2), rather than fractures limited to the anterolateral tip (O'Driscoll type 1). This study aims to explore the potential association between radiologic elbow varus angles and O'Driscoll coronoid fracture types. This retrospective study was conducted at an urban Level 1 trauma center. Adult patients with anterolateral tip or anteromedial coronoid fractures and an elbow computed tomography (CT) scan within four weeks of injury were identified from February 2014 to July 2023, resulting in 142 patients. The mean age was 48 ± 18 years, and 52% of patients were male (74 of 142). Each coronoid fracture was classified independently according to the O'Driscoll classification by 2 trained observers using radiographs, two-dimensional and three-dimensional CT scans with humeral subtractions, and intraoperative findings. Of the patients, 48% (68 of 142) presented with type 1 anterolateral tip fractures, and 52% (74 of 142) with type 2 anteromedial fractures. Interrater reliability of fracture classification was excellent (kappa = 0.90, 95% confidence interval [CI]: 0.83-0.97). Three elbow varus angles were assessed in this study: Trochlear Articular Surface Angle (TASA), Proximal Ulna Articular Surface Angle (PUASA), and Proximal Ulnar Varus Angle (PUVA). Each angle was measured independently by 2 observers using coronal CT scans. Inter-rater reliability was excellent for TASA (intraclass correlation coefficient [ICC] = 0.95, 95% CI: 0.91-0.97), good for PUASA (ICC = 0.89, 95% CI: 0.79-0.91), and moderate for PUVA (ICC = 0.69, 95% CI: 0.56-0.79). Multivariate logistic regression was performed to evaluate the independent association between each varus angle and fracture type, controlling for age, body mass index, gender, hand dominance, and radial head involvement. The multivariate logistic regression analysis showed no association between the O'Driscoll coronoid fracture types and the TASA (odds ratio [OR]: 0.99; P = .79)', PUASA (OR: 0.99; P = .75), or PUVA (OR: 0.99; P = .86). Occurrence of anteromedial facet fractures is not found to be associated with varus alignment of the elbow in this study. Factors besides the injury mechanism causing translational fractures in the coronoid fracture spectrum should be further explored in future studies to increase our understanding of the etiopathogenesis of the various coronoid fracture types.
We hypothesized that hybrid telerehabilitation, delivered as an adjunct to standard in-person physical therapy (PT), would demonstrate similar improvements in functional scores, pain, and range of motion (ROM) compared with traditional PT, while reducing PT utilization in patients undergoing shoulder arthroplasty and arthroscopic rotator cuff repair (RCR). This retrospective cohort study included 207 adults who underwent shoulder arthroplasty or arthroscopic RCR between 2021 and 2025. Historical controls receiving standard in-person postoperative PT alone (IP-PT; n = 134) were compared with patients receiving hybrid telerehabilitation with the Band Connect platform in addition to in-person postoperative PT (BC+IP-PT; n = 73). Primary outcomes included the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and active range of motion (ROM), assessed preoperatively and at 3 and 6 months postoperatively. Analyses were performed separately for arthroplasty and RCR cohorts using stabilized inverse probability of treatment weighting and generalized estimating equations with additional covariate adjustment for residual imbalance. Secondary outcomes included PT utilization, complications, and reoperations. The study included 85 patients in the arthroplasty cohort (33 BC+IP-PT, 52 IP-PT) and 122 patients in the RCR cohort (40 BC+IP-PT, 82 IP-PT). In both cohorts, changes in ASES score, VAS pain, forward flexion, external rotation, and internal rotation over 6 months were similar between groups (all FDR-p > 0.05). In the arthroplasty cohort, the hybrid group completed fewer weeks of PT (16 ± 6 vs 22 ± 9 weeks; FDR-p = 0.023), fewer in-clinic visits (19 ± 7 vs 24 ± 10; FDR-p = 0.026), and fewer missed appointments (0 ± 1 vs 1 ± 3; FDR-p = 0.030). In the RCR cohort, the hybrid group completed fewer weeks of PT (18 ± 6 vs 23 ± 7 weeks; FDR-p = 0.026) and fewer in-clinic visits (21 ± 8 vs 27 ± 10; FDR-p = 0.020), whereas missed appointments were similar between groups (FDR-p = 0.190). Complication and reoperation rates were similar in the arthroplasty (BC+IP-PT 9.1% vs IP-PT 11.5%, FDR-p = 1.000; BC+IP-PT 3.0% vs IP-PT 1.9%, FDR-p = 1.000) and RCR cohorts (BC+IP-PT 0.0% vs IP-PT 11.0%, FDR-p = 0.059; BC+IP-PT 0.0% vs IP-PT 2.4%, FDR-p = 1.000). Hybrid telerehabilitation following shoulder surgery was associated with comparable clinical outcomes, as well as fewer weeks of physical therapy and fewer in-clinic therapy sessions, supporting its use as an efficient adjunct to traditional postoperative rehabilitation. Level III; Retrospective Cohort Comparison; Treatment Study.
The purpose of this study was to provide 2-year post-operative clinical outcomes and survivorship of a novel, fully 3D-printed humeral prosthesis. This is a prospective case series of 34 patients who underwent anatomic total shoulder arthroplasty (TSA) with a fully 3D-printed humeral prosthesis. Minimum post-operative follow-up was two years. Patient demographics, clinical outcomes, and radiographic outcomes were collected. X-rays were examined for radiolucent lines surrounding the implant. The primary outcome was TSA survivorship. Secondary outcomes were patient-reported outcome measure (PROM) scores and radiographic findings. At a minimum follow-up of 2 years, there were no revisions or reoperations with a prosthetic survivorship of 100%. At final follow-up, patients had significant improvement in American Shoulder and Elbow Surgeons and visual analog scale scores (P < .001), with a mean post-operative American Shoulder and Elbow Surgeons of 93 and visual analog scale of 0.5. The rate of any periprosthetic radiolucent line on X-ray was 2 of 34 (6%). All identified radiolucent lines were <0.5 mm. The results of early clinical follow-up of this fully 3D-printed, off-the-shelf humeral prosthetic are encouraging. Post-operative radiolucent lines appear to be minimal in thickness, infrequent, and of unclear clinical significance given 100% survivorship and reassuring PROMs. Further clinical follow-up of this and other 3D-printed systems is necessary to confirm that additive manufacturing is a mechanically durable and viable method for off-the-shelf TSA manufacturing.