The purpose of this study is to examine the effect of humeral abduction, as expressed by the humeral abduction resting angle (HARA) and scapular HARA (SHARA) on the LSA and DSA using a) 3D CT-derived rTSA preoperative models, and b) consecutive postoperative radiographs obtained at multiple follow-up time points. 3D CT-derived models generated using preoperative planning software and postoperative radiographs of patients who underwent rTSA using the Medacta Shoulder System, with at least one year of follow-up, were analysed. In the 3D models, HARA was adjusted to 10°, 20°, and 30°, and LSA and DSA were measured at each position and compared using one-way ANOVA. For each patient, consecutive radiographs were obtained on postoperative day 1 and at 3, 6, and 12 months postoperatively. HARA and SHARA was measured on each radiograph. Then, pairs of consecutive radiographs were grouped according to their difference in HARA: <10°, 10°-20°, and >20°. Independent-samples t-tests were used for pairwise comparisons. Intra-rater reliability and inter-rater reliability were evaluated using the intra-class correlation coefficient (ICC). Pearson's and Spearman's coefficients were applied to investigate possible correlations. In total, 45 preoperative 3D models and 135 postoperative radiographs were analysed. In the 3D model analysis, mean DSA decreased from 48° at 10° of HARA to 44° at 20°, and 39° at 30° (p<0.001), whereas mean LSA increased from 84° at 10° of HARA to 86° at 20°, and 89° at 30° (p<0.001). When examining radiographs, variability in HARA was present in 95% of the cases. The mean HARA difference between pairs of consecutive radiographs was 10° ± 10°. All comparisons performed in the respective pairs of radiographs showed the same pattern: in every pair, the radiograph with the higher HARA and SHARA demonstrated significantly higher LSA and significantly lower DSA (p < 0.001). The intra-rater ICC was 0.98 for DSA and 0.99 for LSA for 3D measurements, whereas the inter-rater ICC was 0.77 for DSA, 0.79 for LSA, 0.86 for HARA, and 0.81 for SHARA for radiographic measurements. There was a statistically significant, moderate positive correlation between HARA, SHARA and LSA and a statistically significant moderate to strong negative correlation between HARA, SHARA and DSA in both 3D models and radiographs (p < 0.001). In conclusion, this study shows that shoulder resting abduction significantly affects both LSA and DSA after rTSA. Higher humeral abduction results in higher LSA and lower DSA in both 3D models and radiographs. Humeral abduction should therefore be taken into account when planning lateralization and distalization in rTSA, and it should be controlled in future studies evaluating correlations with clinical outcomes.
Current patient-reported outcome measures (PROMs) are long, have complex scoring systems, suffer from ceiling and floor effects, are not universally applicable, and have a high administrative burden. In response, we have developed the Subjective Shoulder Scale (S3), a novel PROM designed to overcome these limitations and provide a comprehensive, efficient, and patient-centered evaluation of 7 key domains. Items for S3 were generated by reviewing existing questionnaires and refined using input from patients and an expert panel. Seven questions assess pain, range of motion, strength, shoulder stability, activities of daily living, sports and leisure activities, and mental well-being. After pilot testing in 20 participants, test-retest reliability was evaluated in 100 participants by calculating Cronbach's alpha and the intraclass correlation coefficient. To test validity and responsiveness, 124 participants completed both the S3 and the American Shoulder and Elbow Surgeons questionnaire before and after undergoing various shoulder procedures. Pearson's correlation coefficients, exploratory factor analysis, and responsiveness were determined by calculating the effect size and establishing thresholds for the minimal clinically important difference, substantial clinical benefit, and patient-acceptable symptom state. Pilot testing confirmed clarity, relevance, readability, and ease of use. In the full psychometric evaluation cohort of 244 participants (mean ± standard deviation age 59 ± 13 years; 50% females), the S3 exhibited excellent test-retest reliability (intraclass correlation coefficient = 0.96) and high internal consistency (Cronbach's α = 0.93). No ceiling or floor effects were observed. Exploratory factor analysis supported a unidimensional structure, and convergent validity was established through a strong positive correlation with the American Shoulder and Elbow Surgeons questionnaire (r = 0.71, P < .001). S3 is also responsive, with thresholds of 12.4 points for minimal clinically important difference, 19.9 points for substantial clinical benefit, and 38-83 points for patient acceptable symptom state. S3 is a reliable, valid, responsive PROM for capturing the effects of diverse shoulder conditions. By addressing weaknesses of existing questionnaires, S3 may facilitate personalized treatment planning through more efficient, meaningful patient evaluations.
The utility and optimal threshold for serum laboratory tests taken prior to revision shoulder arthroplasty are unknown. We performed a multi-institutional study of consecutive revision shoulder arthroplasties to define the optimal thresholds of serum laboratory samples to predict bacterial presence in intraoperative cultures with and without Definite Periprosthetic Joint Infection (PJI). Multicenter data was collected on 579 revision shoulder arthroplasties. Preoperative serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complete blood count differentials, and ratios were reported. Analysis was stratified based on International Consensus Meeting (ICM) Definite and Non-Definite PJI and two different thresholds of culture positivity (≥2 or ≥3). Receiver operating characteristic (ROC) curves were constructed, and area under the curve (AUC), optimal thresholds, and diagnostic utility for each test were calculated. Eighty-three patients (14%) had Definite PJI per ICM criteria while 496 (86%) had Non-Definite PJI. Cutibacterium was the most common bacteria recovered in both Definite PJI and Non-Definite PJI. For Definite PJI using a threshold of ≥3 positive cultures, AUC values were 0.543 for ESR and 0.659 for CRP. Optimal thresholds based on ROC curves were 50.5 mm/hr for ESR and 5.9 mg/L for CRP. Sensitivity and specificity were 0.422 and 0.714, respectively, for ESR and 0.818 and 0.536, respectively, for CRP. For Non-Definite PJI, the AUC value was below 0.5 for ESR indicating the test was worse than chance. AUC values for CRP were 0.533 and 0.540 using thresholds of ≥2 and ≥3 positive cultures, respectively. Optimal threshold based on ROC curves were 9.1. This is the first large-scale, multicenter study of consecutive revision shoulder arthroplasties analyzing the utility of preoperative serum laboratory values in predicting positive intraoperative cultures. Overall diagnostic utility of these tests in predicting bacterial presence is low in the setting of both Definite and Non-Definite PJI, particularly serum ESR. In approaching patients with more obvious clinical symptoms (Definite PJI), optimal cutoff values are 50 mm/hr for ESR and 10 mg/L for CRP. When approaching workup of a patient without obvious signs of infection (Non-Definite PJI), serum ESR and CRP have limited value in predicting presence of bacteria at the time of revision arthroplasty.
Coronal shear fractures of the distal humerus are rare but severe injuries. Reconstruction is often challenging, especially in comminuted cases, which is why many surgeons opt for an elbow arthroplasty in those cases. However, total elbow arthroplasty is associated with a variety of potential problems itself. Therefore, the aim of this study was to present the functional and clinical outcome of coronal shear fractures treated by osteosynthetic reconstruction in a short- to mid-term follow-up, and to identify possible risk factors for an inferior outcome. We performed a retrospective follow-up assessment of 51 consecutive patients (30 women; median age 56 years, (IQR 39-62)) who underwent osteosynthetic reconstruction for coronal shear fractures between 2012 and 2022 after a minimum follow-up period of two years. The Mayo Elbow Performance Score, Oxford Elbow Score, and Disabilities of the Arm, Shoulder and Hand score were evaluated, and all available radiographs were analyzed. All complications and revision procedures were assessed. Univariable and multivariate regression analyses were performed to identify potential risk factors for a poor outcome following osteosynthetic reconstruction. After a median follow-up period of 43 (IQR 28-78) months, the median Mayo Elbow Performance Score was 100 (IQR 85-100), the median Oxford Elbow Score was 42 (IQR 34-46), and median Disabilities of the Arm, Shoulder and Hand score was 6 (IQR 2-28). The median ROM was 148° (IQR 126-155) for flexion, 0° (IQR 0-0) for extension, 90° (IQR 85-90) for pronation, and 90° (IQR 85-90) for supination. There was no extension deficit on the injured site. The overall complication and reoperation rates were 35.3% and 27.4%, respectively, with severe elbow stiffness being the most common reason for revision. Increasing Dubberley classification and posterior comminution were significantly associated with a poor outcome and higher rates of complications and revision. This short- to mid-term follow-up shows good functional results after osteosynthetic reconstruction in coronal shear fractures despite high complication and revision rates. However, increasing Dubberley classification, posterior comminution and the presence of complications show inferior outcome scores. This study shows that osteosynthetic reconstruction can be an option even in comminuted coronal shear fractures. Nevertheless, patient factors need to be considered and an individual decision concerning the surgical treatment is necessary. Patients should be counseled about the high complication rates and inferior outcome with increasing Dubberley classification. Level III.
Optimizing patient outcomes in reverse total shoulder arthroplasty remains a subject of ongoing research. Newly described radiographic angles allow the determination of the glenoid and humeral component contributions to lateralization and distalization, which might play a role in patient outcomes. Thus, this study aims to explore the effect of radiographically measured glenoid versus humeral lateralization and distalization on patient reported outcomes and reoperation. 217 consecutive patients who underwent rTSA from November 2016 to August 2022 were retrospectively reviewed. Pre-operative and final follow-up subjective shoulder value (SSV), visual analogue scale for pain (VAS), and American Shoulder and Elbow Surgeons Score (ASES), and unplanned reoperations were recorded. Preoperative and postoperative Lateralization Shoulder Angle (LSA) and Distalization Shoulder Angle (DSA) were also recorded. Postoperative Glenoid Lateralization Angle (GLA), Humeral Lateralization Angle (HLA), modified Distalization Shoulder Angle (mDSA), Glenoid Distalization Angle (GDA), and Humeral Distalization Angle (HDA). Correlations between different pairings of radiographic angular measurements were calculated along with correlations between individual radiographic measurements and each patient reported outcome measure. Greater positive change from preoperative to postoperative LSA and smaller postoperative DSA were significantly correlated with improved SSV in both univariable and multivariable analysis. A larger decrease from preoperative to postoperative LSA was associated with higher odds of reporting VAS > 0 on univariable analysis at follow up. Otherwise, there were no associations between radiographic measurements and postoperative outcome scores. The strongest correlation for postoperative lateralization measurements was between LSA and HLA (r = +0.83) and for postoperative distalization measurements was between mDSA and GDA (r = +0.72). Greater postoperative LSA and HLA values had higher odds of reoperation (post LSA OR = 1.11; p = 0.011, post HLA OR = 1.10; p = 0.047). Greater positive change from preoperative to postoperative LSA was associated with improved subjective-shoulder value scores. Lower global distalization was associated with greater subjective-shoulder value scores. While global lateralization may be beneficial in moderation along with limiting global distalization, the independent effects of glenoid or humeral-sided lateralization or distalization measured radiographically may have a lesser impact on patient reported outcomes.
Failed shoulder arthroplasty often presents with glenoid bone loss, posing a challenge for both surgeons and patients. This study aimed to evaluate the available revision strategies for failed shoulder arthroplasty in the presence of severe glenoid bone loss. Severe bone loss was defined as a glenoid that is not capable of reconstruction using a standard reverse total shoulder glenoid or augmented baseplate. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PubMed and Google Scholar were systematically searched for (Revision) AND (Glenoid bone loss) AND (Arthroplasty), AND (Shoulder) by 2 authors independently. Statistical analysis was performed using RevMan software. Initially, 249 references were retrieved. After duplicate removal and abstract and title screening, 40 full-text studies comprising of 656 patients met eligibility criteria. The mean patient age was 67.7 years (range, 62.4-71.2), with a mean follow-up of 33 months (range, 16-50). Regarding functional outcomes, custom glenoid implants demonstrated the greatest improvements in American Shoulder and Elbow Surgeons and Constant scores, with mean differences (MDs) of 42.4 and 35.8, respectively (P < .001 for both). Custom implants also provided the best pain relief (MD: 5.79, P < .001). For range of motion, bone grafting with reverse total shoulder arthroplasty provided the best improvements in external rotation (MD: 21.0°) and forward flexion (MD: 67.4°) (P < .001 for both). Custom glenoid implants provided the best functional outcomes and pain relief in revision shoulder arthroplasty with glenoid bone loss. The findings of this study would suggest that given in the short term of superior performance in improving pain, with higher American Shoulder and Elbow Surgeons and Constant scores, custom glenoid components warrant further long-term study of these issues and long-term survival of the implants.
Margin convergence repair is a technique that embraces the philosophy of "harnessing the ox rather than roping the bull" for the repair of massive rotator cuff tears and has been shown to provide satisfactory functional outcomes. However, previous studies have generally relied on traditional scoring systems, leaving the clinical relevance of the outcomes from the patient's perspective and the effect of patient characteristics on these results largely unknown. Therefore, this study aimed to evaluate the Minimal Clinically Important Difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) in patients who underwent arthroscopic margin convergence repair for massive rotator cuff tears and to analyze the impact of patient-related factors on functional recovery. Regarding predictors, we hypothesized that patients with older age and larger sagittal tear size would be less likely to achieve clinically meaningful outcomes. This retrospective case series study was conducted on patients who underwent arthroscopic repair for massive rotator cuff tears between 2014 and 2023. Patients who underwent partial margin convergence repair using a combination of tendon-to-tendon sutures and anchor fixation were included in the study. The evaluation comprised the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), visual analog scale (VAS), and range of motion (ROM) measurements. The proportion of patients who achieved the thresholds for the MCID, SCB, and PASS were identified based on the ASES, SSV, and VAS. Regression analysis was conducted to determine the predictors of achieving these thresholds. The study included 60 patients (mean age 62.5 ± 9.2 years; mean follow-up 66.0 ± 36.1 months). The thresholds for MCID, PASS, and SCB were 24.5, 69.0, and 41.5 for ASES; 25.0, 62.5, and 32.5 for SSV; and 2.0, 2.5, and 4.5 for VAS, respectively. The proportions of patients who achieved these thresholds were as follows: ASES (83%, 75%, 68%), SSV (78%, 73%, 72%), and VAS (83%, 77%, 63%). Older age was associated with lower odds of achieving MCID, PASS, and SCB, similarly a larger sagittal tear size and longer symptom duration reduced the odds of reaching PASS and SCB. Partial repair using the margin convergence procedure is an effective treatment for massive rotator cuff tears, with the majority of patients achieving clinically meaningful outcomes at a minimum follow-up of 2 years. Lower rates of clinical success can be expected in patients with older age, longer symptom duration, and larger sagittal tear size.
Return to sport (RTS), particularly golf, and athletic performance following reverse (rTSA) and anatomic (aTSA) shoulder arthroplasty remain largely understudied. Moreover, limited data exist on characteristics that predict successful RTS. This study aimed to evaluate return to golf after shoulder arthroplasty, as well as identify patient factors associated with optimal return to play. A multicenter analysis utilizing RTS questionnaires was distributed to patients undergoing rTSA or aTSA at 17 institutions. We assessed preoperative golf participation, return to golf postoperatively, golf performance relative to preoperative level, and frequency of golf participation. Overall subjective satisfaction with their operative shoulder during golf activities was assessed numerically (0-10). Two separate age and sex matched propensity score analyses were performed; first to compare rTSA and aTSA performed for osteoarthritis with an intact rotator cuff (GHOA), and second to compare rTSA performed for GHOA and rotator cuff arthropathy (RCA). Golf-specific outcomes included change of self-reported handicap and driving distance before and after surgery, as well as whether hand dominance influenced outcomes. 208 patients reported golf participation, with a mean follow-up of 24.3 ± 5.7 months. The cohort was 77.9% male, with a mean age of 69.0 ± 7.9 years and BMI of 29.0 ± 5.5. Postoperatively, 88.9% (n=185) returned to golf, and 79.3% (n=165) reported that their performance improved/remained unchanged. Most patients (46.8%) returned within 3-6 months, and another 31.7% between 7-12 months. After propensity score matching, 91 rTSA and 48 aTSA patients were analyzed. Return-to-golf rates were similar (rTSA 95.6% vs. aTSA 90.0%, P=0.313), as were rates of maintained/improved performance (84.6% vs. 81.3%, P=0.313). No significant differences were found in pre- or postoperative handicap, driving distance, or outcomes based on surgery on the dominant vs. nondominant side. Patients demonstrate a high rate of returning to golf following both rTSA and aTSA. Among golfers the ability to return to play and performance level was comparable between arthroplasty types. No significant differences were observed between rTSA and aTSA in terms of postoperative handicap, driving distance, or side of surgery relative to hand dominance. However, despite these similarities, revision arthroplasty was independently associated with worse postoperative patient perceived golf performance. As the number of active patients undergoing shoulder arthroplasty continues to rise, the ability to provide sport-specific counseling is essential for setting realistic expectations and supporting recovery.
Proximal humerus fractures (PHFs) account for 5% to 6% of all adult fractures. The optimal surgical management for PHFs remains under debate, with 2 of the most common operations being open reduction and internal fixation (ORIF) and reverse total shoulder arthroplasty (rTSA). Social determinants of health (SDOHs) have gained particular attention in many medical fields because of their relationship to health outcomes, with the Social Vulnerability Index (SVI) as an example of an adopted measure of geographic disadvantage. The purpose of this study was to investigate the associations between SVI percentiles and insurance status to adverse postoperative outcomes following surgical treatment of PHFs using either ORIF or rTSA. This was a retrospective chart review of patients with PHFs who were treated surgically with either ORIF or rTSA between 2016 and 2023 at a large metropolitan health care system. Patient demographics were recorded, and SVI percentiles were determined using patient addresses. Demographic variables were descriptively analyzed based on type of surgery and SVI quartile group. Univariate and multivariate logistic regression analyses were conducted to investigate associations between SVI percentiles and insurance status to adverse postoperative outcomes. A total of 215 patients with PHFs were included in this study, with 118 in the ORIF group and 97 in the rTSA group. From the multivariate analysis in the ORIF group, there was an association with increasing SVI percentiles and higher odds of returning to the emergency department (odds ratio [OR] = 1.023, P = .002) and having a hospital readmission (OR = 1.028, P = .001). Additionally, patients in the ORIF group with private insurance had lower odds of hospital readmission (OR = 0.077, P = .001) compared with patients who had Medicaid. Patients in the rTSA group did not have significant associations with adverse postoperative outcomes based on increasing SVI percentiles or insurance status. This study demonstrated that higher SVI percentiles and Medicaid status were associated with adverse postoperative outcomes in patients who underwent ORIF for treatment of their PHFs. Higher SVI percentiles and insurance status did not appear to be associated with adverse postoperative outcomes in the rTSA group. This study highlighted the way in which SDOHs and choice of surgery relate to adverse postoperative outcomes in patients with PHFs.
Total shoulder arthroplasty, especially reverse shoulder arthroplasty, has expanded rapidly, yet contemporary national trends and projections relative to hip and knee arthroplasty are not fully defined. This study evaluates trends of shoulder arthroplasty in the United States from 2012 to 2022 and projects volumes through 2035. The National Inpatient Sample (NIS) and National Ambulatory Surgery Sample (NASS) were analyzed using ICD and CPT codes to identify shoulder, hip, and knee arthroplasty procedures. Annual procedural volume and incidence per 100,000 population were calculated by age and sex. Linear, log-linear, and logistic regression models projected future trends to 2035. Between 2012 and 2022, total shoulder arthroplasty increased 212% from 55,245 to 172,559 procedures, with incidence rising from 17.6 to 51.7 per 100,000. In the same time period, total hip and knee arthroplasty increased by 45% and 25%, respectively. Shoulder hemiarthroplasty declined by 55%. Growth was observed across all age and sex groups, with the largest increase in patients aged 65 to 74 years. Log-linear projections show that the growth rate of total shoulder arthroplasty exceeds the growth rate of hip and knee arthroplasty, with estimates in 2035 reaching 334,000 to 905,000 procedures. Our study demonstrates that shoulder arthroplasty continues to grow exponentially while shoulder hemiarthroplasty declines. These trends highlight the importance of healthcare planning, surgical workforce preparation, and patient counseling for an aging population with expanding shoulder arthroplasty indications.
Reverse shoulder arthroplasty (rTSA) is increasingly used as a revision option, but long-term survivorship and patient-reported outcomes (PROs) after revision rTSA remain poorly defined. We hypothesized that revision rTSA for failed reverse shoulder arthroplasty (failed rTSA) would have inferior survivorship and patient reported outcomes when compared to revision rTSA for failed anatomic total shoulder arthroplasty (failed aTSA) or failed hemiarthroplasty (failed HA). Moreover, we hypothesized that that shoulders undergoing secondary revision would have a higher risk of failure when compared to those undergoing first-time revision surgery. This study is a retrospective review of a prospectively collected, single-surgeon institutional database from 2002-2022. Patients undergoing first-time revision rTSA for aseptic mechanical failure of a prior arthroplasty were included if they had ≥12 months of follow-up or required subsequent revision within 12 months. Survivorship was assessed using Kaplan-Meier analysis. PROs (ASES scores and satisfaction) were collected at one year, with subgroup analysis by index failed arthroplasty type: failed HA, failed aTSA, and failed rTSA. Modes of failure after secondary revision were also examined. Statistical significance was set at P<0.05. Of 464 first-time revision rTSA for mechanical failure from 2002-2022, 320 revision rTSAs had appropriate follow-up and met inclusion criteria, with mean follow-up of 50.3 ± 45.7 months. Mean age was 67.4 ± 10.0 years; 54.1% were female. Overall survivorship of revision rTSA was 86.4% at 2 years, and 71.4% at 10 years. In terms of survivorship stratified by index arthroplasty, the survivorship of failed HA, failed aTSA, and failed rTSA was the following: failed HA: 2-year 93.4% and 10-year 74.2%; failed aTSA: 2-year 88.6% and 10-year 82.1%; failed rTSA: 2-year 74.6% and 10-year 59.5%. Overall survivorship was inferior in shoulders revised from failed rTSA compared with failed HA or failed aTSA (P<0.001). At one year, the overall cohort reported mean ASES of 61.3 ± 25.0, with 48.8% achieving patient acceptable symptom state (PASS). Shoulders revised from failed rTSA had lower ASES scores (53.3 ± 26.2) than those revised from failed HA (63.3 ± 23.1) or failed aTSA (64.3 ± 25.0) (p=0.008). Of the 320 revision rTSAs, 58 (18.1%) required secondary revision; mechanisms of failure included instability (5.0%), humeral loosening (4.1%), infection (4.1%), glenoid failure (3.4%), and periprosthetic fracture (1.6%). Of these, 17 (29.3%) underwent tertiary revision. Secondary revisions due to humeral loosening showed the highest hazard for tertiary failure. Revision rTSA for mechanical failure demonstrates modest long-term durability and functional improvement, with over 70% survivorship at 10 years. However, less than half of patients achieved acceptable symptom states at short term follow-up. Specifically, revision from failed rTSA yields inferior survivorship and patient-reported outcomes when compared to failed aTSA or failed HA. Secondary revision procedures carried greater risk of failure, with humeral loosening remaining particularly difficult to manage. These findings highlight the need for careful patient counseling and ongoing investigation into strategies to improve survivorship after revision rTSA.
Aseptic glenoid loosening is the most common cause of revision after anatomic total shoulder arthroplasty (aTSA). Inlay glenoid components have been shown to reduce edge loading and opposite-edge lift-off forces compared with onlay glenoids. Early clinical results of inlay glenoids have been promising, although there is a paucity of literature detailing mid- to long-term follow-up. We report the minimum five-year clinical and radiographic outcomes after aTSA with the Arthrosurface inlay glenoid component and a stemless, aspherical humeral head in an active, young patient population. A retrospective review of aTSA with an inlay glenoid component and an aspherical humeral head component was performed for 45 shoulders. Patients were evaluated with patient-reported outcome measures, range of motion, and radiographs. Return to occupational and sporting activity, complications, and reoperations were analyzed. A total of 45 patients were available for an average follow up of 82.2 ± 21.7 months. The average age of the cohort was 54.9 +/- 7.6 years and 41/45 (91.1%) were males. ASES, VAS, SANE, and SF-12 physical patient reported outcome measures (PROMs) were all significantly improved. Each of these improvements in PROMs also exceeded the established minimum clinically important difference (MCID). Active forward elevation significantly improved from 116.0 +/- 28.4 degrees pre-operatively to 158.8 +/- 20.6 degrees post-operatively. Active external rotation significantly improved from 26.0 +/- 14.5 degrees to 53.3 +/- 16.2 degrees. Five total patients underwent a revision shoulder arthroplasty during the study period. Four had revision to a reverse total shoulder arthroplasty (rTSA) for subscapularis failure (2), superior rotator cuff failure (1), and stiffness (1). No patient was revised for symptomatic glenoid loosening. Another patient had an antibiotic spacer placed for infection. Among the 30 patients with five-year radiographic follow-up, there was no significant progression of radiolucency around the glenoid component between initial post-operative films and final follow-up. Anatomic total shoulder arthroplasty with the Arthrosurface inlay glenoid coupled with a stemless, aspherical humeral head in a young, active population results in durable improvements in function and range of motion with minimal evidence of glenoid loosening at mid-term follow-up.
Reverse total shoulder arthroplasty (rTSA) consistently improves pain and function; however, the biomechanical mechanisms underpinning post-operative function and joint-level adaptations remain incompletely defined. Advanced measurement tools, including motion capture, electromyography (EMG), inertial measurement units, and accelerometry, enable objective assessment of joint motion, muscle activation, and real-world arm use. This systematic review synthesizes evidence from studies using advanced biomechanical methods to evaluate post-operative kinematics, upper-limb activity, and muscle activation after rTSA. Seven databases (1985-2025) were searched for observational studies reporting quantitative biomechanical outcomes after rTSA, compared with pre-operative baselines, contralateral shoulders, or healthy controls. Outcomes were categorized as kinematics, real-world upper-limb activity, or neuromuscular activation. Methodological quality was assessed using Joanna Briggs Institute criteria, and levels of evidence were classified according to Journal of Shoulder and Elbow Surgery guidelines. Twenty-four studies (10 cohort and 14 case-control; all Level III) met inclusion criteria. Twenty-one had moderate risk of bias and 3 high risk. Implant designs, surgical indications, and follow-up durations were heterogeneous. High-rigor optical and electromagnetic motion capture studies showed consistent gains in forward elevation, while glenohumeral contribution, axial rotation, and scapulohumeral rhythm remained reduced relative to contralateral or healthy shoulders. Elevation occurred predominantly through increased scapulothoracic upward rotation, retraction, and posterior tilt. Laboratory-based inertial measurement unit studies showed similar patterns of greater scapular contribution despite nonstandardized coordinate systems. Wearable sensors reported increased post-operative arm use and improved interlimb symmetry, although time spent above shoulder height remained limited. EMG studies demonstrated increased deltoid and upper-trapezius activation with limited posterior cuff recruitment. rTSA restores forward elevation primarily via compensatory scapulothoracic motion and deltoid-driven neuromuscular strategies rather than normalization of glenohumeral mechanics. Standardized, longitudinal studies integrating high-fidelity kinematics, EMG, and real-world activity monitoring, with explicit reporting of implant construct parameters, are needed to clarify how surgical technique and implant design influence post-operative biomechanics and functional recovery.
Many patients undergoing shoulder arthroplasty - either reverse shoulder arthroplasty (rTSA) or anatomic shoulder arthroplasty (aTSA) - strongly desire to return to sport, yet return-to-sport (RTS) outcomes remain incompletely defined. This study aimed to determine RTS rates following rTSA and aTSA and to identify patient- and sport-specific factors associated with postoperative athletic performance. A multicenter retrospective analysis with prospective administration of RTS questionnaires was conducted among patients who underwent rTSA or aTSA between one and three years postoperatively. Twenty-four ASES surgeons from 17 U.S. institutions participated. Study design and parameters were defined using a Delphi consensus method. The RTS questionnaire assessed participation in seven sports: golf, pickleball, tennis, running, weightlifting, yoga, and swimming. Outcomes included RTS status, changes in performance, enjoyment, participation frequency, time to RTS, and shoulder satisfaction (0-10). Univariate ANOVA compared outcomes across sports. Two age- and gender-matched propensity score analyses compared (1) rTSA versus aTSA for glenohumeral osteoarthritis (GHOA) and (2) rTSA for GHOA versus rotator cuff arthropathy (RCA). Multivariate logistic regression identified predictors of worse postoperative performance. A total of 961 patients completed the questionnaire; 55.9% (n=537) participated in at least one sport preoperatively and attempted RTS postoperatively, yielding 656 sport participations. Mean follow-up was 24.0 ± 8.1 months, mean age was 68.3 ± 8.2 years, mean BMI was 28.5 ± 5.8, and 65.6% were male. Across all sports, 89.2% of participants were still playing, and 80.2% reported improved or unchanged performance, with no differences between sports. Overall RTS rates were highest for running (92.9%), tennis (92.3%), and weightlifting (93.1%). Most patients returned within 3-6 months (44.7%). In matched GHOA cohorts (n=165 each), rTSA demonstrated higher rates of improved or stable performance (87.9% vs 78.9%, P=0.039) and greater satisfaction (P=0.007) compared to aTSA, with similar RTS rates (93.3% vs 89.1%). Diagnosis of GHOA (OR 0.20, P=0.001) and post capsulorrhaphy arthropathy (OR 0.07, P=0.021) were independently associated with lower odds of worsened postoperative sport performance. Return to sport following shoulder arthroplasty is high, with most patients reporting maintained or improved performance. In patients with GHOA, rTSA was associated with higher rates of improved or stable sport performance and greater satisfaction compared to aTSA.
Glenoid vault defects are often observed in revision shoulder arthroplasty, and improper management of glenoid bone loss during revision to reverse total shoulder arthroplasty (rTSA) increases the risk of complications. However, there is limited understanding of the types of glenoid vault defects that occur in patients. Therefore, the purpose of this study was to three-dimensionally characterize the underlying glenoid morphology of patients with failed shoulder arthroplasties subsequently undergoing revision arthroplasty to rTSA. Computed tomography scans of 100 patients pre-operative to revision arthroplasty to rTSA (Revision Group) and 35 healthy cadaveric control scapulae (Control Group) were three-dimensionally reconstructed. A negative projection glenoid vault was created and residual screw or peg holes were removed and smoothed. Glenoid defects were quantified using various size, area, volume, and geometric measures of the negative projection and the glenoid. A cluster analysis was performed on the Revision Group to group patients based on glenoid shape and find patterns in the underlying glenoid morphology using principal measures: normalized distance (height; width; maximum projection thickness; smoothed maximum residual vault thickness), angular (anterior tilt; inclination; version), and radius of curvature (ROC) (superior-inferior ROC; anterior-posterior ROC; vault-sphere ROC). When compared to the Control Group, the measures of the Revision Group showed more variation with higher standard deviations. The cluster analysis formed two clusters, between which 6 of the principal measures had statistically significant differences. Of the principal measures, Cluster A had larger height and maximum projection thickness, more retroversion, and smaller ROCs when compared to Cluster B. Of the other measurements, projection volume, lateral surface area, circumferential surface area, and height-width ratio were larger in Cluster A than in Cluster B. Glenoid morphology after failed arthroplasty is highly variable and may require novel defect management strategies. Additionally, the formation of clusters based on glenoid morphology indicates that patterns exist in the types of glenoid defects, highlighting a need to further investigate a three-dimensional classification system and potentially new standardized revision implant component designs for revision to rTSA cases.
Olecranon fractures are common fractures of the elbow and may lead to symptomatic post-traumatic osteoarthritis (OA). The incidence and risk factors for ulnohumeral OA after an olecranon fracture remain uncertain. Therefore, this review aimed to: 1) determine the incidence of OA following isolated olecranon fractures; 2) assess the role of instability and comminution in the development of OA, and 3) assess the impact of OA on patient-reported outcome measures (PROMs). Multiple medical databases were searched for studies containing the terms "olecranon", "osteoarthritis", and "fracture". Studies were screened for predetermined inclusion and exclusion criteria, including a minimum follow-up of 24 months and radiographic assessment of OA. Patient and treatment characteristics were collected alongside clinical and functional outcomes. The studies' methodological quality was assessed using the MINORS criteria. The Mayo classification was used to assess olecranon fractures for comminution and instability, categorizing them into three types: type 1 (non-displaced, stable), type 2 (displaced, stable), and type 3 (displaced, unstable). Each type is subdivided into A (non-comminuted) or B (comminuted). Due to a high degree of heterogeneity, pooling of the data was avoided; instead, results were summarized using ranges, medians, and interquartile ranges. Eleven studies were included, comprising a total of 362 patients with a median follow-up of 41 months (Range: 27-240; IQR: 29-74). The MINORS scores for these studies ranged from poor to moderate. The median OA incidence across these studies was 19% (Range: 0%-35%; IQR: 3%-26%). The median OA incidence was 25% (Range: 0%-50%; IQR: 13%-38%) for Mayo type 1 fractures, 16% (Range: 0%-30%; IQR: 0%-25%) for type 2, and 50% (Range: 40%-100%; IQR: 45%-75%) for type 3. For non-comminuted fractures (type 2A), the median OA incidence was 16% (Range: 0%-28%; IQR: 0%-18%), while for comminuted fractures (type 2B), the median was 24% (Range: 0%-38%; IQR: 17%-30%). Mayo Elbow Performance Score (MEPS) scores for patients with OA were reported in 3 studies with a median score of 93 (Range: 83-94). The median MEPS across all included studies was 92 (Range: 86-98; IQR: 90-96). This review identified a median OA incidence of 19% at a median follow-up of 41 months following isolated olecranon fractures. However, final PROMs ranged from good to excellent regardless of fracture type or the presence of OA. Given that all studies were heterogeneous and of poor to moderate quality, additional larger studies with preferably prospective designs are needed to assess if comminution or instability affects the development of ulnohumeral OA even after appropriate surgical treatment.
Revision total elbow arthroplasty is technically demanding and carries a substantial risk of postoperative neurological complications because of scarring, altered anatomy, implant removal, and repeated humeral and ulnar exposure. The incidence, nerve distribution, and recovery profile of nerve injury after revision total elbow arthroplasty remain incompletely defined. This study aimed to systematically review the literature to define the incidence, recovery profile, and risk factors for nerve injury after revision TEA. A systematic review of the literature was performed in accordance with PRISMA guidance. Thirteen retrospective case series were included, comprising 282 revision total elbow arthroplasties in 271 patients. Random-effects meta-analysis of proportions was undertaken where the data permitted. The primary outcome was postoperative nerve injury following revision total elbow arthroplasty. Secondary outcomes included nerve type, recovery, secondary nerve-related procedures, infection, triceps insufficiency, metallosis, periprosthetic fracture, and re-revision. The pooled incidence of postoperative nerve injury was 22.3% (95% CI 16.3 to 29.6; I2 = 34.6%). The crude incidence was 60 of 282 revisions (21.3%, 95% CI 16.6 to 26.5). The ulnar nerve was involved in 66.7% of all nerve injuries, the radial nerve in 31.7%, and the median nerve in 1.7%. No significant difference in pooled nerve-injury incidence was identified between studies published before 2010 and those published from 2010 onwards (22.9% vs 21.4%, p = 0.837). Recovery reporting was heterogeneous; among injuries with numerically extractable outcomes, 85.4% improved partially or completely (95% CI 72.2 to 93.9). Secondary nerve-related procedures were reported in seven studies. Pooled complication estimates were 10.2% for infection, 13.6% for triceps insufficiency, 25.5% for metallosis, 15.9% for periprosthetic fracture, and 14.0% for re-revision. Postoperative nerve injury is a common and clinically important complication of revision total elbow arthroplasty, affecting approximately one in five cases. The ulnar nerve is most frequently involved, although radial nerve injury accounts for a substantial proportion of cases. Many neuropathies improve during follow-up, but persistent deficits and the need for secondary nerve-related procedures are not uncommon. Future studies should adopt standardised neurological definitions and reporting to improve comparability and guide preventive surgical strategies.
Outpatient total shoulder arthroplasty (TSA) is increasingly performed as perioperative pathways and value-based care models expand. However, a subset of patients scheduled for outpatient TSA require unexpected inpatient admission, which may indicate higher perioperative risk and increased resource use. We hypothesized that older age, greater comorbidity burden, and longer operative time would be associated with conversion from planned outpatient TSA to inpatient admission, and that conversion would be associated with worse short-term outcomes. Planned outpatient TSA cases were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2021. Revision arthroplasty, hemiarthroplasty, procedures for infection or malignancy, fracture-related cases, emergency or other nonelective cases, records with missing length of stay (LOS), and extreme LOS outliers were excluded. All included cases were planned outpatient procedures; patients with LOS 0-1 day comprised the Outpatient cohort, and those with LOS ≥2 days comprised the Conversion-to-Inpatient cohort. Demographics, comorbidities, operative time, and 30-day outcomes were compared between groups, and multivariable logistic regression identified independent predictors of conversion and associations with adverse events. A total of 6,755 planned outpatient TSA cases met inclusion criteria, including 6,302 (93.3%) Outpatient and 453 (7.2%) Conversion-to-Inpatient cases. Compared with Outpatient patients, the Conversion-to-Inpatient cohort was older (70.3 ± 9.6 vs 68.0 ± 9.5 years), more often female, and more frequently Hispanic, with higher BMI and a greater proportion of American Society of Anesthesiologists class ≥3 and comorbidities (all P < .05). Mean operative time was longer among converted patients (127.9 ± 59.3 vs 104.7 ± 40.8 minutes, P < .001). On multivariable analysis, older age, female sex, Hispanic ethnicity, ASA ≥3, diabetes, COPD, and longer operative time were independent predictors of conversion. Conversion-to-Inpatient status was associated with higher odds of 30-day reoperation, overall morbidity, bleeding transfusion, and non-home discharge, while adjusted 30-day readmission did not differ significantly between cohorts. Unplanned conversion from outpatient to inpatient status occurs in approximately 7% of planned outpatient TSAs and is associated with identifiable demographic, comorbidity, and operative risk factors, as well as higher morbidity, transfusion requirements, and non-home discharge. These findings may help inform patient counseling and perioperative planning for outpatient TSA pathways.
It has previously been considered that approximately 30% of acute traumatic posterior sternoclavicular joint (SCJ) injuries are associated with a significant injury to the retrosternal structures. However, over the past 50 years there have only been a handful of such cases described in the literature. We have undertaken a computed tomography (CT) arteriogram within 48 hours on a series of patients who have sustained an acute posterior SCJ injury to assess the incidence of associated retrosternal vascular injuries. Between May 2016 and December 2023, patients who had sustained an acute posterior SCJ injury and underwent a CT arteriogram within 24 hours of admission to hospital were reviewed. At the time of injury, the patients were specifically assessed for any associated clinical mediastinal or vascular symptoms. For the patients who underwent operative reduction and stabilization, the retrosternal vascular structures were visualized and assessed. Patient-reported outcomes were assessed at final follow-up by the following scores: short version of the Disabilities of the Arm, Shoulder and Hand (Quick-DASH), Rockwood SCJ Score, Constant score, and the Single Assessment Numeric Evaluation (SANE). Patients were also asked whether they had any specific retrosternal or vascular symptoms. A total of 24 patients were available at final follow-up. Sixteen patients had a posterior SCJ dislocation, and 8 had a posteriorly displaced Salter-Harris II fracture of the medial end of the clavicle. The mean age at the time of injury was 27.6 years (15-69), and the mean follow-up was 77.8 months (25-131). One patient had mediastinal symptoms in the form of dyspnea at the time of injury. On CT arteriogram, there was no evidence of a vascular injury, pseudoaneurysm, or bleeding in any of the patients. Five patients had a hematoma associated with the capsular injury, 13 patients had evidence of compression of the left brachiocephalic vein, and 1 patient had additional compression of the aortic arch. There was no evidence of any vascular injury on inspection in the 20 patients who underwent operative reduction and stabilization. At final follow-up, the mean Quick-DASH score was 2.0 (0-20.3), Rockwood SCJ Score was 14.5 (11-15), Modified Constant Score was 96.7 (69-100), and SANE score was 98.7 (80-100). None of the patients described any associated mediastinal or vascular problems. Following an acute posterior SCJ injury, the incidence of retrosternal vascular injuries is less than had previously been considered. This should allow an adequate window of time for the management of this injury to be undertaken in an appropriate specialist unit.
Various fixation methods of distal biceps brachii tendon rupture (buttons, screws, and anchors) has been shown to have similar outcomes. However, the impact of these different implants on total day-of-surgery costing has yet to be examined. The purpose of this study was to explore the day-of-surgery (DOS) costs between different types of implants used for distal biceps repairs using time-driven activity-based costing (TDABC). A retrospective review of all patients who underwent primary operative treatment for distal biceps rupture from January 2018 through May 2025 within a single medical system was conducted. Inclusion criteria consisted of patients who had surgical repair of a torn distal biceps brachii tendon. Exclusion criteria included having had a surgery other than a distal biceps repair, history of prior surgery on the affected biceps brachii tendon, incomplete costing or implant data, and revision distal biceps repairs. Patient demographics, implant types, operative characteristics, anesthesia data, retear and revision rates, and day-of-surgery (DOS) costing were evaluated. Statistical analyses conducted included descriptive statistics, t-tests, Mann-Whitney U tests, and linear regressions to identify cost drivers. Of the 433 patients who met the inclusion criteria, 96.8% (n=419) were male with a mean age of 50.2±10.1 years and a mean body mass index (BMI) of 31.2±5.8 kg/m2. The average operative time was 59.8±20.1 minutes. Fixation techniques included buttons (42.7%), suture anchors (20.3%), and a combination of buttons and screws (37.0%). The average total DOS cost was $2,146.70±$539.29. Operative times were significantly different between fixation techniques (p=0.002). Retears occurred in only 2 (0.5%) patients, both of whom received only suture anchors for fixation. The total DOS costs for distal biceps repairs were lowest when suture anchors were used and highest when buttons and screws were used. Significant predictors of cost included the type of fixation, operative time, implant manufacture, anesthesia type, and age (all p <0.05). Operative time and total implant cost together accounted for 80.8% of total DOS cost variance. These findings suggest that suture anchors may offer a cost-effective option without compromising clinical outcomes. Within the current atmosphere of value-based care in orthopaedics, these findings can help equip surgeons in efforts to be more cost-aware in decision-making.