Schoch, Bradley S

Background: Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of proximal humerus fractures (PHFs) with reliable clinical improvement. Lateralized RSA implants have conferred superior outcomes compared with the original Grammont design in patients with nontraumatic indications. However, in the setting of a PHF, lateralized components can place increased tension across the tuberosity fracture site and potentially compromise tuberosity healing and outcomes. This systematic review and meta-analysis sought to determine the effect of implant design on clinical outcomes after RSA for PHFs. Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported implant manufacturer details. Our primary outcomes included postoperative external rotation (ER), forward elevation (FE), abduction, Constant score, rate of greater tuberosity (GT) healing, and the incidence of complications compared between medialized vs. lateralized global implant design. Results: Globally lateralized RSA cohorts (478 RSAs total with cumulative lateral offset achieved through humeral or glenoid lateralization or both humeral and glenoid lateralization) were found to have a greater mean postoperative Constant score compared with globally medialized (medialized glenoid and medialized humerus) RSA cohorts with 1,494 total medialized RSAs (66 vs. 59, p = 0.006), but there was no significant difference regarding mean postoperative ER (30° vs. 22°, p = 0.078), FE (117° vs. 119°, p = 0.708), or abduction (103° vs. 107°, p = 0.377). On meta-regression, neither implant design nor tuberosity status significantly influenced postoperative ER, FE, abduction, or Constant score on meta-regression independent of mean follow-up and age at surgery. The rate of GT healing was greater in lateralized compared with medialized RSAs (88% vs. 72%, p < 0.001). On meta-regression, medialized RSA design was associated with a 73% lower odds of GT healing (odds ratio = 0.27, 95% confidence interval = 0.11-0.68, p = 0.007) independent of mean follow-up and age at surgery. Conclusion: Lateralized RSA implants conferred no significant functional benefit over medialized implants when used in patients with PHFs. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background A variety of clinically important benchmarks of success (CIBS) have been defined for total shoulder arthroplasty (TSA) to quantify success. However, it is unclear how the preoperative status of the patient influences their likelihood of achieving each CIBS. Questions/purposes (1) What proportion of patients achieve commonly used CIBS after TSA? (2) Is there a relationship between a patients’ preoperative function and their probability of achieving different CIBS? (3) Does there exist preoperative ranges for each outcome measure that are associated with greater achievement of CIBS? Methods We retrospectively queried a multicenter shoulder arthroplasty database for primary anatomic TSA (aTSA) and reverse TSA (rTSA). A total of 2041 aTSAs and 3205 rTSAs were included. The mean ± SD age at time of surgery was 66 ± 9 years for aTSAs and 72 ± 8 years for rTSAs. In all, 51% (1049 of 2041) of aTSAs and 61% (1955 of 3205) of rTSAs were in patients who were women. For aTSAs, osteoarthritis with an intact rotator cuff was the most common preoperative diagnosis (92% [1869 of 2041]). For rTSAs, the most common preoperative diagnoses included rotator cuff tear arthropathy (40% [1280 of 3205]), osteoarthritis with an intact rotator cuff (24% [780 of 3205]), osteoarthritis with a torn rotator cuff (20% [632 of 3205]), and massive rotator cuff tear (10% [309 of 3205]). Outcomes were evaluated at latest follow-up (aTSA 61 ± 36 months, rTSA 47 ± 26 months) and consisted of ROM (abduction, forward elevation, external and internal rotation) as well as the most commonly used outcome scores: the Simple Shoulder Test (SST), Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) score, Shoulder Pain and Disability Index (SPADI), and the Shoulder Arthroplasty Smart (SAS) score. The CIBS that we evaluated included the minimum clinically important difference (MCID), substantial clinical benefit (SCB), patient acceptable symptom state (PASS), minimum clinically important percentage of maximal possible improvement (MCI-%MPI), and substantial clinically important percentage of maximal possible improvement (SCI-%MPI). Prosthesis-specific anchor-based CIBS were adopted from prior publications on patients from this database. Multivariable regression was performed to identify the relationship between preoperative outcome measures and achievement of CIBS. Additionally, receiver operating characteristic (ROC) curve analyses were performed to determine whether thresholds in preoperative outcome measures were associated with achieving CIBS. Results For all ROM measures and outcome scores, poorer preoperative ROM was associated with greater odds of achieving the MCID and SCB but lower odds of achieving the PASS. For the SST and the two scores without ceiling effects (the Constant and SAS scores), poorer preoperative outcome scores were associated with greater odds of achieving the MCI-%MPI and SCI-%MPI, but no association was demonstrated for the ASES, SPADI, and UCLA scores. Graphical analysis demonstrated that patients with greater preoperative ROM and outcome scores had a lower probability of achieving the MCID and SCB but a higher probability of achieving the PASS. For outcome scores with known ceiling effects, patients with more favorable preoperative outcome scores were more likely to achieve the MCI-%MPI and SCI-%MPI than the MCID and SCB, respectively. For outcome scores without ceiling effects, patients undergoing aTSA were more likely to achieve the MCID, MCI-%MPI, and the SCI-%MPI than the SCB, but no clear trend was identified for patients undergoing rTSA. On ROC curve analysis, identified thresholds were reasonably accurate (area under the curve > 0.7) for achievement of measures of absolute improvement (the MCID and SCB), but not for absolute postoperative status (the PASS) or relative improvement (the MCI-%MPI and SCI-%MPI). Conclusion While most patients reported being “much better” (aTSA 75%, rTSA 76%) or “better” (aTSA 15%, rTSA 18%) compared with before surgery, 10% of aTSAs and 6% of rTSAs were either “unchanged” or “worse.” Patients’ likelihood of achieving CIBS depends in part on their baseline function and whether success is defined as absolute improvement, absolute postoperative status, or relative improvement. Patients with more favorable preoperative status are more likely to achieve CIBS that evaluate relative improvement (the MCI-%MPI and SCI-%MPI) than absolute improvement (the MCID and SCB). Future studies are needed to determine which individual CIBS or combinations thereof most accurately represent clinically relevant benefit. Level of Evidence Level III, therapeutic study.

Background: Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of displaced proximal humerus fractures (PHFs) with reliable clinical improvement. However, the preferred techniques for humeral stem fixation are varied and may be influenced by patient and injury characteristics, including bone quality and fracture pattern. This systematic review and meta-analysis sought to determine the effect of humeral component cementing and bone grafting on tuberosity healing rates and functional outcomes after RSA for PHFs. Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported on the use of cemented humeral stems and autograft bone. The primary outcome was the rate of greater tuberosity healing between the various techniques. Secondarily, the authors compared clinical outcomes including postoperative external rotation, forward elevation, abduction, Constant score, and the incidence of complications and revision surgery. Outcomes were compared based on the use of an uncemented press-fit stem, a fully cemented stem without bone graft, or a partially cemented stem with humeral head autograft (i.e., black and tan technique). Results: Forty-eight studies reporting on 1,797 RSAs were included (mean patient age, 75 years; follow-up, 34 months; 81% female). Tuberosity healing was highest in the uncemented cohort, then the black and tan cohort, and lowest in the cemented cohort (80% vs. 70% vs. 61%, p = 0.006). No significant differences in postoperative range of motion, Constant score, complication rates, or revision rates were found. Conclusion: Uncemented fixation with a press-fit stem was associated with superior greater tuberosity healing rates; however, functional outcomes and complications did not differ among techniques. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

» Instability and dislocation after reverse shoulder arthroplasty may occur in up to 31% of patients. » Clinical risk factors for instability include younger age, male sex, increased body mass index, preoperative diagnosis of proximal humerus fracture or rotator cuff pathology, history of instability of the native shoulder or after surgery, and a medical history of Parkinson’s disease. » Patients with rheumatoid arthritis and decreased proximity to the coracoid may also be at greater risk. » In patients at a high risk of instability, surgeons should consider a more lateralized prosthesis (particularly in patients with an incompetent rotator cuff), repairing the subscapularis (particularly when using a medialized prosthesis), and upsizing the glenosphere (>40 mm in male and 38–40 mm in female patients). » While potentially useful, less evidence exists for the use of a constrained liner (particularly with a lateralized glenosphere and/or in low-demand patients) and rotating the polyethylene liner posteriorly to avoid impingement. Level of Evidence: Level V . Narrative Review. See Instructions for Authors for a complete description of levels of evidence.

Background As no consensus exists on the optimal postoperative rehabilitation protocol in terrible triad injuries, we sought to characterize the reported protocols and relate them to postoperative range of motion (ROM) measures and Mayo Elbow Performance Score (MEPS). Methods A systematic review was performed by searching PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles on the operative treatment of terrible triad injuries reporting postoperative rehabilitation protocols were included. Included studies were descriptively summarized. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies criteria. Meta-analysis compared postoperative ROM measures and the MEPS between patients initiating passive ROM exercises at ≤7 days vs. >7 days. Results Our review included 36 articles with 1123 elbows (66% male, mean age: 43 years, follow-up: 27 months). Of the studies reporting physical therapy protocols, it was most commonly initiated at 7 days postoperatively (6/36, 17%), passive ROM exercises at 7 days (3/25, 12%), and active ROM at 21 days (4/26, 15%). On meta-analysis, early passive ROM initiation was not associated with improved elbow ROM or MEPS. Discussion While rehabilitation protocols commonly advised passive ROM at one week post-operatively, meta-analysis did not support functional benefits of early passive ROM. Study design Systematic Review; Level of evidence, 4.

Background This study sought to characterize the tipping point values (the functional scores that patients deem dysfunctional enough to warrant surgery) for patients undergoing first revision reverse total shoulder arthroplasty (rTSA). Methods This study was a retrospective review of a prospectively collected single-institution database of patients undergoing first revision rTSA between August 2015 and December 2019. Tipping point evaluation utilized preoperative scores including the American Shoulder and Elbow Surgeons (ASES), raw and normalized Constant, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), and University of California-Los Angeles (UCLA) scores, and active range of motion including abduction, forward elevation (FE), external rotation (ER), and internal rotation score (IR) prior to elective revision rTSA. Results We included 125 revision rTSAs. Tipping points were 37.6 ASES score, 30.5 raw Constant score, 35.5 normalized Constant score, 68.1 SPADI, 3.7 SST, 13.2 UCLA score, 64° abduction, 69° FE, 23° ER, and 3.1 IR. Higher SST was found for older patients and patients with a lower body mass index. Lower abduction and FE tipping points were reported in patients undergoing revision rTSA for rotator cuff failure, unexplained pain, and implant wear. Discussion These tipping points can help surgeons counsel patients regarding when to undergo revision rTSA. Level of evidence Level III; retrospective cohort study; treatment study.

Abstract: Today, well-designed randomized clinical trials (RCTs) are considered the pinnacle of clinical research, and they inform many practices in orthopaedics. When designing these studies, researchers conduct a power analysis, which allows researchers to strike a balance between (1) enrolling enough patients to detect a clinically important treatment effect (i.e., researchers can be confident that the effect is unlikely due to chance) and (2) cost, time, and risk to patients, which come with enrolling an excessive number of patients. Because researchers will have a desire to conduct resource-efficient RCTs and protect patients from harm, many studies report a p value that is close to the threshold for significance. The concept of the fragility index (FI) was introduced as a simple way to interpret RCT findings, but it does not account for RCT design. The adoption of the FI conflicts with researchers’ goals of designing efficient RCTs that conserve resources and limit ineffective or harmful treatments to patients. The use of the FI may reflect many clinicians’ lack of familiarity with interpreting p values beyond “significant” or “nonsignificant.” Instead of inventing new metrics to convey the same information provided by the p value, greater emphasis should be placed on educating clinicians on how to interpret p values and, more broadly, statistics, when reading scientific studies.

Background Improper sizing of the humeral head component in anatomic total shoulder arthroplasty (ATSA) can overstuff the joint, potentially compromising outcomes. The purpose of this study was to validate a novel method of evaluating glenohumeral joint overstuffing in which superoinferior and mediolateral overstuffing can be evaluated independently relative to the native humeral anatomy. Methods We identified 25 patients who underwent ATSA and the best Grashey radiograph taken within 1 year of follow-up was assessed using our proposed technique. First, a circle overlaying the implanted humeral head was made. Then, Iannotti's Perfect Circle (IPC) was drawn as originally described. Measurements of superior and medial overstuffing were made using our proposed axes. Inter-rater reliability was assessed by computing interclass correlation coefficients (ICC) using a one-way model. Measurements were summarized as the mean and range, with positive values denoting overstuffing. Results The inter-rater reliability for all measurements was excellent (ICC > 0.9). Compared to our method, the IPC method would have missed 77% of overstuffed cases. Conclusion We present a reproducible method to assess glenohumeral joint overstuffing in ATSA. This technique addresses limitations of other methods that underestimate overstuffing. Further study is needed to establish a clinically significant value of overstuffing based on the proposed method.

» Biomechanical studies report that thin scapular spine (SS) morphology, superiorly placed glenoid components, and increased glenoid baseplate screws contribute to increased acromial and SS strain and may increase fracture risk. » Clinical risk factors of acromial and SS fractures after reverse shoulder arthroplasty include increasing age, female sex, osteoporosis, rheumatoid arthritis, thin midsubstance acromion morphology, previous acromioplasty, and surgical indication of cuff tear arthropathy. » Clinical studies show that, in isolation, excessive humeral lengthening, humeral lateralization, and glenoid medialization may increase risk of acromial and SS fractures. » Biomechanical studies suggest that a combination of glenoid medialization and humeral lateralization (MG/LH) may reduce fracture risk, although this requires clinical correlation. » Surgeons might reduce fracture risk in patients of high-risk groups by guarding against excessively lengthening the humerus, using a MG/LH prosthesis, and targeting screws to avoid the scapular notch and base of the SS. Level of Evidence: Level V . Narrative Review. See Instructions for Authors for a complete description of levels of evidence.

Background The increasing incidence of reverse total shoulder arthroplasties (RTSA) has led to an increase in revision surgery. We aimed to compare patients undergoing re-revision RTSA to a matched cohort undergoing first-revision RTSA. Methods A retrospective review of all revision RTSAs was performed at a single institution. Sixteen shoulders that underwent re-revision RTSA were matched 1:3 to shoulders that underwent revision RTSA with a minimum two-year follow-up. Outcome scores including the American Shoulder and Elbow Surgeons Shoulder Score (ASES), Short-Form 12 (SF-12), Shoulder Pain and Disability Index (SPADI), and Simple Shoulder Test (SST) scores, range of motion (ROM), and improvement from preoperative to postoperative outcomes after re-revision RTSA were assessed. Additionally, postoperative outcomes after re-revision RTSA were compared to patients that underwent first revision RTSA and subsequently compared to the minimal clinically important difference (MCID) values for the outcome scores and ROM measurements assessed. Results Sixteen shoulders that underwent re-revision RTSA and 78 revision RTSAs met the final inclusion criteria to be included in this study. Significant improvement from preoperative to postoperative re-revision RTSA was seen in the ASES score (p = 0.046), SPADI score (p = 0.044), SST (p = 0.008), abduction (p = 0.016), and elevation (p = 0.025), but not the SF-12 score (p = 0.396), external rotation (p = 0.449), or internal rotation (p = 0.451). Outcomes after revision RTSA were found to be superior to outcomes after re-revision RTSA for all outcome scores (ASES p = 0.029, SF-12 p = 0.018, SPADI p = 0.003) except the SST score (p = 0.080) and all ROM measures (p > 0.05 for all). Internal rotation was equivalent postoperatively between both groups. From preoperative to postoperative re-revision RTSA, the mean improvement exceeded the MCID for the SST score, abduction, forward elevation, and external rotation. When comparing postoperative revision RTSA to postoperative re-revision RTSA, the mean difference between revision and re-revision RTSA exceeded the MCID for the SPADI score and external rotation. The complication rate was 19% in shoulders undergoing first revision and 41% in shoulders undergoing re-revision RTSA. Conclusion Patients undergoing re-revision RTSA receive improvement in clinical outcomes, but do not achieve outcomes comparable to those achieved after first revision RTSA.