King, Joseph J

While anatomic total shoulder arthroplasty is a successful procedure that provides reliable pain relief and restoration of function in most patients, its success has been limited by glenoid component loosening. While series reporting the outcomes of inlay glenoid components have demonstrated excellent clinical outcomes with low rates of component loosening and need for revision, surgeons have been hesitant to adopt these implants due to concerns of inadequate pain relief secondary to the remaining glenoid rim contacting the humeral head implant. The inset glenoid component, a variant of the traditional inlay components, has gained interest because its design aims to achieve similar stability to traditional inlay components through implantation within strong subchondral bone, reduce the amount of glenoid vault removed compared to inlay components, and has a glenoid face designed to limit the rocking-horse phenomenon. In limited series, the inset glenoid component has demonstrated superior biomechanical and clinical performance compared to traditional onlay glenoid components. Although there have been minimal clinical studies investigating the inset glenoid in comparison to onlay and inlay components to date, a subset of case series with short-term follow-up have demonstrated favorable outcomes. The purpose of this article was to review the design rationale, biomechanical evidence, and clinical performance of the inset glenoid component.

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: 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.

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.

Purpose To evaluate return to play (RTP) and return to same level of play (RTSP) rates as well as preoperative and postoperative in‐game performance metrics in baseball pitchers who underwent ulnar collateral ligament reconstruction (UCLR). Secondarily, this review sought to assess outcomes based on primary versus revision UCLR as well as level of competition. Methods This review was performed using Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane Database of Systematic Reviews were queried to identify articles evaluating UCLR in baseball players between January 2002 and October 2022. Data included RTP, RTSP, and performance metrics including earned run average, innings pitched, walks and hits per inning pitched, batting average against, strikeouts per 9 innings, walks per 9 innings, percentage of fastballs thrown, and average fastball velocity. The Methodological Index for Non‐randomized Studies criteria were used for quality assessment. Results Analysis included 25 articles reporting on 2,100 elbows. After primary UCLR, RTP ranged from 336 to 615 days (57% to 100% achieved) and RTSP ranged from 330 to 513 days (61% to 95%). After revision UCLR, RTP ranged from 381 to 631 days (67% to 98%) and RTSP ranged from 518 to 575 days (42% to 78%). When stratifying primary UCLR outcomes by competitive level, RTP and RTSP ranged respectively from 417 to 615 days (75% to 100%) and 513 days (73% to 87%) for Major League Baseball only, 409 to 615 days (57% to 100%) and 470 to 513 days (61% to 95%) for Major League Baseball plus Minor League Baseball, and 336 to 516 days (73% to 85%) and 330 days (55% to 74%) for college plus high school. Heterogeneity was seen in postoperative sports performance metrics. Conclusions Although more than half of baseball players appear able to RTP after primary and revision UCLR, RTSP rates after revision UCLR were as low as 42% in the literature. Preoperative and postoperative performance metrics varied. Level of Evidence Level IV, systematic review of Level II‐IV studies.

» 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.