Is there a threshold of preoperative function that predicts failure to achieve clinically significant outcomes after total and reverse shoulder arthroplasty?

BackgroundThe purpose of this study was to determine if there is a threshold of preoperative function that is predictive of postoperative outcomes and the likelihood of achieving clinically significant outcomes following shoulder arthroplasty (SA).MethodsWe retrospectively identified patients who underwent a primary SA at our institution. Patients with preoperative and postoperative American Shoulder and Elbow Surgeons scores (ASES) were included in our analysis. A receiver operating characteristic (ROC) analysis was utilized to reach a preoperative ASES threshold correlated with achievement of the following clinically significant outcomes: minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state. This analysis was performed for our entire SA cohort and subanalyzed for total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). Fischer exact tests were used to analyze categorical data while continuous data were analyzed using t-tests. For the ROC, area under the curve (AUC) was calculated, along with bootstrap 95% confidence intervals and P values, with <0.05 as significant.ResultsA total of 516 patients were included (164 TSA and 352 RSA). ROC analysis yielded a preoperative ASES above 54 as predictive of failure to achieve MCID for all SAs (AUC, 0.77; P < .001), above 49 for TSA (AUC 0.74, P < .001), and above 56 for RSA (AUC 0.79, P < .001). Patients with preoperative ASES scores above 54 were significantly less likely to achieve MCID (odds ratio 5.1, P < .001) and SCB (odds ratio 7.2, P < .001); however, they had higher postoperative ASES scores (84 vs. 78, P < .001). A preoperative ASES score of 73 corresponded to a 50% chance of achieving MCID. ROC analysis also yielded a preoperative ASES score above 51 as predictive of failure to achieve SCB for all SA, TSA, and RSA (AUC: 0.79, 0.78, and 0.80, respectively, all P < .001). A preop ASES score of 52 corresponded to a 50% chance of achieving SCB.ConclusionPreoperative ASES scores above 49-56 are predictive of failure to achieve MCID and SCB following TSA and RSA. Although patients above these preoperative thresholds achieve higher absolute ASES scores at the final follow-up, they experienced less relative improvement from baseline. This will help surgeons counsel individual patients about appropriate expectations after arthroplasty.     

Minimum clinically important difference for the American Shoulder and Elbow Surgeons score after revision shoulder arthroplasty

BackgroundPatients undergoing revision total shoulder arthroplasty (TSA) typically achieve smaller improvements in outcome measurements than those undergoing primary TSA. The minimum clinically important difference (MCID) in the American Shoulder and Elbow Surgeons (ASES) questionnaire for primary shoulder arthroplasty ranges from 13.6 to 20.9, but the MCID for revision shoulder arthroplasty remains unclear. This study aims to define the MCID in ASES score for revision TSA and ascertain patient factors that affect achieving the MCID threshold.MethodsPatients were identified from an institutional shoulder arthroplasty database. Prospective data collected included demographic variables, prior shoulder surgeries, primary and revision implants, indication for revision, and pre- and postoperative ASES scores. All patients provided informed consent to participate. An anchor-based method was used with a binary answer choice. The MCID was calculated using the receiver-operator curve (ROC) method, and the sensitivity, specificity, and area under the curve were obtained from the ROC. MCID values were compared between groups using Student's t-test. Multivariate logistic regression modeling was used to determine significant predictors for reaching MCID. Significance was defined as P< .05.ResultsA total of 46 patients underwent revision TSA with minimum 2-year follow-up. The MCID using ROC method was 16.7 with 71% sensitivity and 62% specificity. There was a trend toward males being more likely to reach MCID after revision arthroplasty (P= .058). There were also trends toward increased forward flexion and abduction range of motion in patients who met MCID (P= .08, P= .07). Multivariate logistic regression modeling demonstrated male sex to be associated with achieving MCID (P= .03), while younger age and fewer prior shoulder surgeries demonstrated a trend to association with achieving MCID (P= .06, P= .10).ConclusionThe MCID for ASES score in patients undergoing revision shoulder arthroplasty is similar to previously reported MCID values for patients undergoing primary shoulder arthroplasty. Younger, male patients with fewer prior shoulder surgeries were more likely to achieve MCID after revision TSA.Level of EvidenceLevel III; Retrospective Comparative Treatment Study     

Use of machine learning to assess the predictive value of 3 commonly used clinical measures to quantify outcomes after total shoulder arthroplasty

BackgroundAn important psychometric parameter of validity that is rarely assessed is predictive value. In this study we utilize machine learning to analyze the predictive value of 3 commonly used clinical measures to assess 2-year outcomes after total shoulder arthroplasty (TSA).MethodsXGBoost was used to analyze data from 2790 TSA patients and create predictive algorithms for the American Shoulder and Elbow Surgeons (ASES), Constant, and the University of California Los Angeles (UCLA) scores and also quantify the most meaningful predictive features utilized by these measures and for all questions comprising each measure to rank and compare their value to predict 2-year outcomes after TSA.ResultsOur results demonstrate that the ASES, Constant, and UCLA measures rarely considered the most-predictive features relevant to 2-year TSA outcomes and that each outcome measure was composed of questions with different distributions of predictive value. Specifically, the questions composing the UCLA score were of greater predictive value than the Constant questions, and the questions composing the Constant score were of greater predictive value than the ASES questions. We also found the preoperative Shoulder Pain and Disability Index (SPADI) score to be of greater predictive value than the preoperative ASES, Constant, and UCLA scores. Finally, we identified the types of preoperative input questions that were most-predictive (subjective self-assessments of pain and objective measurements of active range of motion and strength) and also those that were least-predictive of 2-year TSA outcomes (subjective task-specific activities of daily living questions).DiscussionMachine learning can quantify the predictive value of the ASES, Constant, and UCLA scores after TSA. Future work should utilize this and related techniques to construct a more efficient and effective clinical outcome measure that incorporates subjective and objective input questions to better account for the preoperative factors that influence postoperative outcomes after TSA.Level of EvidenceLevel III; Retrospective Comparative Study     

The influence of mental health on outcomes following total shoulder arthroplasty

BackgroundAnxiety and depression symptoms have been associated with higher pain and lower functional scores in patients with glenohumeral osteoarthritis (GHOA). The influence of mental health on outcomes following total shoulder arthroplasty (TSA) for GHOA has not been fully investigated .MethodsThis observational cohort study included 143 shoulders in 135 subjects undergoing TSA for GHOA. Preoperative imaging was assessed for glenoid wear pattern. Patients completed preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Pain Scale (VAS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores. The Western Ontario Osteoarthritis Score (WOOS) was collected postoperatively. Mean postoperative pain and functional scores, improvement from preoperative scores, and surgical regret were compared between varying severity of anxiety or depression and pattern of glenoid wear.ResultsCompared to subjects without anxiety, those with moderate-to-severe anxiety reported worse postoperative ASES (p=0.019), WOOS (p<0.01) and PROMIS UE (p=0.02) and higher PROMIS PI scores (p<0.01). Compared to those without depression, those with moderate-to-severe depression reported worse postoperative ASES and WOOS and higher VAS and PROMIS Pain scores (p<0.01). Linear regression showed that anxiety and concentric glenoid wear were associated with worse postoperative PROMIS scores. There were no significant differences in pre-to-postoperative improvement in any outcome measures among those with and without anxiety or depression. Patients with moderate-to-severe depression were less likely to want to undergo the same procedure again (p=0.035).DiscussionPatients with anxiety and depression report similar improvements in pain and function following TSA similar to those without depression or anxiety. Despite the similar improvement, those with moderate-to-severe depression and anxiety symptoms reported persistently lower functional and higher pain scores. Though most patients are satisfied following TSA, those with moderate-to-severe depression may be more likely to regret undergoing surgery. Future studies should identify mental health symptoms preoperatively and evaluate the effect of preoperative intervention on postoperative outcomes following TSA.     

Development of a predictive model for a machine learning–derived shoulder arthroplasty clinical outcome score

BackgroundWe use machine learning to create predictive models from preoperative data to predict the Shoulder Arthroplasty Smart (SAS) score, the American Shoulder and Elbow Surgeons (ASES) score, and the Constant score at multiple postoperative time points and compare the accuracy of each algorithm for anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA).MethodsClinical data from 2270 patients who underwent aTSA and 4198 patients who underwent rTSA were analyzed using 3 supervised machine learning techniques to create predictive models for the SAS, ASES, and Constant scores at 6 different postoperative time points using a full input feature set and the 2 different minimal feature sets. Mean absolute errors (MAEs) quantified the difference between actual and predicted outcome scores for each model at each postoperative time point. The performance of each model was also quantified by its ability to predict improvement greater than the minimal clinically important difference (MCID) and the substantial clinical benefit (SCB) patient satisfaction thresholds for each outcome measure at 2-3 years after surgery.ResultsAll 3 machine learning techniques were more accurate at predicting aTSA and rTSA outcomes using the SAS score (aTSA: ±7.41 MAE; rTSA: ±7.79 MAE), followed by the Constant score (aTSA: ±8.32 MAE; rTSA: ±8.30 MAE) and finally the ASES score (aTSA: ±10.86 MAE; rTSA: ±10.60 MAE). These prediction accuracy trends were maintained across the 3 different model input categories for each of the SAS, ASES, and Constant models at each postoperative time point. For patients who underwent aTSA, the XGBoost predictive models achieved 94%-97% accuracy in MCID with an area under the receiver operating curve (AUROC) between 0.90-0.97 and 89%-94% accuracy in SCB with an AUROC between 0.89-0.92 for the 3 clinical scores using the full feature set of inputs. For patients who underwent rTSA, the XGBoost predictive models achieved 95%-99% accuracy in MCID with an AUROC between 0.88-0.96 and 88%-92% accuracy in SCB with an AUROC between 0.81-0.89 for the 3 clinical scores using the full feature set of inputs.DiscussionOur study demonstrated that the SAS score predictions are more accurate than the ASES and Constant predictions for multiple supervised machine learning techniques, despite requiring fewer input data for the SAS model. In addition, we predicted which patients will and will not achieve clinical improvement that exceeds the MCID and SCB thresholds for each score; this highly accurate predictive capability effectively risk-stratifies patients for a variety of outcome measures using only preoperative data.Level of evidenceLevel III; Retrospective Comparative Study     

The influence of computed tomography preoperative planning on clinical outcomes after anatomic total shoulder arthroplasty: a matched cohort analysis

BackgroundEvaluation, characterization, and correction of glenoid deformity are an important part of performing anatomic total shoulder arthroplasty (TSA). Three-dimensional computed tomography (3D CT) planning has been shown to improve implant position, but the impact on clinical outcomes is less clear. The purpose of the current study is to compare clinical outcomes of TSA performed with 3D CT preoperative planning with matched controls performed without CT-based planning.MethodsUtilizing a multicenter shoulder arthroplasty registry, patients who underwent a TSA with 2-year clinical follow-up were retrospectively identified. These patients were divided into two cohorts based on technique for glenoid guide pin placement based on surgeon preference: 1) those who utilized 3D preoperative templating with or without patient-specific instrumentation (PSI) and 2) a control group of TSAs performed without 3D CT preoperative planning. The two groups were matched 1:1 based on age, sex, and baseline American Shoulder and Elbow Surgeons (ASES) score. Patient-reported outcomes and active range of motion (ROM) obtained at 2 years postoperatively were assessed and compared between the two cohorts. A subgroup analysis was also performed comparing outcomes in patients with 3D CT preoperative planning with and without PSI.ResultsData collection was performed on 84 study patients with 3D CT preoperative planning (51 with PSI and 33 without) and 84 matched control patients without CT-based planning (168 patients in total). Baseline characteristics were similar between the groups. Improvement from baseline for the ASES score (study group: 45.4, controls: 39.0, P = .029) and external rotation at 90^° of abduction (study group: 42^° vs. 29^°, P = .009) was significantly greater in the CT-based planning group than that in matched controls. There were no other significant differences in improvement in outcomes or ROM between the two groups. Within the 3D CT cohort, there were no significant differences in patient-reported outcomes or ROM between TSAs performed with or without PSI. A significantly greater percentage of patients with 3D CT planning achieved a patient acceptable symptomatic state than controls (89% vs. 75%, P = .016).ConclusionTSAs performed with 3D CT preoperative glenoid planning with or without utilization of PSI were associated with statistically significantly greater improvement from baseline in ASES scores and external rotation at 90^° of abduction than TSA performed without 3D CT planning. The clinical significance of this finding is unclear, as the differences failed to meet a clinically significant threshold.     

Establishing thresholds for achievement of clinically significant satisfaction at two years following shoulder arthroplasty: the patient acceptable symptomatic state

BackgroundThe patient acceptable symptomatic state (PASS) represents clinical improvement following surgery that patients deem as satisfactory; however, thresholds for achieving this clinical benchmark have not yet been established beyond 1 year following primary and reverse shoulder arthroplasty.MethodsA prospectively maintained registry was retrospectively queried for patients undergoing either a primary TSA or RTSA at a single institution between November, 2015 and October, 2017. All patients completed the ASES, SANE, and Constant patient-reported outcome (PRO) scores at the 2-year time point. PASS threshold scores were calculated using anchor-based methodology with subsequent calculation of achievement rates. Multivariate logistic regression was used to identify demographic and clinical variables associated with the likelihood of PASS achievement.ResultsA total of 93 TSA (mean age 61.4 ± 8.5 years, 32.3% female) and 111 RTSA (mean age 70.0 ± 8.1 years, 51.4% female) patients met final inclusion criteria. One-hundred sixty-five patients (80.8%) responded to the binary anchor question as “satisfied” regarding their surgical outcome. The PASS cutoffs for ASES, SANE, and Constant were 81.7, 85.7, and 24.0, respectively (AUC > 80%), with PASS achievement rates ranging from 50.7% to 59.9% for the entire study population and 66.7% to 83.3% for a risk-stratified subgroup. Patients undergoing TSA had a significantly higher PASS achievement rate relative to RTSA (P = .010) for ASES. Independent risk factors for decreased PASS achievement included lower preoperative PRO score, prior shoulder surgery, sedentary lifestyle, smoking, workers’ compensation status, and diabetes mellitus (DM).ConclusionThe majority of patients reach the PASS benchmark by 2 years after shoulder arthroplasty, with an optimal subgroup of risk-stratified patients achieving PASS at a rate greater than 80% for ASES. Patients undergoing TSA have a higher likelihood of reaching the PASS than patients undergoing RTSA, independent of other variables. Lower baseline outcome scores, prior shoulder surgery, smoking, and sedentary lifestyle are associated with lower PASS rates after TSA. Worker's compensation status and comorbid DM are predictive of reduced PASS rates after RTSA. Primary diagnosis and glenoid morphology did not have a significant impact on the rate of achieving the PASS. This information is valuable for patient selection and counseling prior to shoulder arthroplasty.Level of EvidenceLevel III; Prognostic Study; Retrospective Case Series.     

Anatomic shoulder arthroplasty in workers’ compensation patients: predictors of success and return to work

BackgroundIn patients with shoulder arthritis, workers’ compensation (WC) status presents unique challenges to the clinician because of the socioeconomic and psychosocial aspects attendant to patients covered on this type of insurance. Patients, surgeons, and these insurance programs would be informed by a better understanding of the factors that may impact the results of a shoulder arthroplasty as treatment for glenohumeral arthritis in this population. The objectives of this study were to determine: (1) the extent to which patient-reported outcomes are impacted by WC status in comparison to patients covered by other types of insurance, (2) which factors are predictive of a successful outcome of shoulder arthroplasty as defined by improvement exceeding the minimal clinically important difference (MCID), (3) the ability of WC patients to return to their presurgical occupation after arthroplasty.MethodsThis was a retrospective study of a longitudinally maintained institutional database of 677 patients who underwent primary anatomic shoulder arthroplasty with a minimum 2-year follow-up, 39 of whom had WC insurance. These patients were compared to a matched cohort of 78 patients without WC insurance. Primary outcome measures included SST scores, SANE scores, and need for revision surgery. Univariate and multivariate analyses were performed to determine preoperative characteristics associated with success as defined by improvement greater than the MCID of the SST.ResultsSuccess, defined as improvement beyond MCID, occurred in a significantly lower proportion of WC patients compared to non-WC patients (64% vs. 94%, P< .001). Older age (P= .010) and a higher preoperative SF-36 role physical domain score (a measure of the patient's perceived limitations in routine activities;P= .007) were associated with improvement beyond the MCID on univariate analysis. Higher preoperative SF-36 role physical domain scores had the greatest correlation with a successful outcome (OR 1.19, 95% 0.99-1.43, P= .07). A significantly lower percentage of patients with physically-demanding jobs returned to previous occupation compared to patients with non-physically-demanding jobs (13% vs. 73%, P= .001).ConclusionsThe challenges in treating patients covered by WC are underscored by the high percentage of these patients that do not improve beyond the MCID and the high percentage of patients with physically-demanding jobs that are unable to return to their presurgical occupation. Those patients who report less disability with routine daily activities (ie, higher SF-36 role physical domain scores) may fare better with anatomic shoulder arthroplasty. Patients with physically-demanding jobs should be counseled that return to their previous occupation is unlikely.Level of EvidenceLevel III; Retrospective Cohort Comparative Study     

Correlation of patient-reported outcome measurement information system-upper extremity with American Shoulder and Elbow Surgeons scores in shoulder arthroplasty

BackgroundMultiple outcome measure surveys are available to assess preoperative and postoperative outcomes for a variety of orthopedic procedures such as shoulder arthroplasty. Although legacy instruments such as American Shoulder and Elbow Surgeons (ASES) remain popular, there remains no singular gold standard survey instrument for shoulder arthroplasty patients, and alternative instruments have been developed to better capture clinical outcomes. The goal of this study is to compare the efficacy of Patient-Reported Outcome Measurement Information System-Upper Extremity (PROMIS-UE) using computer adaptive technology with ASES scores both preoperatively and postoperatively in shoulder arthroplasty patients. Our hypothesis is that there would be a strong correlation between PROMIS-UE and ASES scores both preoperatively and postoperatively in total shoulder arthroplasty patients.MethodsPatients who underwent total shoulder arthroplasty and agreed to complete baseline and 1-year follow-up of ASES and PROMIS-UE scores were included. Patients also completed PROMIS-Physical Function (PROMIS-PF) as a third point comparison. Responses to these instruments were statistically analyzed and compared using Pearson correlation coefficients. Floor and ceiling effects were then calculated.ResultsNinety patients were included in this study, all of whom completed the PROMIS-UE, PROMIS-PF, and ASES surveys both preoperatively and 12 months postoperatively. The mean age in this cohort was 68.9 years (standard deviation [SD] 8.4 years, range 39-89). The mean preoperative and postoperative PROMIS-UE scores were 26.6 (SD 6.7, range 14.7-44.6) and 41.8 (SD 10.3, range 20.2-56.4) respectively. Mean preoperative and postoperative PROMIS-PF computer adaptive technology scores were 35.7 (SD 9.54, range 34.2-64) and 44.3 (SD 9.22, range 23.5-73.3) respectively. The mean ASES score was 37.5 preoperatively (SD 18.0, range 5-99.5) and 77.5 postoperatively (SD 20.5, range 25.0-100.0). PROMIS-UE demonstrated a moderate correlation with ASES preoperatively and a strong correlation postoperatively (r = 0.52, confidence interval 0.27-0.60; r = 0.70, confidence interval 0.55-0.78, respectively). PROMIS-UE demonstrated a minor floor effect preoperatively (7.8%) but significant ceiling effect postoperatively (24.4%) and ASES demonstrated a mild ceiling effect at final follow-up (8.9%). There were otherwise no other floor or ceiling effects at all other time points across each survey.ConclusionPROMIS-UE correlates well with ASES at both baseline and 1-year postoperation for patients undergoing total shoulder replacement. In addition, the change seen between both baseline and 1 year outcome scores for both scoring systems also correlates strongly, suggesting that PROMIS-UE may be a suitable alternative to ASES for this patient population.     

Failure rates and outcomes after anatomic total shoulder arthroplasty are equivalent irrespective of subscapularis repair technique

BackgroundSubscapularis management during total shoulder arthroplasty (TSA) remains an area of debate. Although subscapularis-sparing techniques exist, most TSAs are performed through a deltopectoral interval with the subscapularis released and repaired. A paucity of literature exists comparing transosseous repair (TOR) with direct primary tendon repair (PTR) of a subscapularis tenotomy. Our study compared outcomes after TOR and PTR in patients undergoing anatomic TSA.MethodsThis retrospective study included patients who underwent primary anatomic TSA through a deltopectoral approach with subscapularis tenotomy using either PTR or TOR for repair. Outcome measures included subscapularis failure rates, visual analog scale (VAS) scores, American Shoulder and Elbow Surgeons (ASES) survey scores, internal rotation range of motion and strength, complications, and reoperation rates at 3 months, 1 year, and 2 years.ResultsInstitutional database query identified 306 patients who had primary anatomic TSA, 114 of whom had PTR and 192 TOR. Postoperative ASES and VAS scores were significantly improved at all time points in both groups compared with the preoperative scores (P < .001). Average active internal rotation was significantly improved at all time points in the PTR group (P < .001). In the TOR group, significant improvement was noted at 1 and 2 years but not at 3 months. Overall, subscapularis failure occurred in 13 patients, and complications that did not require surgery were noted in 28 patients. Reoperation was performed in 18 patients. However, subscapularis failures, complications not requiring surgery, and reoperations were not significantly different between the two groups. The difference in average internal rotation range of motion between the TOR and PTR groups was statistically significant at 3 months (P = .015) but not at 1 year (P = .265), although the difference trended toward significance again at the 2-year mark (P = .080). No significant differences were noted between the two groups in internal rotation strength, VAS scores, and ASES averages.ConclusionBoth transosseous and primary soft-tissue repair techniques after subscapularis tenotomy result in good outcomes after primary anatomic TSA. No differences were found between groups regarding clinical subscapularis failure rate, internal rotation range of motion or strength, VAS, or ASES scores at 2-year follow-up.Level of evidenceLevel III, Retrospective Comparative Study     

The association of comorbidity indices and minimal clinically important difference in a population undergoing shoulder arthroplasty

BackgroundShoulder arthroplasty (SA) procedures are increasingly common. The Charlson and Elixhauser indices are ICD-10 based measures used in large databases to describe the patient case mix in terms of secondary medical conditions. There is a paucity of data on the relationship between these indices and patient-reported outcome measures (PROMs) after shoulder arthroplasty.MethodsPatients undergoing SA from 2016-2018 were identified in the electronic medical records. Charlson and Elixhauser comorbidities were used to calculate comorbidity scores according to established algorithms (eg Elixhauser-Walraven). Patient shoulder-specific (American Shoulder and Elbow Surgeons (ASES) score and Shoulder Activity Scale (SAS)) and general health scales (SF-12 Mental Component Score (MCS) and Physical Component Score (PCS) and Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI)) PROMs were obtained from our institution’s shoulder registry. Linear regression models adjusting for age and sex evaluated associations between comorbidity scores and PROMs. Receiver operating characteristic (ROC) curves determined optimal cutoffs, maximizing sensitivity and specificity to identify patients likely to fail to meet minimal clinically important difference (MCID) values.ResultsA total of 1817 SA procedures were identified. Higher Charlson and Elixhauser-Walraven scores were significantly associated with lower baseline SAS and SF-12 PCS. Patients with higher Charlson scores had lower baseline ASES (P = .003) and lower baseline (P = .0002) and 2-year (P = .02) SF-12 MCS. No significant associations were found for PROMIS-PI with either index. The Charlson score better predicted the failure to meet MCID for SF-12 PCS with an AUC of 0.64, compared to 0.55 for Elixhauser-Walraven. Conversely, Elixhauser-Walraven better predicted PROMIS-PI with an AUC of 0.66, compared to 0.53 for Charlson. Moderate AUCs were observed for the remaining PROMs, ranging from 0.57-0.64, with little difference between index scores.ConclusionHigher Charlson and Elixhauser-Walraven scores were associated with lower baseline scores on most PROMs. Generally, the Charlson score performed better than the Elixhauser-Walraven score in predicting worse outcomes at 2 years. Comorbidity indices may be useful as a decision aid to provide appropriate expectations of outcomes for patients undergoing SA.     

Does non-spherical humeral head with inlay glenoid re-center the glenohumeral joint?

BackgroundTreatment of glenohumeral osteoarthritis (OA) with Walch type B glenoid poses a challenge for orthopedic surgeons. Although various techniques have been described, it is still a major concern in terms of management and long-term results. We hypothesized that total shoulder arthroplasty (TSA) using a combination of non-spherical humeral head resurfacing (HHR) and inlay glenoid replacement would re-center the glenohumeral joint in patients with Walch type B glenoid without surgical correction of glenoid version.MethodsWe retrospectively screened patients who underwent TSA using a combination of non-spherical HHR and inlay glenoid replacement for primary glenohumeral OA with posteriorly subluxated humeral head (HH) (Walch Type B1, B2 and B3) between 2015 and 2019. Ratios of preoperative and postoperative HH subluxation were compared using Walch index and the point of contact ratio method. Two orthopedic surgeons performed radiographic measurements blinded to each other. Means of 2 independent measurements were included in the final analysis for each shoulder. We also screened for postoperative complications, dislocation events and radiographic loosening.ResultsInitial cohort included 49 patients. A total of 29 shoulders in 28 patients were eligible for screening. The numbers of shoulders with Walch type B1, B2, and B3 glenoids were 3, 22, and 4, respectively. Mean preoperative and postoperative Walch indices were 56.57 ± 6.08% and 49.47 ± 4.78%, respectively. The mean preoperative and postoperative point of contact ratios were 62.97 ± 8.45% and 50.08 ± 3.87%, respectively. The difference between preoperative and postoperative subluxation ratios was significant for both methods (P < .01). Inter-rater reliability was found to be good-excellent. The overall complication rate at a mean follow-up period of 37.79 months was 10.34% (3/29). One patient experienced deep vein thrombosis (DVT) (3.22%) on postoperative day 8. Two patients experienced infection (6.45%), one of which required a revision TSA (3.22%) at 19 months after surgery. No patient experienced shoulder dislocation and no loosening was detected on postoperative radiographs.ConclusionWhen coupled with an inlay glenoid component in patients with eccentric glenoid wear and posterior subluxation, glenohumeral re-centering was consistently observed in this challenging patient population without the use of joint correction or augmentation procedures. It will be important to follow the clinical outcomes over the long-term to determine whether these observations translate to better clinical results than other techniques currently employed to deal with eccentric erosion and posterior subluxation of the arthritic glenohumeral joint although recent published mid-term results suggest results equal to or better than previously reported results in literature with different reconstructive techniquesLevel of evidenceLevel IV; Retrospective cohort     

Role of preoperative PROMIS scores in predicting postoperative outcomes and likelihood of achieving MCID following reverse shoulder arthroplasty

BackgroundThe patient-reported outcomes measurement information system (PROMIS) has emerged as an efficient and valid outcome measure in various shoulder surgeries. The purpose of this study was to investigate the influence of preoperative PROMIS scores in predicting postoperative PROMIS scores and the likelihood of achieving a minimal clinically important difference (MCID) following primary reverse total shoulder arthroplasty for cuff tear arthropathy. We hypothesize that preoperative PROMIS scores will influence both postoperative PROMIS scores and the probability of achieving MCID.Methods73 patients undergoing reverse shoulder arthroplasty by a board-certified shoulder and elbow surgeon were given three PROMIS CAT forms: PROMIS Upper Extremity Physical Function CAT v2.0 (“PROMIS-UE”), PROMIS Pain Interference v1.1 (“PROMIS-PI”), and PROMIS Depression v1.0 (“PROMIS-D”).). PROMIS CAT domain t scores were assessed for significance between both time points using a Paired Samples t test. Minimal clinically important difference (MCID) was calculated using the distribution method and each PROMIS domain was subsequently assessed for its discriminatory ability in predicting postoperative improvement equal to or greater than the MCID through receiver operating characteristic (ROC) curve analysis.ResultsOur cohort consisted of 73 patients (49.3% male) and an average age of 69.7 years (standard deviation, 11.9). Mean follow-up time point was 9.6 months (standard deviation, 5.0) after surgery. Preoperative PROMIS-UE, PROMIS-PI, and PROMIS-D were 29.5 ± 6.2, 63.3 ± 5.4, and 50.1 ± 9.2, respectively. Each domain significantly improved at 10-months, on average, to 40.9 ± 7.8, 51.4 ± 8.5, 42.6 ± 8.1, respectively. Following the distribution-based method for MCID calculation, we found the following MCID values for PROMIS-UE, PROMIS-PI, and PROMIS-D: 3.1, 2.7, and 4.6, respectively. ROC analysis revealed strong predictive ability for PROMIS-UE (AUC = 0.717, p < 0.05), moderative predictive ability for PROMIS-PI (AUC = 0.634, p < 0.05), and excellent predictive ability for PROMIS-D (AUC = 0.864, p < 0.05). Specifically, preoperative cutoff values of <26.0, >70.0, and >52.5 for PROMIS-UE, PROMIS-PI, and PROMIS-D are especially predictive of achieving MCID.ConclusionsPreoperative baseline scores can serve as strong predictors of success in patients undergoing primary reverse shoulder arthroplasty and can be used to both counsel patients on surgery and to tailor postoperative protocols.Level of evidenceLevel II.     

High prevalence of early stress shielding in stemless shoulder arthroplasty

IntroductionThe rates of early stress shielding in stemless total shoulder arthroplasty (TSA) in current literature are very low and inconsistent with our observations. We hypothesized that the incidence of early stress shielding in stemless TSA would be higher than previously reported.MethodsAll stemless TSA in a prospective database using a single humeral implant comprised the study cohort of 104 patients, of which 76.0% (79 patients) had a minimum one year radiographic and clinical follow-up. Radiographs were reviewed for humeral stress shielding, humeral radiolucent lines, and humeral or glenoid loosening/migration. Stress shielding and radiolucent lines were classified by location. Demographics and clinical outcomes, including American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) pain score, were compared between patient cohorts with and without stress shielding.ResultsAt one year, 41.8% of patients had humeral stress shielding. Medial calcar osteolysis was seen in 32.9% of all patients and 78.8% of the stress shielding cohort. There were no cases of radiolucent lines or humeral or glenoid loosening/migration. There was no significant difference in age between cohorts (P = .308), but there were significantly more females (P = .034) and lower body mass index in the stress shielding cohort (P = .004). There were no significant differences in preoperative ASES (P = .246) or VAS scores (P = .402) or postoperative ASES (P = .324) or VAS scores (P = .323).ConclusionStress shielding in stemless TSA is more prevalent than previously published, largely due to infrequently reported medial calcar osteolysis. Stress shielding is more common in women and patients with lower body mass index. At early follow-up there were no significantly worse outcomes in the stress shielding cohort, but longer-term follow-up is needed to fully understand the impact of stress shielding on function and stability.     

Anatomic vs. reverse shoulder arthroplasty for glenohumeral osteoarthritis with intact rotator cuff: a retrospective comparison of patient-reported outcomes using the systems outcomes database with up to 5-year follow-up

BackgroundThe growing enthusiasm for the use of reverse shoulder arthroplasty (RSA) in the treatment of primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff is based on data derived from single-center studies with limited generalizability and follow-up. This study compared patient-reported outcomes (PROs) between RSA and total shoulder arthroplasty (TSA) for the treatment of primary GHOA with up to 5-year follow-up and examined temporal trends in the treatment of GHOA between 2012 and 2021.MethodsA retrospective review was performed on patients with primary GHOA undergoing primary arthroplasty surgery from the Surgical Outcomes System global registry between 2012 and 2021. PROs including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and visual analog scale (VAS) for pain were compared between RSA and TSA at 1, 2, and 5 years postoperatively.ResultsA total of 4451 patients were included, with 2693 (60.5%) undergoing TSA and 1758 (39.5%) undergoing RSA. Both RSA and TSA provided clinically excellent outcomes at 1 year postoperatively (ASES: 80.8 ± 17.9 vs. 85.9 ± 15.2, respectively; SANE: 74.8 ± 24.7 vs. 79.5 ± 22.9; VAS pain: 1.3 ± 2.0 vs. 1.1 ± 1.7; all P < .05) that were maintained at 2 years (ASES: 81.3 ± 19.3 vs. 87.3 ± 14.9; SANE: 74.8 ± 26.2 vs. 79.7 ± 24.7; VAS pain: 1.3 ± 2.1 vs. 1.0 ± 1.6; all P < .05) and 5 years (ASES: 81.7 ± 16.5 vs. 86.9 ± 15.3; SANE: 71.6 ± 28.5 vs. 78.2 ± 25.9; VAS pain: 1.0 ± 1.7 vs. 1.0 ± 1.7; all P < .05), with statistical significance favoring TSA. After controlling for age and sex, there was an adjusted difference of 4.5 units in the ASES score favoring TSA (P = .005) at 5 years postoperatively but no differences in adjusted SANE (P = .745) and VAS pain (P = .332) scores. The use of RSA for GHOA grew considerably over time, from representing only 17% of all replacements performed for GHOA in 2012 to nearly half (47%) in 2021 (P < .001).ConclusionRSA as a treatment for GHOA with an intact rotator cuff seems to yield PROs that are largely clinically equivalent to TSA extending to 5 years postoperatively. The observed statistical significance favoring TSA appears to be of marginal clinical benefit based on established minimal clinically important differences and may be a result of the large sample size. Further research using more granular clinical data and examining differences in range of motion and complications is warranted as it may change the value analysis.     

Return to golf after shoulder arthroplasty: golf performance and outcome scores

BackgroundGolf is an increasingly popular sport in the United States, especially among the age group of patients undergoing joint replacement. Return to golf after hip and knee arthroplasty has been previously studied. However, the quality and level of play after total shoulder arthroplasty (TSA) are less defined, especially after reverse shoulder arthroplasty (RSA). We hypothesize that shoulder pain and performance will improve during golf similarly after both anatomic and reverse total shoulder arthroplasties.MethodsThis is a retrospective cohort study of 69 patients identified as playing golf recreationally before undergoing either anatomic or RSA. All patients were cleared to return to golf activities 3 months after surgery. A golf-specific questionnaire was emailed to patients focusing on their experience returning to golf after shoulder arthroplasty. Results after TSA were compared with RSA. Patient-reported and functional outcome scores were evaluated.ResultsThe median age at surgery was 70 (62-73) years with 47 (68.1%) total shoulder replacements and 22 (31.9%) reverse shoulder replacements. Thirty-six (52.1%) patients returned to playing golf within 6 months and sixty (87.0%) patients returned to playing golf within 12 months after surgery. Enjoyment of golf either improved or stayed the same in 51 patients (91.0%). There was no significant change in the handicap score after shoulder replacement. Pain experienced during golf improved significantly from a median visual analog score pain of 6 to 1 (P < .001), with slightly greater improvement in pain for patients who underwent TSA (P = .025). Driving distance improved for 52.2% of patients, with patients who underwent TSA reporting significantly greater improvements in distance (P = .014). For all other questions, patients treated with anatomic shoulder arthroplasty and RSA reported similar experiences. American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, Single Assessment Numerical Evaluation score, visual analog score function, active flexion, and external rotation all significantly improved at the most recent follow-up (P < .001).ConclusionReturn to golf after both reverse and anatomic total shoulder arthroplasties is a realistic expectation, with significant improvements in pain and function while playing golf. Enjoyment playing golf, golf performance, and average length of drive improve in approximately half of all patients. Patients treated with anatomic shoulder arthroplasty and RSA can expect similar golf experiences after surgery, with patients who underwent TSA experiencing a better improvement in driving distance.     

Predictors of patient satisfaction and outcomes following reverse total shoulder arthroplasty

BackgroundObjective clinical outcomes and patient satisfaction via patient reported outcome measures (PROMs) can vary following reverse total shoulder arthroplasty (rTSA). The purpose of this study was to analyze patient specific preoperative factors that may predict postoperative PROMs and satisfaction following rTSA.MethodProspective data was collected on 144 consecutive patients who underwent primary rTSA at our institution between 2012 and 2018, all with minimum 2 year follow-up. Age, gender, race, BMI, previous surgery on the index shoulder, and comorbidity burden were analyzed as potential predictors. Shoulder specific clinical measures were collected both pre- and postoperatively via range of motion testing with active abduction, internal, and external rotation. PROMs included global shoulder function, Simple Shoulder Test (SST) and the American Shoulder and Elbow Surgeons (ASES) scoring systems, and cumulative patient satisfaction. Statistical analysis included comparison of pre- and postoperative outcome measures across the cohort as a whole and between each of the potential predictors in question. The relationship between predictors and postoperative cumulative satisfaction was investigated, with specific attention to identify the strongest predictors and account for confounding variables. Statistical significance was determined at P < .05.ResultsAll range of motion scores and PROMs were significantly improved from preoperative to postoperative assessment. Patient satisfaction was excellent with 92% rating their shoulder as “much better” or “better.” Women and minority patients displayed significantly worse preoperative active abduction, SST, and ASES, but were found to have no significant difference in these measures postoperatively. Younger age was associated with a significantly worse postoperative ASES score. Female sex was associated with significantly higher postoperative satisfaction, while minority status was associated with significantly lower cumulative satisfaction. Postoperative global shoulder function, SST, and ASES were not significantly influenced by sex, race, previous surgery, BMI, or comorbidity burden. Postoperative ASES and global shoulder function demonstrated to be independent predictors of “much better” satisfaction rating.ConclusionPostoperative PROMs and cumulative satisfaction are not influenced by BMI, previous surgery, or comorbidity burden in our cohort. Relative to their respective counterparts, older patients, females, and white patients are more likely to demonstrate higher satisfaction with their outcome following rTSA as measured by PROMs or cumulative satisfaction. Improvements in the ASES and global shoulder function scores most consistently predict higher postoperative satisfaction.Level of evidenceLevel IV; Case Series; Treatment Study     

Comparison of mid-term outcomes of total shoulder arthroplasty for B2 and A glenoids treated with trabecular metal glenoid components

BackgroundTreatment of B2 glenoids in total shoulder arthroplasty (TSA) has been associated with worse clinical outcomes and increased rates of glenoid loosening. The purpose of this study was to describe and compare the mid-term outcomes of TSA using a trabecular metal-backed glenoid in patients with B2 and A glenoids.MethodsPatients who underwent anatomic TSA with a trabecular metal-backed glenoid component (second generation trabecular metal glenoid) for primary osteoarthritis and had minimum 5-year follow-up were reviewed. All patients underwent eccentric glenoid reaming to treat biconcavity, if present. Preoperative imaging was reviewed and patients were divided into 2 groups: Type A and Type B2. Mid-term outcome measures including patient-rated outcome scores (Patient Reported Outcome Measurement Information System and American Shoulder and Elbow Surgeons [ASES]) and shoulder range of motion were determined. ASES score was compared between groups. Radiographs were graded for radiolucent lines and posterior humeral head migration and evaluated for glenoid loosening.ResultsTwenty-two patients had Type A glenoids and 22 patients had B2 glenoids. Sixteen patients in the A group and 18 patients in the B2 group had full radiographic and physical exam follow-up. Both groups had similar follow-up (6.7 ± 1.1 years A, 6.6 ± 0.9 years B2, P = .88). Groups were similar in terms of age at surgery, gender distribution, body mass index, severity of medical comorbidities, and hand dominance distribution. The B2 patients had a mean preoperative glenoid retroversion of 17.5° ± 6.7° and posterior subluxation of 8.5% ± 5.3%. No patients in either group had evidence of glenoid loosening at follow-up. No patients required revision surgery. Nine of 16 in the A group had evidence of mild radiolucent lines (8 grade 1, 1 grade 2). Eight of 18 patients in the B2 group had mild radiolucencies (all grade 1). Two of 16 Type A and 6 of 18 B2 patients had evidence of posterior humeral migration, but all cases were graded as mild. Both groups had similar follow-up mean ASES scores (95.5 A, 89.0 B2, P = .25).ConclusionAt minimum 5-year follow-up, patients who underwent TSA with a trabecular metal-backed glenoid component demonstrated excellent clinical and patient-reported outcomes regardless of preoperative glenoid morphology (A or B2). No patients in either group had evidence of glenoid loosening or required revision surgery. These favorable mid-term outcomes of trabecular metal-backed glenoids in B2 deformities need to be followed longitudinally to determine long-term durability.Level of EvidenceLevel III; Retrospective Comparative Study     

Midterm outcomes of revision shoulder arthroplasty

BackgroundSince the introduction of shoulder arthroplasty, the indications have been expanding. Because of the increasing number of arthroplasty procedures, revision surgeries are also inevitable. The purpose of our study is to delineate a large number of revision shoulder arthroplasty cases treated in different ways, including antibiotic spacer placement (ABX), hemiarthroplasty (HA), anatomic total shoulder arthroplasty (aTSA), and reverse total shoulder arthroplasty (rTSA), and to analyze the relationship between preoperative factors and clinical outcomes.MethodsWe reviewed our institution's records of revision shoulder arthroplasty between January 1, 2000, and October 1, 2017. Preoperative information included age at the time of surgery, gender, body mass index, and infection status. Pre- and postoperatively, we gathered 6 patient-reported clinical outcomes and 3 range-of-motion parameters (elevation, abduction, and external rotation). Postoperative complications were also assessed. Then, we examined the differences between the pre- and postoperative outcomes. As a secondary analysis, we performed multivariable regression analysis on the same outcomes, accounting for age at the time of surgery, infection status, and previous surgery type.ResultsAmong the 341 revisions performed, 138 cases met inclusion criteria of at least a 2-year follow-up with pre- and postoperative functional outcome scores. The majority of our revision procedures were to a rTSA (92 cases, 67%), followed by aTSA (28 cases, 20%), and ABX/HA (18 cases, 13%). The mean age at the time of our index surgery was 66 years old. In aTSA and rTSA, all the postoperative outcomes (ie, ASES, Constant, UCLA, SST, SPADI, SF-12 scores, and 3 AROMs) were significantly improved beyond the minimal clinically important difference (MCID) except SF-12 scores in aTSA (P = .25) and active external rotation in rTSA (P = .73). None of the ABX/HA's postoperative outcomes achieve significant improvement or MCID. Multivariable regression analysis showed that older age at the time of surgery was significantly associated with better outcomes in 3 of the 6 patient-reported outcomes (ASES, SST, and SPADI; P = .023, .023, and .028, respectively).ConclusionRevision aTSA and rTSA showed statistically and clinically significant improvement postoperatively. ABX and HA did not achieve meaningful postoperative improvement. Overall, patients getting revision shoulder arthroplasty at an older age had better patient-reported outcomes.Level of evidenceLevel III; Retrospective Cohort Study