Remote Patient Monitoring of Postoperative Rehabilitation.

Postoperative rehabilitation is a critical part of the treatment algorithm for patients with shoulder issues. When patients could not go to in-person therapy, many therapists pivoted to a remote option, and several application-based rehabilitation programs emerged. This article will discuss the shift to remote patient rehabilitation and will highlight the benefits and potential pitfalls of remote rehabilitation. It will also discuss ways to monitor patients remotely as they are performing their postoperative rehabilitation exercises. Finally, it will discuss how these remote platforms can be used, and what the user experience is like for the patient and the surgeon.

Is there a difference in outcomes between the first and second surgical procedures in patients who have bilateral shoulder operations?

BACKGROUND: Some patients who have shoulder surgery on 1 shoulder go on to have surgery on their contralateral shoulder. It is unclear whether the clinical improvements following the second surgical procedure are as significant as the improvements after the first surgical procedure. METHODS: All patients who underwent surgery on both shoulders performed by a single surgeon between March 2013 and June 2018 were eligible for inclusion. Visual analog scale (VAS) scores were obtained preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years for both shoulders. Scores were then compared based on hand dominance and which shoulder was treated first. Complications were also recorded. RESULTS: Overall, 105 patients (210 surgical procedures) were included. Of the patients, 66 underwent bilateral open shoulder surgery and 39 underwent bilateral arthroscopic shoulder surgery. There was a significant reduction in VAS scores from preoperative to postoperative levels following surgery (5.9 before surgery vs. 1.7 after surgery). We found no difference in VAS scores at any time point when comparing whether the dominant or nondominant shoulder was operated on first. Significantly higher VAS scores were observed at 2 weeks, 6 weeks, and 3 months following the first shoulder operation compared with the second; by 6 months and beyond, there was no longer a difference. CONCLUSION: Patients who undergo bilateral shoulder surgery have more pain in the first 3 months following their first shoulder operation compared with their second. However, there is no difference in pain scores at 6 months and beyond between shoulders.

Clinical and radiographic outcomes after Latarjet using suture-button fixation.

BACKGROUND: Latarjet has become a common treatment option for patients with shoulder instability in the setting of bone loss. The coracoid is commonly secured with screws. METHODS: All patients who underwent Latarjet with suture-button fixation with minimum 1-year follow-up were eligible for inclusion. Preoperative demographic and clinical outcome data including American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), and Visual Analog Scale (VAS) were recorded and compared with postoperative scores. Radiographs were reviewed for signs of nonunion. Complications were recorded. RESULTS: Overall 21 patients (76% male, average age: 30.4 ± 11.3 years) underwent Latarjet with suture-button fixation. Significant improvements at 1 year were seen in ASES (P < 0.001), SANE (P < 0.001), and VAS (P = 0.011) scores compared with preoperative scores. Of the 21 patients who had reached 1-year follow-up, 17 (81%) reached 2-year follow-up. For the 17 patients who reached 2-year follow-up, there were significant improvements in ASES (P = 0.001), SANE (P = 0.001), and VAS (P = 0.005) scores from preoperative values. When isolating the 17 patients with 2-year follow-up, there were no significant differences between their 1-year and 2-year ASES (P = 0.73), SANE (P = 0.17), and VAS (P = 0.37) scores. Overall, 3 patients (14%) sustained a complication (one redislocation, one with coracoid migration and a fibrous union, and one superior labral tear requiring biceps tenodesis and superior labral repair). CONCLUSION: Suture-button fixation of the coracoid during the Latarjet provides encouraging clinical and radiographic outcomes at 1 and 2 years.

Outpatient versus inpatient anatomic total shoulder arthroplasty: outcomes and complications.

BACKGROUND: Total shoulder arthroplasty (TSA) is an effective treatment option for glenohumeral arthritis. Historically, this surgical procedure was performed on an inpatient basis. There has been a recent trend in performing TSA on an outpatient basis in the proper candidates. METHODS: All patients who underwent outpatient TSA performed by a single surgeon between 2015 and 2017 were included. Demographic information and clinical outcome scores, as well as data on complications, readmissions, and revision surgical procedures, were recorded. This group of patients was then compared with a matched cohort of patients who underwent inpatient TSA over the same period. RESULTS: Overall, 94 patients (average age, 60.4 years; 67.0% male patients) underwent outpatient TSA and were included. Patients who underwent outpatient TSA showed significant improvement in all clinical outcome scores at both 1 and 2 years postoperatively. The control group consisted of 77 patients who underwent inpatient TSA (average age, 62.6 years; 53.2% male patients). No significant differences in complications or improvements in clinical outcome scores were found between the inpatient and outpatient groups. CONCLUSION: TSA performed in an outpatient setting is a safe and reliable procedure that provides significant improvement in clinical outcome scores and no difference in complication rates compared with inpatient TSA.

Subscapularis Repair During Reverse Total Shoulder Arthroplasty Using a Stem-Based Double-Row Repair: Sonographic and Clinical Outcomes.

BACKGROUND: Treatment of the subscapularis in reverse total shoulder arthroplasty (RTSA) is a controversial topic, with conflicting evidence regarding outcomes after repair. PURPOSE/HYPOTHESIS: The purpose of this study was to report clinical and sonographic outcomes of a through-implant double-row suture technique for subscapularis repair in RTSA and to compare clinical outcomes and range of motion (ROM) between patients with an intact subscapularis tendon repair versus those whose tendon repair was not intact. The authors hypothesized that the novel repair technique would find more than 80% of tendons intact on ultrasound, with significant improvement in clinical outcome scores and ROM. The authors also hypothesized that patients with an intact subscapularis tendon repair would have better clinical outcomes compared with those with a nonintact tendon repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The study included all patients who underwent RTSA by 1 of 2 surgeons between August 2016 and March 2017 with the through-implant double-row suture technique for subscapularis repair. Subscapularis tendon integrity was assessed postoperatively via ultrasound at minimum 1-year follow-up. American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain visual analog scale (VAS) scores were recorded at the final follow-up visit in addition to ROM measures. RESULTS: A total of 48 patients (31 males, 17 females; mean age, 68.9 ± 7.4 years; mean follow-up, 13.8 ± 2.1 months) were included. On ultrasound, the subscapularis was intact in 83.3% of patients. Regarding preoperative versus postoperative outcome scores, the ASES score (mean ± SD) significantly improved from 38.3 ± 14.7 to 81.9 ± 13.6, the SANE score significantly improved from 29.8 ± 24.2 to 75.5 ± 21.0, and the VAS pain score significantly improved from 5.9 ± 2.1 to 1.2 ± 1.6 (P < .001 for all). Forward flexion and external rotation significantly improved. No significant difference existed in clinical outcome scores or ROM between patients with intact versus torn subscapularis tendons based on ultrasound. CONCLUSION: Subscapularis repair using a stem-based double-row repair technique during RTSA demonstrated an overall healing rate of 83.3%, as evidenced by ultrasound examination at short-term follow-up. Integrity of subscapularis repair did not affect clinical outcome or ROM.

Tuberosity Repair in Reverse Total Shoulder Arthroplasty for Fracture Using a Stem-based Double-row Repair: A Cadaveric Biomechanical Study.

INTRODUCTION: The optimal tuberosity repair method in reverse total shoulder arthroplasty for fracture is unknown. METHODS: Eight matched pairs of cadaver shoulders were randomly assigned to a stem-based tuberosity repair technique or a nonstem-based repair (Boileau technique) and mechanically tested with a 10 kN load cell. Cyclic loading was performed between 10 and 100 N for 500 cycles at 1 Hz, followed by static pull to failure at 33 mm/s. Ultimate load was determined from the maximum load reached during the pull to failure. A paired Student t-test was used to compare the means of the ultimate load and average cyclic displacement of the two sample groups. RESULTS: The ultimate load to failure for the stem-based tuberosity repair technique was significantly higher than the nonstem-based technique (668 ± 164 N versus 483 ± 67 N; P = 0.032). The average cyclic displacement for the stem-based tuberosity repair technique was significantly less than the nonstem-based technique 0 (0.83 ± 0.67 mm versus 3.36 ± 2.36 mm; P = 0.017). CONCLUSION: The stem-based tuberosity repair technique afforded higher ultimate load to failure with less average cyclic displacement than the nonstem-based technique. Consideration to the stem-based technique should be given when performing a tuberosity repair in the setting of reverse total shoulder arthroplasty for fracture. LEVEL OF EVIDENCE: Level III.

Outpatient vs. inpatient reverse total shoulder arthroplasty: outcomes and complications.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) is an effective treatment option for many shoulder conditions. Historically, this surgical procedure was performed on an inpatient basis. There has been a recent trend to perform RTSA on an outpatient basis in proper candidates. METHODS: All patients who underwent outpatient RTSA performed by a single surgeon between 2015 and 2017 were included. Demographic information and clinical outcome scores (American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores), as well as data on complications, readmission, and revision surgery, were recorded. This group of patients was then compared with a cohort of patients who underwent RTSA in the inpatient setting during the same period. RESULTS: Overall, 241 patients (average age, 68.9 years; 52.3% female patients) underwent outpatient RTSA and were included. Patients who underwent outpatient RTSA showed significant improvements in all clinical outcome scores at both 1 and 2 year postoperatively (all P < .0001). The control group of patients who underwent RTSA as inpatients consisted of 373 patients (average age, 72 years; 66% female patients). Significantly more controls had diabetes (P = .007), and controls had a higher body mass index (P = .022). No significant differences existed in improvements in clinical outcome scores between the inpatient and outpatient groups. Complication rates were significantly lower for outpatient cases than for inpatient controls (7.0% vs. 12.7%, P = .023). CONCLUSION: RTSA performed in an outpatient setting is a safe and reliable procedure that provides significant improvements in clinical outcome scores with fewer complications compared with inpatient RTSA.

Can a functional difference be detected in reverse arthroplasty with 135° versus 155° prosthesis for the treatment of rotator cuff arthropathy: a prospective randomized study.

BACKGROUND: The purpose of this randomized controlled trial was to compare humeral inclinations of 135° and 155° in patients undergoing primary reverse shoulder arthroplasty (RSA). Our hypothesis was that forward flexion would be higher in the 155° group but be associated with a higher rate of scapular notching. METHODS: A randomized controlled trial was conducted on 100 primary RSAs performed with a humeral inclination of either 135° or 155°. The prostheses were otherwise identical and a neutral glenosphere was used in all cases. Functional outcome, forward flexion, external rotation, and scapular notching were assessed at a minimum of 2 years postoperatively. RESULTS: There was no difference in range of motion or functional outcome scores between the 2 groups. In the 155° group, forward flexion improved from 76° to 135° (P < .001) and external rotation remained unchanged (29° vs. 30°; P = .835). In the 135° group, postoperative forward flexion improved from 78° to 132° (P < .001) and external rotation was unchanged (28° vs. 29°; P = .814). Scapular notching was observed in 58% of cases with a 155° inclination compared with 21% with a 135° inclination (P = .009). CONCLUSION: With a neutral glenosphere there was no difference in postoperative forward flexion or external rotation after an RSA with a humeral inclination of 135° compared with 155°. Scapular notching was reduced with the use of 135° design compared with a 155° design but persists at a rate of 21% at 2-year follow-up in the absence of a lateralized glenosphere.

Adhesive Capsulitis: Demographics and Predictive Factors for Success Following Steroid Injections and Surgical Intervention.

PURPOSE: Examine demographic factors of all patients treated for adhesive capsulitis by a single surgeon, report the treatments and outcomes of these patients, and determine the effectiveness of various treatments, including corticosteroid injections and operative intervention in relation to risk factors for adhesive capsulitis. METHODS: All patients treated for adhesive capsulitis by a single surgeon between 2008 to 2014 with minimum 2 years' follow-up were identified via charts and operative reports and were eligible for inclusion. Demographic information including sex and medical comorbidities was documented. Preintervention and postintervention shoulder range of motion was recorded. Specific treatment information (number of corticosteroid injections, etc) was collected. Treatment outcomes were then compared as an aggregate and among varying comorbidities. RESULTS: Overall, 1377 patients were treated for adhesive capsulitis (946 women vs 431 men [P = .001]). For patients with adhesive capsulitis: a higher percentage of men than women had diabetes (24.8% vs 17.3% [P = .001]); nondiabetic patients had better forward flexion at initial presentation than patients with diabetes (114° vs 108° [P = .015]); more patients with diabetes required capsular release than nondiabetic patients (13% vs 7.3% [P = .003]); more nondiabetic patients resolved adhesive capsulitis without corticosteroid or surgical intervention than patients with diabetes (83.6% vs 61.7% [P = .001]); more nondiabetic patients resolved adhesive capsulitis after single corticosteroid injection than did patients with diabetes (95.9% vs 86.7% [P = .001]). Multiple intraarticular corticosteroid injections provided no added benefit over a single injection in resolving adhesive capsulitis in patients with diabetes and nondiabetic patients. CONCLUSION: In shoulder adhesive capsulitis, women and patients with diabetes are more commonly affected, patients with diabetes respond less favorably to physical therapy in isolation and physical therapy plus corticosteroid injections than nondiabetic patients. No benefit from multiple intraarticular corticosteroid injections was seen compared with a single intraarticular corticosteroid injection in patients with diabetes and nondiabetic patients. Patients with diabetes and nondiabetic patients have functional improvement after capsular release and manipulation if conservative treatment for adhesive capsulitis fails. LEVEL OF EVIDENCE: III, case control.

Proximal stress shielding is decreased with a short stem compared with a traditional-length stem in total shoulder arthroplasty.

BACKGROUND: This study compared the outcome and radiographic humeral adaptations after placement of a traditional-length (TL) or short-stem (SS) humeral component during total shoulder arthroplasty (TSA). The hypothesis was there would be no difference in outcome or radiographic adaptations. METHODS: A multicenter retrospective review was performed of primary TSAs performed with a TL or SS press-fit humeral component. The stems were identical in geometry and coating, with the only variable being stem length. Functional outcome and radiographs were reviewed at a minimum of 2 years postoperatively in 58 TL stems and 56 SSs. RESULTS: There were significant improvements in all range of motion and functional outcome from baseline (P < .001) but no difference between the groups (P > .05). TL stems were placed in anatomic alignment 98% of the time compared with 86% of the SS cases (P = .015), but alignment did not influence outcome. Cortical thinning was more common in the medial metaphysis with the TL stem (74%) than with the SS (50%; P = .008). Partial calcar osteolysis was seen in 31% of TL stems and in 23% of SSs (P = .348). There was no difference in loosening or shift between the 2 groups. CONCLUSION: There is no difference in functional outcome at short-term follow-up between a TL stem and a SS in TSA. The pattern of radiographic adaptations may differ based on stem length. Further study is needed to evaluate the mid- to long-term differences, particularly with regard to calcar osteolysis.

Radiographic changes differ between two different short press-fit humeral stem designs in total shoulder arthroplasty.

BACKGROUND: The purpose of this study was to compare the radiographic changes of the humerus in the short term after total shoulder arthroplasty with two different short-stem humeral components. The hypothesis was that there would be no difference in radiographic changes or functional outcome based on component type. METHODS: A retrospective review was conducted of primary total shoulder arthroplasties performed with a short press-fit humeral component. Group A included a collarless humeral stem with an oval geometry and curved stem (Ascend or Ascend Flex; Wright Medical, Memphis, TN, USA). Group B included a humeral stem with a metaphyseal collar, rectangular geometry, and straight stem (Apex; Arthrex, Inc., Naples, FL, USA). Radiographic changes and functional outcome were evaluated at a minimum of 2 years postoperatively. RESULTS: There were 42 patients in group A and 35 patients in group B available for analysis. There was no difference in functional outcome between the groups. In group A, the mean total radiographic change score of the humerus was 3.9, with changes classified as low in 38% and high in 62%. In group B, the mean total radiographic change score of the humerus was 2.5, with changes classified as low in 77% and high in 23% (P < .001). Medial calcar osteolysis was present in 71% of group A compared with 28.5% of group B (P < .001). CONCLUSION: At short-term follow-up, there is no difference in functional outcome or revision between 2 different humeral stem designs. However, bone adaptive changes and the rate of medial calcar osteolysis are significantly different.

Healing and functional outcome of a subscapularis peel repair with a stem-based repair after total shoulder arthroplasty.

BACKGROUND: The purpose of this study was to evaluate functional outcome and healing of a subscapularis peel with a stem-based repair after total shoulder arthroplasty (TSA). The hypothesis was that the repair would lead to subscapularis healing in the majority of cases. METHODS: A prospective analysis was performed on a consecutive series of TSAs. Range of motion and functional outcome were assessed according to American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Simple Shoulder Test, and visual analog scale scores at a minimum follow-up of 1 year. Belly-press and lift-off tests were also performed. An ultrasound evaluation assessed subscapularis healing at final follow-up. RESULTS: At a mean follow-up of 15 months, 60 patients (mean age, 64 years) were examined. Mean forward flexion improved from 115° to 137°. External rotation at the side improved from 27° to 52°, and internal rotation improved from L4 to L2 (P < .05). American Shoulder and Elbow Surgeons score improved from 34.3 to 79.8 (P < .001). Likewise, the Single Assessment Numeric Evaluation and Simple Shoulder Test scores showed significant improvement from 33.1 to 85.3 and 4.3 to 10.2, respectively (P < .001). The visual analog scale score for pain decreased from 5.8 to 0.7 (P < .001). On ultrasound examination, the subscapularis was healed intact in 55 cases (91.7%), attenuated in 3 cases (5%), and torn in 2 cases (3.3%). CONCLUSION: A stem-based repair of a subscapularis peel after TSA leads to functional improvement in the majority of cases with >90% postoperative healing of the subscapularis.

Biomechanical Study of a Subscapularis Repair Technique for Total Shoulder Arthroplasty.

Secure subscapularis repair is an essential element of total shoulder arthroplasty. Some surgeons prefer subscapularis peel because of ease of use, but some evidence suggests that lesser tuberosity osteotomy provides better fixation. The authors developed a novel, through-implant repair technique and performed a biomechanical study of its strength with cadaveric specimens. The authors obtained 20 matched pairs of cadaveric shoulders and inserted an uncemented short-stemmed humeral prosthesis that facilitates through-implant repair in all specimens. For each cadaver, the subscapularis was repaired with lesser tuberosity osteotomy and standard suture technique on 1 side, and the contralateral subscapularis was repaired with a novel through-implant suture repair and subscapularis peel technique. Displacement of the subscapularis footprint, ultimate load to failure, and stiffness of each repair were measured and compared between fixation groups. Mean±SD displacement of the lesser tuberosity osteotomy group was 0.75±0.94 mm at 10 cycles and 2.24±2.76 mm at 500 cycles. Mean±SD load to failure was 612±185 N, and mean±SD ultimate stiffness was 119±32 N/mm. No significant differences were noted between the lesser tuberosity osteotomy group and the subscapularis peel group in mean±SD displacement at 10 cycles (1.09±1.30 mm, P=.31), mean±SD displacement at 500 cycles (2.85±2.43 mm, P=.26), mean±SD load to failure (683±274 N, P=.31), or mean±SD ultimate stiffness (117±37 N/mm, P=.88). In a biomechanical testing model, through-implant subscapularis repair provided secure fixation relative to currently accepted subscapularis repair techniques in total shoulder replacement. [Orthopedics. 2016; 39(5):e937-e943.].

Cost Analysis of Hemiarthroplasty Versus Reverse Shoulder Arthroplasty for Fractures.

Complex proximal humerus fractures in older patients can be treated with hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA), with both providing good pain relief and function. This study compared the costs, complications, and outcomes of HA vs RSA after proximal humerus fracture in older patients. Patients 65 years or older who were admitted between January 2007 and August 2011 with a 3- or 4-part proximal humerus fracture and treated with HA or RSA were identified. Surgeries were performed at the same institution by 1 of 3 surgeons trained in trauma or shoulder surgery. Operating room costs, implant costs, total costs to the patient and hospital, and range of motion were compared. In the study group, 8 patients (7 women and 1 man; mean age, 77 years) received HA and 16 patients (13 women and 3 men; mean age, 77 years) received RSA. Hemiarthroplasty implant cost and operating room cost were $9140 and $8900 less than those of RSA, respectively (P<.001). The total cost to the patient was $33,480 for HA vs $57,000 for RSA (P<.001) with no difference in admission length, transfusion requirements, or final range of motion. In patients with complex proximal humerus fractures, RSA restored function similar to HA and resulted in better pain and outcome scores. However, RSA had a significantly higher cost to both the patient and the hospital compared with HA. Further investigation of postsurgical rehabilitation costs, skilled nursing needs, or revision surgery will elucidate whether there is long-term functional or financial benefits to RSA over HA. [Orthopedics. 2016; 39(4):230-234.].

Early Outcomes Following Metal-on-Metal Reverse Total Shoulder Arthroplasty in Patients Younger Than 50 Years.

Reverse total shoulder arthroplasty (TSA) is a useful intervention for older patients with glenohumeral arthritis and a deficient rotator cuff. However, as a semiconstrained prosthesis, conventional reverse TSA implanted in a young patient could fail over time secondary to polyethylene wear and subsequent osteolysis. A metal-on-metal prosthesis may avoid this type of failure. The purpose of this study is to assess the outcomes in an initial cohort of young patients who underwent reverse TSA using a metal-on-metal prosthesis. Surgical indications included age younger than 50 years with a functioning deltoid and significant impairment of shoulder function with irreparable rotator cuff due to tumor resection, arthritis, or revision surgery. Nine patients with an average age of 37 years underwent implantation of a custom metal-on-metal reverse TSA prosthesis. All patients had a minimum 12-month follow-up or a failure of their procedure requiring revision surgery prior to 1 year. American Shoulder and Elbow Surgeons (ASES) scores, Constant scores, and range of motion were recorded and analyzed pre- and postoperatively to assess improvement, and all complications were noted. Average ASES score improved from 47 points preoperatively to 73.4 points postoperatively (P=.013). Average Constant and adjusted Constant scores improved from 20.8 points and 16% preoperatively to 61.8 points and 67.3% postoperatively, respectively (P=.019 and P=.068). Mean postoperative active forward flexion and active external rotation were 119.4° and 10°, respectively. Complications included the following: 3 patients sustained a postoperative dislocation, 1 patient had a glenoid fracture and complete loss of fixation of the baseplate, and 1 patient experienced dissociation of the glenosphere from the base-plate. Although metal-on-metal reverse TSA may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are disappointing, and the complication rate is high. [Orthopedics.2016; 39(5):e957-e961.].

How Accurate Are We in Detecting Biceps Tendinopathy?

Biceps tendon pain is frequently called biceps "tendinitis," or inflammation of the biceps tendon. Histologic analysis of biceps tendon biopsies demonstrates changes in tenocyte size, ground substance, collagen organization, and vascularity observed with many different tendinopathies. There are distinct symptoms of biceps tendinopathy and a few provocative maneuvers can help make the diagnosis. Imaging studies (eg, MRI) can show changes in signal sequence or tears. However, MRI has a low sensitivity and frequently results in missed or misdiagnosed biceps pathology. Clinical decision making is best guided by a strong clinical suspicion based on patient history, physical examination, and MRI.

Medialized Versus Lateralized Center of Rotation in Reverse Shoulder Arthroplasty.

Reverse shoulder arthroplasty may be performed using components that medialize or lateralize the center of rotation. The purpose of this prospective study was to directly compare 2 reverse shoulder arthroplasty designs. Two treatment groups and 1 control group were identified. Group I comprised 9 patients using a medialized Grammont-style (GRM) prosthesis with a neck-shaft angle of 155°. Group II comprised 9 patients using a lateralized (LAT) prosthesis with a neck-shaft angle of 135°. Pre- and postoperative assessment of range of motion, American Shoulder and Elbow Surgeons score, and visual analog scale pain score were performed. Radiographic measurements of lateral humeral offset and acromiohumeral distance were compared. The GRM prosthesis achieved greater forward flexion (143.9° vs 115.6°; P=.05), whereas the LAT achieved greater external rotation (35.0° vs 28.3°; P=.07). The lateral humeral offset was greater for the LAT prosthesis compared with the GRM prosthesis, but this distance was not significantly different from that found in the control group. The acromiohumeral distance was significantly greater in the GRM prosthesis group compared with both the LAT and the control groups. The results of this study confirm that different reverse shoulder arthroplasty designs produce radiographically different anatomy. Whereas the GRM prosthesis significantly alters the anatomy of the shoulder, the LAT design can preserve some anatomic relationships found in the normal shoulder. The clinical outcomes indicate that this may have an effect on range of motion, with traditional designs achieving greater forward flexion and lateralized designs achieving greater external rotation.

Neer Award 2015: A randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. The purpose of this study was to evaluate the effect of TXA on postoperative blood loss after shoulder arthroplasty. METHODS: A total of 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application into the wound at the completion of the case. All patients received a postoperative drain. Drain output representing postoperative blood loss, transfusion requirements, and change in hemoglobin level were recorded. All postoperative complications were noted. RESULTS: The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P = .017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P < .001). There were no transfusion requirements or postoperative complications noted in either group. DISCUSSION: In this cohort of patients, those treated with TXA experienced a significantly lower amount of postoperative blood loss and a significantly smaller change in hemoglobin level compared with those treated with placebo. Further work is required to determine the effectiveness and clinical significance of TXA in reducing transfusion requirements in shoulder arthroplasty and, more specifically, shoulder arthroplasty performed for complicated patients or for trauma and fracture patients.

Radiostereometric and Radiographic Analysis of Glenoid Component Motion After Total Shoulder Arthroplasty.

Aseptic glenoid component loosening is a common cause of total shoulder arthroplasty (TSA) failure, but early detection is difficult because pain often appears late and radiolucent lines are of uncertain significance. This study sought to answer the following questions: (1) What types of glenoid component motion may be observed during the first 3 years following implantation?; (2) Is the appearance of radiolucent lines around the glenoid component a reliable indicator of component motion?; and (3) Are clinical outcomes correlated with early glenoid component motion within the first 3 years after TSA? Eleven patients (mean age, 60.6 years) underwent TSA using a cemented, all-polyethylene glenoid component with tantalum bead implantation. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, visual analog scale [VAS] pain score, and range of motion) were compared pre- and postoperatively, and radiolucencies were graded according to the criteria of Lazarus et al. Patients were evaluated using radiostereometric analysis at 6 months and 1, 2, and 3 years postoperatively to measure component micromotion in translation and rotation. At a mean follow-up of 50.2 months, mean ASES score had improved from 30.3 to 81.3 (P<.001), mean VAS pain score had improved from 8 to 1 (P<.001), active forward flexion had improved from 109° to 155° (P=.001), active external rotation had improved from 28° to 54° (P=.003), and internal rotation had improved from the level of the sacrum to L3 (P=.002). Radiolucencies were detected around none of the components at 1 year, 6 components at 2 years, and 5 components at 3 years, and these radiolucencies were mostly found around components that experienced high levels of rotational motion.

Tendinopathy of the long head of the biceps tendon: histopathologic analysis of the extra-articular biceps tendon and tenosynovium.

BACKGROUND: Bicipital tendinitis is a common cause of anterior shoulder pain, but there is no evidence that acute inflammation of the extra-articular long head of the biceps (LHB) tendon is the root cause of this condition. We evaluated the histologic findings of the extra-articular portion of the LHB tendon and synovial sheath in order to compare those findings to known histologic changes seen in other tendinopathies. METHODS: Twenty-six consecutive patients (mean age 45.4±13.7 years) underwent an open subpectoral biceps tenodesis for anterior shoulder pain localized to the bicipital groove. Excised tendons were sent for histologic analysis. Specimens were graded using a semiquantitative scoring system to evaluate tenocyte morphology, the presence of ground substance, collagen bundle characteristics, and vascular changes. RESULTS: Chronic inflammation was noted in only two of 26 specimens, and no specimen demonstrated acute inflammation. Tenocyte enlargement and proliferation, characterized by increased roundness and size of the cell and nucleus with proteoglycan matrix expansion and myxoid degenerative changes, was found in all 26 specimens. Abundant ground substance, collagen bundle changes, and increased vascularization were visualized in all samples. CONCLUSION: Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases. The histologic findings of the extra-articular portion of the LHB tendon and synovial sheath are similar to the pathologic findings in de Quervain tenosynovitis at the wrist, and may be due to a chronic degenerative process similar to this and other tendinopathies of the body.