Humeral Component Version Has No Effect on Outcomes Following Reverse Total Shoulder Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial.

BACKGROUND: Controversy exists regarding the ideal humeral component version to optimize humeral rotation and patient outcomes in reverse total shoulder arthroplasty (rTSA). METHODS: Patients undergoing primary rTSA for rotator cuff tear arthropathy, a massive rotator cuff tear, or primary osteoarthritis with a rotator cuff tear were randomized to placement of the humeral component in neutral version or 30° of retroversion. Shoulder active range of motion and strength and visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES), and Patient-Reported Outcomes Measurement Information System Global 10 (PROMIS-10) scores were collected up to 2 years postoperatively. The goal of the study was to determine whether humeral external rotation and internal rotation are affected by humeral component version following rTSA at 2 years postoperatively. RESULTS: Sixty-six patients were included in the analysis. The median follow-up was 26 months for the neutral and 27 months for the 30° retroversion group. No differences between the groups were observed with respect to the primary diagnosis, sex, age, body mass index, or American Society of Anesthesiologists (ASA) class. The 2 groups did not differ significantly in terms of improvement at 2 years in active shoulder abduction (p = 0.969), forward elevation (p = 1.000), internal rotation measured as the highest spinal level reached (p = 1.000), internal rotation with the arm abducted 90° (p = 0.451), external rotation (p = 0.362), or muscle strength in forward elevation (p = 1.000), abduction (p = 1.000), external rotation (p = 0.617), or internal rotation (p = 1.000). The 2 groups did not differ significantly in terms of improvement in postoperative ASES (p = 1.000), PROMIS-10 physical (p = 1.000), or VAS pain scores (p = 0.718) at the time of final follow-up. In the neutral version group, 1 patient underwent revision for instability and 1 for stiffness. One acromial stress fracture occurred in the 30° humeral retroversion group. Scapular notching was observed in 7 (21.2%) of the patients in neutral version group and 5 (15.2%) of the patients in the 30° retroversion group (p = 0.750). CONCLUSIONS: Securing the humeral component at neutral version or 30° of retroversion in rTSA resulted in similar active shoulder external rotation, internal rotation, forward elevation, abduction, and strength measurements, complication rates, and VAS pain, PROMIS-10 physical, and ASES scores at 2 years postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Complication rates and efficacy of single-injection vs. continuous interscalene nerve block: a prospective evaluation following arthroscopic primary rotator cuff repair without a concomitant open procedure.

Background: To compare the complications and efficacy of pain relief of the interscalene anesthetic block using either a single-injection (SI) vs. a continuous, indwelling catheter (CIC) for arthroscopic rotator cuff repair surgery. Methods: Patients undergoing primary, arthroscopic rotator cuff repair without concomitant open procedure or biceps tenodesis were prospectively enrolled by 4 fellowship-trained sports medicine and shoulder surgeons. Patients received either a SI or CIC preoperatively based on surgeon preference. Patients were contacted by phone to complete a standard questionnaire on postoperative days (PODs) 1, 3, 7, 14, and 28. Patients were asked to rate the efficacy of their subjective pain relief (scale of 0-10), document issues with the catheter, describe analgesic usage, and report pharmacological and medical complications. The primary outcome was measured as complication rate. Postoperative narcotic use, patient satisfaction, and visual analog scale pain scores were measured as secondary outcomes. Results: Seventy patients were enrolled, 33 CIC patients (13 male, 20 female, mean age 61 ± 8 years) and 37 SI patients (20 male, 17 female, mean age 59 ± 10 years). There were significantly more injection/insertion site complications in the CIC group (48%) vs. the SI group (11%, P = .001). The incidence of motor weakness was higher in the CIC group on POD 1 (P = .034), but not at any subsequent time points. On POD 1, CIC patients had a clinically significantly lower pain score compared to SI (3.2 vs. 5.4; P = .020). Similar scores were observed at subsequent time points until POD 28, when CIC again had a lower pain score (0.8 vs. 2.7; P = .005). However, this did not reach clinical significance. All patients in both groups rated a satisfaction of 9 or 10 (scale 0-10) with the anesthesia provided by their nerve block. Conclusion: CIC interscalene nerve blocks had an increased risk for injection site complications and minor complications in the immediate postoperative period when using the CIC for arthroscopic rotator cuff repair without any concomitant open procedures. CIC blocks demonstrated clinically significant superior pain relief on POD 1 but were equal to SI blocks at every time point thereafter. Superior pain relief of CIC at POD 28 was not clinically significant. CIC catheters do not appear to markedly decrease the use of postoperative narcotics. Despite this trend in complication rates and pain scores, all patients in both groups were satisfied with their nerve block.

A two-year comparison of reverse total shoulder arthroplasty mini-humeral tray and augmented mini-glenoid baseplate implants vs. standard implants.

BACKGROUND: Patients who undergo reverse total shoulder arthroplasty (RTSA) are getting younger with greater function expectations. This retrospective, longitudinal study of prospectively collected data compared perceived shoulder function and strength, active shoulder mobility, radiographic evidence of scapular notching, and implant survival over the initial 2-years post-RTSA among patient groups who received either standard central fixation point liner and glenoid baseplate implants, or lower size profile mini-humeral tray with offset trunnion options and mini-augmented glenoid baseplate implants. MATERIALS AND METHODS: Patients who underwent primary RTSA using standard central fixation point liner and glenoid baseplate implants (Group 1, n = 180) were compared with patients who underwent primary RTSA using lower size profile mini-humeral tray with offset trunnion options and mini-augmented glenoid baseplate implants (Group 2, n = 53) for active shoulder mobility, American Shoulder and Elbow Surgeons (ASES) score, perceived ability to lift 10 lbs (4.5 kg) overhead, radiographic evidence of scapular notching, and implant survival. Data was collected pre-surgery, 6-weeks, 6-months, 1-year, and 2-years post-RTSA (p ≤ 0.05). RESULTS: More Group 2 patients had more complex B or C Walch glenoid morphology, while Group 1 had more A1 or A2 types (p ≤ 0.001). Group 2 had greater active shoulder flexion at 6-months, 1-year, and 2-years (p ≤ 0.018) and external rotation (in adduction) at 6-months and 2-years (p ≤ 0.004) compared to Group 1, with higher ASES scores at 6-months and 2-years (p ≤ 0.026) (with small-to-medium effect sizes), and with more patients meeting or exceeding the minimal clinically important difference (MCID) at 2-years (p = 0.045) and patient acceptable symptomatic state (PASS) levels at 6-months, 1-year and 2-years (p ≤ 0.045). Scapular notching was identified in six of 53 (11.3%) Group 2 patients and in 32 of 180 (17.7%) Group 1 patients. Group 1 patients had more grade 2 or greater scapular notching grades compared to Group 2 (p = 0.04). Implant survival was comparable with Group 1 = eight of 180 (4.4%) and Group 2 = 1 of 53 (1.9%) of patients requiring removal for 95.6% and 98.1% implant survival, respectively. CONCLUSION: Limited scapular notching and excellent implant survival was observed in both groups. Despite including individuals with more complex glenoid deficiency, patients receiving the lower size profile implants generally displayed better active shoulder mobility and perceived shoulder function compared to those who received standard implants. These patients also more frequently met or exceeded the MCID by 2-years post-RTSA and PASS levels by 6-months, 1-year, and 2-years post-RTSA, with lower scapular notching grades. LEVEL OF EVIDENCE: Retrospective comparative study.

Effect of vitamin E-enhanced highly cross-linked polyethylene on wear rate and particle debris in anatomic total shoulder arthroplasty: a biomechanical comparison to ultrahigh-molecular-weight polyethylene.

BACKGROUND: Particle-induced osteolysis resulting from polyethylene wear remains a source of implant failure in anatomic total shoulder designs. Modern polyethylene components are irradiated in an oxygen-free environment to induce cross-linking, but reducing the resulting free radicals with melting or heat annealing can compromise the component's mechanical properties. Vitamin E has been introduced as an adjuvant to thermal treatments. Anatomic shoulder arthroplasty models with a ceramic head component have demonstrated that vitamin E-enhanced polyethylene show improved wear compared with highly cross-linked polyethylene (HXLPE). This study aimed to assess the biomechanical wear properties and particle size characteristics of a novel vitamin E-enhanced highly cross-linked polyethylene (VEXPE) glenoid compared to a conventional ultrahigh-molecular-weight polyethylene (UHMWPE) glenoid against a cobalt chromium molybdenum (CoCrMo) head component. METHODS: Biomechanical wear testing was performed to compare the VEXPE glenoid to UHMWPE glenoid with regard to pristine polyethylene wear and abrasive endurance against a polished CoCrMo alloy humeral head in an anatomic shoulder wear-simulation model. Cumulative mass loss (milligrams) was recorded, and wear rate calculated (milligrams per megacycle [Mc]). Under pristine wear conditions, particle analysis was performed, and functional biologic activity (FBA) was calculated to estimate particle debris osteolytic potential. In addition, 95% confidence intervals for all testing conditions were calculated. RESULTS: The average pristine wear rate was statistically significantly lower for the VEXPE glenoid compared with the HXLPE glenoid (0.81 ± 0.64 mg/Mc vs. 7.00 ± 0.45 mg/Mc) (P < .05). Under abrasive wear conditions, the VEXPE glenoid had a statistically significant lower average wear rate compared with the UHMWPE glenoid comparator device (18.93 ± 5.80 mg/Mc vs. 40.47 ± 2.63 mg/Mc) (P < .05). The VEXPE glenoid demonstrated a statistically significant improvement in FBA compared with the HXLPE glenoid (0.21 ± 0.21 vs. 1.54 ± 0.49 (P < .05). CONCLUSIONS: A new anatomic glenoid component with VEXPE demonstrated significantly improved pristine and abrasive wear properties with lower osteolytic particle debris potential compared with a conventional UHMWPE glenoid component. Vitamin E-enhanced polyethylene shows early promise in shoulder arthroplasty components. Long-term clinical and radiographic investigation needs to be performed to verify if these biomechanical wear properties translate to diminished long-term wear, osteolysis, and loosening.

Mini-augmented glenoid baseplate and mini-humeral tray reverse total shoulder arthroplasty implant comparisons: two-year clinical outcomes.

BACKGROUND: Augmented glenoid baseplate and offset humeral tray reverse total shoulder arthroplasty (RTSA) implants may decrease the mechanical impingement that creates scapular notching and improve shoulder function. This study evaluated the clinical efficacy of three different RTSA glenoid baseplate and offset humeral tray combinations for patient-reported shoulder function, pain and instability, radiographic imaging evidence of glenoid baseplate or humeral stem subsidence and migration, bony changes associated with implant loosening, and scapular notching over the initial 2 years post-RTSA. Primary outcomes included active shoulder mobility, perceived function, pain, instability, scapular notching, and implant survival. METHODS: Sixty-seven patients from 6 research sites received one of three different glenoid baseplate and humeral tray combinations. Group 1 (n = 21) received a mini-augmented glenoid baseplate with a standard humeral tray; Group 2 (n = 23) received a standard glenoid baseplate and a mini-humeral tray with 3 trunnion offset options; Group 3 (n = 23) received both a mini-augmented glenoid baseplate and a mini-humeral tray with 3 trunnion offset options. Subjects underwent radiologic evaluation, completed the ASES scale, the EQ-5D-5L quality of life scale, VAS shoulder pain and instability questions, and active shoulder mobility measurements pre-operatively, and 6-weeks, 6-months, 1-2 years post-RTSA. RESULTS: Improved active shoulder mobility, quality of life, perceived function, decreased shoulder pain and instability, excellent implant survival and minimal scapular notching were observed for all groups. Group 3 had better overall active shoulder mobility than the other groups and better perceived function than Group 1. CONCLUSION: The group that received the mini-augmented glenoid baseplate and mini-humeral tray combination had better overall active shoulder flexion, external rotation at 90° abduction, and internal rotation. This group also had better perceived shoulder function compared to the group that received a mini-augmented glenoid baseplate with a standard humeral tray.

Evaluating trunnionosis in modular anatomic shoulder arthroplasties: a retrieval study.

BACKGROUND: Shoulder arthroplasty procedures are widely indicated, and the number of shoulder arthroplasty procedures has drastically increased over the years. Rapid expansion of the utilization of reverse total shoulder arthroplasty has outpaced the more modest growth of anatomic total shoulder arthroplasty (aTSA) while shoulder hemiarthroplasty (HA) has trended down. Recently, shoulder prostheses have transitioned to increasingly modular systems offering more individualized options with the potential for decreased pain and increased range of motion. However, increased primary procedures has resulted in increased revision surgeries, with one potential cause being fretting and corrosion damage within these modular systems. METHODS: Following institutional review board approval, 130 retrieved aTSA and 135 HA explants were identified through database query. Humeral stem and head components were included in all 265 explants, whereas 108 included polyethylene glenoid liner components. All explanted components were macroscopically evaluated for standard damage modes, and taper junctions were microscopically examined for fretting/corrosion using a modified Goldberg-Cusick classification system that was 4-quadrant graded for both the male and female component. Medical records were reviewed for patient demographics and surgical information. RESULTS: In this series, 158 of explants were from female patients (male = 107), and 162 explants were from the right shoulder. Average age at implantation was 61 years (range: 24-83), average age at explanation was 66 years (range, 32-90), and average duration of implantation was 61.4 months (range, 0.5-240). Scratching, edge deformation, and burnishing were the most commonly observed standard damage modes. Of the 265 explants, 146 had a male stem component vs. 118 with a female stem component. Average summed fretting grades on male and female stem components were 8.3 and 5.9, respectively (P < .001). Average summed corrosion grades for male and female stem components were 8.2 and 6.2, respectively (P < .001). Wider male tapers (>11 mm) showed significantly less fretting and corrosion (P < .001). Lastly, mismatched metal compositions between the head and stem components showed greater fretting and corrosion damage (P = .002). CONCLUSION: In this series of 265 aTSA and HA explants, there was substantial damage present on the explanted components. All components demonstrated macroscopic damage. In this retrieval study, small-tapered male stems with small, thin female heads and mismatched metal composition between components were risk factors for increased implant wear. As shoulder arthroplasty volume increases, optimizing design is paramount for long-term success. Additional work could determine the clinical significance of these findings.

Concomitant latissimus dorsi tendon transfer during reverse total shoulder arthroplasty does not improve active external rotation or clinical outcomes in patients with external rotation deficit.

BACKGROUND: To assess the role of latissimus dorsi tendon transfer (LDT) concomitant with reverse total shoulder arthroplasty in patients with external rotation (ER) deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis. METHODS: Patients with a positive external lag sign and <10° of active external rotation (aER) treated with reverse shoulder arthroplasty at a single institution with a minimum 12-month follow-up were retrospectively identified from a prospective database. Basic demographic information along with preoperative and postoperative range of motion (ROM) measures, American Shoulder and Elbow Surgeons score (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value scores were obtained. Statistical analysis was performed to compare ROM and functional outcomes between patients who underwent concomitant LDT and those with no transfer (NT). RESULTS: The LDT (n = 31) and NT (n = 33) groups had similar age, sex distributions, and follow-up length average (24 vs. 30 months). No differences were found between groups at baseline, final follow-up, or magnitude of change for ASES, VAS pain, and Subjective Shoulder Value scores. Baseline ROM measures were similar, except for the LDT group having slightly less aER (-8° vs. 0°; P = .004). In addition, all postoperative ROM measures including aER were similar, except for a slight improvement in active internal rotation in the NT group. The majority of patients were satisfied with their outcome (LDT 84% (n = 26); NT 87% (n = 27); P = .72). CONCLUSION: Patients with ER deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis undergoing reverse total shoulder arthroplasty do not have significantly improved ER or patient-reported outcome measures with LDT.

Larger-diameter trunnions and bolt-reinforced taper junctions are associated with less tribocorrosion in reverse total shoulder arthroplasty.

BACKGROUND: Morse taper junction tribocorrosion is recognized as an important failure mode in total hip arthroplasty. Although taper junctions are used in almost all shoulder arthroplasty systems currently available in the United States, with large variation in design, limited literature has described comparable analyses of taper damage in these implants. In this study, taper junction damage in retrieved reverse total shoulder arthroplasty (RTSA) implants was assessed and analyzed. METHODS: Fifty-seven retrieved RTSAs with paired baseplate and glenosphere components with Morse taper junctions were identified via database query; 19 of these also included paired humeral stems and trays or spacers with taper junctions. Components were graded for standard damage modes and for fretting and corrosion with a modified Goldberg-Cusick classification system. Medical records and preoperative radiographs were reviewed. Comparative analyses were performed assessing the impact of various implant, radiographic, and patient factors on taper damage. RESULTS: Standard damage modes were commonly found at the evaluated trunnion junctions, with scratching and edge deformation damage on 76% and 46% of all components, respectively. Fretting and corrosion damage was also common, observed on 86% and 72% of baseplates, respectively, and 23% and 40% of glenospheres, respectively. Baseplates showed greater moderate to severe (grade ≥ 3) fretting (43%) and corrosion (27%) damage than matched glenospheres (fretting, 9%; corrosion, 13%). Humeral stems showed moderate to severe fretting and corrosion on 28% and 30% of implants, respectively; matched humeral trays or spacers showed both less fretting (14%) and less corrosion (17%). On subgroup analysis, large-tapered implants had significantly lower summed fretting and corrosion grades than small-tapered implants (P < .001 for both) on glenospheres; paired baseplate corrosion grades were also significantly lower (P = .031) on large-tapered implants. Factorial analysis showed that bolt reinforcement of the taper junction was also associated with less fretting and corrosion damage on both baseplates and glenospheres. Summed fretting and corrosion grades on glenospheres with trunnions (male) were significantly greater than on glenospheres with bores (female) (P < .001 for both). CONCLUSIONS: Damage to the taper junction is commonly found in retrieved RTSAs and can occur after only months of being implanted. In this study, tribocorrosion predominantly occurred on the taper surface of the baseplate (vs. glenosphere) and on the humeral stem (vs. tray or spacer), which may relate to the flexural rigidity difference between the titanium and cobalt-chrome components. Bolt reinforcement and the use of large-diameter trunnions led to less tribocorrosion of the taper junction. The findings of this study provide evidence for the improved design of RTSA prostheses to decrease tribocorrosion.

Sex-related differences in stemless total shoulder arthroplasty.

BACKGROUND: The use of stemless humeral implants for shoulder arthroplasty is becoming increasingly widespread. However, little is known about the difference in clinical, functional, and radiographic outcomes of stemless shoulder arthroplasty between men and women. Men and women do have reported differences in size, strength, and bone quality. As such, the purpose of this study was to evaluate sex-related differences in outcomes when using stemless humeral implants. METHODS: A retrospective review of 227 patients (men = 143 and women = 84) undergoing stemless shoulder arthroplasty was compared for sex-related differences. Clinical, functional, and radiographic outcomes were compared, including American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale pain scores, range of motion, radiolucencies, operative data, implant data, and complications. Statistical analysis included descriptive statistics, t-tests, chi-square tests, and logistic regression. RESULTS: Preoperatively, men had a statistically significant greater range of motion of forward elevation (P < .01), external rotation (ER) at adduction (P = .04), ER at 90° abduction (P = .03), and baseline ASES scores (P < .01). At 2 years, there were no differences between men and women in ASES score (P = .12), visual analog scale pain score (P = .74), active ER (P = .98), implant migration, or radiolucencies (P > .99). Mean operating time was 9 minutes longer in male patients (P < .01). There was no significant difference in surgical complications, including dislocation, fracture, infection, or loosening. The three-year revision-free survival was 98.8% for women and 97.9% for men. CONCLUSION: Patient sex is not predictive of postoperative functional outcomes after stemless shoulder arthroplasty. The operative time was significantly shorter in female patients, and there was no significant difference in surgical complications between men and women.

Simultaneous bilateral shoulder arthroplasty: a case series.

BACKGROUND: Staged bilateral shoulder arthroplasty procedures have been shown to have good functional outcomes. The next step is to explore the option of simultaneous bilateral shoulder arthroplasty (SBSA). We report on the first case series of SBSA in the United States. The purpose of this study was to examine the safety and postoperative complication profile of SBSA and provide a technique reference for surgeons considering performing or investigating this procedure. METHODS: We conducted a retrospective record review of all the SBSA procedures performed by the senior author between 2007 and 2020. Patient demographic characteristics, surgical information, and postoperative data were collected. Data were compiled, and means, standard deviations, and ranges were calculated. Any readmissions or postoperative complications requiring revision were noted. A cohort of patients matched for age, sex, and body mass index with staged (sequential) bilateral total shoulder arthroplasty was analyzed for comparison. RESULTS: Thirteen patients were identified in the simultaneous group (SBSA). The mean age was 64 ± 15 years, with 9 women (69%) and 4 men (31%); the mean body mass index was 29.1 ± 7.5. The mean American Society of Anesthesiologists score was 2.55 ± 0.7, average blood loss was 364 ± 170 mL (range, 50-600 mL), 5 of 13 patients (38%) underwent blood transfusions, and the mean surgical time was 183 ± 42 minutes. Postoperatively, the mean visual analog scale pain score on postoperative day 1 was 4 ± 2 (range, 0-7), and the mean length of stay was 3.3 days. Postoperative complications included urinary tract infections in 2 patients, urinary retention in 2 patients, and recurrence of paroxysmal atrial fibrillation in 1 patient. No patient was readmitted within 90 days of surgery. One patient underwent a reoperation 2 years postoperatively for symptomatic hardware removal (cerclage cables around the tuberosities). A matched cohort of staged bilateral total shoulder arthroplasty patients was analyzed for comparison. Postoperative complications in the staged group included 1 reverse total shoulder arthroplasty patient with subjective instability that was managed with additional physical therapy. There were no documented readmissions within 90 days or revision arthroplasty procedures in either cohort. CONCLUSIONS: SBSA is a reasonable procedure that can be useful in select patients, with promising short-term safety noted in this series. Prospective randomized studies are needed to assess the long-term safety and efficacy of the procedure.

Stemless reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: The use of reverse total shoulder arthroplasty and stemless anatomic total shoulder replacement has been increasing in the United States every year. Stemless humeral components in reverse total shoulder arthroplasty are only approved for clinical trials in the United States with an investigational device exception with limited data. METHODS: A systematic review on stemless reverse total shoulder arthroplasty was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search was conducted on November 25, 2020, using the MEDLINE/PubMed, Cochrane, and Embase databases. All articles were reviewed by 2 independent evaluators, with any conflicts or issues resolved by consensus or a final decision by the senior author. The primary outcomes extracted were complications, radiographic results, and outcome scores. RESULTS: We evaluated 10 studies that used either the Total Evolutive Shoulder System (TESS) or Verso implant. There were 430 total patients and 437 total procedures; 266 patients in the TESS group underwent a total of 272 procedures, and 164 patients in the Verso group underwent a total of 165 procedures. The mean age at the time of surgery was 73.8 years (range, 38-93 years). The mean follow-up period ranged from 6.4 to 101.6 months per study. There was an overall trend of improved clinical outcome scores, a 0.2% humeral component loosening rate, and an 11.2% complication rate. CONCLUSIONS: This review shows that the clinical and functional outcomes following stemless or metaphyseal reverse total shoulder arthroplasty are quite promising, especially with the low rate of humeral-sided complications. There continues to be a need for additional long-term studies and randomized clinical trials.

Are Suture Tape Knots as Secure as Standard Suture? A Biomechanical Study.

BACKGROUND: Few studies have investigated the biomechanical performance of flat-braided suture tapes versus round-braided sutures after being knotted. PURPOSE: To compare the loop security and knot strength of a standard round-braided suture with 3 commercially available flat-braided suture tapes using 2 types of arthroscopic knots. STUDY DESIGN: Controlled laboratory study. METHODS: One standard suture (SS) and 3 suture tapes (T1, T2, and T3) were tied with the surgeon's knot (SK) and the Tennessee slider (TS), 25 times each, by a single surgeon. Each combination of knots and sutures underwent a preload, cyclic loading, and load to failure. Outcomes were loop security (defined by loop stretch after a 5-N preload), load at clinical failure (3 mm of displacement), and load at ultimate failure (suture rupture or knot slippage). Two-way analysis of variance was used for analysis. RESULTS: Overall, the SK group had greater overall loop security than that of the TS group (0.4 ± 0.3 vs 0.5 ± 0.3 mm of stretch, respectively; P = .020). The clinical failure load varied by suture type (P < .001) but not knot type (P = .106). For both knot types, the SS had the lowest mean ± SD clinical failure load (SK, 171 ± 49 N; TS, 176 ± 37 N), which was significantly less than that of T2 (247 ± 85 N; P < .001) and T3 (251 ± 96 N; P < .001) for the SK type and T2 (231 ± 67 N; P = .023) for the TS type. T2 sutures had the greatest ultimate failure load for both knot types (SK, 418 ± 45 N; TS, 461 ± 57 N), which was significantly greater than SS, T1, and T3 (P < .001 for all). The TS knot had greater overall ultimate failure load than the SK (375 ± 64 vs 350 ± 66 N; P < .001). CONCLUSION: Not all suture tape knots had the same biomechanical properties, although knot security and strength appeared to be adequate for all suture tapes as well as for SS. There was no evidence that suture tape knots are lower profile than SS knots. CLINICAL RELEVANCE: Surgeons should not use suture tape based only on the assumption that it has superior biomechanical properties to a standard round-braided suture.

Radiographic evaluation of humeral head reconstruction with stemmed and stemless spherical implants compared with stemless elliptical head implants.

BACKGROUND: The purpose of this study was to compare the accuracy of anatomic reconstruction of three different humeral head designs after anatomic total shoulder arthroplasty. METHODS: Postoperative radiographs of 117 patients who underwent anatomic total shoulder arthroplasty with three different implant designs (stemmed spherical, stemless spherical, and stemless elliptical) were analyzed for landmarks that represented the prearthritic state and final implant position. We assessed the change in center of rotati7on and humeral head height on the anteroposterior view and the percentage of prosthesis overhang on the axillary lateral view. A modified anatomic reconstruction index, a compound score that rated each of the 3 parameters from 0 to 2, was created to determine the overall accuracy of the reconstruction. RESULTS: Excellent modified anatomic reconstruction index scores (5 or 6 points) were achieved by 68.1% of the cases in the stemless elliptical group compared with 33.3% of the cases in the stemless spherical group and by 28.3% of the cases in the stemmed spherical group (P = .001).The mean difference in restoration of humeral head height (P < .001) and percentage of prosthesis overhang (P < .001) was superior for the stemless elliptical group compared with the two other spherical head groups. There was no difference between groups for the shift in center of rotation (P = .060). CONCLUSIONS: In this radiographic investigation comparing three different humeral head designs with respect to anatomic restoration parameters, the stemless elliptical implant more closely restored the geometry of the prearthritic humeral head as assessed by humeral head height, prosthesis overhang, and a compound reconstruction score.

Prospective, Blinded, Randomized Controlled Trial of Stemless Versus Stemmed Humeral Components in Anatomic Total Shoulder Arthroplasty: Results at Short-Term Follow-up.

BACKGROUND: Stemless humeral components for anatomic total shoulder arthroplasty (aTSA) have several reported potential benefits compared with stemmed implants. However, we are aware of no Level-I, randomized controlled trials (RCTs) that have compared stemless implants with stemmed implants in patients managed with aTSA. We sought to directly compare the short-term clinical and radiographic outcomes of stemless and stemmed implants to determine if the stemless implant is noninferior to the stemmed implant. METHODS: We performed a prospective, multicenter, single-blinded RCT comparing stemless and short-stemmed implants in patients managed with aTSA. Range-of-motion measurements and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant scores were obtained at multiple time points. Device-related complications were recorded. Radiographic evaluation for evidence of loosening, fractures, dislocation, or other component complications was performed. Statistical analysis for noninferiority was performed at 2 years of follow-up for 3 primary end points: ASES score, absence of device-related complications, and radiographic signs of loosening. All other data were compared between cohorts at all time points as secondary measures. RESULTS: Two hundred and sixty-five shoulders (including 176 shoulders in male patients and 89 shoulders in female patients) were randomized and received the allocated treatment. The mean age of the patients (and standard deviation) was 62.6 ± 9.3 years, and 99% of the shoulders had a primary diagnosis of osteoarthritis. At 2 years, the mean ASES score was 92.5 ± 14.9 for the stemless cohort and 92.2 ± 13.5 for the stemmed cohort (p value for noninferiority test, <0.0001), the proportion of shoulders without device-related complications was 92% (107 of 116) for the stemless cohort and 93% (114 of 123) for the stemmed cohort (p value for noninferiority test, 0.0063), and no shoulder in either cohort had radiographic signs of loosening. Range-of-motion measurements and ASES, SANE, and Constant scores did not differ significantly between cohorts at any time point within the 2-year follow-up. CONCLUSIONS: At 2 years of follow-up, the safety and effectiveness of the stemless humeral implant were noninferior to those of the stemmed humeral implant in patients managed with aTSA for the treatment of osteoarthritis. These short-term results are promising given the potential benefits of stemless designs over traditional, stemmed humeral components. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Baseplate Options for Reverse Total Shoulder Arthroplasty.

PURPOSE OF REVIEW: Baseplate fixation has been known to be the weak link in reverse total shoulder arthroplasty (RTSA). A wide variety of different baseplates options are currently available. This review investigates the recent literature to present the reader with an overview of the currently available baseplate options and modes of fixation. RECENT FINDINGS: The main elements that differentiate baseplates are the central fixation element, the size of the baseplate, the shape, the backside geometry, whether or not an offset central fixation exists, the number of peripheral screws, and the availability of peripheral augmentation. The wide array of baseplate options indicates that no particular design has proven superiority. As such, surgeons should be aware of their options and choose an implant that the surgeon is comfortable with and one that best suits the individual patient anatomy. With the growing number of RTSA procedures and registries with long-term follow-up, future investigations will hopefully delineate the ideal baseplate design to optimize survivorship.

Uncemented Reverse Total Shoulder Arthroplasty as Initial Treatment for Comminuted Proximal Humerus Fractures.

OBJECTIVES: To determine whether uncemented implants would provide similar outcomes while avoiding the complications associated with cement in the treatment of elderly patients with proximal humerus fractures (PHFs) with primary reverse total shoulder arthroplasty (RTSA). DESIGN: Case series. SETTING: A single Level I trauma center. PATIENTS/PARTICIPANTS: A prospectively obtained cohort of 30 patients who underwent uncemented RTSA as initial treatment for a comminuted PHF: 4 male, 26 female; average age 71 ± 11 years. INTERVENTION: Uncemented RTSA. MAIN OUTCOME MEASURES: (1) Radiographic analysis, (2) postoperative clinical range of motion, and (3) functional outcome scores: the American Shoulder and Elbow Surgeons Shoulder score and the Simple Shoulder Test score. RESULTS: Radiographic analysis showed 97% achieved stable humeral stem fixation and 70% had healing of the tuberosities in anatomical position. Average range of motion was 130 ± 31 degrees of forward flexion, 32 ± 18 degrees of external rotation, and internal rotation to the midlumbar spine. Average American Shoulder and Elbow Surgeons Shoulder score was 82.0 ± 13.5 (with an average pain rating of 0.8 ± 1.3), and average Simple Shoulder Test score was 69.4% ± 19.1%. CONCLUSIONS: Our data show that treatment of comminuted PHFs in elderly patients with uncemented RTSA can consistently produce good clinical outcomes with a low rate of complications and suggest that cement may not be necessary for RTSA in the trauma setting. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Venous Thromboembolism After Shoulder Arthoplasty and Arthroscopy.

Venous thromboembolism (VTE) in the orthopaedic literature largely focuses on lower extremity trauma and arthroplasty, with relatively few investigations of VTE after shoulder surgery. Because the rate of shoulder surgery, especially arthroplasty, continues to expand, it is important for practicing surgeons to understand the magnitude of risk, potential consequences, and prevention methods with regard to VTE. VTE after shoulder surgery has been a topic of increasing interest over the past decade, and the purpose of this review is to examine the recent literature on pathophysiology, risk factors, incidence, diagnosis, sequelae, prevention, treatment, and current recommendations regarding VTE after shoulder surgery.

Patient Outcomes After Revision of Anatomic Total Shoulder Arthroplasty to Reverse Shoulder Arthroplasty for Rotator Cuff Failure or Component Loosening: A Matched Cohort Study.

PURPOSE: To compare outcomes after conversion of anatomic total shoulder arthroplasty (aTSA) to reverse total shoulder arthroplasty (RTSA) and a matched cohort. METHODS: Patients converted from aTSA to RTSA for rotator cuff failure or component loosening and a primary RTSA matched cohort were retrospectively identified from a prospective database. Demographics and preoperative and postoperative outcomes were obtained and compared. RESULTS: Age, sex, body mass index, follow-up length, and preoperative function were similar between revision (n = 35) and primary (n = 70) groups. At final follow-up, visual analog scale pain (2.4 ± 2.8 versus 1.7 ± 2.8; P = 0.24) and American Shoulder and Elbow Surgeons (68 ± 26 versus 76 ± 24; P = 0.14) scores were similar. The revision group had worse subjective shoulder value scores (63 ± 30 versus 79 ± 21; P = 0.002), satisfaction (74% versus 90%; P = 0.03), and more complications (31% versus 13%; P = 0.02). CONCLUSION: Revision of aTSA to RTSA for component loosening or rotator cuff failure results in function comparable to primary RTSA; however, more complications, worse subjective shoulder value scores, and lower patient satisfaction should be expected. LEVEL OF EVIDENCE: Level III, retrospective comparative.