American Academy of Orthopaedic Surgeons Appropriate Use Criteria for Humeral Component Design During Primary Anatomic Total Shoulder Arthroplasty.

The American Academy of Orthopaedic Surgeons (AAOS) has developed appropriate use criteria (AUC) for humeral component design during primary anatomic total shoulder arthroplasty. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to determine the appropriateness of various humeral component designs during primary anatomic total shoulder arthroplasty. The AUC for humeral component design during primary anatomic total shoulder arthroplasty w ere derived by identifying clinical indications evident during the clinical decision-making process. These scenarios relied on definitions and general assumptions, mutually agreed on by the writing panel during the development of the scenarios. These definitions and assumptions were necessary to provide consistency in the interpretation of the clinical scenarios among experts rating the scenarios and readers using the final criteria. Writing panel members of this AUC developed patient scenarios using these guiding principles: comprehensive (covers a wide range of patients); mutually exclusive (there should be no overlap between patient scenarios/indications); homogeneous (the final ratings should result in equal application within each of the patient scenarios); and manageable (number of total rating items [ie, number of patient scenarios × number of treatments] should be practical for the rating panel). The target number of total rating items is 1,500. This means that not all patient indications and treatments can be assessed within the AUC. The 144 patient scenarios and three treatments were developed by the writing panel, a group of clinicians who are specialists in this AUC topic. Next, a separate, multidisciplinary, rating panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as 'appropriate' (median rating, 7 to 9), 'may be appropriate' (median rating, 4 to 6), or 'rarely appropriate' (median rating, 1 to 3).

Outcome measures reported for the management of proximal humeral fractures: a systematic review.

BACKGROUND: The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature. METHODS: A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength. RESULTS: Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported. CONCLUSION: Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.

Clinical outcomes and complications of reverse shoulder arthroplasty used for failed prior shoulder surgery: a systematic review and meta-analysis.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is frequently performed in the revision setting as a salvage procedure. The purpose of this study was to report the clinical outcomes and complication, reoperation, and revision rates after revision RSA (RRSA) stratified according to the primary shoulder procedure undergoing revision. METHODS: Four databases (Embase, MEDLINE, SPORTDiscus, and Cochrane Controlled Trials Register) were searched for eligible studies published between January 1985 and September 2017. The primary outcomes of interest included pain, active range of motion, and functional outcome scores. Secondary outcomes included complication, reoperation, and revision rates. RESULTS: A total of 43 studies (1041 shoulder arthroplasties) met the inclusion criteria, with a mean follow-up period of 43.8 months (range, 31.1-57.2 months). Pain scores improved in all groups; however, none reached statistical significance. Range of motion improved in all groups, except for external rotation in the RSA category. RRSA demonstrated significant improvements in the Simple Shoulder Test score and Constant score (CS) in the group undergoing hemiarthroplasty (HA) for fracture, CS in the group undergoing HA for other indications, and CS in the group undergoing anatomic total shoulder arthroplasty. Pooled complication rates were highest in the failed RSA group (56.2%), followed by the group undergoing HA for other indications (27.7%), total shoulder arthroplasty group (23.6%), soft-tissue repair group (20.6%), open reduction and internal fixation group (19.0%), and group undergoing HA for fracture (13.6%). CONCLUSIONS: Compared with other revision indications, RRSA for failed HA demonstrated the most favorable outcomes, whereas the highest complication and revision rates were observed in the RSA subgroup. This information is useful when establishing patient expectations regarding the risks, benefits, and complication and revision rates of RRSA.

Quality of internet-based decision aids for shoulder arthritis: what are patients reading?

BACKGROUND: The objective of this study was to assess the source, quality, accuracy, and completeness of Internet-based information for shoulder arthritis. METHODS: A web search was performed using three common Internet search engines and the top 50 sites from each search were analyzed. Information sources were categorized into academic, commercial, non-profit, and physician sites. Information quality was measured using the Health On the Net (HON) Foundation principles, content accuracy by counting factual errors and completeness using a custom template. RESULTS: After removal of duplicates and sites that did not provide an overview of shoulder arthritis, 49 websites remained for analysis. The majority of sites were from commercial (n = 16, 33%) and physician (n = 16, 33%) sources. An additional 12 sites (24%) were from an academic institution and five sites (10%) were from a non-profit organization. Commercial sites had the highest number of errors, with a five-fold likelihood of containing an error compared to an academic site. Non-profit sites had the highest HON scores, with an average of 9.6 points on a 16-point scale. The completeness score was highest for academic sites, with an average score of 19.2 ± 6.7 (maximum score of 49 points); other information sources had lower scores (commercial, 15.2 ± 2.9; non-profit, 18.7 ± 6.8; physician, 16.6 ± 6.3). CONCLUSIONS: Patient information on the Internet regarding shoulder arthritis is of mixed accuracy, quality, and completeness. Surgeons should actively direct patients to higher-quality Internet sources.

What Factors are Associated With Clinically Important Improvement After Shoulder Hemiarthroplasty for Cuff Tear Arthropathy?

BACKGROUND: In selected patients with a desire to maintain activity levels greater than those recommended after reverse total shoulder arthroplasty, hemiarthroplasty remains an option for treatment of cuff tear arthropathy (CTA). However, given the relatively small case series that have been reported to date, little is known regarding which patients will show functional improvement after this surgery. QUESTIONS/PURPOSES: We asked: What factors are associated with achieving the minimum clinically important difference in the simple shoulder test (SST) after hemiarthroplasty for cuff tear arthropathy? PATIENTS AND METHODS: Between 1991 and 2007, two surgeons at one academic center performed 48 shoulder hemiarthroplasties for CTA. No patients were known to have died before data collection, and of those not known to have died, 42 (88%) were available for followup at a mean of 48 months (range, 24-132 months). During that time, the general indications for this approach were glenohumeral arthritis with superior decentering of the humeral head. The majority of the patients with CTA were treated nonoperatively with patient-directed physical therapy and other modalities. A total of 42 patients (42 shoulders; 24 males and 18 females) with CTA were treated with hemiarthroplasty and followed for a mean of 48 months (range, 24-132 months). This is a retrospective study that made use of a longitudinally maintained database, which included physical examination of ROM, the SST, VAS, and standardized radiographs. At latest followup, 33 of 42 patients achieved a clinically important percentage of maximum possible improvement (%MPI) in SST score, defined as an improvement of 30% of the total possible improvement on the 12-point scale (with higher scores representing better results). RESULTS: Intraoperative findings of a rotator cuff tear limited to the supraspinatus and infraspinatus (odds ratio [OR], ∞; 95% CI, 2.01 to ∞; p = 0.020) and limited preoperative external rotation (15° [range, -40° to 45°] vs 35° [range, 20°-45°], OR, 0.71; 95% CI, 0.38-0.90; p < 0.001) were associated with achieving the defined minimum functional improvement (30% of MPI) on multivariate analysis. Preoperative active elevation (p = 0.679) and use of a CTA-specific implant (p = 0.707) were not significantly associated with achievement of 30% of MPI. CONCLUSION: Patients with intact teres minor and subscapularis tendons and patients with lower preoperative external rotation had a better prognosis for achieving a clinically important percentage of MPI at short-term followup. Although some patients were followed for more than 10 years, the majority were followed for fewer than 5 years; future studies will need to determine whether these early functional results are maintained for longer periods. LEVEL OF EVIDENCE: Level III, therapeutic study.

Adolescent Hip Dislocation Combined With Proximal Femoral Physeal Fractures and Epiphysiolysis.

BACKGROUND: The risks and long-term effects of acute hip dislocation combined with proximal femoral physeal fractures and epiphysiolysis have been minimally addressed in the literature. This infrequent combination must be understood to avoid the major complications of complete separation of proximal femoral components during attempted reduction and to predict the probable outcome of surgical treatment. METHODS: Medical records and imaging were retrospectively reviewed to identify patients with a diagnosis of severe to complete slipped capital femoral epiphysis (CFE) or proximal femoral epiphysiolysis in association with hip dislocation. The focus included possible anatomic/vascular disruption and their consequences. RESULTS: Twelve patients were identified. Nine dislocations were posterior; 3 were anterior. In 4 patients, the intact proximal femur was dislocated posteriorly. In 3 patients only the femoral neck was reduced, whereas the CFE remained dislocated. In 1 patient percutaneous pinning was done in the dislocated position before closed reduction. The reduction was successful. In 7 patients only the CFE (4 patients) or femoral neck (3 patients) was displaced at the initial presentation in the emergency room. One patient presented with posterior dislocation associated with complete separation of both components. Ten patients underwent open reduction and internal fixation. Two patients had closed reduction. Nine patients developed complete avascular necrosis, progressive collapse of the femoral head, and degenerative arthritis. Three subsequently had a total hip arthroplasty. One patient developed ischemic change limited to the femoral neck and a nonunion through the epiphysis. One patient had incomplete ischemic necrosis. Only 1 patient had no evidence of ischemic necrosis. CONCLUSIONS: This combination of injuries has several anatomic variations. Leaving the CFE dislocated while reducing only the femoral neck must be avoided. Reduction should be done in the operating room with muscle relaxation. The emergency room is not the venue for reduction. The risk of avascular necrosis is extremely high, whether the separation occurs during the acute dislocation or attempted reduction. LEVEL OF EVIDENCE: Level IV-case series (retrospective review).