The subacromial bursa modulates tendon healing after rotator cuff injury in rats.

Rotator cuff injuries result in more than 500,000 surgeries annually in the United States, many of which fail. These surgeries typically involve repair of the injured tendon and removal of the subacromial bursa, a synovial-like tissue that sits between the rotator cuff and the acromion. The subacromial bursa has been implicated in rotator cuff pathogenesis and healing. Using proteomic profiling of bursa samples from nine patients with rotator cuff injury, we show that the bursa responds to injury in the underlying tendon. In a rat model of supraspinatus tenotomy, we evaluated the bursa's effect on the injured supraspinatus tendon, the uninjured infraspinatus tendon, and the underlying humeral head. The bursa protected the intact infraspinatus tendon adjacent to the injured supraspinatus tendon by maintaining its mechanical properties and protected the underlying humeral head by maintaining bone morphometry. The bursa promoted an inflammatory response in injured rat tendon, initiating expression of genes associated with wound healing, including Cox2 and Il6. These results were confirmed in rat bursa organ cultures. To evaluate the potential of the bursa as a therapeutic target, polymer microspheres loaded with dexamethasone were delivered to the intact bursae of rats after tenotomy. Dexamethasone released from the bursa reduced Il1b expression in injured rat supraspinatus tendon, suggesting that the bursa could be used for drug delivery to reduce inflammation in the healing tendon. Our findings indicate that the subacromial bursa contributes to healing in underlying tissues of the shoulder joint, suggesting that its removal during rotator cuff surgery should be reconsidered.

The subacromial bursa is a key regulator of the rotator cuff and a new therapeutic target for improving repair.

Rotator cuff injuries result in over 500,000 surgeries performed annually, an alarmingly high number of which fail. These procedures typically involve repair of the injured tendon and removal of the subacromial bursa. However, recent identification of a resident population of mesenchymal stem cells and inflammatory responsiveness of the bursa to tendinopathy indicate an unexplored biological role of the bursa in the context of rotator cuff disease. Therefore, we aimed to understand the clinical relevance of bursa-tendon crosstalk, characterize the biologic role of the bursa within the shoulder, and test the therapeutic potential for targeting the bursa. Proteomic profiling of patient bursa and tendon samples demonstrated that the bursa is activated by tendon injury. Using a rat to model rotator cuff injury and repair, tenotomy-activated bursa protected the intact tendon adjacent to the injured tendon and maintained the morphology of the underlying bone. The bursa also promoted an early inflammatory response in the injured tendon, initiating key players in wound healing. In vivo results were supported by targeted organ culture studies of the bursa. To examine the potential to therapeutically target the bursa, dexamethasone was delivered to the bursa, prompting a shift in cellular signaling towards resolution of inflammation in the healing tendon. In conclusion, contrary to current clinical practice, the bursa should be retained to the greatest extent possible and provides a new therapeutically target for improving tendon healing outcomes. One Sentence Summary: The subacromial bursa is activated by rotator cuff injury and regulates the paracrine environment of the shoulder to maintain the properties of the underlying tendon and bone.

Augmentation of Rotator Cuff Healing With Orthobiologics.

The limited regenerative capacity of the tendon-bone enthesis after surgical repair poses a significant challenge to achieving desired clinical outcomes. Biologic augmentation of the repair site has the potential to enhance the biomechanical and histological integrity of the enthesis, leading to lower retear rates and greater patient satisfaction. Platelet-rich plasma, stem cells and bone marrow aspirate concentrate, growth factors, biodegradable or biomimetic scaffolds, and amniotic products have been investigated in preclinical and, in some cases, clinical studies aimed at augmenting tendon-bone healing. Although many of these therapies have achieved some degree of success in improving structural, histological, and clinical outcomes after surgical tendon-bone enthesis repair, none have reliably and consistently lead to clinical improvement. High-quality randomized controlled clinical studies are needed to definitively evaluate the efficacy of these biologic therapies and ultimately determine which, if any, are capable of achieving a tendon-bone repair that is structurally noninferior to the native enthesis before injury.

Biological sex impacts perioperative complications after reverse shoulder arthroplasty for proximal humeral fracture.

BACKGROUND: The purpose of this study was to determine the difference in complication rates between males and females undergoing reverse shoulder arthroplasty for proximal humerus fractures. We hypothesized that (1) females were more likely to undergo reverse shoulder arthroplasty for fracture, and (2) males were more likely to sustain a perioperative complication. METHODS: The National Surgical Quality Improvement Program database was queried to identify patients who underwent reverse shoulder arthroplasty for proximal humerus fracture between 2011 and 2018. Patients were stratified based on biological sex. Patient demographics, comorbidities, and 30-day perioperative complication rates were collected. Univariate analyses and multiple variable logistic regression modeling were performed. RESULTS: About 905 patients were included in the analysis-175 (19.3%) were male and 730 (80.7%) were female. Males were more likely to sustain perioperative complications (26.3% vs. 14.1%; P < .001)-pneumonia (2.9% vs. 0.5%; P = .016), unplanned intubation (2.3% vs. 0.4%; P = .029), and unplanned reoperation (9.1% vs. 1.1%; P < .001). On multivariate analysis, males were at a 2.4-fold increase risk of developing any complication (OR = 2.38 [95% CI 1.55-3.65]; P < .001) and a 10-fold increase risk of returning to the operating room for an unplanned reoperation (OR = 10.59 [95% CI 4.23-27.49]; P < .001) compared with females. CONCLUSION: Females were more likely to undergo reverse shoulder arthroplasty for proximal humerus fracture, but males were at increased risk of sustaining short-term complications. This study provides useful information for clinicians to consider when counseling their patients during the perioperative period.

Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate.

INTRODUCTION: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. METHODS: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. RESULTS: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). CONCLUSION: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.

Editorial Commentary: Delivering the PROMIS for Patients With Shoulder Disorders-Fool's Gold, a Mirage, or an Oasis.

Comparative psychometric performance of Patient-Reported Outcome Measurement Information System (PROMIS) instruments to legacy patient-reported outcomes for shoulder disorders is relevant and timely, as numerous stakeholders are engaged in the process of capturing, comparing, and evaluating performance results at the individual and population health levels. Depending on the stakeholder type, patient-reported outcomes could be used for clinical research, reimbursement, point-of-care, or benchmarking for patient comparison with a matched population cohort or comparative surgeon scorecard. Identifying and using the appropriate patient-reported outcome measure may be dependent on the purpose for measurement and stakeholder engagement and, as such, could be considered fool's gold, a mirage, or an oasis. At this time, PROMIS instruments are not a suitable replacement for legacy patient-reported outcomes when orthopaedic surgeons are looking to perform level I and level II clinical studies to develop future clinical practice guidelines grounded in strong evidence.

Cognitive Training in Orthopaedic Surgery.

INTRODUCTION: Over the past two decades, various factors have led to fewer opportunities for hands-on learning in the operating room among orthopaedic surgery trainees. Innovative training platforms using anatomic models, cadaveric specimens, and augmented reality have been devised to address this deficiency in surgical training, but such training tools are often costly with limited accessibility. Cognitive training is a low-cost training technique that improves physical performance by refining the way in which information is mentally processed and has long been used by professional athletes and world-class musicians. More recently, cognitive training tools have been developed for several orthopaedic surgery procedures, but the overall utility of cognitive training in orthopaedic surgery remains unknown. METHODS: The purpose of this study was to review the existing literature regarding the use of cognitive training in orthopaedic surgery and to summarize the results of investigations comparing cognitive training tools with other methods of learning. To that effect, the PubMed and Embase databases were systematically reviewed for articles related to cognitive training in orthopaedic surgery. RESULTS: Eleven publications met the inclusion criteria, including six randomized controlled trials. Cognitive task analysis and mental rehearsal were the most common forms of cognitive training identified. All 11 publications supported the use of cognitive training in orthopaedic surgery training. In the six randomized controlled trials, the utilization of cognitive training was associated with notably improved surgical performance and increased knowledge compared with traditional methods of learning. DISCUSSION: Based on the limited evidence presented in this review, cognitive training represents a promising, low-cost adjunct to traditional orthopaedic surgery training. Further efforts should be directed at developing and evaluating additional cognitive training tools for orthopaedic surgery trainees.

Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making.

BACKGROUND: The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability. METHODS: A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures. RESULTS: Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48% <10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure. CONCLUSION: The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

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.

Validation of PROMIS Global-10 compared with legacy instruments in patients with shoulder instability.

BACKGROUND: Outcomes instruments are used to measure patients' subjective assessment of health status. The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 was developed to be a concise yet comprehensive instrument that provides physical and mental health scores and an estimated EuroQol-5 Dimension (EQ-5D) score. METHODS: A total of 175 prospectively enrolled patients with shoulder instability completed the PROMIS Global-10, EQ-5D, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index. Spearman correlations between PROMIS scores and the legacy instruments were calculated. Bland-Altman analysis assessed agreement between estimated and actual EQ-5D scores. Floor and ceiling effects were recorded. RESULTS: Correlation between actual and estimated EQ-5D was excellent-good (0.64/p < 0.0005), but Bland-Altman agreement revealed high variability for estimated EQ-5D scores (95% CI: -0.30 to +0.34). Correlation of PROMIS physical scores was excellent-good with ASES (0.69/p < 0.0005), good with SANE (0.43/p<0.0005), and poor with WOSI (0.17/p = 0.13). Correlation between PROMIS mental scores and all legacy instruments was poor. CONCLUSIONS: PROMIS Global-10 physical function scores show high correlation with ASES but poor correlation with other legacy instruments, suggesting it is an unreliable outcomes instrument in populations with shoulder instability. The PROMIS Global-10 cannot replace actual EQ-5D scores for cost-effectiveness assessment in this population. LEVEL OF EVIDENCE: Level II, study of diagnostic test.

Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response.

BACKGROUND: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies. METHODS: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds. RESULTS: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate. CONCLUSION: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

The impact of age on 30-day complications following shoulder instability surgery.

HYPOTHESIS: The purpose of this study was to evaluate short-term outcomes including medical complications, overnight admission, and 30-day readmission with regard to patient age at the time of shoulder instability surgery. METHODS: Patients undergoing surgery for glenohumeral instability were collected from the National Surgical Quality Improvement Program between the years of 2005 and 2016. These patients were separated into cohorts of younger than 25 years, 25-34 years, and older than 34 years. Medical complications, hospital admission, and 30-day readmission were compared using multivariate analysis. RESULTS: Of the 5449 patients included, there were 2035 (37.0%) patients younger than 25 years, 1815 (33.0%) between 25 and 34 years, and 1649 (30.0%) 35 and older. Overall, 81.7% of patients underwent an arthroscopic Bankart repair, 12.6% of patients underwent an open Bankart repair, and 5.7% of patients underwent a Latarjet-Bristow procedure. The risk of 30-day readmission increased with age, ranging from 0.24% for <25 years old to 0.92% for 35 years and older (P = .040). Operative duration greater than 60 minutes (odds ratio [OR] 1.76; P = .001), duration greater than 90 minutes (OR 3.58; P < .001), and American Society of Anesthesiologists class III and IV (OR 1.80; P = .001) were associated with increased risk of overnight hospital stay. Compared with arthroscopic Bankart repair, the Latarjet-Bristow procedure was associated with increased total complications (OR 3.30; P = .021), overnight hospital stay (OR 4.64; P < .001), and 30-day readmission (OR 3.39; P = .013). CONCLUSION: This study demonstrates that even in the relatively young and healthy shoulder instability patient cohort, patients older than 25 years are almost 4 times more likely to experience a complication. Additionally, Latarjet-Bristow procedures are 3-4 times more likely to experience a complication or readmission than other shoulder instability procedures.

Defining massive rotator cuff tears: a Delphi consensus study.

BACKGROUND: A standard definition for massive rotator cuff tears (MRCTs) has not been identified. The purpose of this study is to use the modified Delphi technique to determine a practical, consensus definition for MRCTs. METHODS: This study is based on responses from 20 experts who participated in 4 rounds of surveys to determine a consensus definition for MRCT. Consensus was achieved when at least 70% of survey responders rated an item at least a 4 on a 5-point scale. A set of core characteristics was drafted based on literature review and then refined to achieve a consensus MRCT definition. RESULTS: The following core characteristics reached consensus in the first round: tear size, number of tendons torn, and degree of medial retraction. Magnetic resonance imaging (MRI) and intraoperative findings reached consensus as the modalities of diagnosis. The second round determined that tear size should be measured as a relative value. An initial definition for MRCT was proposed in the third round: retraction of tendon(s) to the glenoid rim and/or a tear with ≥67% greater tuberosity exposure (65% approval). A modified definition was proposed that specified that degree of retraction should be measured in the coronal or axial plane and that the amount of greater tuberosity exposure should be measured in the sagittal plane (90% approval). CONCLUSIONS: This study determined with 90% agreement that MRCT should be defined as retraction of tendon(s) to the glenoid rim in either the coronal or axial plane and/or a tear with ≥67% of the greater tuberosity exposed measured in the sagittal plane. The measurement can be performed either with MRI or intraoperatively.

Development of a clinical risk calculator for prolonged opioid use after shoulder surgery.

BACKGROUND: Understanding risk factors associated with prolonged opioid use to help mitigate abuse and develop presurgical screening programs to identify at-risk patients is paramount. The purpose of this study was to develop and validate a clinical risk assessment tool to preoperatively predict prolonged opioid use after shoulder surgery. METHODS: A total of 561 patients who underwent shoulder surgery within a tertiary health care system were identified, and opioid prescription data were retrospectively collected from the Connecticut Prescription Monitoring and Reporting System. The inclusion criteria were patients aged 18 years or older, and the exclusion criteria were patients not registered in the Connecticut Prescription Monitoring and Reporting System. Quantities of opioids prescribed were documented. Demographic characteristics, surgery type, medications, and medical comorbidities were identified by chart abstraction. Logistic regression was used to calculate odds ratios of patients using opioids longer than 6 weeks, and multivariate analysis was performed on 10 identified patient factors. A concordance index was used to calculate the discriminatory ability of a nomogram to predict prolonged opioid use. RESULTS: Multivariate analysis demonstrated that opioid use prior to surgery, insurance type, procedure type, body mass index, smoking status, and psychiatric disorders were responsible for prolonged opioid use. The prediction accuracy of this model was good, with a calculated concordance index of 0.766 (95% confidence interval, 0.736-0.820). CONCLUSIONS: We present a preoperative predictive calculator to help identify at-risk patients and quantify their risk of prolonged opioid use after shoulder surgery. This is a valuable clinical decision-making tool to identify patients benefitting from referral to pain management specialists and to possibly reduce the risk of opioid abuse and addiction.

Performance of PROMIS Global-10 to Legacy Instruments in Patients With Lateral Epicondylitis.

PURPOSE: To validate the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 for patients who have lateral epicondylitis requiring surgical treatment in comparison with other gold standard patient-reported outcomes. METHODS: Sixty-two patients with lateral epicondylitis of the elbow were prospectively enrolled before arthroscopic treatment. Inclusion criteria were patients 18 years of age or older with a diagnosis of lateral epicondylitis. Each patient completed the PROMIS Global-10, EuroQol 5 Dimension (EQ-5D), American Shoulder and Elbow Surgeons (ASES) assessment form, Mayo Elbow Performance Score (MEPS), and Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH). Spearman correlations were calculated. Bland-Altman agreement tests were conducted between estimated EQ-5D scores from the PROMIS-10 and actual EQ-5D scores. RESULTS: Correlation between the PROMIS-10 and the EQ-5D was excellent (0.72, P < .0001). Bland-Altman 95% limits of agreement for estimated EQ-5D scores ranged from 0.33 below to 0.21 above actual EQ-5D scores. Correlation of the PROMIS-10 physical score was good to excellent with MEPS (0.61, P < .0001) and QuickDASH scores (0.64, P < .0001) and good with the ASES (0.58, P < .0001). Correlation of the PROMIS mental scores was good with QuickDASH (0.50, P < .0001) and poor with ASES (0.26, P = .0492) and MEPS (0.37, P = .0038). CONCLUSIONS: The PROMIS Global-10 physical scores showed good to excellent correlation with gold standard patient-reported outcome instruments, demonstrating it is a reliable tool for outcome assessment in populations with lateral epicondylitis. Despite the excellent correlation with the EQ-5D, the 95% limit of agreement and high variability among the estimated EQ-5D scores derived from the PROMIS-10 suggests that the PROMIS-10 cannot be used as a substitute for actual EQ-5D scores to derive quality-adjusted life years for economic evaluations and cost-effectiveness research. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on the basis of consecutive patients.

Outcomes of Total Shoulder Arthroplasty With Posterior Capsular Plication.

BACKGROUND: Glenoid loosening and instability are among the most common complications after anatomic total shoulder arthroplasty (TSA), resulting in poor function. Posterior instability is one contributing factor. The purpose of this study is to report the clinical and radiographic outcomes of a series of patients treated with posterior capsule plication for intraoperative posterior instability during TSA. It is hypothesized that patients undergoing this procedure will have improvement in posterior stability intraoperatively while not limiting their ROM postoperatively. METHODS: Patients of the senior author were identified who had undergone TSA with posterior capsule plication from 2014 to 2015 based on Current Procedural Terminology (CPT) codes. Their records and preoperative radiographs were retrospectively reviewed for demographic data and preoperative range of motion (ROM) which was documented in the clinic notes. Patients were then evaluated postoperatively to determine the outcomes after TSA with posterior capsule plication. Final follow-up was conducted via telephone survey. RESULTS: Nineteen patients were identified for review; however, only 14 had all imaging available. The mean age at the time of surgery was 63 years. There were 2 A1, 6 B1, and 6 B2 Walch-type glenoids based on preoperative imaging. All but one had equivalent or better ROM for active forward elevation and external rotation postoperatively. One patient required return to operating room at 5 months after developing adhesive capsulitis. CONCLUSION: This study indicates that the use of posterior capsule plication during TSA is a safe method to address posterior subluxation, while still allowing for improved ROM postoperatively.

Management of the Failed Arthroplasty for Proximal Humerus Fracture.

A variety of reasons exist for failure of arthroplasty performed for management of proximal humerus fracture. Revision surgery for these failures is complex and has a high likelihood of inferior outcomes compared with primary arthroplasty. Successful management requires consideration of various modes of failure including tuberosity malunion or resorption, rotator cuff deficiency, glenoid arthritis, bone loss, component loosening, stiffness, or infection. Although revision to a reverse shoulder arthroplasty is an appealing option to address instability, rotator cuff dysfunction, and glenoid arthritis, there are concerns with higher complication rates and inferior results compared with primary reverse replacement. Any treatment plan should appropriately address the cause for failure to optimize outcomes.

Performance of PROMIS Global-10 Compared With Legacy Instruments for Rotator Cuff Disease.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 was recently developed to assess physical and mental health and provide an estimated EuroQol-5 Dimension (EQ-5D) score. This instrument needs to be validated for specific patient cohorts such as those with rotator cuff pathology. HYPOTHESIS: There is moderate to high correlation between the PROMIS Global-10 and legacy patient-reported outcome measures; PROMIS Global-10 will not show ceiling effects; and estimated EQ-5D scores will show good correlation and low variance with actual EQ-5D scores. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 323 patients with rotator cuff disease were prospectively enrolled before treatment. Each patient completed the PROMIS Global-10, EQ-5D, American Shoulder and Elbow Surgeons (ASES) shoulder assessment form, and Single Assessment Numeric Evaluation (SANE), and those with known rotator cuff tears completed the Western Ontario Rotator Cuff Index (WORC). Spearman correlations were calculated. Bland-Altman agreement tests were conducted between estimated EQ-5D scores from the PROMIS and actual EQ-5D scores. Ceiling and floor effects were assessed, defined as ≥15% respondents with highest or lowest possible score. RESULTS: Correlation between the PROMIS Global-10 and EQ-5D was excellent (0.70, P < .0001). Correlation of the PROMIS physical scores was excellent-good with the ASES (0.62, P < .0001), good with the WORC (0.47, P < .0001), and good with the SANE (0.41, P < .0005). Correlation between the PROMIS mental scores was poor with the ASES (0.34, P < .0001), the WORC (0.32, P = .0016), and the SANE (0.24, P < .0001). No floor or ceiling effects were found. Agreement analysis showed substantial variance in individual scores, despite the overall similarity in mean scores between the estimated and actual EQ-5D scores, indicating poor agreement. Bland-Altman 95% limits of agreement for estimated EQ-5D scores ranged from 34% below to 31% above actual EQ-5D scores. CONCLUSION: Physical function scores of the PROMIS Global-10 show high correlation with legacy patient-reported outcome instruments, suggesting that it is a reliable tool for outcome assessment in a population with rotator cuff pathology. The large variability in 95% limit of agreement suggested that the estimated EQ-5D scores from the PROMIS Global-10 cannot replace traditional EQ-5D scores.

Predictors of Length of Stay and Discharge Disposition After Shoulder Arthroplasty: A Systematic Review.

INTRODUCTION: Identifying patient factors that affect length of stay (LOS) and discharge disposition after shoulder arthroplasty is key in managing patient expectations. In this systematic review, we identify patient-specific covariates that correlate with increased LOS and need for discharge to a facility. METHODS: We searched biomedical databases to identify associations between patient-specific factors and LOS and discharge disposition after shoulder arthroplasty. We included all studies involving hemiarthroplasty, anatomic shoulder arthroplasty, and reverse shoulder arthroplasty. Reported patient and provider factors were evaluated for their association with increased LOS and discharge to a facility. RESULTS: Twenty-two studies were identified. Age >65 years, female sex, obesity, and reverse shoulder arthroplasty were associated with extended LOS and correlated with discharge to a facility. Greater hospital and surgeon volume were associated with decreased LOS and decreased risk of discharge to a facility. Local injection of liposomal bupivacaine combined with intravenous dexamethasone was associated with reduced LOS. DISCUSSION: Patient factors affecting LOS and likelihood of discharge to a facility include age >65 years, female sex, diabetes, obesity, and reverse shoulder arthroplasty. These factors can be used to develop studies to preoperatively predict outcomes after shoulder arthroplasty and to help identify patients who may be at risk of prolonged postoperative admission. LEVEL OF EVIDENCE: Prognostic level IV.

Performance of PROMIS Global-10 compared with legacy instruments in patients with shoulder arthritis.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 measures physical and mental health and provides an estimated EuroQol-5 Dimension (EQ-5D) score. The purpose of this study was to determine the correlation between the PROMIS Global-10 and several gold-standard legacy measures to validate its overall performance and usefulness in patients with shoulder arthritis. METHODS: The study prospectively enrolled 161 patients with shoulder arthritis before treatment. Each patient completed the PROMIS, EQ-5D, American Shoulder and Elbow Surgeons (ASES) Assessment Form, Single Assessment Numeric Evaluation (SANE), and Western Ontario Osteoarthritis of the Shoulder (WOOS) Index. Spearman correlations were calculated, and Bland-Altman agreement tests were conducted between estimated EQ-5D scores from the PROMIS and actual EQ-5D scores. Ceiling and floor effects were determined. RESULTS: Correlation between the PROMIS and EQ-5D was excellent (0.72, P < .001). However, agreement for estimated EQ-5D ranged from 0.37 below to 0.36 above actual EQ-5D scores. Correlation of the PROMIS physical score was good with the ASES score (0.57, P < .001) and poor with the SANE score (0.23, P = .0045) and WOOS score (0.11, P = .3743). Correlation of the PROMIS mental score was poor when compared with all patient-reported outcome instruments investigated (ASES score, 0.26 [P = .0012]; SANE score, 0.13 [P = .1004]; and WOOS score, 0.09 [P = .4311]). No floor or ceiling effects were observed. CONCLUSION: PROMIS Global-10 physical scores show excellent correlation with the EQ-5D. However, the PROMIS Global-10 cannot replace actual EQ-5D scores for cost-effectiveness assessment in this population because of the large variance in agreement between actual and PROMIS Global-10-estimated EQ-5D scores. PROMIS Global-10 physical scores showed good correlation with the ASES score but poor correlation with other gold-standard patient-reported outcome instruments, suggesting that it is an inappropriate instrument for outcome measurement in populations with shoulder arthritis.