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BACKGROUND: Revision shoulder arthroplasty continues to add an increasing burden on patients and the healthcare system. This study aimed to delineate long-term shoulder arthroplasty revision incidence, quantify associated Medicare spending, and identify relevant predictors of both revision and spending. METHODS: The complete 2016-2022(Q3) Medicare fee-for-service inpatient and outpatient claims data was analyzed. Patients receiving a primary total shoulder arthroplasty for osteoarthritis, rotator cuff pathology, or inflammatory arthropathy were included and subsequent ipsilateral revision surgeries were identified. The time to revision was modeled using the Prentice, Williams, and Peterson Gap Time Model. Medicare spending within 90 days post-discharge was modeled using a generalized linear model. The analysis was subdivided by index procedure type: anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). RESULTS: A total of 82,949 primary TSAs and 172,524 RSAs were identified. Compared to index TSA cases, index RSA cases had a lower first revision rate in an observation window of nearly 7 years (1.9% vs. 3.5%, p<0.001), but a higher rate of second (11.4% vs. 4.9%, p<0.001) as well as third revision (13.8% vs. 13.8%, p=0.449). TSA spending was significantly lower than RSA spending for the index procedure ($21,531 vs. $23,267, p<0.001), first ($23,096 vs. $26,414, p<0.001), and second ($25,060 vs. $29,983, p<0.001) revision. There was no statistically significant difference in third revision between TSA and RSA groups ($31,313 vs. $30,829, p=0.860). Age, sex, race, and rheumatoid arthritis were among the top predictors of revisions. Top predictors of Medicare spending included having a non-osteoarthritis surgical indication, a hospital stay of three or more days, a discharge to a setting other than home, malnutrition, dementia, stroke, major kidney diseases, and being operated on in a teaching hospital. CONCLUSION: Compared with TSA, RSA was associated with a lower first revision rate, but a higher subsequent revision rate. An index RSA procedure was also associated with higher initial Medicare spending as well as subsequent revision surgery spending compared with an index TSA procedure. Demographics and comorbid medical conditions were among the top predictors of revisions, while procedure-related factors predicted Medicare spending.

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BACKGROUND: Total shoulder arthroplasty (TSA) in patients with rheumatoid arthritis (RA) can present unique challenges. The aim of this study was to compare both systemic and joint-related postoperative complications in patients undergoing primary TSA with RA versus those with primary osteoarthritis (OA). METHODS: Using the TriNetX database, Current Procedural Terminology and International Classification of Diseases, 10th edition codes were used to identify patients who underwent primary TSA. Patients were categorized into two cohorts: RA and OA. After 1:1 propensity score matching, postoperative systemic complications within 90 days following primary TSA and joint-related complications within 5 years following anatomic TSA (aTSA) and reverse shoulder arthroplasty (RSA) were compared. RESULTS: After propensity score matching, the RA and OA cohorts each consisted of 8,523 patients. Within 90 days postoperation, RA patients had a significantly higher risk of total complications, deep surgical site infection, wound dehiscence, pneumonia, myocardial infarction, acute renal failure, urinary tract infection, mortality, and readmission compared to the OA cohort. RA patients had a significantly greater risk of periprosthetic joint infection and prosthetic dislocation within 5 years following aTSA and RSA, and a greater risk of scapular fractures following RSA. Among RA patients, RSA had a significantly higher risk of prosthetic dislocation, scapular fractures, and revision compared to aTSA. CONCLUSIONS: Following TSA, RA patients should be considered at higher risk of systemic and joint-related complications compared to patients with primary OA. Knowledge of the risk profile of RA patients undergoing TSA is essential for appropriate patient counseling and education. Level of evidence: III.

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BACKGROUND: Numerous applications and strategies have been utilized to help assess the trends and patterns of readmissions after orthopaedic surgery in an attempt to extrapolate possible risk factors and causative agents. The aim of this work is to systematically summarize the available literature on the extent to which natural language processing, machine learning, and artificial intelligence (AI) can help improve the predictability of hospital readmissions after orthopaedic and spine surgeries. METHODS: This is a systematic review and meta-analysis. PubMed, Embase and Google Scholar were searched, up until August 30, 2023, for studies that explore the use of AI, natural language processing, and machine learning tools for the prediction of readmission rates after orthopedic procedures. Data regarding surgery type, patient population, readmission outcomes, advanced models utilized, comparison methods, predictor sets, the inclusion of perioperative predictors, validation method, size of training and testing sample, accuracy, and receiver operating characteristics (C-statistic), among other factors, were extracted and assessed. RESULTS: A total of 26 studies were included in our final dataset. The overall summary C-statistic showed a mean of 0.71 across all models, indicating a reasonable level of predictiveness. A total of 15 articles (57%) were attributed to the spine, making it the most commonly explored orthopaedic field in our study. When comparing accuracy of prediction models between different fields, models predicting readmissions after hip/knee arthroplasty procedures had a higher prediction accuracy (mean C-statistic = 0.79) than spine (mean C-statistic = 0.7) and shoulder (mean C-statistic = 0.67). In addition, models that used single institution data, and those that included intraoperative and/or postoperative outcomes, had a higher mean C-statistic than those utilizing other data sources, and that include only preoperative predictors. According to the Prediction model Risk of Bias Assessment Tool, the majority of the articles in our study had a high risk of bias. CONCLUSION: AI tools perform reasonably well in predicting readmissions after orthopaedic procedures. Future work should focus on standardizing study methodologies and designs, and improving the data analysis process, in an attempt to produce more reliable and tangible results. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

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BACKGROUND: Anatomic and reverse shoulder arthroplasty (TSA, RSA) have surged in popularity in recent years. While RSA is Food and Drug Administration (FDA) approved for cases of rotator cuff tear arthropathy, indications have expanded to include, among others, primary glenohumeral osteoarthritis (GHOA). METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were queried through November 2023. Inclusion criteria consisted of studies that compared the utility of TSA to that of RSA for the treatment of GHOA with intact rotator cuff with respect to adverse events, patient-reported outcomes, and range of motion. The ROBINS-I tool was used to assess the risk of bias in the included non-randomized studies, and Review Manager 5.4 was used for statistical analysis. P-values <0.05 were deemed significant. RESULTS: Fourteen studies met the above inclusion criteria. Twelve studies reported adverse outcomes, with the RSA group having a lower rate of complications (odds-ratio=0.54, p=0.004) and reoperations (odds-ratio=0.31, p<.001) relative to TSA at an average follow-up of 3.4 years. Four studies reported SPADI and UCLA scores, while five reported SST scores. These studies showed superior SPADI (p=0.040), UCLA(p=0.006), and SST(p=0.040) scores among the RSA group. No significant differences were seen with regards to other patient reported outcomes. Ten studies reported on range of motion, and the RSA group had a significantly lower external rotation relative to the TSA group (p<.001) while other range of motion parameters did not show statistically significant differences. CONCLUSION: The present study provides support for RSA as a reasonable surgical option for patients with GHOA and an intact rotator cuff, with lower rates of adverse events and better outcomes relative to TSA, although at the expense of decreased external rotation. Patient education and counseling is key in order to decide optimal treatment as part of a shared decision-making process, as well as setting appropriate expectations.

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CASE: A 71-year-old female patient presented with severe glenoid bone loss and deformity after 2 subsequent failed arthroplasty procedures because of baseplate failures. The patients then underwent a conversion from reverse shoulder arthroplasty to hemiarthroplasty, while using a distal radius allograft to augment the deformed glenoid. At the 2-year follow-up, the patient reported minimal pain and satisfactory outcomes. CONCLUSION: This case presents the distal radius as a potentially useful allograft option for augmenting severe glenoid bone loss in the setting of revision shoulder arthroplasty.

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BACKGROUND: Utilization in outpatient total shoulder arthroplasties (TSAs) has increased significantly in recent years. It remains largely unknown whether utilization of outpatient TSA differs across gender and racial groups. This study aimed to quantify racial and gender disparities both nationally and by geographic regions. METHODS: 168,504 TSAs were identified using Medicare fee-for-service inpatient and outpatient claims data and beneficiary enrollment data from 2020 to 2022Q4. The percentage of outpatient cases, defined as cases discharged on the same day of surgery, was evaluated by racial and gender groups and by different census divisions. A multivariate logistics regression model controlling for patient sociodemographic information (White vs. non-White race, age, gender, and dual eligibility for both Medicare and Medicaid), hierarchical condition category (HCC) score, hospital characteristics, year fixed effects, and patient residency state fixed effects was performed. RESULTS: The TSA volume per 1000 beneficiaries was 2.3 for the White population compared with 0.8, 0.6, and 0.3 for the Black, Hispanic, and Asian population, respectively. A higher percentage of outpatient TSAs were in White patients (25.6%) compared with Black patients (20.4%) (P < .001). The Black TSA patients were also younger, more likely to be female, more likely to be dually eligible for Medicaid, and had higher HCC risk scores. After controlling for patient sociodemographic characteristics and hospital characteristics, the odds of receiving outpatient TSAs were 30% less for Black than the White group (odds ratio 0.70). Variations were observed across different census divisions, with South Atlantic (0.67, P < .01), East North Central (0.56, P < .001), and Middle Atlantic (0.36, P < .01) being the 4 regions observed with significant racial disparities. Statistically significant gender disparities were also found nationally and across regions, with an overall odds ratio of 0.75 (P < .001). DISCUSSION: Statistically significant racial and gender disparities were found nationally in outpatient TSAs, with Black patients having 30% (P < .001) fewer odds of receiving outpatient TSAs than White patients, and female patients with 25% (P < .001) fewer odds than male patients. Racial and gender disparities continue to be an issue for shoulder arthroplasties after the adoption of outpatient TSAs.

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BACKGROUND: With the increased utilization of Total Shoulder Arthroplasty (TSA) in the outpatient setting, understanding the risk factors associated with complications and hospital readmissions becomes a more significant consideration. Prior developed assessment metrics in the literature either consisted of hard-to-implement tools or relied on postoperative data to guide decision-making. This study aimed to develop a preoperative risk assessment tool to help predict the risk of hospital readmission and other postoperative adverse outcomes. METHODS: We retrospectively evaluated the 2019-2022(Q2) Medicare fee-for-service inpatient and outpatient claims data to identify primary anatomic or reserve TSAs and to predict postoperative adverse outcomes within 90 days postdischarge, including all-cause hospital readmissions, postoperative complications, emergency room visits, and mortality. We screened 108 candidate predictors, including demographics, social determinants of health, TSA indications, prior 12-month hospital, and skilled nursing home admissions, comorbidities measured by hierarchical conditional categories, and prior orthopedic device-related complications. We used two approaches to reduce the number of predictors based on 80% of the data: 1) the Least Absolute Shrinkage and Selection Operator logistic regression and 2) the machine-learning-based cross-validation approach, with the resulting predictor sets being assessed in the remaining 20% of the data. A scoring system was created based on the final regression models' coefficients, and score cutoff points were determined for low, medium, and high-risk patients. RESULTS: A total of 208,634 TSA cases were included. There was a 6.8% hospital readmission rate with 11.2% of cases having at least one postoperative adverse outcome. Fifteen covariates were identified for predicting hospital readmission with the area under the curve of 0.70, and 16 were selected to predict any adverse postoperative outcome (area under the curve = 0.75). The Least Absolute Shrinkage and Selection Operator and machine learning approaches had similar performance. Advanced age and a history of fracture due to orthopedic devices are among the top predictors of hospital readmissions and other adverse outcomes. The score range for hospital readmission and an adverse postoperative outcome was 0 to 48 and 0 to 79, respectively. The cutoff points for the low, medium, and high-risk categories are 0-9, 10-14, ≥15 for hospital readmissions, and 0-11, 12-16, ≥17 for the composite outcome. CONCLUSION: Based on Medicare fee-for-service claims data, this study presents a preoperative risk stratification tool to assess hospital readmission or adverse surgical outcomes following TSA. Further investigation is warranted to validate these tools in a variety of diverse demographic settings and improve their predictive performance.

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Purpose: Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) serve as metrics to gauge orthopedic treatment efficacy based on anchoring questions that do not account for a patient's satisfaction with their surgical outcome. This study evaluates if reaching MCID, SCB, or PASS values for American Shoulder and Elbow Surgeons score (ASES), Single Alpha Numeric Evaluation (SANE), Simple Shoulder Test (SST), and Visual Analog Score (VAS) for pain following arthroscopic rotator cuff repair (RCR) correlates with overall patient satisfaction. Methods: This was a single-institution, retrospective study of patients who underwent RCR from 2015 to 2019. Pre-operative and 2 year postoperative ASES, SANE, SST, and VAS scores were recorded. Patients underwent a survey to assess: (1) what is your overall satisfaction with your surgical outcome? (scale 1 to 10); (2) if you could go back in time, would you undergo this operation again? (yes/no); (3) for the same condition, would you recommend this operation to a friend or family member? (yes/no). Spearman correlation coefficients were run to assess relationship between reaching MCID, SCB, or PASS and satisfaction. Results: Ninety-two patients were included. Mean preoperative ASES was 51.1 ± 16.9, SANE was 43.3 ± 20.9, SST was 5.4 ± 2.9, and VAS was 4.6 ± 2.1. Mean 2 year ASES was 83.9 ± 18.5, SANE was 81.7 ± 27.0, SST was 9.8 ± 3.2, and VAS was 1.4 ± 1.9. Mean patient satisfaction was 9.0 ± 1.9; 89 (96.7%) patients would undergo surgery again and recommend surgery. Correlation for reaching PASS for SANE and satisfaction was moderate. Correlation coefficients were very weak for all other outcome metrics. Conclusions: Reaching MCID, SCB, and PASS in ASES, SANE, SST, or VAS following RCR did not correlate with a patient's overall satisfaction or willingness to undergo surgery again or recommend surgery. Further investigation into the statistical credibility and overall clinical value of MCID, SCB, and PASS is necessary.

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Background: To effectively counsel patients prior to shoulder arthroplasty, surgeons should understand the overall life trajectory and life expectancy of patients in the context of the patient's shoulder pathology and medical comorbidities. Such an understanding can influence both operative and nonoperative decision-making and implant choices. This study evaluated 5-year mortality following shoulder arthroplasty in patients ≥65 years old and identified associated risk factors. Methods: We utilized Centers for Medicare & Medicaid Services Fee-for-Service inpatient and outpatient claims data to investigate the 5-year mortality rate following shoulder arthroplasty procedures performed from 2014 to 2016. The impact of patient demographics, including fracture diagnosis, year fixed effects, and state fixed effects; patient comorbidities; and hospital-level characteristics on 5-year mortality rates were assessed with use of a Cox proportional hazards regression model. A p value of <0.05 was considered significant. Results: A total of 108,667 shoulder arthroplasty cases (96,104 nonfracture and 12,563 fracture) were examined. The cohort was 62.7% female and 5.8% non-White and had a mean age at surgery of 74.3 years. The mean 5-year mortality rate was 16.6% across all shoulder arthroplasty cases, 14.9% for nonfracture cases, and 29.9% for fracture cases. The trend toward higher mortality in the fracture group compared with the nonfracture group was sustained throughout the 5-year postoperative period, with a fracture diagnosis being associated with a hazard ratio of 1.63 for mortality (p < 0.001). Medical comorbidities were associated with an increased risk of mortality, with liver disease bearing the highest hazard ratio (3.07; p < 0.001), followed by chronic kidney disease (2.59; p < 0.001), chronic obstructive pulmonary disease (1.92; p < 0.001), and congestive heart failure (1.90; p < 0.001). Conclusions: The mean 5-year mortality following shoulder arthroplasty was 16.6%. Patients with a fracture diagnosis had a significantly higher 5-year mortality risk (29.9%) than those with a nonfracture diagnosis (14.9%). Medical comorbidities had the greatest impact on mortality risk, with chronic liver and kidney disease being the most noteworthy. This novel longer-term data can help with patient education and risk stratification prior to undergoing shoulder replacement. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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INTRODUCTION: Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty. METHODS: Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes. RESULTS: A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time ( P < 0.001). DISCUSSION: TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued. LEVEL OF EVIDENCE: Level III, therapeutic retrospective cohort study.

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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.

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BACKGROUND: Distal tibial allograft (DTA) reconstruction for glenoid bone loss is nonanatomic, as it does not match the glenoid radius of curvature (ROC) in the anterior-posterior (AP) plane. The dorsal articular portion of the distal radius has not been previously described as an allograft reconstruction option for glenoid bone loss. PURPOSE: To evaluate distal radius fresh-frozen allograft (DRA) as a potential match for glenoid reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Eighteen fresh-frozen human cadaveric specimens-including 6 shoulder, 6 wrist, and 6 tibia specimens-were used. The ROC and the graft length were measured in the superior-inferior (SI) plane. A 30% defect was created in all glenoid specimens, and both DTAs and DRAs were harvested to assess graft fit after fixation. Computed tomography analysis was used to assess bony ROC and bone mineral density (BMD). RESULTS: The cadaveric specimens had a mean age of 77 years. The mean SI glenoid length was 39.7 mm compared with 36.8 mm for the DRA and 30 mm for the DTA. The ROC in the SI plane was 29 ± 5.3 mm for the glenoid, 37.8 ± 4.9 mm for the DRA, and 24 ± 3.7 mm for the DTA. In the AP plane, the ROC was 39.6 ± 6.6 mm for the glenoid, 30.4 ± 18.6 mm for the DRA, and 126.3 ± 9.5 mm for the DTA. On computed tomography analysis, the ROC in the SI plane was 30.4 ± 1.5 mm for the glenoid, 30.3 ± 5.6 mm for the DRA, and 24.5 ± 9.4 mm for the DTA. In the AP plane, the ROC was 30.8 ± 2 mm for the glenoid, 19.1 ± 2.3 mm for the DRA, and 46.7 ± 21.7 mm for the DTA. The BMD was 226.3 ± 79 Hounsfield units (HU) for the glenoid, 228.5 ± 94.7 HU for the DRA, 235 ± 96.2 HU for the coracoid process, and 235.1 ± 84.6 HU for the DTA. CONCLUSION: Compared with the DTA, the DRA had a greater mean graft length in the SI plane, providing utilization in cases of larger bony defects; the DRA has a more acute ROC in the AP plane (closer to that of the glenoid), providing a greater potential buttress to anterior humeral translation. Compared with currently utilized grafts, the DRA BMD was not significantly diminished. This study presents the DRA as a novel allograft reconstruction option in the setting of anterior glenoid bone loss; further biomechanical and clinical investigation is indicated.

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BACKGROUND: Hyperglycemia is a known risk factor for tendon degeneration due to oxidative stresses from production of advanced glycosylation end products. In patients with diabetes mellitus (DM), analysis of glycated hemoglobin (HbA1c) provides a 3-month window into a patient's glucose control. No guidelines exist for ideal preoperative HbA1c and glucose control prior to arthroscopic rotator cuff repair. This study evaluated if a critical HbA1c level is associated with reoperation following arthroscopic rotator cuff repair. METHODS: We retrospectively evaluated patients with DM who underwent primary arthroscopic rotator cuff repair from January 2014 to December 2018 at a single institution. Patients required a preoperative HbA1c within 3 months of surgery. Medical records were queried to evaluate for reoperation and identify the subsequent procedures performed. Univariate statistical analysis was performed to assess factors associated with reoperation (P < .05 considered significant). Threshold, area under the curve (AUC), analysis was performed to assess if a critical HbA1c value was associated with reoperation. RESULTS: A total of 402 patients met inclusion criteria. Patients had an average age of 65.5 years (range 40-89) at time of surgery; 244 (60.6%) patients were male; and average body mass index was 32.96 ± 5.81. Mean HbA1c was 7.36 (range 5.2-12). Thirty-three patients (8.2%) underwent subsequent reoperation. Six patients (1.5%) underwent capsular release and lysis of adhesions, 20 patients (5.0%) underwent a revision rotator cuff surgery, combination revision rotator cuff repair and lysis of adhesions, graft-augmented revision repair, or superior capsular reconstruction, and 7 patients (1.7%) underwent revision to reverse shoulder arthroplasty (1.7%). There were no cases of reoperation for infection. On AUC analysis, no critical HbA1c value was identified to predispose to reoperation. Interestingly, elevated preoperative American Society of Anesthesiologists (ASA) physical status classification score (2.8 vs. 2.28, P = .001) was associated with a higher reoperation rate. DISCUSSION: In patients with DM, preoperative HbA1c is not a predictive factor for surgical failure requiring reoperation. Stable glycemic control is important to a patient's overall health and may play a role in minimizing postoperative medical complications, but an elevated preoperative HbA1c should not be a strict surgical contraindication for arthroscopic rotator cuff repair. In patients with DM, an elevated ASA score is associated with an increased rate of subsequent reoperation; diabetic patients should be counseled accordingly.

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BACKGROUND: In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality. METHODS: Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics. RESULTS: Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001). CONCLUSIONS: There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

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Background The subacromial balloon is a novel technology that has shown promise in managing a select patient population with massive irreparable rotator cuff tears. The purpose of this study was to quantify the true facility cost difference between subacromial balloon placement (SBP) and partial rotator cuff repair (PCR). Methodology A prospective cohort of patients with massive irreparable rotator cuff tears randomized to SBP versus PCR between 2015 and 2018 was retrospectively reviewed. Demographic variables, medical comorbidities, and range-of-motion (ROM) outcomes for all patients were recorded. True facility costs with respect to personnel were calculated using a time-driven activity based-costing (TDABC) algorithm and were classified into personnel costs and supply costs. Results Seven patients were treated with PCR compared to nine treated with SBP. No significant differences were observed with respect to demographic characteristics. Postoperative mean external rotation was 37° in SBP patients significantly higher than that of PCR patients at 8° (P = 0.023). Personnel time and cost differences while in the operating room (OR) were significantly less for the SBP ($605.58) compared to PCR ($1362.76) (P < 0.001). Implant costs were higher for SBP when compared to PCR, whereas disposable equipment costs were higher for PCR when compared to SBP. The total mean true facility cost was $7658.00 for SBP, significantly higher than that of PCR at $3429.00 (P < 0.001). Conclusions Despite the substantial reduction in personnel costs seen with SBP, the true facility cost of SBP was significantly higher than that of PCR. As this novel technology is used more ubiquitously and its price is negotiated down, the cost savings seen in personnel and OR time will become more significant. Future prospective cost analyses should follow up on the changes in implant costs and account for potential anesthesia cost savings.

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BACKGROUND: Cutibacterium acnes has been described as the most common causative microorganism in prosthetic shoulder infections. Conventional anaerobic culture or molecular-based technologies are usually used for this purpose, but little to no concordance between these methodologies (k = 0.333 or less) has been observed. QUESTIONS/PURPOSES: (1) Is the minimum C. acnes load for detection higher for next-generation sequencing (NGS) than for anaerobic conventional culture? (2) What duration of incubation is necessary for anaerobic culture to detect all C. acnes loads? METHODS: Five C. acnes strains were tested for this study: Four strains were causing infection and were isolated from surgical samples. Meanwhile, the other was a reference strain commonly used as a positive and quality control in microbiology and bioinformatics. To create inoculums with varying degrees of bacterial load, we began with a standard bacterial suspension at 1.5 x 10 8 colony-forming units (CFU)/mL and created six more diluted suspensions (from 1.5 x 10 6 CFU/mL to 1.5 x 10 1 CFU/mL). Briefly, to do so, we transferred 200 µL from the tube with the highest inoculum (for example, 1.5 x 10 6 CFU/mL) to the following dilution tube (1.5 x 10 5 CFU/mL; 1800 µL of diluent + 200 µL of 1.5 x 10 6 CFU/mL). We serially continued the transfers to create all diluted suspensions. Six tubes were prepared per strain. Thirty bacterial suspensions were tested per assay. Then, 100 µL of each diluted suspension was inoculated into brain heart infusion agar with horse blood and taurocholate agar plates. Two plates were used per bacterial suspension in each assay. All plates were incubated at 37°C in an anaerobic chamber and assessed for growth after 3 days of incubation and daily thereafter until positive or Day 14. The remaining volume of each bacterial suspension was sent for NGS analysis to identify bacterial DNA copies. We performed the experimental assays in duplicate. We calculated mean DNA copies and CFUs for each strain, bacterial load, and incubation timepoint assessed. We reported detection by NGS and culture as a qualitative variable based on the identification or absence of DNA copies and CFUs, respectively. In this way, we identified the minimum bacterial load detected by NGS and culture, regardless of incubation time. We performed a qualitative comparison of detection rates between methodologies. Simultaneously, we tracked C. acnes growth on agar plates and determined the minimum incubation time in days required for CFU detection in all strains and loads examined in this study. Growth detection and bacterial CFU counting were performed by three laboratory personnel, with a high intraobserver and interobserver agreement (κ > 0.80). A two-tailed p value below 0.05 was considered statistically significant. RESULTS: Conventional cultures can detect C. acnes at a load of 1.5 x 10 1 CFU/mL, whereas NGS can detect bacteria when the concentration was higher, at 1.5 x 10 2 CFU/mL. This is represented by a lower positive detection proportion (73% [22 of 30]) for NGS than for cultures (100% [30 of 30]); p = 0.004). By 7 days, anaerobic cultures were able to detect all C. acnes loads, even at the lowest concentrations. CONCLUSION: When NGS is negative and culture is positive for C. acnes , there is likely a low bacterial load. Holding cultures beyond 7 days is likely unnecessary. CLINICAL RELEVANCE: This is important for treating physicians to decide whether low bacterial loads necessitate aggressive antibiotic treatment or whether they are more likely contaminants. Cultures that are positive beyond 7 days likely represent contamination or bacterial loads even below the dilution used in this study. Physicians may benefit from studies designed to clarify the clinical importance of the low bacteria loads used in this study at which both methodologies' detection differed. Moreover, researchers might explore whether even lower C. acnes loads have a role in true periprosthetic joint infection.

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BACKGROUND: The importance of administrating prophylactic antibiotics prior to a surgical procedure is well established. Given the difficulty in diagnosing shoulder periprosthetic infections, which are more indolent in nature, some advocate holding prophylactic antibiotics prior to obtaining cultures as there is a concern antibiotics may lead to a false negative culture result. The purpose of this study is to determine whether administration of antibiotics prior to obtaining cultures in revision shoulder arthroplasty influences culture yield. METHODS: This was a retrospective analysis of revision shoulder arthroplasty cases performed at a single institution between 2015 and 2021. During the study period, each surgeon had a standardized protocol that dictated whether antibiotics were given or held prior to each revision surgery. Each case was categorized into either a Preculture antibiotic group, if antibiotics were administered prior to incision, or a Postculture antibiotic group if antibiotics were administered after incision and obtaining cultures. The International Consensus Meeting (ICM) scoring criteria provided by the Musculoskeletal Infection Society was used to categorize the probability of periprosthetic joint infection for each case. Culture positivity was calculated as the ratio of positive cultures and total number of cultures obtained. RESULTS: One hundred twenty-four patients met inclusion criteria. There were 48 patients in the Preculture group and 76 patients in the Postculture group. No significant difference in patient demographics or ICM criteria (P = .09) was observed between the 2 groups. With regard to culture positivity, there was no difference between the Preculture antibiotic group and the Postculture antibiotic group (16% vs. 15%, P = .82, confidence interval = 8%-25% vs. 10%-20%, respectively). CONCLUSION: In the setting of revision shoulder arthroplasty, timing of antibiotic administration did not significantly influence culture yield. This study supports the use of prophylactic antibiotics prior to obtaining cultures in revision shoulder arthroplasty.

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BACKGROUND: Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity. METHODS: This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. RESULTS: In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again. DISCUSSION: Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity.

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BACKGROUND: Studies assessing the relationship between surgeon volume and outcomes have shown mixed results, depending on the specific procedure analyzed. This volume relationship has not been well studied in patients undergoing total shoulder arthroplasty (TSA), but it should be, because this procedure is common, expensive, and potentially morbid. QUESTIONS/PURPOSES: We performed this study to assess the association between increasing surgeon volume and decreasing rate of revision at 2 years for (1) anatomic TSA (aTSA) and (2) reverse TSA (rTSA) in the United States. METHODS: In this retrospective study, we used Centers for Medicare and Medicaid Services (CMS) fee-for-service inpatient and outpatient data from 2015 to 2021 to study the association between annual surgeon aTSA and rTSA volume and 2-year revision shoulder procedures after the initial surgery. The CMS database was chosen for this study because it is a national sample and can be used to follow patients over time. We included patients with Diagnosis-related Group code 483 and Current Procedural Terminology code 23472 for TSA (these codes include both aTSA and rTSA). We used International Classification of Diseases, Tenth Revision, procedural codes. Patients who underwent shoulder arthroplasty for fracture (10% [17,524 of 173,242]) were excluded. We studied the variables associated with the subsequent procedure rate through a generalized linear model, controlling for confounders such as patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, hospital size and teaching status, assuming a binomial distribution with the dependent variable being whether an episode had at least one subsequent procedure within 2 years. The regression was fitted with standard errors clustered at the hospital level, combining all TSAs and within the aTSA and rTSA groups, respectively. Hospital and surgeon yearly volumes were calculated by including all TSAs, primary procedure and subsequent, during the study period. Other hospital-level and surgeon-level characteristics were obtained through public files from the CMS. The CMS Hierarchical Condition Category risk score was controlled because it is a measure reflecting the expected future health costs for each patient based on the patient's demographics and chronic illnesses. We then converted regression coefficients to the percentage change in the odds of having a subsequent procedure. RESULTS: After controlling for confounding variables including patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, and hospital size and teaching status, we found that an annual surgeon volume of ≥ 10 aTSAs was associated with a 27% decreased odds of revision within 2 years (95% confidence interval 13% to 39%; p < 0.001), while surgeon volume of ≥ 29 aTSAs was associated with a 33% decreased odds of revision within 2 years (95% CI 18% to 45%; p < 0.001) compared with a volume of fewer than four aTSAs per year. Annual surgeon volume of ≥ 29 rTSAs was associated with a 26% decreased odds of revision within 2 years (95% CI 9% to 39%; p < 0.001). CONCLUSION: Surgeons should consider modalities such as virtual planning software, templating, or enhanced surgeon training to aid lower-volume surgeons who perform aTSA and rTSA. More research is needed to assess the value of these modalities and their relationship with the rates of subsequent revision. LEVEL OF EVIDENCE: Level III, therapeutic study.

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Introduction: The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the United States and to determine whether these disparities were affected by the COVID-19 pandemic. Methods: Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April to December from 2019 to 2020. Utilization was assessed for White, Black, Hispanic, and Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age, sex, CMS-hierarchical condition categories (HCC) score, dual enrollment (proxy for socioeconomic status), time-fixed effects, and core-based statistical area fixed effects was used to study difference across groups. Results: In 2019, the TSA volume per 1000 beneficiaries was 1.51 for White and 0.57 for non-White, with a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P < .01). There was an overall 14% decrease in TSA volume per 1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference; 8.7%, P = .02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%, P = .05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture. Conclusions: During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA, while disparities were less apparent for proximal humerus fracture.