Publications by authors named "Gregory P Nicholson"

109 Publications

Scapular and humeral elevation coordination patterns used before vs. after Reverse Total Shoulder Arthroplasty.

J Biomech 2021 Jun 8;125:110550. Epub 2021 Jun 8.

DuPage Medical Group, Chicago, IL, USA.

The purpose of this study was to compare scapulohumeral coordination used before and after Reverse Total Shoulder Arthroplasty (RTSA) during the ascent phase of scapular plane arm elevation tasks performed with varied shoulder rotations (neutral, external rotation, and internal rotation). We expected that after RTSA, participants would decrease scapulothoracic upward rotation angular displacement and increase the scapulohumeral rhythm (SHR) vs. before RTSA. 11 RTSA patients (12 shoulders) participated in this study before and after RTSA while optical motion capture measured kinematics of the humerus and scapula relative to the thorax. Angular kinematics were compared pre vs. post-RTSA within-participant using One Dimensional Statistical Parametric Mapping (SPM) t-tests (α = 0.05) and across-participants, using paired t-tests (α = 0.05) adjusted for multiple comparisons. As a group, during arm elevation with neutral rotation, the mean (SD) SHR pre-RTSA was 1.5 (0.5) and increased to 1.7 (0.3) post-RTSA, though, not significantly (p = 0.182). In contrast, during arm elevation with external rotation, the mean (SD) SHR pre-RTSA was 1.3 (0.4) and significantly increased (p = 0.018) post-RTSA to 1.7 (0.3). Likewise, during arm elevation with internal rotation, the mean (SD) SHR pre-RTSA was 1.2 (0.3) and significantly increased (p < 0.001) post-RTSA to 1.7 (0.2). In addition to these and other group trends, participant-specific patterns were uncovered through SPM analyses - with some participants significantly increasing and others significantly decreasing scapulothoracic angular displacements across humerothoracic elevation ranges. Both before and after RTSA, scapulohumeral rhythm ratios were within the range of those previously reported in post-RTSA patients and were smaller than those used by healthy populations.
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http://dx.doi.org/10.1016/j.jbiomech.2021.110550DOI Listing
June 2021

Short stay after shoulder arthroplasty does not increase 90-day readmissions in Medicare patients compared with privately insured patients.

J Shoulder Elbow Surg 2021 Jun 9. Epub 2021 Jun 9.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: As of January 1, 2021, total shoulder arthroplasty was removed from the Medicare inpatient-only list, reflecting a growing belief in the potential merits of same-day discharge regardless of insurance type. It is yet unknown whether Medicare populations, which frequently have more severe comorbidity burdens, would experience higher complication rates relative to privately insured patients, who are often younger with fewer comorbidities. Given the limited number of true outpatient cohorts available to study, discharge at least by postoperative day 1 may serve as a useful proxy for true same-day discharge, and we hypothesized that these Medicare patients would have increased 90-day readmission rates compared with their privately insured counterparts.

Methods: Data on 4723 total shoulder arthroplasties (anatomic in 2459 and reverse in 2264) from 2 large, geographically diverse health systems in patients having either Medicare or private insurance were collected. The unplanned 90-day readmission rate was the primary outcome, and patients were stratified into those who were discharged at least by postoperative day 1 (short inpatient stay) and those who were not. Patients with private insurance (n = 1845) were directly compared with those with Medicare (n = 2878), whereas cohorts of workers' compensation (n = 198) and Medicaid (n = 58) patients were analyzed separately. Forty preoperative variables were examined to compare overall health burden, with the χ and Wilcoxon rank sum tests used to test for statistical significance.

Results: Medicare patients undergoing short-stay shoulder arthroplasty were not significantly more likely than those with private insurance to experience an unplanned 90-day readmission (3.6% vs. 2.5%, P = .14). This similarity existed despite a substantially worse comorbidity burden in the Medicare population (P < .05 for 26 of 40 factors). Furthermore, a short inpatient stay did not result in an increased 90-day readmission rate in either Medicare patients (3.6% vs. 3.4%, P = .77) or their privately insured counterparts (2.5% vs. 2.4%, P = .92). Notably, when the analysis was restricted to a single insurance type, readmission rates were significantly higher for reverse shoulder arthroplasty compared with total shoulder arthroplasty (P < .001 for both), but when the analysis was restricted to a single procedure (anatomic or reverse), readmission rates were similar between Medicare and privately insured patients, whether undergoing a short or extended length of stay.

Conclusions: Despite a substantially more severe comorbidity profile, Medicare patients undergoing short-stay shoulder arthroplasty did not experience a significantly higher rate of unplanned 90-day readmission relative to privately insured patients. A higher incidence of reverse shoulder arthroplasty in Medicare patients does increase their overall readmission rate, but a similar increase also appears in privately-insured patients undergoing a reverse indicating that Medicare populations may be similarly appropriate for accelerated-care pathways.
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http://dx.doi.org/10.1016/j.jse.2021.05.013DOI Listing
June 2021

Predicting Patient Satisfaction With Maximal Outcome Improvement After Biceps Tenodesis.

Orthopedics 2021 May-Jun;44(3):e359-e366. Epub 2021 May 1.

The goal of this study was to determine the threshold for achieving maximal outcome improvement (MOI) on the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (CM) questionnaires that predict satisfaction after isolated biceps tenodesis without concomitant rotator cuff repair. A retrospective analysis of prospectively collected data was performed for patients undergoing isolated biceps tenodesis from 2014 to 2017 at a single institution with minimum 6-month follow-up. Receiver operating characteristic curve analysis was used to determine thresholds for MOI for the ASES, SANE, and CM questionnaires. Stepwise multivariate logistical regression analysis was performed to identify predictors for achieving the threshold for MOI. A total of 123 patients were included in the final analysis. Receiver operating characteristic analysis determined that achieving 43.1%, 62.1%, and 61.4% MOI was the threshold for satisfaction for the ASES, SANE, and CM questionnaires, respectively. Regression analysis showed that concomitant superior labrum anterior-posterior (SLAP) repair was predictive of achieving MOI on the ASES and SANE questionnaires, whereas partial rotator cuff tear was predictive of achieving MOI on the CM questionnaire (<.05 for both). Further, workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors of achieving MOI on the SANE and CM questionnaires (<.05 for all). Achieving MOI of 43.1%, 62.1%, and 61.4% is the threshold for satisfaction after biceps tenodesis for the ASES, SANE, and CM questionnaires, respectively. Concomitant SLAP repair was positively predictive of achieving MOI, whereas workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors. [. 2021;44(3):e359-e366.].
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http://dx.doi.org/10.3928/01477447-20210414-07DOI Listing
July 2021

Clinical Outcomes of Shoulder Stabilization in Females With Glenoid Bone Loss.

Orthop J Sports Med 2021 May 13;9(5):23259671211007525. Epub 2021 May 13.

Department of Orthopaedic Surgery, DuPage Medical Group, Joliet, Illinois, USA.

Background: Nearly all studies describing shoulder stabilization focus on male patients. Little is known regarding the clinical outcomes of female patients undergoing shoulder stabilization, and even less is understood about females with glenoid bone loss.

Purpose: To assess the clinical outcomes of female patients with recurrent anterior shoulder instability treated with the Latarjet procedure.

Study Design: Case series; Level of evidence, 4.

Methods: All cases of female patients who had recurrent anterior shoulder instability with ≥15% anterior glenoid bone loss and underwent the Latarjet procedure were analyzed. Patients were evaluated after a minimum 2-year postoperative period with scores of the American Shoulder and Elbow Surgeons form, Simple Shoulder Test, and pain visual analog scale.

Results: Of the 22 patients who met our criteria, 5 (22.7%) were lost to follow-up, leaving 17 (77.2%) available for follow-up with a mean ± SD age of 31.7 ± 12.9 years. Among these patients, 16 (94.1%) underwent 1.6 ± 0.73 ipsilateral shoulder operations (range, 1-3) before undergoing the Latarjet procedure. Preoperative indications for surgery included recurrent instability with bone loss in all cases. After a mean follow-up of 40.2 ± 22.9 months, patients experienced significant score improvements in the American Shoulder and Elbow Surgeons form, Simple Shoulder Test, and pain visual analog scale ( < .05 for all). There were 2 reoperations (11.8%). There were no cases of neurovascular injuries or other complications.

Conclusion: Female patients with recurrent shoulder instability with glenoid bone loss can be successfully treated with the Latarjet procedure, with outcomes similar to those of male patients in the previously published literature. This information can be used to counsel female patients with recurrent instability with significant anterior glenoid bone loss.
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http://dx.doi.org/10.1177/23259671211007525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8127764PMC
May 2021

Return to sport following Latarjet glenoid reconstruction for anterior shoulder instability.

J Shoulder Elbow Surg 2021 Apr 28. Epub 2021 Apr 28.

Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: Latarjet coracoid transfer reconstruction is the gold standard for the treatment of recurrent shoulder instability with anterior-inferior glenoid bone loss, and return to sport is often a primary outcome of interest in this patient population. The purpose of this study was to determine the rate of return to sport in patients undergoing the Latarjet procedure and variables that are associated with a higher likelihood of a successful return to sport.

Methods: A prospectively maintained institutional registry was retrospectively queried between August 2012 and August 2016 for all patients who underwent the Latarjet procedure. Patients were contacted electronically and via telephone to administer a previously validated and standardized return-to-sport survey. Patients self-reported return to sport, varying sports participation, recurrence of instability, and time to return to sport. Multivariate analysis was performed to determine variables associated with each outcome.

Results: Of 83 patients, 66 (75.3%) were available for final follow-up, of whom 60 participated in sports prior to surgery and were eligible for inclusion. The average follow-up period was 53.8 ± 11.8 months. The average age at surgery was 26.7 ± 11.3 years, and the average body mass index was 26.2 ± 4.0 kg/m. There were 54 patients (90%) who were able to return to sport at an average of 8.6 ± 4.1 months following surgery. In total, 36 patients (60%) were able to return to sport at the same level or a better level of intensity, 19 of 28 patients (67.9%) were able to return to throwing sports without difficulty, and 31 of 60 patients (51.7%) reported that their shoulder was a hindrance to some activity. An increased likelihood of returning to sport was associated with increased body mass index (P = .016), male sex (P = .028), and decreased humeral bone loss volume (P = .034). An increased likelihood of returning to sport at the same level or a better level of intensity was associated with reduced humeral bone loss volume (P = .026). Recurrent instability was associated with humeral bone loss (P = .038).

Conclusion: Although a large majority of patients were able to return to sport following the Latarjet procedure, some patients experienced limitation with throwing and return to sport at the preinjury level. Greater humeral bone loss was associated with inferior outcomes. These findings should be discussed with patients in the preoperative setting to manage expectations appropriately.
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http://dx.doi.org/10.1016/j.jse.2021.04.020DOI Listing
April 2021

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcomes.

J Shoulder Elbow Surg 2021 Apr 2. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA. Electronic address:

Background: Malnutrition is associated with poor postoperative outcomes after knee, hip, and spine surgery. However, whether albumin labs should be part of the routine preoperative workup for shoulder arthroplasty remains understudied. This study investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty.

Methods: All shoulder arthroplasty cases performed at 2 tertiary referral centers between July 2013 and May 2019 (institution 1) and between June 2007 and Feb 2020 (institution 2) were reviewed. A total of 421 primary and 71 revision elective shoulder arthroplasty cases had preoperative albumin levels recorded. Common demographic variables and relevant Elixhauser comorbidities were pulled. Outcomes gathered included extended (>3 days) postoperative inpatient length of stay (eLOS), 90-day readmission, and discharge to rehab or skilled nursing facility (SNF).

Results: The prevalence of malnutrition (albumin <3.5 g/dL) was higher in the revision group compared with the primary group (36.6% vs. 19.5%, P = .001). Reverse shoulder arthroplasty (P = .013) and increasing American Society of Anesthesiologists score (P = .016) were identified as independent risk factors for malnutrition in the primary group. In the revision group, liver disease was associated with malnutrition (P = .046). Malnourished primary shoulder arthroplasty patients had an increased incidence of eLOS (26.8% vs. 13.6%, P = .003) and discharge to rehab/SNF (18.3% vs. 10.3%, P = .045). On univariable analysis, low albumin had an odds ratio (OR) of 2.34 for eLOS (P = .004), which retained significance in a multivariable model including age, American Society of Anesthesiologists score, sex, and body mass index (OR 2.11, P = .03). On univariable analysis, low albumin had an OR of 1.94 for discharge to SNF/rehab (P = .048), but this did not reach significance in the multivariable model. Among revisions, malnourished patients had an increased incidence of eLOS (30.8% vs. 6.7%, P = .014) and discharge to rehab/SNF (26.9% vs. 4.4%, P = .010). In both the primary and revision groups, there was no difference in 90-day readmission rate between patients with low or normal albumin.

Conclusion: Malnutrition is more prevalent among revision shoulder arthroplasty patients compared with those undergoing a primary procedure. Primary shoulder arthroplasty patients with low preoperative albumin levels have an increased risk of eLOS and may have an increased need for postacute care. Low albumin was not associated with a risk of 90-day readmissions. Albumin level merits further investigation in large, prospective cohorts to clearly define its role in preoperative risk stratification.
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http://dx.doi.org/10.1016/j.jse.2021.03.143DOI Listing
April 2021

Patients undergoing anatomic total shoulder arthroplasty achieve clinically significant outcomes faster than those undergoing reverse shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Mar 9. Epub 2021 Mar 9.

Division of Sports Medicine & Shoulder, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA. Electronic address:

Background: Clinically significant outcome (CSO) benchmarks have been previously established for outcome assessment after total shoulder arthroplasty. However, the time required to achieve CSO improvement is not well understood. The purpose of this study was to (1) determine the time-dependent achievement of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) in patients undergoing either anatomic total shoulder (TSA) or reverse total shoulder arthroplasty (RTSA) and compare the results of the 2 populations and (2) identify variables associated with earlier or delayed achievement of each CSO.

Methods: A prospectively maintained institutional registry was retrospectively queried for all patients receiving a primary TSA or RTSA between September 2, 2016-October 31, 2017. The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) was administered to all patients preoperatively and at standardized postoperative time periods: 5-7 months (6-month time point), 11-13 months (1-year time point), and 23-25 months (2-year time point). Cumulative percentages of CSO achievement were calculated using Kaplan-Meier survival curve analysis with interval censoring. A Weibull parametric survival regression analysis was used to investigate the influence of demographic and clinical variables on delayed or earlier CSO achievement.

Results: A total of 153 patients (157 shoulders) undergoing TSA (n = 76) and RTSA (n = 81) were included in the study population. The RTSA cohort was older (70.2 ± 7.5 vs. 61.0 ± 8.4, P < .001), had a lower BMI (28.8 ± 5.9 vs. 31.5 ± 6.5, P = .006), and a greater proportion of females (53.1% vs. 32.9%, P = .017) relative to TSA. For SCB, there was a significant difference in the cumulative percentage of TSA and RTSA patients reaching this threshold at both the 6-month (77.3% vs. 59.0%, P = .024) and 2-year (92.0% vs. 79.5%, P = .048) time periods, with similar findings demonstrated for PASS. There was a significant difference in the average time required to achieve the PASS (TSA: 6.1 months vs. rTSA: 11.6 months, P = .009), but not the MCID (P = .407) or SCB (P = .153). Factors significantly associated with earlier achievement of more than 1 of the CSO benchmarks were regular preoperative physical exercise and diagnosis of rotator cuff tear without osteoarthritis.

Conclusion: Patients undergoing RTSA had lower rates of achieving SCB and PASS at both 6 months and 2 years compared to patients undergoing TSA. Patients undergoing RTSA on average required nearly double the time to achieve PASS compared with those undergoing TSA. In both groups, clinically significant improvement continued for the entire 2-year duration of study follow-up.
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http://dx.doi.org/10.1016/j.jse.2021.02.015DOI Listing
March 2021

Return to sport and weightlifting analysis following distal biceps tendon repair.

J Shoulder Elbow Surg 2021 Mar 3. Epub 2021 Mar 3.

Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: Rupture of the distal biceps tendon is an increasingly frequent injury sustained predominantly by middle-aged men. Despite the prevalence of sport in this age group, little is known regarding return to sport outcomes following surgery.

Methods: Patients undergoing distal biceps tendon repair (DBR) between January 2015 and January 2017 were contacted electronically via e-mail and via telephone to administer a previously validated and standard return to sport survey. Patients self-reported preinjury and current level of sport and activity as well as preinjury and current level of select weightlifts.

Results: A total of 77 of 124 patients were available for follow-up (62.1%). Of these patients, 61 endorsed preoperative sport and were included for analysis. Average follow-up was 38.7 ± 6.7 months. The mean age at surgery was 47.5 ± 8.8 years, and the mean body mass index was 30.3 ± 5.1. The dominant side was affected in 25 of 61 cases. Of the 61 included patients, 57 (93.4%) were able to return to sport at any level (lower, same, or higher intensity than preinjury activity level). Forty of the patients (65.6%) were able to return to sport at same or higher intensity. Mean time to return to sport was 6.0 ± 2.8 months. Days from injury to surgery (odds ratio [OR] 0.999, 95% confidence interval [CI] 0.998-0.999), suture anchor fixation in comparison to suture button (OR 0.602, 95% CI 0.427-0.850), and dominant-side surgery (OR 0.749, 95% CI 0.582-0.963) were associated with a decreased likelihood to return to sport at same or higher level of duty. Single-sided incision in comparison to double (OR 5.209, 95% CI 1.239-20.903) and dominant-side surgery (OR 6.370, 95% CI 1.639-24.762) were associated with increased duration to return to sport.

Conclusion: Distal biceps tendon rupture is a significant injury; however, patients can expect high levels of return to sport following DBR with some residual impairment compared with baseline. It is important to counsel patients on their expectations while taking into account the results of this study: that there will be a small but appreciable decrease in strength compared with preinjury levels.
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http://dx.doi.org/10.1016/j.jse.2021.01.034DOI Listing
March 2021

Time Required to Achieve Clinically Significant Outcomes After Arthroscopic Rotator Cuff Repair.

Am J Sports Med 2020 12 20;48(14):3447-3453. Epub 2020 Oct 20.

Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA.

Background: Recent literature has focused on correlating statistically significant changes in outcome measures with clinically significant outcomes (CSOs). CSO benchmarks are being established for arthroscopic rotator cuff repair (RCR), but more remains to be defined about them.

Purpose: To define the time-dependent nature of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptomatic State (PASS) after RCR and to define what factors affect this time to CSO achievement.

Study Design: Case series; Level of evidence, 4.

Methods: An institutional registry was queried for patients who underwent arthroscopic RCR between 2014 and 2016 and completed preoperative, 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs). Threshold values for MCID, SCB, and PASS were obtained from previous literature for the American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant score. The time in which patients achieved MCID, SCB, and PASS was calculated using Kaplan-Meier analysis. A Cox multivariate regression model was used to identify variables correlated with earlier or later achievement of CSOs.

Results: A total of 203 patients with an average age of 56.19 ± 9.96 years and average body mass index was 30.29 ± 6.49 were included. The time of mean achievement of MCID, SCB, and PASS for ASES was 5.77 ± 1.79 months, 6.22 ± 2.85 months, and 7.23 ± 3.81 months, respectively. The time of mean achievement of MCID, SCB, and PASS for SANE was 6.25 ± 2.42 months, 7.05 ± 4.10 months, and 9.26 ± 5.89 months, respectively. The time of mean achievement of MCID, SCB, and PASS for Constant was 6.94 ± 3.85 months, 7.13 ± 4.13 months, and 8.66 ± 5.46 months, respectively. Patients with dominant-sided surgery (hazard ratio [HR], 1.363; 95% CI, 1.065-1.745; = .014) achieved CSOs earlier on ASES, while patients with workers' compensation status (HR, 0.752; 95% CI, 0.592-0.955; = .019), who were current smokers (HR, 0.323; 95% CI, 0.119-0.882; = .028), and with concomitant biceps tenodesis (HR, 0.763; 95% CI, 0.607-0.959; = .021) achieved CSOs on ASES at later timepoints. Patients with distal clavicle excision (HR, 1.484; 95% CI, 1.028-2.143; = .035) achieved CSOs earlier on SANE. Patients with distal clavicle excision (HR, 1.689; 95% CI, 1.183-2.411, = .004) achieved CSOs earlier on Constant, while patients with workers' compensation insurance status (HR, 0.671; 95% CI, 0.506-0.891; = .006) and partial-thickness tears (HR, 0.410; 95% CI, 0.250-0.671; < .001) achieved CSOs later on Constant. Greater preoperative score was associated with delayed achievement of CSOs for ASES, SANE (HR, 0.993; 95% CI, 0.987-0.999; = .020), and Constant (HR, 0.941; 95% CI, 0.928-0.962; < .001).

Conclusion: A majority of patients achieved MCID by 6 months after surgery. Dominant-sided surgery and concomitant distal clavicle excision resulted in faster CSO achievement, while workers' compensation status, concomitant biceps tenodesis, current smoking, partial-thickness rotator cuff tears, and higher preoperative PROMs resulted in delayed CSO achievement.
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http://dx.doi.org/10.1177/0363546520962512DOI Listing
December 2020

Development of supervised machine learning algorithms for prediction of satisfaction at 2 years following total shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Jun 1;30(6):e290-e299. Epub 2020 Oct 1.

Division of Sports Medicine & Shoulder, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA. Electronic address:

Background: Patient satisfaction after primary anatomic and reverse total shoulder arthroplasty (TSA) represents an important metric for gauging patients' perception of their care and surgical outcomes. Although TSA confers improvement in pain and function for most patients, inevitably some will remain unsatisfied postoperatively. The purpose of this study was to (1) train supervised machine learning (SML) algorithms to predict satisfaction after TSA and (2) develop a clinical tool for individualized assessment of patient-specific risk factors.

Methods: We performed a retrospective review of primary anatomic and reverse TSA patients between January 2014 and February 2018. A total of 16 demographic, clinical, and patient-reported outcomes were evaluated for predictive value. Five SML algorithms underwent 3 iterations of 10-fold cross-validation on a training set (80% of cohort). Assessment by discrimination, calibration, Brier score, and decision-curve analysis was performed on an independent testing set (remaining 20% of cohort). Global and local model behaviors were evaluated with global variable importance plots and local interpretable model-agnostic explanations, respectively.

Results: The study cohort consisted of 413 patients, of whom 331 (82.6%) were satisfied at 2 years postoperatively. The support vector machine model demonstrated the best relative performance on the independent testing set not used for model training (concordance statistic, 0.80; calibration intercept, 0.20; calibration slope, 2.32; Brier score, 0.11). The most important factors for predicting satisfaction were baseline Single Assessment Numeric Evaluation score, exercise and activity, workers' compensation status, diagnosis, symptom duration prior to surgery, body mass index, age, smoking status, anatomic vs. reverse TSA, and diabetes. The support vector machine algorithm was incorporated into an open-access digital application for patient-level explanations of risk and predictions, available at https://orthopedics.shinyapps.io/SatisfactionTSA/.

Conclusion: The best-performing SML model demonstrated excellent discrimination and adequate calibration for predicting satisfaction following TSA and was used to create an open-access, clinical decision-making tool. However, rigorous external validation in different geographic locations and patient populations is essential prior to assessment of clinical utility. Given that this tool is based on partially modifiable risk factors, it may enhance shared decision making and allow for periods of targeted preoperative health-optimization efforts.
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http://dx.doi.org/10.1016/j.jse.2020.09.007DOI Listing
June 2021

Cost-effectiveness analyses in shoulder arthroplasty: a critical review using the Quality of Health Economic Studies (QHES) instrument.

J Shoulder Elbow Surg 2021 May 19;30(5):1007-1017. Epub 2020 Aug 19.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Hypothesis: The purpose of this study was to perform a systematic review to identify cost-analysis studies pertaining to shoulder arthroplasty, provide a comprehensive review of published studies, and critically evaluate the quality of the available literature using the Quality of Health Economic Studies (QHES) instrument.

Methods: A systematic review of the literature was performed to identify cost analyses examining shoulder arthroplasty. The inclusion criteria included studies pertaining to either shoulder hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA. Articles were excluded based on the following: nonoperative studies, nonclinical studies, studies not based in the United States, and studies in which no cost analysis was performed. The quality of studies was assessed using the QHES instrument. One-sided Fisher exact testing was performed to identify predictors of both low-quality (ie, QHES score < 25th percentile) and high-quality (ie, QHES score > 75th percentile) cost analyses based on items within the QHES checklist.

Results: Of the 196 studies screened, 9 were included. Seven studies conducted cost analyses comparing reverse TSA vs. arthroscopic rotator cuff repair, HA, or total hip arthroplasty, and 2 studies examined TSA vs. HA for primary glenohumeral arthritis. The average QHES score among all studies was 86.22 ± 13.39 points. Failure to include an annual cost discounting rate was associated with a low-quality QHES score (P = .03). In addition, including a discussion of the magnitude and direction of potential biases was associated with a high-quality score (P = .03).

Conclusions: Shoulder arthroplasty is a cost-effective procedure when used to treat a multitude of shoulder pathologies. The overall quality of cost analysis in shoulder arthroplasty is relatively good, with an average QHES score of 86.22 points. Studies failing to include an annual cost discounting rate are more likely to score below the 25th percentile, whereas those including a discussion of the magnitude and direction of potential biases are more likely to achieve a score in excess of the 75th percentile.
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http://dx.doi.org/10.1016/j.jse.2020.07.040DOI Listing
May 2021

Reoperation Risk After Total Elbow Arthroplasty Versus Open Reduction Internal Fixation for Distal Humerus Fractures in Elderly Patients.

J Orthop Trauma 2020 09;34(9):503-509

Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL; and.

Objective: To compare reoperation risk after total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF) for intra-articular distal humerus fractures in elderly patients.

Design: Retrospective comparative.

Setting: Five percent Medicare Part B claims database.

Patients: Patients older than 65 years of age with closed distal humerus fractures undergoing TEA or ORIF from 1996 to 2016.

Intervention: TEA and ORIF.

Main Outcome Measure: Reoperation risk based on multivariate Cox proportional hazards modeling.

Results: A total of 142 TEA and 522 ORIF cases were identified. TEA patients had a greater age and Charlson Comorbidity Index , as well as a higher prevalence of rheumatoid arthritis and osteoporosis than ORIF patients (P < 0.05). Although reoperation risk was lower for TEA than that for ORIF within the entire cohort (11.3% vs. 25.1%; hazard ratio = 0.49; P = 0.014), no significant difference was found for TEA and ORIF performed between 2006 and 2016 (12.6% vs. 18.4%; hazard ratio = 0.73; P = 0.380). The death rate was 65.5% in the TEA group at 3.6 years and 55.7% in the ORIF group at 4.9 years.

Conclusions: TEA was associated with a decreased reoperation risk compared with ORIF, although this difference did not exist for more recent procedures after popularization of the locking plate technology and half of the reoperations after ORIF were for instrumentation removal. The high death rate within several years of the index procedure may contribute to the low TEA revision rate beyond the short-term when following patients into the medium and long term. Further study comparing TEA and locked plating using prospective, randomized data with long-term follow-up and functional outcomes is warranted.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001767DOI Listing
September 2020

Establishing clinically significant outcome thresholds for the Single Assessment Numeric Evaluation 2 years following total shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Apr 23;30(4):e137-e146. Epub 2020 Jul 23.

Division of Sports Medicine & Shoulder, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA. Electronic address:

Background: Single Assessment Numerical Evaluation (SANE) is a simple, time-efficient patient-reported outcome measure (PROM) used to assess postoperative shoulder function. Clinically significant outcome values and ability to correlate with longer legacy PROM scores at 2 years following shoulder arthroplasty are unknown.

Methods: A retrospective analysis was performed using SANE, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores that were collected at a minimum 2-year follow-up. A total of 153 patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) were included. A distribution-based method was used to determine the minimal clinically important difference (MCID). An anchor-based method was used to determine substantial clinical benefit (SCB). The following anchor question was collected alongside the PROMs and graded on a 15-point Likert-type scale to establish the SCB: "Since your surgery, has there been any change in the pain in your shoulder?" Linear regression was used to assess correlations between PROMs.

Results: SANE showed moderate correlation with ASES (R = 0.493) and Constant (R = 0.586) scores (P < .001). The MCID value was 14.9, and the SCB absolute value was 80.4 (area under the curve = 0.663) for SANE. Multivariate logistic regression demonstrated that patients undergoing RTSA were less likely to achieve SCB on all 3 outcome measures (P < .02).

Conclusions: This study establishes concurrent construct validity for SANE and suggests that it is a valid metric to assess the MCID and SCB at 2 years following anatomic TSA and RTSA. SANE demonstrated moderate correlations with ASES and Constant scores. Patients undergoing RTSA demonstrated a lower propensity to achieve SCB at 2 years postoperatively compared with anatomic TSA.
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http://dx.doi.org/10.1016/j.jse.2020.07.011DOI Listing
April 2021

Efficacy of the modified Frailty Index and the modified Charlson Comorbidity Index in predicting complications in patients undergoing operative management of proximal humerus fracture.

J Shoulder Elbow Surg 2021 Mar 7;30(3):658-667. Epub 2020 Jul 7.

Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA. Electronic address:

Background: Comorbidity indices such as the 5-factor modified Frailty Index (mFI-5) and modified Charlson Comorbidity Index (mCCI) are widely used in outcomes research.

Methods: A total of 3893 patients who underwent total shoulder arthroplasty (n=975), hemiarthroplasty (n=495), or open reduction and internal fixation (n=2423) for the treatment of proximal humerus fracture from 2005-2017 were identified from the National Surgical Quality Improvement Program database. Data regarding demographics, comorbidities, American Society of Anesthesiologists class, and postoperative complications were collected, and the mFI-5 and mCCI were calculated for each case. Multivariate logistic regression models and receiver operating characteristic curve analyses were performed.

Results: The patient population had a mean age of 68.0 ± 13.2 years, body mass index of 29.1 ± 8.1 and mean operative time of 119.9 ± 55.5 minutes. The most common complications within this cohort were extended length of stay (4 days or more) (1085/3893; 27.87%), transfusion (377/3893; 9.68%), unplanned reoperation (97/3893; 2.49%), urinary tract infection (43/3893; 1.10%), death (42/3893; 1.08%), and deep vein thrombosis (40/3893; 1.03%). After accounting for patient demographics, the mFI-5 (odds ratio [OR] = 1.105, P < .001) and mCCI (OR = 1.063, P < .001) were significantly associated with incidence of any adverse event. Both comorbidity indices had low positive predictive value and high negative predictive value for all adverse events.

Conclusion: The comorbidity indices mCCI and mFI-5 are both strongly associated with adverse events but have moderate ability to predict complications following surgical treatment of proximal humerus fractures.
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http://dx.doi.org/10.1016/j.jse.2020.06.014DOI Listing
March 2021

Salvage reverse total shoulder arthroplasty for failed anatomic total shoulder arthroplasty: a cohort analysis.

J Shoulder Elbow Surg 2020 Jul;29(7S):S134-S138

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: Reverse total shoulder arthroplasty (RTSA) as a revision procedure for failed anatomic total shoulder arthroplasty (TSA) is increasing in incidence. The purpose of this study was to analyze the results of RTSA as a revision salvage procedure for failed TSA and identify factors that influenced those outcomes.

Methods: All anatomic TSAs that were revised to RTSAs in adult patients, under the care of 2 senior surgeons at a single academic center from 2006 to 2018, were queried and reviewed. Cases in which hemiarthroplasty or RTSA was revised to RTSA were excluded. Electronic medical records and survey databases were reviewed for each subject. Demographic and surgical details were reviewed and analyzed with descriptive statistics. Preoperative and postoperative range of motion (ROM) including active forward elevation and active external rotation were evaluated. Patient-reported outcome surveys including the American Shoulder and Elbow Surgeons survey, Single Assessment Numeric Evaluation, and visual analog scale for pain were collected and analyzed. Improvement in ROM and outcome survey measures was assessed with 2-sample t tests. Complication and reoperation rates were analyzed with descriptive statistics.

Results: A total of 75 patients (32 men and 43 women) were available for analysis at a mean of 22.3 months. The subjects were aged 60.3 ± 11.3 years at the time of TSA and 64.6 ± 9.7 years at the time of RTSA. The average period between TSA and RTSA was 4.3 years. The 3 most common indications for revision RTSA were painful arthroplasty (n = 62, 82.7%), rotator cuff failure (n = 56, 74.7%), and unstable arthroplasty (n = 25, 33.3%), but the majority of patients had multiple indications for surgery (n = 69, 92%). Significant improvements were found in all outcome measures from the time of failed TSA diagnosis to most recent follow-up after salvage RTSA with the exception of active external rotation: American Shoulder and Elbow Surgeons score, 39 ± 15 preoperatively vs. 62 ± 25 postoperatively; Single Assessment Numeric Evaluation, 27 ± 23 vs. 60 ± 30; visual analog scale pain score, 5 ± 2 vs. 3 ± 3; and active forward elevation, 79° ± 41° vs. 128° ± 33°. Major complications occurred in 21 patients (28.4%) after salvage RTSA, and 9 (12%) underwent reoperation.

Conclusions: RTSA for failed TSA can improve pain, function, and quality-of-life measures in patients with various TSA failure etiologies. However, postoperative ROM and patient-reported outcomes do not reach the values seen in the primary RTSA population.
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July 2020

Return to sporting activity after ulnar nerve transposition for isolated neuritis in competitive overhead athletes.

J Shoulder Elbow Surg 2020 Jul 14;29(7):1401-1405. Epub 2020 May 14.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Background: Although ulnar neuritis can occur secondary to ulnar collateral ligament pathology, stress fractures, and traction apophysitis, isolated ulnar nerve dysfunction can lead to medial elbow pain. The purpose of this study was to evaluate the short-term outcomes of overhead athletes undergoing anterior ulnar nerve transposition for ulnar neuropathy.

Methods: All overhead athletes who underwent isolated ulnar nerve transposition between 2009 and 2016 for refractory ulnar neuritis were identified. The primary outcome was return to sport, and secondary outcome measures included the Kerlan-Jobe Orthopaedic Clinic score; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder and Hand score; Single Assessment Numeric Evaluation score; and visual analog scale score for pain. Complication and reoperation rates were recorded.

Results: A total of 26 overhead athletes (21 male and 5 female athletes) underwent ulnar nerve transposition at an average age of 18.4 years (range, 11-25 years). Of the patients, 24 (92%) returned to their sporting activity at an average of 2.7 months postoperatively, including 16 (62%) at the previous level of play. The average visual analog scale pain score improved from 4.7 (±2.5) to 0.4 (±1.5) (P = .015). The average postoperative patient-reported outcome scores were as follows: Kerlan-Jobe Orthopaedic Clinic score, 80 (95% confidence interval [CI], 72.7-87.0); Single Assessment Numeric Evaluation score, 85 (95% CI, 75.4-94.7); Quick Disabilities of the Arm, Shoulder and Hand score, 5 (95% CI, 2.1-7.7); and Mayo Elbow Performance Score, 91 (95% CI, 86.8-96.0).

Conclusion: Cubital tunnel syndrome can cause medial elbow pain in overhead athletes in the presence of a normal ulnar collateral ligament. At mid-term follow-up, 92% of overhead athletes returned to sport after ulnar nerve transposition, with 62% resuming their previous level of performance.
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July 2020

Comparative Clinical Outcomes of Reverse Total Shoulder Arthroplasty for Primary Cuff Tear Arthropathy Versus Severe Glenohumeral Osteoarthritis With Intact Rotator Cuff: A Matched-Cohort Analysis.

J Am Acad Orthop Surg 2020 Dec;28(23):e1042-e1048

From the Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC (Dr. Waterman), the University of Illinois Chicago School of Medicine, Chicago, IL (Mr. Dean), Department of Orthopaedic Surgery, the Rush University Medical Center, Chicago, IL (Ms. Naylor, Dr. Otte, Ms. Sumner-Parilla, and Dr. Nicholson), and the Rothman Orthopaedic Institute, New York, NY (Dr. Romeo).

Introduction: The purpose of this study was to compare the short- to mid-term outcomes of patients who underwent reverse total shoulder arthroplasty (RTSA) for severe glenohumeral osteoarthritis (GHOA) with an intact rotator cuff (RC) to a matched rotator cuff arthropathy (RCA) cohort.

Methods: Between 2004 and 2014, all patients who underwent RTSA for severe GHOA with a minimum 2-year follow-up were identified. Demographic and baseline variables were extracted from the medical records. Subjects were matched in the ratio of 1:2 to RTSA subjects with RCA, while controlling for the demographic and intraoperative variables. Postoperative active forward elevation (AFE), active external rotation, American Shoulder and Elbow Surgeons Score (ASES), Visual Analog Scale (VAS), and Simple Shoulder Test were recorded. Complications and revision surgery rates were noted. Comparative multivariate analysis was performed. Preoperative Walch classification for each subject was obtained through radiograph review, and the impact of classification was assessed using one-way analysis of variance testing.

Results: One hundred thirty-six patients were available with mean follow-up 32.3 ± 12.3 months. Baseline range of motion and patient reported outcome scores were similar between the groups (P > 0.05), except for Simple Shoulder Test (intact rotator cuff: 5.7 ± 7.4 versus RCA: 2.4 ± 1.8, P = 0.037). The intact RC group had significantly, superior absolute outcome measures for active external rotation (P = 0.006), and SST (P = 0.048), but not for SANE (P = 0.055), VAS (P = 0.464), ASES (P = 0.084), and AFE (P = 0.099). No notable difference was observed between the groups for improvement in motion, survey scores, or complications. Walch osteoarthritis classification did not impact the outcome measurements in the severe GHOA with the intact RC group (P > 0.05).

Discussion: Patients who underwent RTSA for severe GHOA with intact RC demonstrate similar consistent improvement in outcomes to demographically similar patients with RCA. The severity of GHOA defined by the Walch classification did not impact the outcomes at the 2-year follow-up.

Level Of Evidence: Level III Therapeutic Study.
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http://dx.doi.org/10.5435/JAAOS-D-19-00493DOI Listing
December 2020

In Older Patients with Proximal Humeral Fractures, Reverse Shoulder Arthroplasty and Nonoperative Treatment Did Not Differ for Overall Function or Quality of Life at 12 Months.

J Bone Joint Surg Am 2020 05;102(10):906

Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois.

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http://dx.doi.org/10.2106/JBJS.20.00254DOI Listing
May 2020

Risk Factors and Complications for Revision Shoulder Arthroplasty.

HSS J 2020 Feb 28;16(1):9-14. Epub 2019 Feb 28.

3Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA.

Background: Revision shoulder arthroplasty has become increasingly common as primary arthroplasty has become more widespread.

Questions/purposes: We sought to answer two questions: What are the risks factors for revision shoulder arthroplasty? What are the complications associated with revision shoulder arthroplasty?

Methods: A retrospective search of a national insurance database from the years 2013 to 2016 was undertaken for billing codes of patients undergoing revision shoulder arthroplasty. The odds ratios for revision of various patient demographic characteristics and comorbidities were determined. The incidences of various complications within 90 days of revision were determined.

Results: A total of 824 cases of revision shoulder arthroplasty were found. Eighty-seven patients (10.5%) had infections prior to revision and 133 patients (16.1%) had dislocations prior to revision. Of the risk factors examined, smoking status was associated with the highest odds ratio for revision (8.1). Additionally, depression, Charlson Comorbidity Index (CCI), male gender, renal failure, and diabetes were significant risks factors for revision. The most common complication of revision shoulder arthroplasty was found to be surgical site infection, affecting 10.9% of patients. In the time period studied, 89 patients underwent more than one revision shoulder arthroplasty.

Conclusion: Despite limitations inherent in database studies, this data may have utility for surgeons in pre-operative counseling of patients on their risk.
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http://dx.doi.org/10.1007/s11420-019-09673-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6973731PMC
February 2020

Anatomic total shoulder arthroplasty with an inlay glenoid component: clinical outcomes and return to activity.

J Shoulder Elbow Surg 2020 Jun 31;29(6):1188-1196. Epub 2019 Dec 31.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: Biomechanical studies show that inlay glenoid components in total shoulder arthroplasty (TSA) can reduce edge loading and opposite-edge lift-off forces with humeral translation compared with onlay glenoids. However, clinical data for these implants are lacking. We report clinical outcomes and return to activities after anatomic TSA with an inlay glenoid component and a stemless ovoid humeral head in an active, young patient population.

Methods: A retrospective review of TSA with an inlay glenoid component and an ovoid humeral head component was performed for 27 shoulders. Patients were evaluated with patient-reported outcome measures, range of motion, and radiographs. Return to occupational and sporting activity, complications, and reoperations were analyzed.

Results: A total of 27 shoulders were available for minimum 2-year follow-up. Age averaged 52.1 years, and 92.6% of shoulders were in male patients. The preoperative Walch grade was A1 or A2 in 15 shoulders (55%), B1 in 8 (30%), and B2 in 4 (15%). Patients showed significant improvements in patient-reported outcome measures, active forward flexion, and external rotation (P < .001) with no reoperations. At an average of 3.7 months, the rate of return to work was 92.6%, with 76.0% of those patients returning to their preoperative occupational demand level. At an average of 9.1 months, 75% of patients who responded to our custom survey returned to sport, with 50% achieving the same level or a higher level of sporting activity. Annual postoperative radiographs revealed no inlay component loosening.

Conclusion: Anatomic TSA with an inlay glenoid coupled with a stemless ovoid humeral head in an active population resulted in improved clinical outcomes, no reoperations or radiographic loosening, and a high rate of return to activity at shorter-term follow-up.
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http://dx.doi.org/10.1016/j.jse.2019.10.003DOI Listing
June 2020

Next-generation sequencing for diagnosis of infection: is more sensitive really better?

J Shoulder Elbow Surg 2020 Jan 13;29(1):20-26. Epub 2019 Oct 13.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: The utility of next-generation sequencing (NGS) in differentiating between active infection and contaminant or baseline flora remains unclear. The purpose of this study is to compare NGS with culture-based methods in primary shoulder arthroplasty.

Methods: A prospective series of primary shoulder arthroplasty patients with no history of infection or antibiotic use within 60 days of surgery was enrolled. All patients received standard perioperative antibiotics. After skin incision, a 10 × 3-mm sample of the medial skin edge was excised. A 2 × 2-cm synovial tissue biopsy was taken from the rotator interval after subscapularis takedown. Each sample set was halved and sent for NGS and standard cultures.

Results: Samples from 25 patients were analyzed. Standard aerobic/anaerobic cultures were positive in 10 skin samples (40%, 95% confidence interval [CI] 20%-60%) and 3 deep tissue samples (12%, 90% CI 1%-23%]). NGS detected ≥1 bacterial species in 17 of the skin samples (68%, 95% CI 49%-87%) and 7 deep tissue samples (28%, 95% CI 9%-47%). There was a significant difference (P < .03) in the mean number of bacterial species detected with NGS between the positive standard culture (1.6 species) and the negative standard culture groups (5.7 species).

Conclusion: NGS identified bacteria at higher rates in skin and deep tissue samples than standard culture did in native, uninfected patients undergoing primary procedures. Further research is needed to determine which NGS results are clinically relevant and which are false positives before NGS can be reliably used in orthopedic cases.
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http://dx.doi.org/10.1016/j.jse.2019.07.039DOI Listing
January 2020

Construct validation of machine learning in the prediction of short-term postoperative complications following total shoulder arthroplasty.

J Shoulder Elbow Surg 2019 Dec 3;28(12):e410-e421. Epub 2019 Aug 3.

Loma Linda University Medical Center, Loma Linda, CA, USA.

Background: We aimed to demonstrate that supervised machine learning (ML) models can better predict postoperative complications after total shoulder arthroplasty (TSA) than comorbidity indices.

Methods: The American College of Surgeons-National Surgical Quality Improvement Program database was queried from 2005-2017 for TSA cases. Training and validation sets were created by randomly assigning 80% and 20% of the data set. Included variables were age, body mass index (BMI), operative time, smoking status, comorbidities, diagnosis, and preoperative hematocrit and albumin. Complications included any adverse event, transfusion, extended length of stay (>3 days), surgical site infection, return to the operating room, deep vein thrombosis or pulmonary embolism, and readmission. Each SML algorithm was compared with one another and to a baseline model using American Society of Anesthesiologists (ASA) classification. Model strength was evaluated by calculating the area under the receiver operating characteristic curve (AUC) and the positive predictive value (PPV) of complications.

Results: We identified a total of 17,119 TSA cases. Mean age, BMI, and length of stay were 69.5 ± 9.6 years, 31.1 ± 6.8, and 2.0 ± 2.2 days. Percentage hematocrit, BMI, and operative time were of highest importance in outcome prediction. SML algorithms outperformed ASA classification models for predicting any adverse event (71.0% vs. 63.0%), transfusion (77.0% vs. 64.0%), extended length of stay (68.0% vs. 60.0%), surgical site infection (65.0% vs. 58.0%), return to the operating room (59.0% vs. 54.0%), and readmission (64.0% vs. 58.0%). SML algorithms demonstrated the greatest PPV for any adverse event (62.5%), extended length of stay (61.4%), transfusion (52.2%), and readmission (10.1%). ASA classification had a 0.0% PPV for complications.

Conclusion: With continued validation, intelligent models could calculate patient-specific risk for complications to adjust perioperative care and site of surgery.
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http://dx.doi.org/10.1016/j.jse.2019.05.017DOI Listing
December 2019

Correction to: Risk Factors and Complications for Revision Shoulder Arthroplasty.

HSS J 2019 07 1;15(2):210. Epub 2019 May 1.

3Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA.

[This corrects the article DOI: 10.1007/s11420-019-09673-3.].
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http://dx.doi.org/10.1007/s11420-019-09683-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609772PMC
July 2019

Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.

J Shoulder Elbow Surg 2019 Nov 12;28(11):2238-2246. Epub 2019 Jul 12.

Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: Single Assessment Numeric Evaluation (SANE) offers a simple method of evaluating patients' sense of functional improvement after shoulder arthroplasty.

Methods: Patients receiving total shoulder arthroplasties were retrospectively queried between 2014 and 2017. Patients completed questionnaires involving SANE, American Shoulder and Elbow Surgeons (ASES) score, and Constant scores at the 1-year interval. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were calculated using the anchor-based methodology.

Results: A total of 207 patients with an average age of 66.7 ± 10.3 years and a body mass index of 31.5 ± 7.3 were available for analysis. The SANE score was the only score to have acceptable area under curve (AUC) (70.5%) for achieving MCID with a cutoff of 28.8. In terms of SCB, ASES (88%) and SANE (70.5%) had acceptable AUC with cutoffs of 20.7 and 50.2, respectively. All 3 scores had excellent AUC (>80%) for PASS with cutoffs of 81.9, 75.5, and 24.5 for ASES, SANE, and Constant scores, respectively. Normalized SANE scores were weakly correlated with ASES and Subjective Constant after normalizing for scale (R2 < 0.4). Achieving MCID by SANE was correlated with achieving MCID by Constant (P < .001). Achieving SCB and PASS by SANE was correlated with achieving SCB and PASS by ASES and Constant (ASES: P = .007, P < .001; Constant: P < .001, P < .001).

Conclusion: The present study establishes clinically significant outcomes for SANE. Achievement of clinically significant outcomes in SANE was correlated with achieving meaningful outcomes with legacy measures of ASES and Constant scores. SANE may be used as a simple and efficient measure of patient outcome after total shoulder arthroplasty.
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November 2019

Analysis of Return to Sport and Weight Training After Repair of the Pectoralis Major Tendon.

Am J Sports Med 2019 07 15;47(9):2151-2157. Epub 2019 Jul 15.

Rush University Medical Center, Chicago, Illinois, USA.

Background: The use of routine patient-reported outcomes after repair of the pectoralis major tendon (PMT) is often prone to the ceiling effect owing to the high functional demand of those who sustain this injury.

Hypothesis: A significant number of patients are expected to fail to achieve return to preoperative activity after PMT repair despite achieving significant improvements in functional score.

Study Design: Case series; Level of evidence, 4.

Methods: A prospectively maintained institutional database was reviewed for all patients undergoing PMT repair from 2010 to 2016. Patients were surveyed with regard to pre- and postoperative participation in sports, level of intensity, maximum weight repetitions in exercises utilizing the PMT, and American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores.

Results: Forty-four patients (73.3%) were available for final follow-up. All patients were male. Mean ± SD follow-up was 51.1 ± 24.1 months. Mean age was 39.6 ± 8.8 years (range, 24-61 years), and mean body mass index was 28.6 ± 3.5 kg/m. The dominant side was affected in 20 of 44 cases. Acute repairs were performed in 30 cases and chronic in 14. There were statistically significant improvements in both ASES and SANE scores ( < .001). Return to sport at any level was achieved by 43 of 44 (97.7%) patients, while 22 of 44 patients (50.0%) reported returning to sport at the same or better intensity as preinjury status. On average, there was a 23.3% ± 45.6% decrease in 1-repetition maximum (1RM) barbell bench press, 14.7% ± 62.3% decrease in 5-repetition maximum barbell bench press, 24.3% ± 21.8% decrease in 1RM dumbbell bench press, 35.7% ± 32.1% decrease in 1RM dumbbell fly, and 15.6% ± 39.8% decrease in consecutive push-ups able to be performed. Seventeen patients (38.6%) reported a degree of apprehension that affected their ability to lift weights. When all preoperative variables were accounted for, history of surgery to the contralateral shoulder (odds ratio, 0.600; 95% CI, 0.389-0.925) was associated with a decreased likelihood of returning to sport at the same or better level of intensity, while injury sustained during sport had a greater likelihood (odds ratio, 2.231; 95% CI, 1.234-4.031).

Conclusion: Patients undergoing PMT repair should expect significant functional improvements and a low complication rate. Yet, only 50% are able to return to preoperative intensity of sport, and they will also have significant reductions in their ability to weight lift.
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July 2019

Reverse shoulder arthroplasty for proximal humerus fracture: a more complex episode of care than for cuff tear arthropathy.

J Shoulder Elbow Surg 2019 Nov 9;28(11):2139-2146. Epub 2019 Jul 9.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.

Background: The purpose of this investigation is to identify the in-hospital and 30-day postoperative complications for reverse total shoulder arthroplasty (RTSA) performed because of proximal humerus fracture (PHFx) vs. cuff tear arthropathy (CTA), and determine whether acute fracture is associated with differences in complications after RTSA.

Methods: The National Surgical Quality Improvement Program database was queried for RTSA performed for PHFx and CTA. This database contains surgical outcomes within 30 days after the index procedure. Patients underwent a 1:1 propensity matched based on preoperative demographics and comorbidities. Outcomes included operative time, length of stay (LOS), complications, transfusion, readmission, and discharge destination.

Results: A total of 1006 patients (503 per group) were included. With a PHFx, operative time was longer (129.5 ± 54.2 vs. 96.0 ± 40.0 minutes, P < .001), and the patients were more likely to have an adverse event (19.0% vs. 8.2%, P < .001), require transfusion (15.71% vs. 3.98%, P < .001), have longer LOS (3.8 ± 3.6 vs. 2.2 ± 1.7 days, P < .001), and were more likely to be discharged to an extended care facility (27.2% vs. 10.3%, P < .001). PHFx was an independent risk factor for an adverse event after an RTSA.

Conclusions: RTSA to treat PHFx is associated with longer LOS, increased complications, and discharge to an extended care facility compared with RTSA for CTA. Patients with PHFx require more health care resources than patients with CTA. It is imperative for surgeons, patients, families, governments, hospital systems, and insurance payers to recognize the differences in resource utilization for RTSA in treating PHFx compared with CTA.
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http://dx.doi.org/10.1016/j.jse.2019.03.032DOI Listing
November 2019

Figure-of-eight Reconstruction of the Sternoclavicular Joint: Outcomes of Sport and Work.

Orthopedics 2019 Jul 28;42(4):205-210. Epub 2019 May 28.

Instability of the sternoclavicular joint is a challenging condition given the proximity of neurovascular structures and minimal osseous constraint, and little is known regarding return to activity. A prospectively maintained institutional registry was retrospectively queried for all sternoclavicular joint reconstructions performed from 2005 to 2016. All included patients were asked to answer questions from a previously established survey to assess return to sport, work, and satisfaction following surgery. Ten patients (12 shoulders) were available for long-term follow-up (71.4%; range, 26-145 months). There were significant improvements in both visual analog scale (-2.3±3.0) and American Shoulder and Elbow Surgeons (+29.7±29.6) scores (P<.001, respectively). Seven patients reported good to excellent satisfaction, and all patients reported they would undergo the surgery again in hindsight. Regarding sports, 4 of 9 (44.4%) were able to return to sport, 1 of 9 (11.1%) was able to return to same or better intensity, and 4 of 8 (50%) were able to perform a push-up having done so prior to injury. In total, 3 of 7 (42.9%) returned to work, with 1 of 7 (14.3%) returning to same or better intensity. None of the heavy-duty workers were able to return to their preinjury level of duty. Although figure-of-eight reconstruction of the sternoclavicular joint provides consistent clinical improvement and acceptable levels of patient satisfaction, most patients were unable to return to preinjury activity. Patients should be counseled preoperatively regarding appropriate expectations. Workers with strenuous responsibilities should be advised to find alternative employment opportunities. [Orthopedics. 2019; 42(4):205-210.].
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http://dx.doi.org/10.3928/01477447-20190523-03DOI Listing
July 2019

Outpatient shoulder arthroplasty: outcomes, complications, and readmissions in 2 outpatient settings.

J Shoulder Elbow Surg 2019 Jun 24;28(6S):S118-S123. Epub 2019 May 24.

Rothman Orthopaedic Institute, Philadelphia, PA, USA.

Background: There is currently a paucity of non-database studies looking at safety and outcomes after outpatient shoulder arthroplasty. The purpose of this study was to report our initial safety experience with outpatient shoulder arthroplasty including 90-day complications and readmissions. Our hypothesis was that the rate of early complications after outpatient shoulder arthroplasty would be low and similar to that of inpatient procedures regardless of outpatient setting.

Methods: We analyzed 50 consecutive patients who underwent outpatient shoulder arthroplasties (44 anatomic total shoulder arthroplasties, 4 reverse total shoulder arthroplasties, and 2 hemiarthroplasties) from 2014-2017. The readmission rate and complications were recorded. All patients were available for minimum 3-month follow-up. Preoperative and postoperative Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and visual analog scale scores were recorded.

Results: The average age was 56.9 ± 6.9 years; average body mass index, 29.75 ± 5.9; and average Charleston Comorbidity Index, 1.6 ± 1.2. There were 6 complications (12%) (hematoma, deep venous thrombosis, axillary nerve injury, acute infection, and 2 subscapularis failures). Only 4 occurred within the 90-day global period, and only 1 patient required readmission. Our subscapularis failures occurred after 3 months postoperatively and required additional surgery (arthroscopic repair and revision to reverse total shoulder arthroplasty). At last follow-up, all had significant improvements (P < .001) in range of motion and functional scores (American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and visual analog scale scores). No difference in the complications and functional outcomes was found between the patients based on their surgical setting.

Conclusion: Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. No difference in complications and outcomes occurs regardless of outpatient setting.
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http://dx.doi.org/10.1016/j.jse.2019.04.006DOI Listing
June 2019

A Flat Anterior Glenoid Corresponds to Subcritical Glenoid Bone Loss.

Arthroscopy 2019 06 3;35(6):1788-1793. Epub 2019 May 3.

Midwest Orthopedics, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To define a quickly recognizable pattern for subcritical bone loss using the inflection point between the superior and inferior glenoid.

Methods: Following institutional review board approval, 3-dimensional reconstructions of 31 shoulder computed tomography scans from cadaveric specimens were obtained. Exclusion criteria were age >65 years or evidence of fracture or arthritis of the glenoid. An en face image was obtained for each glenoid. A vertical line was defined at the most anterior point of the superior glenoid. The area of the inferior glenoid anterior to this vertical line, area of the total glenoid, chord length of the anterior portion, and a best-fit circle for the inferior glenoid were measured. These numbers were compared with determine predicted bone loss relative to this vertical line. This investigation was performed at Rush University Medical Center, Chicago, IL.

Results: The mean surface area of the glenoid anterior to the vertical line was 10.2% (95% confidence interval [CI], 9.6-10.9) of the total glenoid, and 12.8% (95% CI, 12.0-13.6) of the best-fit circle of the inferior glenoid. The chord length measurement was 16.8% (95% CI, 15.7-18.3) of the total diameter of the best-fit circle. Compared with the best-fit circle, bone loss to this vertical line would represent >10% bone loss in 80.7% of patients and >13.5% bone loss in 35.5% of patients (range, 14.3%-18.1%). The negative predictive value of the vertical line was 19% for predicting 10% bone loss, 65% for predicting 13.5% bone loss, 74% for predicting 15% bone loss, and 100% for predicting 20% bone loss.

Conclusions: A flat anterior glenoid may offer a consistent pattern that corresponds to 12.8 ± 3% bone loss relative to a best-fit circle. This measurement is in line with published values of subcritical bone loss, making this a clinically useful pattern to recognize in patients with subcritical glenoid bone loss.

Clinical Relevance: Our results suggest that an easily recognizable pattern of a flat anterior glenoid may correspond with more recently suggested levels of subclinical bone loss in patients with anterior shoulder instability.

Level Of Evidence: Level III, diagnostic study.
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http://dx.doi.org/10.1016/j.arthro.2018.12.034DOI Listing
June 2019

Biceps Tenodesis Is a Viable Option for Management of Proximal Biceps Injuries in Patients Less Than 25 Years of Age.

Arthroscopy 2019 04;35(4):1036-1041

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To evaluate outcomes after biceps tenodesis performed in patients younger than 25 years, to evaluate reoperations and complications in this population, and to critically appraise return to preinjury level of play for this population.

Methods: Forty-five consecutive patients younger than 25 years underwent subpectoral biceps tenodesis for biceps tendinopathy or biceps-labral complex injuries including SLAP tears. Biceps tenodesis was performed using an interference screw technique. Patients with a minimum 2-year follow-up were analyzed. Functional outcomes were assessed with the visual analog scale score, American Shoulder and Elbow Surgeons (ASES) score, ASES functional score, Simple Shoulder Test score, and range of motion. Activity level and return to sport were followed postoperatively.

Results: Of the 45 patients younger than 25 years who underwent biceps tenodesis, 36 (80%) were available for follow-up at a minimum of 2 years, with a mean age of 19.8 years and mean follow-up period of 38.6 months. Of these 36 patients, 34 (94%) were athletes, with 20 patients playing at collegiate level. All clinical outcome scores improved, with the ASES score improving from 54.7 to 81.7, the ASES functional score improving from 17.5 to 25.1, and the Simple Shoulder Test score improving from 7.4 to 10.1 (P < .001). At the time of follow-up, 4 patients (11%) had undergone revision surgery for other injuries. Of the 34 athletes, 25 (73%) returned to sports, with 19 returning at the same level and 6 returning at a lower level of play; 77% of overhead athletes returned to sports.

Conclusions: When indicated, biceps tenodesis offers an alternative to SLAP repair in young patients. Biceps tenodesis in patients younger than 25 years yields satisfactory outcomes, with two-thirds of patients returning to sport and a low revision rate.

Level Of Evidence: Level IV, therapeutic case series.
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http://dx.doi.org/10.1016/j.arthro.2018.10.151DOI Listing
April 2019
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