Shoulder Arthroplasty and Arthrodesis

Number: 0837

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses shoulder arthroplasty and arthrodesis.

Medical Necessity

Aetna considers the following procedures medically necessary:
1. Food and Drug Administration (FDA) approved total shoulder arthroplasty prosthesis for adult members when the following criteria are met:
  1. Member has advanced joint disease demonstrated by:
    1. Pain and functional disability that interferes with activities of daily living (ADL) from advanced destructive joint disease associated with osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the shoulder joint; and
    2. Limited range of motion or crepitus of the glenohumeral joint on physical examination: and
    3. Severe pain and loss of function of at least 6 months duration that interferes with ADL: and
    4. Radiographic evidence of destructive degenerative joint disease (as evidence by 2 or more of the following: irregular joint surfaces, glenoid sclerosis, osteophyte changes, flattened glenoid, cystic changes in the humeral head, or joint space narrowing) of shoulder joint); and
    5. History of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the medical record (see Note). If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable. Requirements for conservative therapy may be waived for persons with glenoid bone loss with anterior or posterior subluxation (not superior or proximal humeral migration) or with avascular necrosis of the humeral head with collapse in the presence of severe osteoarthritis of the shoulder. Note: Physical therapy needs to be confirmed either by the actual PT notes, or by documentation in the member claims history. Members should have at least 12 weeks of non-surgical treatment documented in the medical record (24 weeks of non-surgical treatment for persons with relative contraindications of morbid obesity (BMI > 40) or age less than 50 years), with at least half of the necessary conservative therapy consisting of formal physical therapy in the past year, including all of the following, unless contraindicated:
      1. Anti-inflammatory medications or analgesics; and
      2. Flexibility and muscle strengthening exercises, and
      3. Activity modification; and
      4. Supervised physical therapy within the past year (ADLs diminished despite completing a plan of care); and
      5. Intra-articular injections of steroids into the shoulder (optional); and
      6. For rheumatoid arthritis only, anti-cytokine agents (e.g., etanercept, infliximab) and non-biologic DMARDs (e.g., azathioprine, cyclosporine, gold salts, hydroxychloroquine, leflunomide, methotrexate, or sulfasalazine); or
  2. Treatment of proximal humeral fracture or nonunion confirmed by imaging with pain interfering with ADLs; or
  3. Treatment of proximal humeral fracture malunion confirmed by imaging with pain interfering with ADLs; or
  4. Malignancy of glenohumeral joint or surrounding soft tissue confirmed by imaging.
2. Reverse shoulder arthroplasty for adult members with the following indications:
  1. Deficient rotator cuff with glenohumeral arthropathy and limited ability to actively flex the upper extremity to 90 degrees against gravity; or
  2. Failed hemiarthroplasty; or
  3. Failed total shoulder arthroplasty with failed rotator cuff that is non-repairable; or
  4. Massive rotator cuff tears with pseudo-paralysis and without osteoarthritis; or
  5. Reconstruction after a tumor resection; or
  6. Proximal humeral fractures that are not repairable or cannot be reconstructed with other techniques and are associated with a deficient rotator cuff;
  and who meet all of the following criteria:
  1. Pain and functional disability of at least 6 months duration that interferes with ADL (6 months not required for fractures or reconstruction for tumor resection); and
  2. History of of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the medical record (see Note). If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable. Trial of conservative therapy is not required for fractures, reconstruction following tumor resection, glenoid bone loss with anterior or posterior subluxation (not superior or proximal humeral migration) or with avascular necrosis of the humeral head with collapse in the presence of severe osteoarthritis of the shoulder. Note: Physical therapy needs to be confirmed either by the actual PT notes, or by documentation in the member claims history. Members should have at least 12 weeks of nonsurgical treatment documented in the medical record (24 weeks of non-surgical treatment for persons with relative contraindications of morbid obesity (BMI > 40) or age less than 50 years), with at least half of the necessary conservative therapy consisting of formal physical therapy in the past year, including all of the following, unless contraindicated:
    1. Anti-inflammatory medications or analgesics; and
    2. Flexibility and muscle strengthening exercises, and
    3. Activity modification; and
    4. Supervised physical therapy within the past year (ADLs diminished despite completing a plan of care); and
    5. Intraarticular injections of steroids into the shoulder (optional); and
  3. Member's deltoid is intact; and
  4. Member’s joint must be anatomically and structurally suited to receive selected implants (i.e., adequate bone stock to allow for firm fixation of implant); and
  5. Member must have at least 90 degrees of passive shoulder range of motion (elevation/flexion); and
  6. Member does not have a condition that would place excessive stress on the implant (i.e., Charcot’ joint).
3. Shoulder hemiarthroplasty for adult members with the following indications:
  1. Rotator cuff tear arthropathy (severe rotator cuff tearing and end-stage arthritic disease); or
  2. Radiographic evidence of destructive degenerative joint disease from osteoarthritis or rheumatoid arthritis (as evidence by 2 or more of the following: irregular joint surfaces, glenoid sclerosis, osteophyte changes, flattened glenoid, cystic changes in the humeral head, or joint space narrowing) of shoulder joint); or
  3. Osteonecrosis without glenoid involvement; or
  4. Arthritic conditions in which the glenoid bone stock is inadequate to support a glenoid prosthesis; or
  5. Proximal humerus fracture not amenable to internal fixation;
  and who meet all of the following criteria:
  For members with significant conditions or co-morbidities, the risk/benefit of total shoulder arthroplasty, hemiarthroplasty, reverse shoulder arthroplasty, or shoulder arthroplasty revision or replacement should be appropriately addressed in the medical record.
4. Shoulder arthrodesis, for the following indications:
  1. Active tuberculosis or bacterial infection of the joint; or
  2. Brachial plexus palsy with flail shoulder; or
  3. Recurrent shoulder dislocation; or
  4. Resection of tumor; or
  5. Irreparable rotator cuff tears; or
  6. Failed total shoulder arthroplasty; or
  7. Paralytic disorders of infancy.
  Where member has advanced disease demonstrated by:
  1. Chronic, severe pain and functional disability that interferes with ADL; and
  2. Imaging evidence confirming the diagnosis; and
  3. History of of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the medical record (see Note). If conservative therapy is not appropriate, the medical record must clearly document why such approach is not. Note: Physical therapy needs to be confirmed either by the actual PT notes, or by documentation in the member claims history. Members with should have at least 12 weeks of non-surgical treatment documented in the medical record (24 weeks of non-surgical treatment for persons with relative contraindications of morbid obesity (BMI > 40) or age less than 50 years), with at least half of the necessary conservative therapy consisting of formal physical therapy, including all of the following, unless contraindicated or otherwise not appropriate:
    1. Anti-inflammatory medications or analgesics; and
    2. Activity modification; and
    3. Supervised physical therapy within the past year (ADLs diminished despite completing a plan of care); and
    4. Assistive device use, as appropriate.
  For members with significant conditions or co-morbidities, the risk/benefit of shoulder arthrodesis should be appropriately addressed in the medical record.
5. Revision or replacement of shoulder arthroplasty prosthesis for the following indications when accompanied by pain and functional disability (interference with ADL):
  1. Aseptic loosening of 1 or more prosthetic components confirmed by imaging, or
  2. Fracture of one or more components of the prosthesis confirmed by imaging, or
  3. Displaced peri-prosthetic fracture; or
  4. Progressive or substantial periprosthetic bone loss; or
  5. Bearing surface wear leading to symptomatic synovitis; or
  6. Confirmed peri-prosthetic infection by gram stain and culture, or
  7. Instability or dislocation of the glenoid or humeral components; or
  8. Migration of the humeral head; or
  9. Upon individual case review, persistent shoulder pain of unknown etiology not responsive to a period of non-surgical care for 6 months (with at least 2 months of formal physical therapy). Physical therapy needs to be confirmed either by the actual PT notes, or by documentation in the member claims history.
6. Aetna considers total shoulder arthroplasty, hemiarthroplasty, reverse shoulder arthroplasty or arthroplasty revision or replacement not medically necessary in persons with any of the following absolute contraindications:
  1. Active infection of the joint or active systemic bacteremia that has not been totally eradicated; or
  2. Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the shoulder; or
  3. Rapidly progressive neurological disease; or
  4. Allergy to components of the implant (e.g., cobalt, chromium or alumina).
Aetna considers total shoulder arthroplasty, shoulder hemiarthroplasty, reverse shoulder arthroplasty, and shoulder arthroplasty revision or replacement experimental and investigational for all other indications.
Experimental and Investigational
1. Total shoulder arthroplasty for ochronotic arthritis, and in persons with glenohumeral osteoarthritis who have an irreparable rotator cuff tear.
2. Total shoulder arthroplasty with a cage glenoid because its long-term effectiveness has not been established.
3. The following procedures are considered experimental and investigational because the effectiveness of the approach has not been established:
  1. Computer-assisted musculoskeletal surgical navigation for shoulder arthroplasty. Note: Robotic assistance is considered integral to the primary procedure and not separately reimbursed
  2. Custom instrumentation for the procedure including cutting blocks
  3. Custom joint implants
  4. Microfracturing of the shoulder
  5. Pre-operative advanced imaging that is required for any experimental and investigational procedure (e.g., where required for computer-assisted surgical navigation, robotic-assisted surgical navigation, or for customized patient implants and/or instrumentation)
  6. Subacromial balloon spacer for the treatment of rotator cuff tears
  7. Superior capsular reconstruction for the treatment of rotator cuff tears
  8. Three-dimensional pre-operative imaging for total shoulder arthroplasty
  9. Use of acellular dermal extracellular matrix for shoulder capsular reconstruction.
Policy Limitations and Exclusions

Note: Biceps tenodesis is considered integral to all shoulder arthroplasty surgery, and is not separately reimbursed.
Related CMS Coverage Guidance

This Clinical Policy Bulletin (CPB) supplements but does not replace, modify, or supersede existing Medicare Regulations or applicable National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The supplemental medical necessity criteria in this CPB further define those indications for services that are proven safe and effective where those indications are not fully established in applicable NCDs and LCDs. These supplemental medical necessity criteria are based upon evidence-based guidelines and clinical studies in the peer-reviewed published medical literature. The background section of this CPB includes an explanation of the rationale that supports adoption of the medical necessity criteria and a summary of evidence that was considered during the development of the CPB; the reference section includes a list of the sources of such evidence. While there is a possible risk of reduced or delayed care with any coverage criteria, Aetna believes that the benefits of these criteria – ensuring patients receive services that are appropriate, safe, and effective – substantially outweigh any clinical harms.

Code of Federal Regulations (CFR):

42 CFR 417; 42 CFR 422; 42 CFR 423.

Internet-Only Manual (IOM) Citations:

CMS IOM Publication 100-02, Medicare Benefit Policy Manual; CMS IOM Publication 100-03 Medicare National Coverage Determination Manual.

Medicare Coverage Determinations:

Centers for Medicare & Medicaid Services (CMS), Medicare Coverage Database [Internet]. Baltimore, MD: CMS; updated periodically. Available at: Medicare Coverage Center. Accessed November 7, 2023.
Related Policies
- CPB 0661 - Joint Resurfacing

Table:
Applicable CPT / HCPCS / ICD-10 Codes
Code	Code Description
CPT codes not covered for indications listed in the CPB:
Microfracturing of the shoulder, application of acellular dermal extracellular matrix - no specific code
*Total shoulder arthroplasty*:
CPT codes covered if selection criteria are met :
23472	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder) [not covered for those who have an irreparable rotator cuff tear]
CPT codes not covered for indications listed in the CPB:
Cage glenoid - no specific code
0054T	Computer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images
0055T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
20985	Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less
23430	Tenodesis of long tendon of biceps
29828	Arthroscopy, shoulder, surgical; biceps tenodesis
76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation
76377	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation
Other HCPCS codes related to the CPB:
73200 - 73202	Computed tomography, upper extremity; with or without contrast material
73218 - 73223	Magnetic resonance (e.g., proton) imaging, upper extremity
HCPCS codes covered if selection criteria are met :
Custom joint prosthetics- no specific code
C1776	Joint device (implantable)
HCPCS codes not covered if selection criteria are met:
Custom instrumentation for the procedure including cutting block -no specific code
ICD-10 codes covered if selection criteria are met :
C40.00 - C40.02	Malignant neoplasm of scapula and long bones of upper limb [malignancy of glenohumeral joint or surrounding soft tissue]
C49.10 - C49.12	Malignant neoplasm of connective and other soft tissue of upper limb, including shoulder [malignancy of glenohumeral joint or surrounding soft tissue]
C76.40 - C76.42	Malignant neoplasm of upper limb
M05.00 - M05.9	Rheumatoid arthritis
M12.511 - M12.519	Traumatic arthropathy, shoulder
M19.011 - M19.019	Osteoarthrosis, localized, primary, shoulder region [not covered for those who have an irreparable rotator cuff tear]
M19.111 - M19.119	Post-traumatic osteoarthritis, shoulder
M19.211 - M19.219	Osteoarthrosis, localized, secondary, shoulder region
M24.811 - M24.819	Other specific joint derangement of shoulder, not elsewhere classified [crepitus]
M87.021 - M87.029	Idiopathic aseptic necrosis of humerus [head]
S42.001+ - S42.199+ [7th character K or P]	Malunion or nonunion of fracture of shoulder
S42.201+ - S42.496+	Fracture of humerus
ICD-10 not covered for indications listed in the CPB:
M14.811 - M14.819	Arthropathies in other specified diseases classified elsewhere, shoulder [ochronotic arthritis]
M75.100 - M75.122	Unspecified rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic
*Reverse shoulder arthroplasty*:
CPT codes covered if selection criteria are met :
23472	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder) [reverse shoulder arthroplasty]
CPT codes not covered for indications listed in the CPB:
0054T	Computer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images
0055T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
20985	Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-less
HCPCS codes covered if selection criteria are met :
C1776	Joint device (implantable)
ICD-10 codes covered if selection criteria are met :
C40.00 - C40.02	Malignant neoplasm of scapula and long bones of upper limb [reconstruction after a tumor resection]
C43.60 - C43.62, D03.60 - D03.63	Malignant melanoma of skin of upper limb, including shoulder [reconstruction after a tumor resection]
C44.601 - C44.609	Unspecified malignant neoplasm of skin of lupper limb, including shoulder [reconstruction after a tumor resection]
C49.10 - C49.12	Malignant neoplasm of connective and other soft tissue of upper limb, including shoulder [reconstruction after a tumor resection]
C76.40 - C76.42	Malignant neoplasm of upper limb [reconstruction after a tumor resection]
M12.811 - M12.819	Other specified arthropathies NEC, shoulder [glenohumeral arthropathy]
M75.50 - M75.52	Bursitis of shoulder
M75.100 - M75.102	Unspecified rotator cuff tear or rupture of shoulder, not specified as traumatic [rotator cuff syndrome]
M75.110 - M75.112	Incomplete rotator cuff tear or rupture of shoulder, not specified as traumatic
M75.120 - M75.122	Complete rotator cuff tear or rupture of shoulder, not specified as traumatic
S42.201+ - S42.296+	Fracture of upper end of humerus
Z96.611 - Z96.619	Presence of artificial shoulder joint [failed hemiarthroplasty or failed total shoulder arthroplasty with failed rotator cuff that is nonrepairable]
*Shoulder Hemiarthroplasty*:
CPT codes covered if selection criteria are met :
23470	Arthroplasty, glenohumeral joint; hemiarthroplasty
CPT codes not covered for indications listed in the CPB:
0054T	Computer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images
0055T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
20985	Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-less
HCPCS codes covered if selection criteria are met :
C1776	Joint device (implantable)
ICD-10 codes covered if selection criteria are met :
M05.00 - M05.9	Rheumatoid arthritis
M12.511 - M12.519	Traumatic arthropathy, shoulder
M19.011 - M19.019	Osteoarthrosis, localized, primary, shoulder region
M19.111 - M19.119	Post-traumatic osteoarthritis, shoulder
M19.211 - M19.219	Osteoarthrosis, localized, secondary, shoulder region
M24.811 - M24.819	Other specific joint derangement of shoulder, not elsewhere classified [crepitus]
M75.80 - M75.82	Other shoulder lesions [Rotator cuff tear arthropathy with severe rotator cuff tearing]
M87.021 - M87.029	Idiopathic aseptic necrosis of humerus [head] [without glenoid involvement]
S42.001+ - S42.199+ [7th character K or P]	Malunion or nonunion of fracture of shoulder
S42.201+ - S42.496+	Fracture of humerus
*Revision or replacement of shoulder arthroplasty prosthesis*:
CPT codes covered if selection criteria are met :
23333	Removal of foreign body, shoulder; deep (subfascial or intramuscular)
23334	Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component
23335	Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)
23473 - 23474	Revision of total shoulder arthroplasty, including allograft when performed; humeral and/or glenoid component
CPT codes not covered for indications listed in the CPB:
0054T	Computer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images
0055T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
20985	Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-less
HCPCS codes covered if selection criteria are met :
C1776	Joint device (implantable)
ICD-10 codes covered if selection criteria are met :
M12.211 – M12.219	Villonodular synovitis (pigmented), shoulder
M65.111 – M65.119	Other infective (teno)synovitis, shoulder
M65.811 – M65.819	Other synovitis and tenosynovitis, shoulder
M67.311 – M67.319	Transient synovitis, shoulder
M97.31XA - M97.32XS	Periprosthetic fracture around internal prosthetic shoulder joint
S43.001+ - S43.086	Subluxation and dislocation of shoulder joint; anterior, posterior or inferior
T84.038+ - T84.039+	Mechanical loosening of prosthetic joint [shoulder]
T84.018+ - T84.019	Broken internal joint prosthesis [shoulder]
T84.038+ - T84.039+	Mechanical loosening of other internal prosthetic joint [shoulder]
T84.59x+	Infection and inflammatory reaction due to other internal joint prosthesis [shoulder]
*Shoulder arthrodesis*:
CPT codes covered if selection criteria are met :
23800	Arthrodesis, glenohumeral joint
23802	Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)
CPT codes not covered for indications listed in the CPB:
0054T	Computer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images
0055T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
20985	Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-less
ICD-10 codes covered if selection criteria are met :
A15.0 - A19.9	Tuberculous infection
A80.0 - A80.9	Acute poliomyelitis [paralytic disorders of infancy]
C40.00 - C40.02	Malignant neoplasm of scapula and long bones of upper limb [resection of tumor] [resection of tumor]
C49.10 - C49.12	Malignant neoplasm of connective and other soft tissue of upper limb, including shoulder [resection of tumor] [resection of tumor]
G54.0	Brachial plexus disorders [with flail shoulder]
G80.0 - G80.9	Cerebral palsy [paralytic disorders of infancy]
M75.120 - M75.122	Complete rotator cuff tear or rupture of shoulder, not specified as traumatic
P11.4, P11.9, P14.2, P14.8 - P14.9	Other cranial and peripheral nerve injuries due to birth trauma [paralytic disorders of infancy]
S43.001+ - S43.086	Subluxation and dislocation of shoulder joint [recurrent]
S43.421+ - S43.429+	Sprain of rotator cuff capsule
Z96.611 - Z96.619	Presence of artificial shoulder joint [failed total shoulder arthroplasty]
ICD-10 codes not covered for indications listed in the CPB:
A00.0 - B99.9	Certain infectious and parasitic diseases [active infection of the joint, active systemic bacteremia or active skin infection]
G20 - G21.9	Parkinson's disease [rapidly progressive neurological disease]
G56.80 - G56.83	Other mononeuritis of upper limb [rapidly progressive neurological disease]
G58.7	Mononeuritis multiplex [rapidly progressive neurological disease]
G61.0	Guillain-Barre syndrome [rapidly progressive neurological disease]
L08.0 - L08.9	Other local infections of skin and subcutaneous tissue [active skin infection]
T56.0X1A - T56.94xS	Toxic effect of metals
T78.49xA - T78.49xS	Other allergy [allergy to components of the implant (e.g., cobalt, chromium or alumina]
Subacromial balloon spacer and superior capsular reconstruction:
HCPCS codes not covered for indications listed in the CPB:
C9781	Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromioplasty, and biceps tenodesis when performed
ICD-10 codes not covered for indications listed in the CPB:
M75.100 - M75.102	Unspecified rotator cuff tear or rupture, not specified as traumatic
M75.110 - M75.112	Incomplete rotator cuff tear or rupture not specified as traumatic
M75.120 - M75.122	Complete rotator cuff tear or rupture not specified as traumatic

Background

Shoulder arthroplasty (also known as shoulder replacement surgery) was first carried out in the United States in the 1950s for the treatment of severe glenohumeral joint fractures. Over the years, shoulder arthroplasty has been employed for the treatment of many other painful conditions/diseases of the shoulder (e.g., various forms of arthritis). According to the Agency for Healthcare Research and Quality, approximately 53,000 people in the United States undergo shoulder arthroplasty each year. This compares to more than 900,000 Americans a year who have knee and hip arthroplasty. Shoulder arthroplasty should be considered if non-surgical treatments like medications as well as changes in activity are no longer helpful in relieving pain (American Academy of Orthopaedic Surgeons [AAOS], 2011).

Farmer et al (2007) stated that although outcomes of shoulder, hip, and knee arthroplasties have been well-described, there have been no studies directly comparing the outcomes of these procedures as treatments for osteoarthritis (OA). These investigators compared the inpatient mortality, complications, length of stay, and total charges of patients who had shoulder arthroplasty for OA with those of patients who had hip and knee arthroplasties for OA. A review of the Maryland Health Services Cost Review Commission discharge database identified 994 shoulder arthroplasties, 15,414 hip arthroplasties, and 34,471 knee arthroplasties performed for OA from 1994 to 2001. There were no in-hospital deaths after shoulder arthroplasty, whereas 27 (0.18 %) and 54 (0.16 %) deaths occurred after hip and knee arthroplasties, respectively. Compared with patients who had hip or knee arthroplasties, patients who had shoulder arthroplasties had, on average, a lower complication rate, a shorter length of stay, and fewer total charges. The latter had 1/2 as many in-hospital complications, were 1/6 as likely to have a length of stay 6 days or greater, and were 1/10 as likely to be charged more than $15,000. The authors believed shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties.

The American Academy of Orthopaedic Surgeons’ clinical practice guideline on “The treatment of glenohumeral joint osteoarthritis” (AAOS, 2009) provided the following recommendations:

The work group is unable to recommend for or against the use of injectable corticosteroids when treating patients with glenohumeral joint OA (Strength of the recommendation: Inconclusive)
The use of injectable viscosupplementation is an option when treating patients with glenohumeral joint OA (Strength of the recommendation: Weak)
The work group is unable to recommend for or against the use of arthroscopic treatments for patients with glenohumeral joint OA. These treatments include debridement, capsular release, chondroplasty, microfracture, removal of loose bodies, and biologic and interpositional grafts, subacromial decompression, distal clavicle resection, acromioclavicular joint resection, biceps tenotomy or tenodesis, and labral repair or advancement (Strength of recommendation: Inconclusive)
The work group is unable to recommend for or against open debridement and/or non-prosthetic or biologic interposition arthroplasty in patients with glenohumeral joint OA. These treatments include allograft, autograft, and biologic and inter-positional grafts (Strength of recommendation: Inconclusive)
Total shoulder arthroplasty (TSA) and hemiarthroplasty are options when treating patients with glenohumeral joint OA (Strength of recommendation: Weak)
The work group suggests TSA over hemiarthroplasty when treating patients with glenohumeral joint OA (Strength of Recommendation: Moderate)
In the absence of reliable evidence, it is the opinion of this work group that TSA not be performed in patients with glenohumeral OA who have an irreparable rotator-cuff tear (Strength of recommendation: Consensus)
The work group is unable to recommend for or against physical therapy following shoulder arthroplasty (Strength of recommendation: Inconclusive)

Izquierdo and colleagues (2010) noted that the AAOS’s clinical practice guideline was based on a systematic review of published studies on the treatment of glenohumeral OA in the adult patient population. Of the 16 recommendations addressed, 9 were inconclusive. Two were reached by consensus: physicians use peri-operative mechanical and/or chemical venous thromboembolism prophylaxis for shoulder arthroplasty patients and TSA should not be performed in patients with glenohumeral OA who have an irreparable rotator-cuff tear. Four options were graded as weak: the use of injectable viscosupplementation; TSA and hemiarthroplasty as treatment; avoiding shoulder arthroplasty by surgeons who perform fewer than 2 shoulder arthroplasties per year (to reduce the risk of immediate post-operative complications); and the use of keeled or pegged all-polyethylene cemented glenoid components. The single moderate-rated recommendation was for the use of TSA rather than hemiarthroplasty. The authors stated that management of glenohumeral OA remains controversial; the scientific evidence on this topic can be significantly improved.

In a prospective, randomized, double-blind clinical trial, Litchfield et al (2011) compared cemented and uncemented humeral fixation in TSA for primary shoulder OA. Patients with primary shoulder OA requiring replacement were screened for eligibility. After providing informed consent, subjects received baseline clinical and radiologic assessments, computed tomography scans, and standardized TSA. After glenoid component insertion, patients were randomized to either a cemented or uncemented humeral component. The primary outcome was the WOOS (Western Ontario Arthritis of the Shoulder Index) score at 2 years. Other outcomes included the Short Form 12 score, American Shoulder and Elbow Surgeons score, McMaster-Toronto Arthritis Patient Preference Disability Questionnaire, operative time, complications, and revisions. Patients were assessed by a blinded evaluator at 2 and 6 weeks and 3, 6, 12, 18, and 24 months post-operatively. A total of 161 patients consented to be included and were randomized: 80 in the cemented group and 81 in the uncemented group. There were no significant differences in demographics or baseline evaluations between groups, except for gender. The 12-, 18-, and 24-month WOOS scores showed a significant difference in favor of the cemented group. The cemented group also had better strength and forward flexion. As expected, the operative time was significantly less for the uncemented group. The authors concluded that these findings provided level I evidence that cemented fixation of the humeral component provides better quality of life, strength, and range of motion than uncemented fixation.

The American College of Occupational and Environmental Medicine’s occupational medicine practice guideline on “Evaluation and management of common health problems and functional recovery in workers” (ACOEM, 2011) provided the following recommendations:

Total shoulder arthroplasty for moderate-to-severe shoulder (glenohumeral and acromioclavicular joint) OA (B = Moderate evidence-base: At least 1 high-quality study or multiple lower-quality studies relevant to the topic and the working population)
Arthroplasty, most commonly hemiarthroplasty, for select patients with displaced proximal humeral fractures (I = Insufficient Evidence: Evidence is insufficient or irreconcilable)
Arthroplasty for osteonecrosis (I = Insufficient Evidence: Evidence is insufficient or irreconcilable)
Total shoulder arthroplasty is contraindicated in young patients

The AAOS (2011) stated that conditions that cause shoulder pain and disability, and lead patients to consider shoulder joint replacement surgery include:

Avascular necrosis (osteonecrosis)
Failed previous shoulder replacement surgery
Osteoarthritis
Post-traumatic arthritis
Rheumatoid arthritis
Rotator-cuff tear arthropathy
Severe fractures.

Sanchez-Sotelo (2011) stated that shoulder arthroplasty has been the subject of marked advances over the last few years. Modern implants provide a wide range of options, including resurfacing of the humeral head, anatomic hemiarthroplasty, TSA, reverse shoulder arthroplasty and trauma-specific implants for fractures and nonunions. Most humeral components achieve successful long-term fixation without bone cement. Cemented all-polyethylene glenoid components remain the standard for anatomic TSA. The results of shoulder arthroplasty vary depending on the underlying diagnosis, the condition of the soft-tissues, and the type of re-construction. Total shoulder arthroplasty seems to provide the best outcome for patients with OA and inflammatory arthropathy.

In a Cochrane review, Singh et al (2011) determined the benefits and harm of surgery for shoulder OA. These investigators performed a systematic review of clinical trials of adults with shoulder OA, comparing surgical techniques (TSA, hemiarthroplasty, implant type and fixation) to placebo, sham surgery, non-surgical modalities, and no treatment. They also reviewed trials that compared various surgical techniques, reporting patient-reported outcomes (pain, function, quality of life, etc.) or revision rates. They calculated the risk ratio for categorical outcomes and mean differences for continuous outcomes with 95 % confidence interval (CI). There were no controlled trials of surgery versus placebo or non-surgical interventions. A total of 7 studies with 238 patients were included. Two studies compared TSA to hemiarthroplasty (n = 88). Significantly worse scores on the 0 to 100 American Shoulder and Elbow Surgeons scale (mean difference, -10.05 at 24 to 34 months; 95 % CI: -18.97 to -1.13; p = 0.03) and a non-significant trend toward higher revision rate in hemiarthroplasty compared to TSA (relative risk 6.18; 95 % CI: 0.77 to 49.52; p = 0.09) were noted. With 1 study providing data (n = 41), no differences were noted between groups for pain scores (mean difference 7.8; 95 % CI: -5.33 to 20.93), quality of life on Medical Outcomes Study Short-Form 36 physical component summary (mean difference 0.80; 95 % CI: -6.63 to -8.23), and adverse events (relative risk 1.2; 95 % CI: 0.4 to 3.8). The authors concluded that TSA was associated with better shoulder function, with no other demonstrable clinical benefits compared to hemiarthroplasty. They stated that more studies are needed to compare clinical outcomes between them and comparing shoulder surgery to sham, placebo, and other non-surgical treatment options.

In a systematic review and meta-analysis, Carter and colleagues (2012) characterized the change in generic and shoulder-specific health-related quality-of-life (QOL) measures resulting from TSA. These investigators identified published studies reporting pre-operative and post-operative health-related QOL outcomes for patients receiving TSA. Health-related QOL measures were identified, and meta-analysis was used to calculate standardized mean differences (SMDs, reflective of the effect size) and 95 % CI for each scale. A total of 20 studies (1,576 TSA) met the inclusion criteria. Outcome measures were analyzed after an average post-operative follow-up duration of 3.7 +/- 2.2 years. The Short Form-36 demonstrated significant improvement in physical component summary scores (SMD = 0.7, p < 0.001) but not in mental component summary scores (SMD = 0.2, p = 0.37). Significant improvements were observed in the visual analog scale score for pain (SMD = -2.5, p < 0.001) and scores on 3 shoulder-specific measures: the Constant score (SMD = 2.7, p < 0.001), American Shoulder and Elbow Surgeons score (SMD = 2.9, p < 0.001), and Simple Shoulder Test (SMD = 2.3, p < 0.001). The authors concluded that TSA leads to significant improvements in scores for function and pain. Shoulder-specific measures of function consistently showed the greatest degree of improvement, with large effect sizes. They noted that TSA also leads to significant improvements in overall physical well-being, with a moderate-to-large effect size.

Singh et al (2012) evaluated the frequency of, and risk factors for, peri-prosthetic fractures during and following TSA. All adults treated with a primary TSA or humeral head replacement at the Mayo Clinic Medical Center from 1976 to 2008 were identified. Peri-prosthetic fractures were validated by medical record review. Univariate and multivariable-adjusted logistic regression analyses were used to assess the association of demographic factors (age, sex, and body mass index [BMI]), underlying diagnosis, implant fixation (cemented or uncemented), American Society of Anesthesiologists (ASA) class, and co-morbidity as assessed with the Deyo-Charlson index. The cohort consisted of 2,207 patients treated with a total of 2,588 primary TSA and 1,349 patients treated with 1,431 humeral head replacements. A total of 72 medical-record-confirmed peri-prosthetic fractures occurred in association with TSA. These consisted of 47 intra-operative fractures (40 humeral fractures, 5 glenoid fractures, and 2 fractures for which the site was unclear) and 25 post-operative fractures (20 humeral fractures, 3 glenoid fractures, and 2 fractures for which the site was unclear). There were 33 fractures associated with the humeral head replacements -- 15 were intra-operative (8 humeral fractures and 7 glenoid fractures), and 18 were post-operative (16 humeral fractures and 2 glenoid fractures). In the multivariable regression analysis of TSA, female sex (odds ratio [OR], 4.19; 95 % [CI]: 1.82 to 9.62; p < 0.001; a 2.4 % rate for women versus 0.6 % for men) and the underlying diagnosis (p = 0.04; post-traumatic arthritis: OR, 2.55; 95 % CI: 0.92 to 7.12) were associated with a significantly higher risk of intra-operative humeral fracture in general, and female sex was associated with the risk of intra-operative humeral shaft fracture (odds ratio [OR], infinity; p < 0.001). In combined analyses of all patients (treated with either TSA or humeral head replacement), a higher Deyo-Charlson index was significantly associated with an increased risk of post-operative peri-prosthetic humeral shaft fracture (OR, 1.27; 95 % CI: 1.11 to 1.45); p < 0.001), after adjusting for the type of surgery (TSA or humeral head replacement). The authors concluded that overall risk of peri-prosthetic fractures after TSA or humeral head replacement was low. Women had a significantly higher risk of intra-operative humeral shaft fracture. The underlying diagnosis (especially post-traumatic arthritis) was significantly associated with the risk of intra-operative humeral fracture, and co-morbidity was significantly associated with the risk of post-operative humeral shaft fracture.

The Swedish Orthopedic Institute (2012) states that “In most cases, someone who requires total-shoulder replacement has some form of arthritis. Arthritis can cause the person to suffer pain, stiffness and limited function. Beyond limited or painful mobility, night-time pain is a primary symptom of shoulder problems. While there are several types of arthritis, most shoulder-replacement patients have rheumatoid arthritis (chronic joint inflammation) or osteoarthritis (a degenerative joint disease)”.

An UpToDate review on “Glenohumeral osteoarthritis” (Anderson, 2012) states that “Repeat x-rays should be performed at 3 months to look for disease progression if the patient has lost significant range of motion and/or symptoms have been progressive despite the above measures. Surgical consultation can be considered if symptoms fail to improve significantly with 2 injections, stretching exercises, and time (6 to 12 months). The primary indication for surgery is pain that is unresponsive to medical management. The established surgical treatment for shoulder osteoarthritis is prosthetic replacement, except in very young patients where an arthroscopic debridement and removal of osteophytes might be attempted to delay the need for prosthetic replacement. The outcomes of this procedure, however, are unpredictable, and should be seen as a measure of last resort in patients otherwise unsuitable for replacement due to age or functional requirements …. Either hemiarthroplasty or total shoulder replacement (a more complicated and technically more difficult procedure) is performed, depending upon the condition of the glenoid. Both are associated with a high degree of success in the appropriate patients (greater than 72 to 90 %). Hemiarthroplasty results in less improvement in function compared with total shoulder arthroplasty, but does not differ with respect to benefit for pain, range of motion, quality of life or strength. Arthritis of the glenoid is responsible for continued pain and the need for revision arthroplasty in some patients who undergo initial hemiarthroplasty”.

An UpToDate review on “Osteonecrosis (avascular necrosis of bone)” (Jones, 2012) recommends that in patients with stage 4 osteonecrosis of the humeral head, and those who have less severe radiographic disease but continued symptoms, TSA is the treatment of choice.

Duquin et al (2012) reported the results and complications of unconstrained shoulder arthroplasty, one of several methods for treatment of proximal humeral fracture nonunions. From 1976 to 2007, a total of 67 patients underwent unconstrained shoulder arthroplasty for proximal humeral nonunion and were followed for more than 2 years. There were 49 women and 18 men with a mean age of 64 years and a mean duration of follow-up of 9 years (range of 2 to 30 years). The fracture type according to the Neer classification was 2-part in 36 patients, 3-part in 16, and 4-part in 15. Hemiarthroplasty was performed in 54 patients and TSA was done in the remaining 13. There were 33 excellent or satisfactory results according to the modified Neer rating. Tuberosity healing about the prosthesis occurred in 35 shoulders. The mean pain score improved from 8.3 pre-operatively to 4.1 at the time of follow-up (p < 0.001). The average active shoulder elevation and external rotation improved from 46^° and 26^° to 104^° and 50^° (p < 0.001). Shoulders with anatomic or nearly anatomic healing of the tuberosities had greater active elevation at the time of final follow-up (p = 0.02). There were 14 complications in 12 patients, with 12 re-operations including 5 revisions. Kaplan-Meier survivorship with revision as the end point was 97 % (95 % [CI]: 94.3 to 100) at 1 year and 9 3% (95 % CI: 88.0 to 99.2) at 5, 10, and 20 years. The authors concluded that shoulder arthroplasty decreases pain and improves function in patients with a proximal humeral nonunion. However, the overall results are satisfactory in less than half of the patients.

In a multi-center, retrospective study, Favard et al (2012) evaluated the rate of complications and the functional improvement with different types of shoulder arthroplasties after a minimum follow-up of 8 years. A total of 198 shoulders including 85 primary OA of the shoulder, 76 rotator-cuff tear arthropathies, 19 avascular necrosis, and 18 RA were included in this study. Arthroplasties included 104 anatomic TSA, 77 reverse arthroplasties and 17 hemiarthroplasties. Ten patients had their arthroplasty revised, and 134 patients with TSA were able to be present at the final follow-up or provide information on their case. Function was evaluated by the Constant-Murley score and loosening by standard radiographs. In the group with primary OA of the shoulder, there were 8 complications (11 %) including 6 (8.3 %) requiring implant revision. In the group of rotator-cuff arthropathies, there were 9 (14.7 %) complications including 4 (6.5 %) requiring implant revision. In the group with RA, there was 1 complication, and no surgical revision was necessary. There were no complications in the group with avascular necrosis. Glenoid migration occurred in 28.5 % of anatomic TSA, and 3.4 % of reverse arthroplasties. This difference was significant (p < 0.001). The Constant-Murley score was significantly improved in all etiologies. The authors concluded that glenohumeral arthropathies can be successfully treated by arthroplasty. Anatomic TSA was shown to be associated with a high-risk of glenoid loosening at radiographic follow-up, which makes us hesitate to use the cemented polyethylene implant, especially in young patients.

In a prospective, longitudinal study, Razmjou et al (2013) compared clinical and radiologic outcomes of TSA using 3 different prosthetic designs

the Neer II system,
the Bigliani-Flatow (BF), and
a stemless prosthesis, the Total Evolutive Shoulder System (TESS).

Patients with advanced OA of the glenohumeral joint who underwent TSA were followed up for 2 years. Four patient-oriented disability outcomes were used. The clinical data collected before surgery and at follow-up assessments during a 2-year period included active range of motion (ROM) in 6 directions and strength. Radiographic signs of glenoid and humeral component loosening were recorded. The incidence of humeral head subluxation was documented. A total of 74 patients completed the study. There was a significant improvement in the 4 disability measures, ROM, and strength at 2 years in all 3 groups (p < 0.0001). Active external rotation at 90^° abduction was statistically significantly lower in the Neer II group (p = 0.001). The incidence of lucent lines around the glenoid component was higher in the Neer II group (p = 0.0002). No statistically significant relationship was seen between type of prosthesis and patient satisfaction (p > 0.05). The authors concluded that the 3 types of TSA prostheses used in this study all provided significant improvement in pain and function and were associated with high patient satisfaction. The Neer II was associated with less active external rotation and more lucent lines.

Fevang et al (2012) evaluated function, pain, and QOL after shoulder arthroplasty in 4 diagnostic groups. Patients with shoulder arthroplasties registered in the Norwegian Arthroplasty Register from 1994 through 2008 were posted a questionnaire in 2010. A total of 1,107 patients with rheumatoid arthritis (RA), OA, acute fracture (AF), or fracture sequela (FS) returned completed forms (65 % response rate). The primary outcome measure was the Oxford shoulder score (OSS), which assesses symptoms and function experienced by the patient on a scale from 0 to 48. A secondary outcome measure was the EQ-5D, which assesses QOL. The patients completed a questionnaire concerning symptoms 1 month before surgery, and another concerning the month before they received the questionnaire. Patients with RA and OA had the best results with a mean improvement in OSS of 16 units, as opposed to 11 for FS patients. Both shoulder pain and function had improved substantially. The change in OSS for patients with AF was negative (-11), but similar end results were obtained for AF patients as for RA and OA patients. Quality of life had improved in patients with RA, OA, and FS. Good results in terms of pain relief and improved level of function were obtained after shoulder arthroplasty for patients with RA, OA, and-to a lesser degree-FS. A shoulder arthropathy had a major effect on QOL, and treatment with shoulder replacement substantially improved it.

The American Academy of Orthopedic Surgeons’ clinical practice guideline on “The treatment of glenohumeral joint osteoarthritis” (AAOS, 2009) provided the following: The work group is unable to recommend for or against open debridement and/or non-prosthetic or biologic interposition arthroplasty in patients with glenohumeral joint OA. These treatments include allograft, autograft, and biologic and inter-positional grafts (Strength of recommendation: Inconclusive).

Biological glenoid resurfacing with or without prosthetic humeral head replacement has been suggested as a means to avoid the potential complications of polyethylene use in younger patients with glenohumeral arthritis. A variety of biologic surfaces, including anterior capsule, autogenous fascia lata, and Achilles tendon allograft, have been used; however, there is little evidence in the peer-reviewed literature that these biological grafts can provide a durable bearing surface over time. Poor clinical outcomes related to persistent post-operative infection have also been reported (Elhassan et al, 2009).

The 2012 textbook Canale & Beaty: Campbell's Operative Orthopaedics comments that, as it has become clear that glenoid arthritis continues to be a long-term concern for patients undergoing isolated shoulder hemiarthroplasty, some authors have explored various types of glenoid resurfacing procedures, particularly for younger, higher-demand patients. These interposition techniques aim to allow the metal humeral head to articulate with a cushioning surface rather than with the native glenoid in an effort to minimize arthritic progression and subsequent pain. A high number of failures and poor outcomes have been reported using Achilles tendon allograft as a resurfacing material with hemiarthroplasty. Recently, lateral meniscal allografts have been used as an interposition material. Although joint space narrowing did occur, glenoid erosion did not progress, suggesting that the lateral meniscus may offer some protection against glenoid wear. While most interposition procedures have demonstrated early success, there are few long-term reports; therefore, further follow-up studies are necessary to better determine their ultimate outcomes.

According to the 2009 textbook DeLee: DeLee and Drez’s Orthopaedic Sports Medicine, biologic resurfacing of focal glenoid chondral lesions or glenoid arthritis is a viable alternative to total shoulder arthroplasty in the young patient. Focal glenoid lesions that fail arthroscopic techniques can be “covered” with a soft tissue graft. Hemiarthroplasty of the proximal humerus or a humeral resurfacing implant coupled with a biologically resurfaced glenoid alleviates many of the complications associated with glenoid component wear and loosening in young patients in short-term follow-up.

Elhassan et al (2009) reported that soft-tissue resurfacing of the glenoid, with arthroplasty of the humeral head, has been proposed as a viable treatment option for younger patients with symptomatic osteoarthritis of the shoulder. The purpose of their study was to evaluate their results with soft-tissue resurfacing of the glenoid in patients with glenohumeral arthritis who were less than 50 years of age, as there was concern that this type of procedure was leading to poor outcomes. Between 2000 and 2006, a total of 13 patients with an average age of 34 years underwent soft-tissue resurfacing of the glenoid and humeral head arthroplasty. Achilles tendon allograft was used in 11 patients; fascia lata autograft in 1; and anterior shoulder joint capsule in 1. Three patients had resurfacing of the humeral head with a stemless resurfacing implant, and 10 patients had a hemiarthroplasty. The patients were followed for a minimum of 2 years or until failure, and the duration of follow-up averaged 48 months. The results were graded with a visual analog pain scale, the subjective shoulder value, and the Constant and Murley score. Radiographic review was performed in order to determine the degree of joint space loss and glenoid erosion. Ten of the 13 patients required a revision total shoulder arthroplasty at a mean of 14 months (range of 6 to 34 months) post-operatively. The principal reasons for revision were persistent pain and a decreased range of motion. Radiographic evaluation at the time of the revision surgery demonstrated loss of joint space and glenoid erosion in all cases. At the revision surgery, the allograft was found to be absent, and thick scar tissue, which may have been a graft remnant, was found at the perimeter of the glenoid. Of the 3 patients who did not have a revision arthroplasty, 1 had good function, pain relief, and an improved range of motion; however, the post-operative course of the other 2 was complicated by infection. One of them had a salvage with early irrigation and debridement as well as intravenous antibiotics, whereas the other underwent resection arthroplasty because of persistent infection. The authors concluded, “soft-tissue resurfacing of the glenoid with an Achilles tendon allograft combined with humeral head arthroplasty is not a reliable method of treatment of glenohumeral arthritis in an active patient younger than 50 years of age, as the clinical outcome is poor. Moreover, no evidence indicated that the graft acts as a durable bearing surface”.

Krishnan and colleagues (2007) published the 2- to 15-year outcomes of 34 patients (36 shoulders) who were managed with biologic glenoid resurfacing and humeral head replacement either with cement (10 shoulders) or without cement (26 shoulders). The study group included 30 men and 4 women with an average age of 51years whose diagnoses included primary glenohumeral osteoarthritis (18 shoulders), post-reconstructive arthritis (12), post-traumatic arthritis (5), and osteonecrosis (1). Anterior capsule was used for 7 shoulders, autogenous fascia lata for 11, and Achilles tendon allograft for 18. The mean American Shoulder and Elbow Surgeons score was 39 points pre-operatively and 91 points at the time of the most recent follow-up. According to Neer's criteria, the result was excellent for 18 shoulders, satisfactory for 13, and unsatisfactory for 5. Glenoid erosion averaged 7.2 mm and appeared to stabilize at 5 years. There were no revisions for humeral component loosening. Complications included infection (2 patients), instability (3 patients), brachial plexitis (1 patient), and deep-vein thrombosis (1 patient). Factors that appeared to be associated with unsatisfactory results were the use of capsular tissue as the resurfacing material and infection.

The American Academy of Orthopaedic Surgeons' clinical practice guideline on “The treatment of glenohumeral joint osteoarthritis” (2014) stated that “In the absence of reliable evidence, it is the opinion of this work group that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear”. (Strength of Recommendation: Consensus)

Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures

Gupta et al (2015) compared the outcomes of open reduction and internal fixation (ORIF), closed reduction and percutaneous pinning, hemi-arthroplasty (HA), and reverse shoulder arthroplasty (RSA) for proximal humerus fractures (PHFs). The search was performed on September 9, 2012 using an explicit search algorithm in the following databases: Medline, SportDiscus, CINAHL, and Cochrane Central Register of Controlled Trials. Inclusion criteria were English language studies reporting clinical outcomes after surgical treatment of 3- or 4-part PHFs with a minimum of 1-year follow-up. Levels 1 to 4 studies were eligible for inclusion. Study methodological quality and bias was evaluated using the Modified Coleman Methodology Score. Two-proportion Z test and multi-variate linear regression analyses were used for group comparisons. Significantly better clinical outcomes were observed for ORIF over HA and RSA (American Shoulder and Elbow Score, Disabilities of Arm, Shoulder, and Hand, Constant) (p < 0.05). However, ORIF had a significantly higher re-operation rate versus HA and RSA (p < 0.001 for both). Comparing HA with RSA, there was no difference in any outcome measure. The rate of tuberosity nonunion was 15.4 % in the HA group. The authors concluded that there were more complications following closed reduction and percutaneous pinning versus ORIF, HA, and RSA (p < 0.05); ORIF for PHFs demonstrated better clinical outcome scores but with a significantly higher re-operation rate; HA and RSA were effective as well, but tuberosity nonunion remains a concern with HA.

Dezfuli et al (2016) noted that reverse total shoulder arthroplasty (RTSA) has been shown to be an effective treatment for PHF. These investigators evaluated outcomes of all patients with PHFs treated with RTSA as a primary procedure for acute PHF, a delayed primary procedure for symptomatic PHF malunion or nonunion, a revision procedure for failed PHF HA, or a revision procedure for failed ORIF. Patients who underwent RTSA for PHF were evaluated for active ROM and Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test-12, American Shoulder and Elbow Surgeons (ASES), University of California-Los Angeles (UCLA) shoulder rating scale, Constant, and 12-Item Short Form Health Survey scores. Scaption and external rotation (ER) strength were also assessed. Reverse total shoulder arthroplasty was performed in 49 patients with PHF; 13 patients underwent RTSA for acute PHF, 13 for malunion or nonunion, 12 for failed PHF HA, and 11 for failed PHF ORIF; ER ROM, SPADI, ASES, UCLA, and Constant scores achieved significance. The acute fracture group significantly out-performed the failed HA group in SPADI, ASES, and UCLA scores. The malunion/nonunion group significantly out-performed the failed HA group in ASES and UCLA scores. The acute fracture and malunion/nonunion groups each had significantly greater ER than the failed HA group. The authors concluded that RTSA is an effective treatment option for PHF as both a primary and a revision procedure. Primary RTSA out-performed RTSA done as a revision procedure; RTSA for acute PHF is comparable to RTSA for malunions and nonunions. These outcomes of revision RTSA for failed HA and ORIF are more promising than previously published.

Chalmers and Keener (2016) stated that since its introduction in the United States in 2003, RTSA has been used with increasingly frequency as surgeons have observed the remarkable improvement in pain, ROM, and function associated with this implant. Reverse total shoulder arthroplasty was initially used exclusively for elderly, low-demand individuals with end-stage rotator cuff tear arthropathy. However, RTSA is now being increasingly successfully employed for the management of irreparable rotator cuff tears, glenohumeral OA with an intact rotator cuff, acute PHFs, the sequelae of PHFs, neoplasms of the proximal humerus, inflammatory arthropathy, young patients as well as failed anatomic TSA and HA. The authors concluded that while long-term outcomes are pending, short- and mid-term follow-up results suggested that in experienced hands, RTSA may be a reasonable treatment for many previously difficult to treat pathologies within the shoulder.

Shannon et al (2016) evaluated the outcomes of patients with failed osteosynthesis who undergo salvage RTSA compared with patients undergoing primary RTSA for PHFs. These investigators retrospectively reviewed 18 patients who underwent primary RTSA for acute PHFs and 26 patients who underwent arthroplasty after failed ORIF between 2003 and 2013. Minimum follow-up was 2 years, with a mean follow-up of 3 years (range of 2.0 to 6.0). There are no statistically significant differences in clinical outcomes between the 2 cohorts in the ASES scores and in the most recent forward flexion or external rotation. The salvage RTSA cohort experienced a higher complication rate (8 %), including dislocation and aseptic loosening. The primary RTSA cohort had a 5 % complication rate, with 1 late prosthetic joint infection requiring re-operation. The authors concluded that although RTSA after failed ORIF has a higher rate of complications compared with acute RTSA, the revision and re-operation rate as well as clinical outcomes and shoulder function remained comparable. They noted that when a surgeon approaches these complex fractures in patients with poor underlying bone stock, the findings of this study supported acute arthroplasty or ORIF with the knowledge that salvage RTSA still has the potential to achieve good outcomes if osteosynthesis fails.

Torchia and colleagues (2019) stated that recent literature has shown that acute RTSA provided good outcomes in the treatment of displaced proximal humeral fractures, and there have also been recent studies showing that delayed RTSA can be successfully used for sequelae of proximal humeral fractures such as nonunion and malunion. In a meta-analysis, these researchers compared the outcomes of acute RTSA for fracture and delayed RTSA for fracture sequelae. They searched the Medline, Embase, and Cochrane Library databases, and included all studies reporting on RTSA for the treatment of proximal humeral fracture sequelae with a comparison group of acute RTSA or with no comparison group in adults with a mean age of greater than 65 years and at least 2 years of follow-up. These investigators calculated weighted MDs (WMD)s for ROM, SMDs for clinical outcome scores, and relative risks (RRs) for dichotomous outcomes. A total of 16 studies met the inclusion criteria, which comprised 322 patients undergoing RTSA for fracture sequelae. Of these studies, 4 were comparative (46 patients) whereas 12 were case series (276 patients). Among studies directly comparing acute versus delayed RTSA, no differences in forward flexion (p = 0.72), clinical outcome scores (p = 0.78), or all-cause re-operation (p = 0.92) were found between the 2 groups. Patients undergoing delayed RTSA achieved 6° more external rotation than those undergoing acute RTSA; this difference was significant (p = 0.01). The authors concluded that given the risks associated with surgery in the elderly population, consideration may be given to an initial trial of non-operative treatment in these patients, saving RTSA for those in whom non-operative treatment failed without compromising the ultimate outcome.

Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears

Lin and colleagues (2016). Stated that RTSA, which reverses the ball and socket of the shoulder joint, was designed as a solution for pseudo-paralysis and rotator cuff arthropathy (RCA).

Patzer and associates (2016) stated that therapeutic options for the treatment of irreparable rotator cuff tears are fluent, dependent on the patients' claims and demands and on the grade of the ongoing RCA. A partial rotator cuff reconstruction with sufficient tenolysis combined with interval slide techniques to restore the anterior and posterior force couple may be indicated if there is no fatty degeneration greater than grade-III of the rotator cuff muscles in a well-centered joint. The margin convergence technique with side-by-side adaptation of the tendon limbs may reduce the load on the reconstructed tendons. The role of the suprascapular nerve, which can probably be constricted by the retracted rotator cuff, and its therapy has not been completely clarified. When distinct symptoms are present, neurolysis may be reasonable. Tendon transfers can be indicated in a co-operative patient less than 65 years of age with a higher grade of muscular atrophy but without degenerative changes greater than grade-II according to Hamada with the loss of active external rotation (ER) but performable active flexion. For postero-superior tears the latissimus dorsi or recently the teres major tendon transfer to the rotator cuff footprint may be appropriate. For non-reconstructable antero-superior tears a partial transfer of the pectoralis major tendon is possible. Careful subacromial arthroscopic debridement (AD) combined with biceps tenotomy (BT) and a cautious or reversed decompression may reduce the pain temporarily without having an influence on active motion until with the loss of active elevation the indication for a RSA is reached.

Garofalo and co-workers (2016) stated that rupture of the anterior and middle deltoid muscle associated with RCA could result in a definitive loss of shoulder function. These investigators evaluated clinical outcomes after a concomitant RSA and deltoid repair under these circumstances. Between 2006 and 2012, a total of 18 consecutive patients with a mean age of 69.7 years, affected by massive irreparable rotator cuff tear (MIRCT) and associated dehiscence or rupture of anterior and middle deltoid muscle underwent this operation through a modified antero-superior approach; 4 patients referred a previous shoulder surgery and deltoid tear was iatrogenic. The other 14 cases had an attritional deltoid tears. The average follow-up was 64 months (range of 25 to 121 months). The mean active forward elevation (AFE) passed from a pre-operative mean of 53 ± 9.1 (range of 45 to 70) to 132.7 ± 11.6^° (85 to 155^°), active ER passed from a pre-operative mean value of 22.4 ± 3.6^° (range of 18 to 26) to an average of 33.7 ± 4.7^° (range of 30 to 40^°). Mean Constant score increased from 42 ± 6.1 (range of 31 to 51) pre-operatively to 72.3 ± 8.2 (range of 57 to 82) post-operatively. At final review, deltoid contour subjectively was satisfactory to all patients with no palpable defects. The authors concluded that RSA associated with a repair of deltoid tear could be a viable surgical option in cases of tear involving the anterior and middle deltoid associated with a RCA.

Virk and colleagues (2016) reviewed the current understanding of the role of RTSA for the management of irreparable rotator cuff tears without arthritis based on authors personal experience and available scientific literature. Reverse total shoulder arthroplasty is a constrained arthroplasty system that can allow the deltoid and remaining rotator cuff to substitute for the lost function of irreparable rotator cuff. Furthermore, the pain relief is consistent with often a dramatic improvement in patient comfort, shoulder function and stability. In patients with pseudo-paralysis of the shoulder without advanced arthritis, RTSA effectively restored forward elevation above the shoulder but may not dramatically improve ER or internal rotation (IR). However, due to concerns over implant longevity, caution has to be exercised when using RTSA for symptomatic irreparable rotator cuff tears with preserved AFE and in patients less than 65 years of age. The authors concluded that RTSA is a reasonable surgical option for irreparable rotator cuff repair without arthritis. However, caution should be exercised when offering RTSA to young patients and patient without pseudo-paralysis because they can have a higher complication and dissatisfaction rate. In addition, longevity of RTSA and subsequent need for revision surgery remains a significant concern in this population.

Thorsness and Romeo (2016) stated that compared with smaller tears, massive rotator cuff tears (MRCT) present significant clinical management dilemmas for the treating surgeon because they are often fraught with structural failure and poor outcomes. To optimize healing, current surgical methods look to optimize footprint coverage and enhance the biological environment for healing. Double-row techniques have demonstrated clear biomechanical advantages in controlled cadaveric studies, but have yet to demonstrate clear clinical effectiveness over more simple repair techniques. When repairs for MRCT fail, options include revision repair or superior capsular reconstruction, an option to bridge the tissue gap with human dermal allograft or fascia lata autograft in hopes of containing the humeral head from superior migration and precluding RCA. The authors stated that although latissimus transfers remain a reasonable option for MRCT in appropriately indicated patients, clinical results are often unpredictable. They noted that older patients with chronic, MRCT with pseudo-paralysis can achieve predictable, often excellent clinical results with a RTSA.

In a systematic review, Petrillo and colleagues (2017) reported the outcomes and complications of RSA in MIRCT and cuff tear arthropathy (CTA). These investigators performed a systematic review of the literature contained in Medline, Cochrane, Embase, Google Scholar and Ovid databases on May 1, 2016, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words "reverse total shoulder arthroplasty" or "reverse total shoulder prostheses" with "rotator cuff tears"; "failed rotator cuff surgery"; "massive rotator cuff tears"; "irreparable rotator cuff tears"; "cuff tear arthropathy"; "outcomes"; "complications" were matched. All articles reporting outcomes and complications of RSA for the management of MIRCT or CTA were included. The comparison between pre-operative and post-operative clinical scores, as well as ROM, was performed using the Wilcoxon-Mann-Whitney test; p values lower than 0.05 were considered statistically significant. A total of 7 articles were included in this qualitative synthesis. A statistically significant improvement in all clinical scores and ROM was found comparing the pre-operative value with the post-operative value. The degrees of retroversion of the humeral stem of the RSA did not influence the functional outcomes in a statistically significant fashion. There were 17.4 % of complications. The most frequent was heterotopic ossification, occurring in 6.6 % of patients. Revision surgery was necessary in 7.3 % of patients. The authors concluded that RSA restored pain-free ROM and improved function of the shoulder in patients with MIRCT or CTA. However, complications occurred in a high percentage of patients. They stated that the lack of level I studies limited the real understanding of the potentials and limitations of RSA for the management of MIRCT and CTA.

Sevivas and associates (2017) stated that MRCT are very large tears that are often associated with an uncertain prognosis. Indeed, some MRCT even without OA are considered irreparable, and non-anatomic solutions are needed to improve the patient's symptoms. Reverse shoulder arthroplasty is an option that can provide a more predictable pain relief and recovery of function. However, outcomes after RSA for irreparable MRCT (MIRCT) have not been well defined. In a systematic review with meta-analysis, these investigators reviewed the findings associated with the use of RSA in this subset of patients and analyzed the effect on patient functional status and pain. These researchers carried out a comprehensive search until October 2015 using Medline, Scopus, Cochrane Database of Systematic Reviews, and Central Register of Controlled Trials databases. Studies that assessed the outcomes of RSA in patients with MIRCT without OA (with at least 2 years of follow-up) were included. If the results of MIRCT without OA were not possible to subgroup, the study was excluded. Methodologic quality was assessed using the Coleman Methodology Score. Included were 6 studies (266 shoulders) with a follow-up ranging from 24 to 61.4 months. The mean Coleman Methodology Score was 58.2 ± 11.8 points. There was an overall improvement from pre-operative to post-operative assessments of the clinical score (Cohen d = 1.35, p < .001), forward flexion (d = 0.50, p = 0.009), ER (d = 0.40, p < 0.001), function (d = 1.04, p < 0.001), and pain (d = -0.89, p < 0.001). The authors concluded that patients with MIRCT without presence of OA have a high likelihood of achieving a painless shoulder and functional improvements after RSA.

Kang and co-workers (2017) noted that MIRCT cause significant shoulder pain and dysfunction. Physical therapy (PT), AD-BT, and hemi-arthroplasty (HA) are treatments shown to reduce pain and improve QOL. Reverse total shoulder arthroplasty is a newer surgical treatment option that may offer improved function. A cost-effectiveness analysis of these interventions has never been performed, and no head-to-head comparative effectiveness trials currently exist. In this study, a Markov decision analytic model was used to compare RTSA, HA, AD-BT, and PT as treatments for elderly patients with MIRCT. Probabilities for complications, peri-operative death, conversion procedures, and re-operations were derived from the literature, and costs were determined by average Medicare reimbursement rates from 2011. Reverse total shoulder arthroplasty yielded the most quality-adjusted life years (QALY) with 7.69, but greater benefits came at higher costs compared with other treatments. Sensitivity analyses showed that PT was the most cost-effective intervention at a health utility of 0.75 or greater (QALY 7.35). The health utility of RTSA was 0.72 or less (QALY 7.48) or RTSA probability of no complications was 0.83 or less (QALY 7.48 at cost of $23,830). Reverse total shoulder arthroplasty yielded benefits at a cost considered good value for money compared with other treatments. The authors concluded that RTSA is the preferred and most cost-effective therapeutic option for elderly patients with MIRCT. For patients seeking pain relief without functional gains, AD-BT can be considered a cost-effective and cheaper alternative.

Microfracturing of the Shoulder

Frank et al (2010) stated that microfracture is an effective surgical treatment for isolated, full-thickness cartilage defects with current data focused on applications in the knee. No studies describing clinical outcomes of patients who have undergone microfracture in the shoulder joint have been reported. These researchers hypothesized that treatment of glenohumeral joint articular defects using microfracture would demonstrate similar short-term clinical outcomes when compared with other joints. From March 2001 to August 2007, a total of 16 patients (17 shoulders) who underwent arthroscopic microfracture of the humeral head and/or glenoid surface were retrospectively reviewed. All patients were examined by an independent, blinded examiner and completed surveys containing the Simple Shoulder Test (SST), American Shoulder and Elbow Score (ASES), and visual analog scale (VAS). Two patients were lost to follow-up, for a follow-up rate of 88 %. Three patients went on to subsequent shoulder surgery and were considered to have failed results. The mean age was 37.0 years (range of 18 to 55 years) with an average follow-up of 27.8 months (range of 12.1 to 89.2 months). The average size of humeral and glenoid defects was 5.07 cm(2) (range of 1.0 to 7.84 cm(2)) and 1.66 cm(2) (range of 0.4 to 3.75 cm(2)), respectively. There was a statistically significant decrease from 5.6 +/- 1.7 to 1.9 +/- 1.4 (p < 0.01) in VAS after surgery as well as statistically significant improvements (p < 0.01) in SST (5.7 +/- 2.1 to 10.3 +/- 1.3) and ASES (44.3 +/- 15.3 to 86.3 +/- 10.5). Twelve (92.3 %) patients claimed they would have the procedure again. The authors concluded that microfracture of the glenohumeral joint provided a significant improvement in pain relief and shoulder function in patients with isolated, full-thickness chondral injuries. Moreover, they stated that longer-term studies are needed to determine if similar results are maintained over time.

Gross et al (2012) conducted a systematic review of clinical outcomes after cartilage restorative and reparative procedures in the glenohumeral joint, to identify prognostic factors that predict clinical outcomes, to provide treatment recommendations based on the best available evidence, and to highlight literature gaps that require future research. These investigators searched Medline (1948 to week 1 of February 2012) and Embase (1980 to week 5 of 2012) for studies evaluating the results of arthroscopic debridement, microfracture, osteochondral autograft or allograft transplants, and autologous chondrocyte implantation for glenohumeral chondral lesions. Other inclusion criteria included minimum 8 months' follow-up. The Oxford Level of Evidence Guidelines and Grading of Recommendations Assessment, Development and Evaluation (GRADE) recommendations were used to rate the quality of evidence and to make treatment recommendations. A total of 12 articles met the inclusion criteria, which resulted in a total of 315 patients; 6 articles pertained to arthroscopic debridement (n = 249), 3 to microfracture (n = 47), 2 to osteochondral autograft transplantation (n = 15), and 1 to autologous chondrocyte implantation (n = 5). Whereas most studies reported favorable results, sample heterogeneity and differences in the use of functional and radiographic outcomes precluded a meta-analysis. Several positive and negative prognostic factors were identified. All of the eligible studies were observational, retrospective case series without control groups; the quality of evidence available for the use of the aforementioned procedures is considered "very low" and "any estimate of effect is very uncertain". The authors concluded that more research is needed to determine which treatment for chondral pathology in the shoulder provides the best long-term outcomes. They encouraged centers to establish the necessary alliances to conduct blinded, randomized clinical trials and prospective, comparative cohort studies necessary to rigorously determine which treatments result in the most optimal outcomes. At this time, high-quality evidence is lacking to make strong recommendations, and decision-making in this patient population is performed on a case-by-case basis.

Milano and colleagues (2013) evaluated the effectiveness of a marrow-stimulating technique with microfractures of the greater tuberosity during arthroscopic rotator cuff repair. A total of 80 patients with a full-thickness rotator cuff tear underwent an arthroscopic single-row repair. Patients were divided into 2 groups of 40 cases each. In group 1, standard repair was performed; in group 2, microfractures of the greater tuberosity were performed to enhance tendon repair. Clinical outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score and normalized Constant score. Tendon integrity was assessed with magnetic resonance imaging. Multivariate analysis was performed to determine which predictors were independently associated with the outcome. Significance was set at p < 0.05. The mean follow-up was 28.1 ± 3 months; 7 patients were lost to follow-up (2 in group 1 and 5 in group 2). Comparison between groups did not show significant differences for baseline characteristics. The mean DASH score was 28.6 ± 21.3 points in group 1 and 23.3 ± 20.1 points in group 2. Although the difference was not statistically significant, the CI included a 10-point value (minimal clinically important difference) in favor of the microfracture group. The difference in the Constant score between groups was not significant. The tendon healing rate was 52.6 % in group 1 and 65.7 % in group 2, without a significant difference between groups. Subgroup analysis for tear size showed that group 2 had a significantly greater healing rate than group 1 for large tears (p = 0.040). Multivariate analysis showed that age, timing of symptoms, tear location, tendon retraction, and fatty infiltration significantly affected the outcomes. The authors concluded that post-operative magnetic resonance imaging did not show any significant difference between groups in structural integrity. However, subgroup analysis showed a significantly greater healing rate in the microfracture group for large tears involving the supraspinatus and infraspinatus.

The American Academy of Orthopaedic Surgeons (AAOS)’s clinical practice guideline on “The treatment of glenohumeral joint osteoarthritis” (2014) stated that “The work group is unable to recommend for or against the use of arthroscopic treatments for patients with glenohumeral joint osteoarthritis. These treatments include debridement, capsular release, chondroplasty, microfracture, removal of loose bodies, and biologic and interpositional grafts, subacromial decompression, distal clavicle resection, acromioclavicular joint resection, biceps tenotomy or tenodesis, and labral repair or advancement”.

Hunnebeck and colleagues (2017) noted that an increasing number of young patients are diagnosed with chondral lesions. Minimally invasive surgical techniques are important in order to delay progression of the early stages of OA and the need for total joint replacement. In this study, patients (n = 32) who had received microfracturing of the shoulder were retrospectively enrolled, of whom 5 had received shoulder replacements after a mean time of 47 months. Of these patients, 23 completed the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley Scores in addition to an additional subjective questionnaire. Patients were then clinically examined and received X-ray analysis of the operated shoulder. Data from an additional 4 patients were acquired by telephone interview. Mean follow-up was 105 months. Of the included patients, 13/27 patients reported no pain, 12/27 patients moderate pain. Of these 12, 6/27 reported pain only at night and 3/27 only during rest. Concerning the outcome of surgery, 19/27 patients were "satisfied" or "very satisfied". There was a statistically significant increase in internal rotation, but no further differences in the ROM pre- and post-operatively. Patients without any signs of OA before surgery showed statistically significantly better outcomes. There was a statistically significant increase in radiological signs of OA in pre- versus post-operative patients. Patients with bipolar lesions showed statistically significantly poorer subjective shoulder value (SSV) results. The authors concluded that although microfracturing did not prevent radiographic progression, microfracture of the glenohumeral joint might be worth considering as part of a treatment regimen for younger patients who may not yet be treated with arthroplasty.

Frehner and Benthien (2018) provided a literature review from 2010 to 2014 concerning the quality of evidence in clinical trials regarding microfracture in attempt to repair articular cartilage. These investigators focused on microfracturing, since this appeared to be the best documented technique. Interest in evaluation of publication quality has risen in orthopedic sports medicine recently. Thus, these researchers thought it was necessary to evaluate recent clinical trials being rated for their evidence-based medicine (EBM) quality. They also compared the mean impact factor of the journals publishing the different studies as an indicator of the study's citation and evaluated for a change over the studied time frame. To measure the EBM level, these investigators applied the modified Coleman Methodology Score (CMS) introduced by Jakobsen. The impact factor, which is a measurement of the yearly average number of citations of articles recently published in that journal, was evaluated according to self-reported values on the corresponding journal's website. They found that the mean CMS has not changed between 2010 and 2014. The mean impact factor has also not changed between 2010 and 2014. The CMS variance was high, pointing to different qualities in the evaluated studies. There was no evidence that microfracturing was superior compared to other cartilage repair procedures. The authors concluded that microfracture could not be seen as an evidence-based procedure. Moreover, they stated that further research is needed and a standardization of the operating method is desirable. Furthermore, there is a need for more substantial studies on microfracturing alone without additional therapies.

In a case-series study, Wang and associates (2018) presented long-term clinical outcomes of patients undergoing microfracture of full-thickness articular cartilage defects of the glenohumeral joint. A total of 16 consecutive patients (17 shoulders) were retrospectively reviewed who underwent arthroscopic microfracture of the humeral head and/or glenoid surface, with or without additional procedures between 2001 and 2008 and with a minimum follow-up of 8.5 years. All patients completed pre- and post-operative surveys containing the visual analog scale (VAS), American Shoulder and Elbow Surgeons form, and Simple Shoulder Test. Complications and re-operations were analyzed. Failure was defined by biological resurfacing or conversion to arthroplasty. Of the original 16 patients (17 shoulders), 13 patients (14 shoulders) were available for mean follow-up at 10.2 ± 1.8 years after microfracture (range of 8.5 to 15.8 years), for an overall clinical follow-up rate of 82 %. The patients (6 men, 7 women) were 36.1 ± 12.9 years old at time of microfracture. The average size of humeral head defects was 5.20 cm2 (range of 4.0 to 7.84 cm2), and the average size of glenoid defects was 1.53 cm2 (range of 1.0 to 3.75 cm2); 4 patients (4 shoulders) underwent at least 1 re-operation, and 3 were considered to have structural failures. The average time to failure was 3.7 years after microfracture (range of 0.2 to 9.6 years). The overall survival rate was 76.6 % at 9.6 years. For these patients, there were statistically significant improvements in VAS, Simple Shoulder Test, and American Shoulder and Elbow Surgeons scores as compared with pre-operative values at long-term follow-up (p < 0.05 for all), without any significant change from short-term (mean of 2.3 years) to long-term (mean of 10.2 years) follow-up. There was no significant difference in Single Assessment Numeric Evaluation or Short Form-12 Physical or Mental scores between short- and long-term follow-up. When compared with short-term follow-up, in which 2 patients had already failed, 1 additional patient progressed to failure at 9.6 years after the original microfracture; 2 patients (2 shoulders) were considered to have clinical failure. Owing to the overall number of failures (3 structural failure and 2 clinical failure), the total long-term success rate of glenohumeral microfracture is 66.7 % in the current study. The authors concluded that treating full-thickness symptomatic chondral defects of the glenohumeral joint with microfracture could result in long-term improved function and reduced pain for some patients. However, in this study, 21.4 % of patients needed conversion to arthroplasty less than 10 years after the index microfracture procedure, and 33 % to 42 % of patients were considered to have potential clinical failure. These investigators stated that additional studies with larger patient cohorts are needed. Level of Evidence = IV.

Furthermore, an UpToDate review on “Management of rotator cuff tears” (Marin and Martin, 2018) does not mention microfracture as a therapeutic option.

Use of Acellular Dermal Extracellular Matrix for Shoulder Capsular Reconstruction

Ely et al (2014) stated that despite advances in surgical techniques, 20 % to 90 % of rotator cuff (RC) repairs fail. They tend to fail at the suture-tendon junction due to tension at the repair and gap formation prior to healing. This study evaluated the gap formation and ultimate tensile failure loads of a RTC repair with a de-cellularized human dermal allograft. Augmentation of a RTC repair with an extracellular matrix graft decreased gap formation and increased load to failure in a human RC repair model.

Lee et al (2014) noted that acromio-clavicular (AC) separations are one of the most common shoulder injuries that may lead to pain, disability, and dysfunction of the shoulder girdle. Over 100 different surgical procedures have been described in the literature for the treatment of this injury. Initial surgical repairs were non-anatomic and non-biological. In recent years, allograft reconstruction has become accepted for the treatment of chronic separations, but most reconstructions are aimed at restoring the coraco-clavicular ligaments. Very little attention has been placed on the reconstruction of the AC joint itself. The technique described is an anatomic, biological reconstruction of the coraco-clavicular ligaments to restore stability in the vertical plane, and of the AC joint to restore stability in the horizontal plane.

Mirzayan et al (2015) stated that rupture of the distal bicep brachii tendon has received significant attention as a result of increased awareness of injury, numerous surgical fixation techniques, and debate regarding single versus dual incision surgery. The majority of ruptures may be fixed primarily. On rare occasion, the tendon may be attritionally thinned, or may not have the elasticity to be directly repaired back to the radial tuberosity. These investigators described a technique for using acellular dermal allograft to augment (not bridge) attritional distal biceps ruptures.

Gilot et al (2014) stated that despite advances in surgical technology, as well as generally good outcomes, repairs of full-thickness RC tears (RCTs) showed a re-tear rate of 25 % to 57 % and may fail to provide full return of function. The repairs tend to fail at the suture-tendon junction, which is due to several factors, including tension at the repair site, quality of the tendon, and defective tissue repair. One strategy to augment repair of large to massive RTC tears is the development of biological scaffold materials, composed of extra-cellular matrix (ECM). The goal was to strengthen and evenly distribute the mechanical load across the repair site, thus minimizing the rupture risk of the native tendon while providing the biological elements needed for healing. The promising results of ECM-derived materials and their commercial availability have increased their popularity among shoulder surgeons. In contrast to a traditional open or arthroscopically assisted mini-open approach, this completely arthroscopic technique offered the full advantages warranted by the use of a minimally invasive approach. This technical guide described arthroscopic RTC repair using an ECM graft technique.

Gilot et al (2015) compared the results of arthroscopic repair of large to massive RCTs with or without augmentation using an ECM graft and presented ECM graft augmentation as a valuable surgical alternative used for biomechanical reinforcement in any RCT repair. These investigators performed a prospective, blinded, single-center, comparative study of patients who underwent arthroscopic repair of a large to massive RCT with or without augmentation with ECM graft. The primary outcome was assessed by the presence or absence of a re-tear of the previously repaired RTC, as noted on ultrasound (US) examination. The secondary outcomes were patient satisfaction evaluated pre-operatively and post-operatively using the 12-item Short Form Health Survey, the American Shoulder and Elbow Surgeons shoulder outcome score, a visual analog scale score, the Western Ontario Rotator Cuff index, and a shoulder activity level survey. They enrolled 35 patients in the study: 20 in the ECM-augmented RC repair group and 15 in the control group. The follow-up period ranged from 22 to 26 months, with a mean of 24.9 months. There was a significant difference between the groups in terms of the incidence of re-tears: 26 % (4 re-tears) in the control group and 10 % (2 re-tears) in the ECM graft group (p = 0.0483). The mean pain level decreased from 6.9 to 4.1 in the control group and from 6.8 to 0.9 in the ECM graft group (p = 0.024). The American Shoulder and Elbow Surgeons score improved from 62.1 to 72.6 points in the control group and from 63.8 to 88.9 points (p = 0.02) in the treatment group. The mean Short Form 12 scores improved in the 2 groups, with a statistically significant difference favoring graft augmentation (p = 0.031), and correspondingly, the Western Ontario Rotator Cuff index scores improved in both arms, favoring the treatment group (p = 0.0412). The authors concluded that the use of ECM for augmentation of arthroscopic repairs of large to massive RCTs reduced the incidence of re-tears, improves patient outcome scores, and was a viable option during complicated cases in which a significant failure rate was anticipated. Level of Evidence = III. This was a small study (n = 20 in the ECM group) with shorter-term follow-up (mean of 24.9 months).

Levenda et al (2015) described an arthroscopic method specifically developed to augment RC repair using a flexible acellular dermal patch (ADP). In this method, an apparently complex technique is simplified by utilizing specific steps to augment a RC repair. In this method, using a revised arthroscopic technique, RC repair was performed. This technique allowed easy passage of the graft, excellent visualization, minimal soft tissue trauma, and full four-corner fixation of an ADP. A total of 12 patients underwent RC repair with augmentation using the combination of this method and ADP. Due to the technique and biomechanical characteristics of the material, the repairs have been stable and with high patient satisfaction. The authors concluded that these clinical results should be considered with the limitations of an informal case series. Moreover, they stated that while further long-term study and the larger patient base are needed to have significance, these short-term (1-year) results demonstrated favorable outcomes especially in patients with an increased risk of failure.

Katthagen et al (2016) noted that the superior capsule reconstruction (SCR) is a novel therapeutic option for massive, irreparable postero-superior RCTs. Treatment goals of such tears are to reduce pain, restore shoulder function and delay the development of advanced cuff tear arthropathy. Current non-prosthetic treatment options include debridement and partial RC repair, bridging RC reconstruction with a graft and latissimus dorsi transfer, although each has different factors which limit their clinical application. Superior capsule reconstruction is a promising alternative treatment for irreparable postero-superior RCT. It utilized a graft from the superior glenoid to the greater tuberosity to stabilize the humeral head. In a study by Mihata and colleagues of 23 patients who underwent SCR with a fascia lata autograft at a minimum of 2 years follow-up, the American Shoulder and Elbow Surgeons (ASES) score improved significantly from 23.5 pre-operatively to 92.9. Post-operative MRI showed 83 % of patients had intact reconstructions with no progression of muscle atrophy. The authors concluded that from their early results, pain relief has been dramatic and they believed the inter-position effect of the graft may also play a role in decreasing pain. They stated that patient selection and long-term benefits need to be investigated in further clinical trials.

Petri et al (2016) evaluated minimum 2-year clinical outcomes after open revision biologic patch augmentation in patients with massive RC re-tears who had deficient RC tendons with healthy RC muscles. Patients with massive postero-superior RC re-tears who underwent open revision RC repair with patch augmentation were identified from a surgical registry. Outcomes data collected included American Shoulder and Elbow Surgeons; Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary scores along with post-operative patient satisfaction, and activity modification. There were 10 men and 2 women (13 shoulders, 1 bilateral) with a mean age of 57 years (range of 26 to 68 years). All patients had at least 1 prior arthroscopic RC repair. After patch augmentation, there were no complications, no adverse reactions to the patch, and no patients required further surgery; 1 patient (7.7 %) with 4 prior cuff repairs had a documented postero-superior re-tear on MRI 2 months after repair. Minimum 2-year outcome scores were available for 12 of 13 (92.3 %) shoulders after a mean follow-up period of 2.5 years (range of 2.0 to 4.0 years). The ASES score improved by 21.5 points. Although the pain component of the ASES score and the total ASES score did not improve significantly, the function component of the ASES score improved significantly when compared with their pre-operative baselines (p < 0.05). Median patient satisfaction at final follow-up was 9/10 (range of 2 to 10). The authors concluded that biologic patch augmentation with human acellular dermal allograft was a safe and effective treatment method for patients with massive RC re-tears with deficient postero-superior RC tendons in the presence of healthy RC muscles. Level of Evidence = IV. This was a small study (n = 12) with short-term follow-up (mean of mean of 2.5 years).

Hirahara et al (2017) noted that SCR is performed to reduce the pain and disability caused by irreparable supraspinatus RCTs. These investigators discussed 9 cases of irreparable RCT managed with arthroscopic SCR with dermal allograft. At minimum 2-year follow-up (mean of 32.38 months), the patients were prospectively evaluated on the ASES shoulder index, a VAS for pain, acromial-humeral distance, and US. Patients were compared before and after surgery and against historical controls who underwent repair of massive RCTs. From before surgery to 2 years after surgery, mean ASES score improved significantly (p < 0.00002), from 43.54 to 86.46, and mean VAS pain score decreased significantly (p < 0.00002), from 6.25 to 0.38. For the historical controls at final follow-up, mean ASES score was 70.71 (p = 0.11), and mean VAS pain score was 3.00 (p < 0.05). Mean acromial-humeral distance improved from 4.50 mm before surgery to 8.48 mm immediately after surgery (p < 0.0008) and 7.60 mm 2 years after surgery (p < 0.05). Ultrasonography revealed pulsatile vessels within the allograft tissue between 4 and 8 months after surgery; 1 patient underwent reverse total shoulder arthroplasty (RTSA) for anterior escape; another had the graft rupture after a motor vehicle accident. The authors concluded that these findings showed SCR with dermal allograft effectively restored the superior restraints in the glenohumeral joint and yielded outstanding clinical outcomes even after 2 years, making it an excellent viable alternative to RTSA. This was a small study (n = 9) with short-to mid-term follow-up (mean of mean of 32.38 months).

Hartzler and Burkhart (2017) stated that SCR of the shoulder has recently gained popularity as an option for joint-preserving shoulder surgery for patients with an irreparable RCT. In the absence of glenohumeral arthritis, RCT irreparability should only be diagnosed for most patients after a careful diagnostic arthroscopy. Superior capsular reconstruction adds biological, passive, superior constraint to the glenohumeral joint, thereby optimizing the RC force couples and improving joint kinematics. At short-term follow-up, SCR has been shown to be effective for pain relief and restoration of active shoulder motion, even in the worst cases of shoulder dysfunction (true shoulder pseudo-paralysis). The rapid early adoption and expansion of SCR is justified by its excellent anatomical, biomechanical, and short-term clinical results. The techniques for arthroscopic SCR using dermal allograft continue to improve; however, the operation remains technically demanding. Patients with risk factors for irreparability and who might benefit from reconstruction of the superior capsule should be counseled about the operation as an additional, joint-preserving procedure that can be done in conjunction with arthroscopic, partial RC repair.

In a retrospective, case-series study, Pennington et al (2018) reported the findings of 88 consecutive shoulders with irreparable RCT that they treated with arthroscopic SCR using an acellular dermal allograft. These researchers also presented the concept of superior capsular distance to quantitatively measure the decreased distance present upon restoration of superior capsular integrity. A retrospective review was conducted of patients treated with arthroscopic SCR with a minimum 12-month follow-up. Outcome analysis was performed via an internet-based outcome-tracking system to evaluate VAS and ASES scores. Radiographic analysis of antero-posterior radiographs analyzed acromio-humeral interval and superior capsular distance. Digital dynamometric strength and functional range of motion (ROM) assessments were also obtained. The main inclusion criteria for patients in this analysis was all patients who underwent SCR during the time period of this report. A total of 86 patients with an average age of 59.4 years presented with massive RCT (Cofield greater than 5 cm). Outcome data revealed improvement in VAS (4.0 to 1.5), and ASES (52 to 82) scores at 1 year (p = 0.005). Radiographic analysis showed increase in acromio-humeral interval (mean of 7.1 mm pre-operatively to mean of 9.7 mm at 1 year) (p = 0.049) and superior capsular distance (mean of 52.9 mm pre-operatively to mean of 46.2 mm at 1 year) (p = 0.011). Strength improved significantly (forward flexion/abduction/external rotation of 4.8/4.1/7.7 lb pre-operatively to 9.8/9.2/12.3 lb at 1 year) as well as ROM (forward flexion/abduction of 120°/103° pre-operatively to 160°/159° at 1 year) (p = 0.044/p = 0.007/p = 0.02). At follow-up, 90 % of patients were satisfied. The authors concluded that this analysis revealed that arthroscopic SCR with acellular dermal allograft had been successful in decreasing pain and improving function in this patient subset. Radiographic analysis has also shown a consistent and lasting decrease in superior capsular distance and increase in acromio-humeral interval, indicating maintenance of superior capsular stability. Level of Evidence = IV.

In summary, there is insufficient evidence to support the use of acellular dermal extracellular matrix for shoulder capsular reconstruction. Available data are mainly case-series studies with short-term follow-up.

Rehabilitation Following Anatomic and Reverse Shoulder Arthroplasty

Bullock and colleagues (2019) noted that TSA is indicated for patients with glenohumeral arthritis. In this procedure, the humeral head and glenoid surface are replaced with prosthetic components. Reverse total shoulder arthroplasty is indicated for patients with glenohumeral arthritis and a poorly functioning rotator cuff. In this procedure, a glenosphere articulates with a humerosocket. While those surgeries are commonly performed, a thorough review of the literature is needed to determine the areas of agreement and variations in post-operative rehabilitation. These researchers described the literature on rehabilitation protocols following anatomic TSA and RTSA. They carried out a computerized search in medical databases from inception to May 21, 2018 for relevant descriptive studies on TSA and RTSA rehabilitation protocols. The methodological index for non-randomized studies tool and the modified Downs and Black tool for randomized controlled trials were used for assessment of the individual studies. A total of 16 studies met the inclusion criteria, of which 1 provided level I evidence, 1 provided level III evidence, 2 provided level IV evidence, and 12 provided level V evidence; 10 of the studies described rehabilitation guidelines for TSA and 6 described those for RTSA. Following TSA, the use of a sling was recommended for a duration that varied from 3 to 8 weeks, and 4 of the 10 published protocols included resisted exercise during the initial stage of healing (the first 6 weeks after surgery); 7 of 10 published protocols recommended limiting shoulder external rotation to 30° and that passive ROM be fully restored by 12 weeks post-surgery. Suggested use of a sling post RTSA varied from "for comfort only" to 6 weeks, motion parameters varied from no passive ROM to precautionary range limits, and all protocols agreed on performing deltoid isometric exercises early post-surgery. There was a high level of heterogeneity for the rehabilitation guidelines and associated precautions for both TSA and RTSA. The authors concluded that the majority of published protocols were descriptive in nature. Published rehabilitation strategies following TSA and RTSA were based on biomechanical principles, healing time frames, and exercise loading principles, with little consistency among protocols. These researchers stated that there is a need to determine optimal rehabilitation approaches following TSA and RTSA based on clinical outcomes. Level of Evidence = V.

Total Shoulder Arthroplasty for Ochronotic Arthritis

Dorleijn and colleagues (2019) noted that alkaptonuria is a rare inherited autosomal recessive disorder resulting in large joint OA with black discoloration of the cartilage. The glenohumeral is the 3rd most affected joint. These investigators reported the findings of 2 cases of ochronotic shoulder arthropathy with 3 shoulder joint replacements. Stemless shoulder arthroplasty was implanted with moderate-to-good results up to 2 years follow-up regarding pain and ROM. These researchers stated that longer follow-up is needed to evaluate mid-term follow-up in this specific patient group.

Total Shoulder Arthroplasty with a Cage Glenoid

Grey and associates (2015) examined the preliminary outcomes of a hybrid cage glenoid design in comparison to pegged all-polyethylene glenoid components in anatomic TSA (aTSA). A total of 92 patients undergoing primary aTSA with minimum 2-year follow-up were reviewed; 46 patients had an ultra-high molecular weight polyethylene (UHMWPE) cemented pegged glenoid component, and 46 had a hybrid cage glenoid component. Patient data were retrospectively reviewed from prospectively acquired data in a multi-center institutional review board (IRB) approved database. These age, gender, and follow-up matched patients were evaluated and scored pre-operatively and a latest follow-up using the SST, UCLA, ASES, Constant, and SPADI scoring metrics. Additional measures included active abduction, elevation, and external rotation. Radiolucent line assessment of the glenoid was performed by use of a Grashey and axillary radiograph at latest follow-up. A Student's 2-tailed, unpaired t-test was used to identify differences in pre-operative and post-operative results, where p < 0.05 denoted a significant difference. All patients demonstrated significant improvements in pain and function following treatment with the primary aTSA. The database contained 3 complications for the aTSA patients with a cage glenoid, and 3 complications for patients with a UHMWPE pegged glenoid. Radiographic data was available for 37 of 46 cage glenoid patients and 29 of 46 UHMWPE pegged glenoid patients; 5 of 37 cage glenoid patients had a radiolucent line (13.5 %) with an average radiographic line score of 0.22; 8 of 29 UHMWPE peg glenoid patients had a radiolucent line (27.6 %) with an average radiographic line score of 0.57. Cage aTSA patients were associated with significantly less blood loss than aTSA UHMWPE pegged glenoid patients (average blood loss = 242 versus 337 ml; p = 0.022). The authors concluded that at minimum 2-year follow-up, hybrid cage aTSA components showed equal clinical outcomes to UHMWPE pegged glenoids. However, the hybrid cage components had significantly fewer radiolucent lines and less intra-operative blood loss. Moreover, these researchers stated that additional and longer-term clinical and radiographic follow-up is needed to confirm these early findings.

Friedman and colleagues (2019) reported the clinical and radiographic outcomes of a hybrid cage glenoid compared with an age-matched, sex-matched, and follow-up-matched cohort of cemented all-polyethylene peg glenoids in patients undergoing aTSA with 2 years' minimum follow-up. These investigators reviewed 632 primary aTSA patients from an international multi-institutional database; 316 patients received hybrid cage glenoids and were matched for age, sex, and follow-up with 316 patients with cemented all-polyethylene peg glenoids. Each cohort received the same humeral component. Scoring was performed in all patients pre-operatively and at latest follow-up using 5 outcome scoring metrics and 4 active ROM measurements. A Student 2-tailed unpaired t-test identified differences in outcomes; p < 0.05 denoted a significant difference. Cage glenoid patients had significantly lower rates of radiolucent glenoid lines (9.0 % versus 37.6 %, p < 0.0001) and radiolucent humeral lines (3.0 % versus 9.1 %, p = 0.0088) than all-polyethylene peg glenoid patients. In the cage glenoid cohort, 4 cases of aseptic glenoid loosening (1.3 %) and 4 cases of articular surface dissociation (1.3 %) occurred. In the all-polyethylene peg cohort, 12 cases of aseptic loosening (3.8 %) occurred. Cage glenoid patients had a significantly lower revision rate than all-polyethylene peg glenoid patients (2.5 % versus 6.9 %, p = 0.0088). The authors concluded that at a mean 50-month follow-up, cage glenoids demonstrated equally good clinical outcomes to all-polyethylene peg glenoids. Cage glenoids had significantly fewer radiolucent lines around both the glenoid and humeral components and a lower revision rate. Moreover, these researchers stated that longer-term follow-up is needed to confirm these promising, short-term results.

Reverse Total Shoulder Arthroplasty for Oncologic Reconstruction of the Proximal Humerus

Trovarelli and co-workers (2019) noted that after proximal humerus resection for bone tumors, restoring anatomy and shoulder function remains demanding because muscles and bone are removed to obtain tumor-free surgical margins. Current modes of reconstruction such as anatomic modular prostheses, osteoarticular allografts, or allograft-prosthetic composites and arthrodeses are associated with relatively poor shoulder function related to loss of the deltoid and rotator cuff muscles. Newer prosthetic designs like the (RTSA are felt to be useful in other reconstructions where rotator cuff function is compromised; thus, it appeared logical that it might help in tumor reconstructions in patients where the deltoid muscle and its innervation can be preserved. In a retrospective, non-randomized, study, these researchers examined complications that are associated with tumor resection and reconstruction with a modular RTSA as well as the functional results of modular RTSA in these patients. From January 2011 to January 2018, these investigators treated 52 patients for bone tumors of the proximal humerus. Of these, 3 patients were treated with fore-quarter amputation, 14 were treated with standard modular proximal humerus implants, 7 were treated with allograft-prosthetic composites (RTSA-APC), and 28 were treated with a modular RTSA. In general, they used anatomic modular prosthetic reconstruction if during the tumor resection none of the abductor mechanism could be spared. On the other hand, they preferred reconstruction with RTSA if an innervated deltoid muscle could be spared, but the rotator cuff and capsule could not, using RTSA-APC or modular RTSA if humeral osteotomy was distal or proximal to deltoid insertion, respectively. In this study, these researchers retrospectively analyzed only patients treated with modular RTSA after proximal humerus resection. They excluded 3 patients treated with modular RTSA as revision procedures after mechanical failure of previous biological reconstructions and 3 patients treated after December 2016 to obtain an expected minimum follow-up of 2 years. There were 9 men and 13 women, with a mean (range) age of 55 years (18 to 71). Reconstruction was carried out in all patients using silver-coated modular RTSA protheses. Patients were clinically checked according to oncologic protocol. Complications and function were evaluated at final follow-up by the treating surgeon and shoulder surgeon. Complications were evaluated according to Henderson classification. Functional results were assessed with the Musculoskeletal Tumor Society (MSTS) score (range of 0 points to 30 points), Constant-Murley score (range 0 to 100), and American Shoulder and Elbow Surgeons score (range of 0 to 100); statistical analysis was carried out using Kaplan-Meier curves. Complications occurred in 5 of 22 patients; there was a shoulder dislocation (Type I) in 4 patients and aseptic loosening (Type II) in 1. Function in these patients on the outcomes scales was generally satisfactory; the mean MSTS score was 29, the mean Constant score was 61, and the mean American Shoulder and Elbow Surgeons score was 81. The authors concluded that although this was a small series of patients with heterogeneous diagnoses and resection types, and these investigators were unable to directly compare the results of this procedure with those of other available reconstructions, they found patients treated with RTSA achieved reasonable shoulder function after resection and reconstruction of a proximal humerus tumor. It may not be valuable in all tumor resections, but in patients in whom the deltoid can be partly spared, this procedure appeared to reasonably restore short-term shoulder function. Moreover, these researchers stated that future larger studies with longer follow-up are needed to confirm these promising preliminary findings. Level of Evidence = IV.

The authors stated that this study had several drawbacks. First, this was a retrospective, non-randomized patient series with potential selection biases. The authors used the modular RTSA after proximal humerus resection only when it is possible to preserve the deltoid muscle and the axillary nerve. Avoiding this reconstruction in larger resections when the surgeon cannot spare an innervated deltoid muscle to obtain oncologically correct margins may result in functional outcomes that look better than if RTSA had been used unselectively. However, these researchers thought that if none of the abductor mechanism can be spared, the reconstruction would act only as a “spacer” to preserve function of the elbow, wrist, and hand; and it would not require a more expensive option such as RTSA. Second, these investigators carried out this reconstruction both in patients with metastatic disease who have potentially poor prognosis and in patients with primary bone tumors. This resulted in a very heterogeneous population, but this is not unexpected considering the rarity of the pathology treated. Consequently, since the patients’ diagnoses were heterogeneous, a survival analysis was precluded. However, analysis of patient survival was not an objective of this study since difference in survival between primary and secondary tumors is not related to the type of reconstructions but with the different biological aggressiveness of the tumors. Considering good functional results and QOL, the authors thought that patients with metastatic disease and poor prognosis, especially those expected to survive longer than 1 year, should also be offered the opportunity for a functional reconstructive option. Third, these researchers presented results only at short-term; however, insofar as their principal objective was to describe early complications, they believed their follow-up duration was sufficient. These investigators stated that future studies are needed to examine reconstructive durability. Dislocation was the most frequent complication and occurred primarily in the immediate post-operative period, but complications at longer term could not be assessed in this study and may yet prove to be important; therefore, further studies are needed to evaluate long-term complications and function.

Ayvaz and associates (2020) stated that the treatment of proximal humerus tumors with endoprostheses is associated with a high risk of implant-related surgical complications. Because of extensive soft-tissue resection and muscular detachment during surgery, instability is the most common serious complication. A RTSA with a highly constrained design is one option to mitigate instability, but few studies have reported the results of this prosthesis for proximal humerus tumor resections. These investigators examined the short-term functional results of the constrained RTSA in terms of MSTS, DASH, and Constant-Murley scores and ROM values. They also examined the frequency of revision, using a competing-risks estimator to evaluate implant survival, the causes of the revisions that occurred, and the proportion of patients who experienced dislocations at short-term follow-up. Between January 2014 and June 2017, these researchers treated 55 patients with proximal humeral resections and reconstructions for malignant tumors. Of those, 18 (33 %) of patients were treated with the constrained, RTSA implant. During that period, no other constrained RTSA implant was used; however, 7 (13 %) of patients were treated with conventional (unconstrained) RTSA implants, 15 (27 %) had hemiarthroplasties, 8 (15 %) of patients had biologic reconstructions with auto- or allo-grafts and 7 (13 %) underwent amputation. During the period in question, the general indications for use of the constrained device under study were resection of the deltoid muscle/axillary nerve or the deltoid insertion on the humerus due to tumor invasion, or extensive rotator cuff and surrounding soft tissue resection that might result in shoulder instability. During this period, these indications were adhered to consistently; 4 of 18 patients treated with the study implant died (3 died with the implant intact) and none was lost to follow-up before 2 years, leaving 14 patients (7 women and 7 men) for study at a median (range) follow-up of 35 months (25 to 65). Two authors examined the clinical and functional status of each patient with ROM (flexion, extension, internal and external rotation, abduction, and adduction) and MSTS, (range of 0 % to 100 %), Constant-Murley (range of 0 % to 100 %), and DASH (range of 0 points to 100 points) scores. For the MSTS and Constant-Murley scores, higher percentage scores meant better functional outcome; and for the DASH score, a higher score meant more severe disability. Radiographs were obtained at each visit and were used to detect signs of loosening, which these investigators defined as progressive radiolucencies between visits, prosthetic component migration, and fragmentation/fracture of the cement. The Sirveaux classification was used to determine scapular notching. A competing risks analysis with 95 % CIs was carried out to estimate the cumulative incidence of revision surgery, which these researchers defined as any re-operation in which the implant was removed or changed for any reason, with patient mortality as a competing event. At the most recent follow-up, the median (range) MSTS score was 78 % (50 to 90), the DASH score was 20 (8 to 65), and the Constant-Murley score was 53 % (26 to 83). The median ROM was 75° in forward flexion (40 to 160), 78° in abduction (30 to 150), 35° in internal rotation (10 to 80), and 33° in external rotation (0 to 55). Post-operatively, 2 of 14 patients underwent or were supposed to undergo revision surgery, and the cumulative incidence of revision surgery was 18 % for both 30 and 48 months (95 % CI: 2 to 45). During the study period, no patients reported instability, and no dislocations occurred.

The authors concluded that these findings were concerning because the revision risk with this constrained RTSA implant was higher than has been reported by others for other proximal humerus prostheses. The highly constrained design that helps prevent instability might also transmit increased stresses to the humeral component-bone interface; thus, making it susceptible to loosening. These researchers believed that any other implant with a similar degree of constraint would have the same problem; and changing the indications for patient selection may not solve this issue. These theories need to be tested biomechanically, but these investigators’ desire was to warn surgeons that while trying to prevent instability, they might trade one complication (instability) for another: aseptic loosening. Level of Evidence = IV.

Ferlauto and colleagues (2021) noted that in recent years, there has been growing interest in the use of RTSA for reconstruction of the proximal humerus after oncologic resection; however, the indications and outcomes of oncologic RTSA remain unclear. In a systematic review, these researchers examined studies that reported outcomes of patients who underwent RTSA for oncologic reconstruction of the proximal humerus. Extracted data included demographic characteristics, indications, operative techniques, outcomes, and complications; weighted means were calculated according to sample size. A total of 12 studies were included, containing 194 patients who underwent RTSA for oncologic reconstruction of the proximal humerus. The mean patient age was 48 years, and 52 % of patients were men. Primary malignancies were present in 55 % of patients; metastatic disease, 30 %; and benign tumors, 9 %. The mean humeral resection length was 12 cm. The mean post-operative Musculoskeletal Tumor Society score was 78 %; Constant score, 60; and Toronto Extremity Salvage Score, 77 %. The mean complication rate was 28 %, with shoulder instability accounting for 63 % of complications. Revisions were carried out in 16 % of patients, and the mean implant survival rate was 89 % at a mean follow-up across studies of 53 months. The authors concluded that although the existing literature is of poor study quality, with a high level of heterogeneity and risk of bias, RTSA appeared to be a suitable option in appropriately selected patients undergoing oncologic resection and reconstruction of the proximal humerus. The most common complication was instability. Moreover, these researchers stated that higher-quality evidence is needed to help guide decision-making on appropriate implant utilization for patients undergoing oncologic resection of the proximal humerus. Level of Evidence = IV.

Stemless Shoulder Arthroplasty

Wiater and co-workers (2020) noted that stemless humeral components for aTSA have several reported potential benefits compared with stemmed implants; however, these researchers were aware of no Level-I, randomized controlled trials that have compared stemless implants with stemmed implants in patients managed with aTSA. In a prospective, single-blinded, multi-center, randomized controlled trial, these investigators compared the short-term clinical and radiographic outcomes of stemless and stemmed implants to examine if the stemless implant is non-inferior to the stemmed implant; ROM measurements, ASES, Single Assessment Numeric Evaluation (SANE), and Constant scores were obtained at multiple time-points. Device-related complications were recorded. Radiographic evaluation for evidence of loosening, fractures, dislocation, or other component complications was carried out. Statistical analysis for non-inferiority was carried out at 2 years of follow-up for 3 primary endpoints: ASES score, absence of device-related complications, and radiographic signs of loosening. All other data were compared between cohorts at all time-points as secondary measures. A total of 265 shoulders (including 176 shoulders in male patients and 89 shoulders in female patients) were randomized and received the allocated treatment. The mean age of the patients (and standard deviation) was 62.6 ± 9.3 years, and 99 % of the shoulders had a primary diagnosis of OA. At 2 years, the mean ASES score was 92.5 ± 14.9 for the stemless cohort and 92.2 ± 13.5 for the stemmed cohort (p value for non-inferiority test, < 0.0001), the proportion of shoulders without device-related complications was 92 % (107 of 116) for the stemless cohort and 93 % (114 of 123) for the stemmed cohort (p value for non-inferiority test, < 0.0063), and no shoulder in either cohort had radiographic signs of loosening; ROM measurements, ASES, SANE, and Constant scores did not differ significantly between cohorts at any time-point within the 2-year follow-up. The authors concluded that at 2 years of follow-up, the safety and effectiveness of the stemless humeral implant were non-inferior to those of the stemmed humeral implant in patients managed with aTSA for the treatment of OA. The researchers stated that these short-term findings were promising given the potential benefits of stemless designs over traditional, stemmed humeral components.

The authors stated that this study had several drawbacks. First, follow-up was only 2 years; longer-term radiographic and clinical follow-up may reveal differences that were not apparent at short-term follow-up. However, it was worth noting that studies of similar stemless implants have shown no deterioration of shoulder function at intermediate-term follow-up. Second, surgeons could not be blinded to treatment. To address this limitation, primary endpoints were chosen such that surgeon bias should have played little role: ASES scores were determined on the basis of a patient questionnaire, device failure modes were independent of the surgeon, and an independent radiographic reviewer assessed the radiographs. Third, given the low rates of device-related complications and component loosening in the present study, the 2-year follow-up rates of 87 % and 90 % may have introduced error; if even only a few of the patients who were lost to follow-up had device-related complications or component loosening, it could have had a substantial impact on the results. Last, it should be noted that the scope of this study was intentionally limited in order to answer a specific question (i.e., whether a stemless implant is non-inferior to a stemmed implant in patients with adequate metaphyseal bone quality). A single stemless implant was compared with a single stemmed implant, and patients who were considered to be poor candidates for a stemless implant (i.e., those with osteoporosis, osteomalacia, or other disorders possibly compromising fixation of the implant in the metaphysis) were excluded. The findings of this trial could not necessarily be applied to other stemless designs, nor should they be applied to patients with poor metaphyseal bone quality.

Willems and colleagues (2021) noted that stemless shoulder arthroplasty relies solely on cementless metaphyseal fixation and is designed to avoid stem-related problem such as intra-operative fractures, loosening, stress shielding or stress-risers for peri-prosthetic fractures. Many designs are currently on the market, although only 6 anatomic and 2 reverse arthroplasty designs have results published with a minimum of 2-year follow-up. Compared to stemmed designs, clinical outcome was equally good using stemless designs in the short- and medium-term follow-up, which was also the case for overall complication and revision rates. Intra-operative fracture rate was lower in stemless compared to stemmed designs, most likely due to the absence of intra-medullary preparation and of the implantation of a stem. Radiologic abnormalities around the humeral implant were less frequent compared to stemmed implants, possibly as a consequence of the closer resemblance to native anatomy. Between stemless implants, several significant differences were found in terms of clinical outcome, complication and revision rates, although the level of evidence was low with high study heterogeneity; thus, firm conclusions could not be drawn. The authors concluded that there is a need for well-designed, long-term, randomized trials with sufficient power to examine the superiority of stemless over conventional arthroplasty, and of one design over another. Furthermore, a well-designed study is needed to analyze the success of revision after primary stemmed versus stemless designs.

The authors stated that this study had several drawbacks. First, the fusion of TSA and HA results, since most of the included articles did not distinguish between TSA and HA results. As moderate evidence showed that results of HA might be inferior to TSA, combining these results could negatively influence TSA results. It should also be noted that substantial differences in baseline characteristics between TSA and HA patients commonly exist, such as age, osteoarthritis grade, indication, etc. In an attempt to analyze a difference in outcome between these 2 types, these researchers carried out a subgroup analysis comparing stemless TSA versus HA results. No significant difference in CMS or ROM was found, although baseline characteristics between these groups were not provided or were very sparse; thus, these findings should be interpreted with caution. Second, the differences of design in stemless systems. This made an overview of results less reliable, as every feature might have its own possible advantage or disadvantage. In the current literature, it is not possible to examine the influence of these features independently. Third, high study heterogeneity, with substantial differences in baseline characteristics, which made comparisons between studies or systems less reliable. Furthermore, most were single-surgeon series, with differences in indication and approach. Most of these studies had a low quality of evidence, with a short overall mean follow-up of 3.2 years, and with the majority having a high risk of bias. In addition, 5 out of 8 RSA studies and 13 out of 23 studies reported a possible conflict of interest, although a subgroup analysis did not show superior results comparing absolute CMS and forward elevation in studies with a possible conflict of interest to studies without. Fourth, the sparse data regarding different patient- and surgeon-reported outcomes, and the wide array of different scores used in studies. From a total of 9 different outcome scores, the CMS was described most, followed by the ASES score. The CMS was the only outcome score that included an objective strength and function measurement. Although mentioned in one table with other patient-reported outcome scores, the results of the CMS should not be interpreted as such. With regard to the subgroup analyses, the most important weakness was the difference in follow-up between systems; outcomes deteriorated over time. In an attempt to examine differences between short- and medium-term follow-up, an analysis was carried out that revealed no significant differences in CMS. Although this comparison was conducted across different systems, and high heterogeneity was present. These investigators used annual rates to compare radiologic outcomes and complication and revision rates between systems. It is important to note that most findings did not have a linear correlation with time. For instance, rates of radiologic abnormalities around the humeral implant were higher with longer follow-up, but their first appearance could take up to 4 years.

Kostretzis and associates (2021) stated that reverse shoulder prostheses are increasingly used for treatment of rotator cuff tear arthropathy and other degenerative shoulder diseases. In recent years, aiming for bone stock preservation has led to the design of metaphyseal humeral components without a stem. In a systematic review, these researchers examined the complication and re-intervention rates, as well as the clinical and radiographic outcomes in patients who underwent RSA with stemless implants. The systematic review of the literature was completed until May 2020 using PubMed, Embase, CINAHL and Cochrane databases, according to PRISMA guidelines. The literature search yielded 2,942 studies, of which 13 were included in this review, with a total of 517 patients and a mean follow-up between 6.4 and 101.6 months. The total complication rate was 6.5 %, while 3.3 % were humeral associated complications. Finally, the rate of shoulders that underwent a re-intervention was 6.7 %, with 1.4 % relating to a humeral component reason. Stemless RSA led to substantial improvements in patient reported outcome measures and ROM across all studies. Scapular notching was reported in 15.2 %, and lucencies around humeral component were reported in 0.8 % of shoulders. The authors concluded that stemless RSA resulted in low complication and re-intervention rates at the mid-term follow-up. The reported clinical and radiological outcomes showed that these prostheses had at least equivalent outcomes with their stemmed counterparts. Moreover, these researchers stated that further studies are needed to examine the long-term longevity and performance of the stemless humeral implants. Level of Evidence = IV.

Three-Dimensional Pre-Operative Imaging for Total Shoulder Arthroplasty

In a retrospective, comparative study, Cancienne and colleagues (2021) determined the incidence in the U.S. of pre-operative three-dimensional (3D) imaging before aTSA for OA and to examined if pre-operative imaging is associated with decreased complication rates. Using a Medicare insurance database, these researchers identified all patients who underwent computed tomography (CT; n = 9,380) and/or magnetic resonance imaging (MRI; n = 15,653) before aTSA for a diagnosis of OA from 2005 to 2014. The incidence of imaging over time was analyzed and complication rates compared between patients with imaging to matched controls. The incidence of pre-operative 3D imaging significantly increased over time, with CT increasing more than MRI. Compared to controls, patients with pre-operative CT imaging had significantly lower revision rates at 2 years (OR 0.72 (0.64 to 0.82), p = 0.008). There were no other significant differences in the other complications studied. The authors concluded that the use of pre-operative 3D imaging for aTSA for a diagnosis of OA has increased dramatically, with the use of CT increasing the most. Patients who underwent pre-operative CT imaging experienced lower revision rates at 2 years post-operatively compared to matched controls without such imaging. Level of Evidence = III. This was a retrospective study with short-term follow-up; well-designed studies with long-term follow-up are needed to the clinical value of 3D pre-operative imaging for aTSA.

Werthel and associates (2021) described a quantitative 3D CT method to measure rotator cuff muscle volume, atrophy, and balance in healthy controls and in 3 pathological shoulder cohorts. A total of 102 CT scans were included in the analysis: 46 healthy, 21 cuff tear arthropathy (CTA), 18 irreparable rotator cuff tear (IRCT), and 17 primary OA. The 4 rotator cuff muscles were manually segmented and their volume, including intra-muscular fat, was calculated. The normalized volume (NV) of each muscle was calculated by dividing muscle volume to the patient's scapular bone volume. Muscle volume and percentage of muscle atrophy were compared between muscles and between cohorts. Rotator cuff muscle volume was significantly decreased in patients with OA, CTA, and IRCT compared to healthy patients (p < 0.0001). Atrophy was comparable for all muscles between CTA, IRCT, and OA patients, except for the supraspinatus, which was significantly more atrophied in CTA and IRCT (p = 0.002). In healthy shoulders, the anterior cuff represented 45 % of the entire cuff, while the posterior cuff represented 40 %. A similar partition between anterior and posterior cuff was also found in both CTA and IRCT patients; however, in OA patients, the relative volume of the anterior (42 %) and posterior cuff (45 %) were similar. The authors concluded that the findings of this study showed that rotator cuff muscle volume was significantly decreased in patients with OA, CTA, or IRCT compared to healthy patients, but that only minimal differences could be observed between the different pathological groups suggesting that the influence of rotator cuff muscle volume and atrophy (including intra-muscular fat) as an independent factor of outcome may be over-estimated.

The authors stated that this study had 2 main drawbacks. First, the size of the cohort of pathological shoulders was relatively small due to the difficulty in obtaining CT scans with both bone and soft tissue algorithms and with the entire scapula, which was unfortunately often truncated at its medial or distal tip. With the recent push for high-quality CT protocols for use in pre-operative planning software, future CT scan exams will likely cover the entire scapula. Second, at present, this method is time-consuming (around 3 hours per muscle) as it requires manual segmentation of muscles; however, algorithms are being developed for automatic segmentation using either statistical shape modelling or deep learning techniques.

Subacromial Balloon Spacer / Superior Capsular Reconstruction for the Treatment of Rotator Cuff Tears

In a systematic review, Kooistra et al (2019) examined evidence for improvements in outcome for all reported types of treatment modalities (physical therapy [PT], tenotomy or tenodesis of the long head of the biceps, debridement, partial repair, subacromial spacer, deltoid flap, muscle transfer, rotator cuff advancement, graft interposition, superior capsular reconstruction (SCR), and reversed shoulder arthroplasty (RSA)] used for irreparable posterosuperior rotator cuff tears without glenohumeral osteoarthritis (OA). The primary objective was to inform patients regarding expectations of the amount of clinical improvement following these treatments. These investigators carried out a systematic search in Medline, Embase, CINAHL, and Cochrane databases for studies on irreparable posterosuperior rotator cuff lesions without glenohumeral OA, published from January 2007 until January 2019, with minimum 2-year follow-up. Studies with pre-operative and/or intra-operative determination of rotator cuff tear irreparability were included. These researchers defined the non-adjusted Constant Score as the primary outcome. A total of 60 studies (2,000 patients) were included with a fair mean quality score, according to the Modified Coleman Methodology Score. The employed definitions of “irreparable” were mainly based on MRI criteria and were highly variable among studies. The smallest weighted mean pre-operative to post-operative improvements in Constant Score were reported for biceps tenotomy/tenodesis (10.7 points) and PT (13.0). These were followed by debridement (21.8) and muscle transfer (27.8), whereas the largest increases were reported for partial repair (32.0), subacromial spacer (32.5), rotator cuff advancement (33.2), RSA (34.4), graft reconstruction (35.0), deltoid flap (39.8), and SCR (47.4). Treatment using deltoid flap showed highest mean weighted improvement in Constant Score among studies with available medium-term (4 to 5 years) follow-up. Treatments with deltoid flap, muscle transfer, and debridement were the only treatments with available long-term (8 to 10-year) follow-up and showed similar improvements in Constant Score at this time-point. The authors concluded that the variability in patient characteristics, co-interventions, outcome reporting, and length of follow-up in studies on irreparable rotator cuff tears without OA complicated sound comparison of treatments. Clinically important treatment effects were observed for all 11 different treatment modalities. Level of Evidence = IV.

Juhan et al (2019) noted that rotator cuff disease is one of the most common causes of shoulder pain, yet controversy still exists regarding treatment of "irreparable" tears. Non-operative management, including PT and steroid injections, should be reserved for those without significant pain or functional impairment. Debridement may be used for low-demand patients, and should be carried out with partial cuff repair, subacromial decompression, and/or acromioplasty to maximize outcomes. Biceps tenotomy and/or tenodesis have been shown to reduce post-operative pain and improve satisfaction when performed in conjunction with rotator cuff repairs, with no difference in functional outcome comparatively. Tendon transfers have been advocated with the potential benefit to improve function and decrease pain. More recently, extracellular matrix and human-derived dermal allografts have been used off-label as patch grafts in irreparable tears. SCR techniques and subacromial balloon spacers serve a similar function by acting to depress the humeral head in a cuff-deficient shoulder, however long-term data is needed before widespread adoption of these procedures. Finally, RSA serves as a salvage option for low demand elderly patients.

Kucirek et al (2021) stated that massive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, especially among joint-preserving options, has been shown to be superior. These investigators discussed recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, SCR, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. These researchers also offered guidance on surgical indications based on their clinical experience. Partial repair may offer reasonable clinical improvement for patients with lower pre-operative function despite high re-tear rates. Furthermore, several types of interposition grafts have shown promising short-term results and may out-perform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral OA or pseudo-paralysis, and recently received FDA approval for use in the U.S. SCR is a technically demanding procedure that appears to produce excellent short-term results especially when performed at high volume; however, long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. The authors concluded that irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral OA is especially controversial. For older patients with low-demand lifestyles and glenohumeral OA, RTSA is an effective therapeutic option . For all discussed procedures, patient selection appeared to play a critical role in clinical outcomes.

In a retrospective, cohort study, Familiari et al (2021) examined associations between clinical and demographic parameters and Constant-Murley (CM) scores following subacromial balloon placement for the treatment of massive, irreparable rotator cuff tears and assessed implant survival, shoulder function, and patient satisfaction. These researchers prospectively analyzed patients with rotator cuff tears deemed irreparable on pre-operative MRI for whom non-operative therapy was unsuccessful and who underwent balloon placement from 2014 to 2017 with minimum 1-year follow-up. Shoulder function was assessed using the CM score and the 12-Item Short Form Health Survey. The study included 51 patients (22 women and 29 men) with a mean age at surgery of 63 years (range of 50 to 78 years). The mean follow-up period was 36 months (range of 24 to 56 months). The post-operative acromio-humeral interval (AHI) and total pre-operative CM score predicted the post-operative CM score at final follow-up. The implant survival rates were 92 % at 6 and 12 months, 90 % at 2 years, and 87 % at 3 and 4 years; 5 patients underwent RTSA, and 1 underwent latissimus dorsi tendon transfer. Post-operatively, mean CM scores (± standard deviation) improved for range of motion (ROM; from 11 ± 5.4 to 34 ± 6.8) and strength (from 13 ± 5.4 to 28 ± 12) (p < 0.01 for both). The total CM score improved from 27 ± 7.4 pre-operatively to 77 ± 15 post-operatively (p < 0.01). The physical and mental component summary scores on the 12-Item Short Form Health Survey improved from 27 ± 5.0 to 51 ± 6.5 (p = 0.02) and from 44 ± 15 to 56 ± 8.0, respectively (p < 0.01); 38 patients reported excellent satisfaction, 8 were satisfied, and 5 were dissatisfied. Of the patients, 50 (98 %) exceeded the minimal clinically important difference (10.4 or higher) and patient acceptable symptom state (44 or higher). The authors concluded that at mean 3-year follow-up, subacromial balloon spacer placement for the treatment of massive, irreparable rotator cuff tears was associated with a significant improvement in shoulder function, limited need for revision surgery, and high patient satisfaction. A greater post-operative acromio-humeral interval and lower pre-operative CM score predicted a lower post-operative CM score at final follow-up. Level of Evidence = IV.

The authors stated that all patients underwent biceps tenotomy in conjunction with subacromial balloon spacer placement. Concerns have been raised regarding the need to better isolate the benefits of spacer placement from concomitant tenotomy. Although this cohort had longer follow-up than those of other subacromial spacer balloon studies, longer follow-up may show higher rates of revision surgery, which may suggest lower efficacy. These researchers included no control group in this study, and 10 of the initial 61 patients were lost to follow-up. Increased AHI was associated with lower CM scores, but these investigators were unable to determine a mechanistic relationship given the retrospective study design. Finally, these researchers used implant revision as a proxy for implant survivorship and did not directly examine the integrity of implants in patients who did not require revision surgery.

Viswanath and Drew (2021) noted that rotator cuff tears are a common cause of disability and pain. The ideal treatment for truly irreparable rotator cuffs is still debated, and one recent surgical advance is the development of the subacromial balloon spacer. These researchers examined the available evidence and indications for this device. They carried out a literature search using the MeSH search terms combining "balloon spacer" and "irreparable cuff tear". A total of 20 studies using the balloon spacer as a treatment modality in more than 2 patients, were analyzed. A total of 513 patients were analyzed, representing 83 % of those initially identified as meeting the inclusion criteria. The majority of studies recommended the device, with only 4 suggesting it was not recommended based on their results. Notable bias was present in the studies analyzed, and there were no studies providing greater than Level III evidence. The authors concluded that the subacromial balloon spacer is one possible therapeutic option for older, low-demand patients with a full thickness rotator cuff tear involving only the supraspinatus tendon, who also have no arthritis and have preserved active elevation beyond 90°. However, the results of 2 large, prospective, randomized trials are awaited to provide satisfactory evidence regarding the use of the balloon spacer.

In a matched-pairs, case-control study, Malahias et al (2021) examined if arthroscopic partial repair with the additional use of a biodegradable subacromial spacer would be a better treatment for irreparable massive rotator cuff tears (MRCT) compared to single arthroscopic partial repair. This trial included 32 patients suffering from irreparable MRCT who underwent an arthroscopic partial repair with (Group B: 16 patients) or without (Group A: 16 patients) InSpace Balloon (ISB) implantation. For the clinical and functional assessment of the patients, the visual analog scale (VAS), Constant score, American Shoulder and Elbow Surgeons Shoulder Score (ASES), range of motion (ROM), and patients' satisfaction were obtained. The 2 groups were matched in all baseline demographic and clinical characteristics (n.s.). All mean final quantitative post-operative clinical and functional scores of group A (partial repair and ISB) and group B (single partial repair), as well as active ROM, were significantly improved (t-test) in comparison with the mean pre-operative values (p < 0.05). No significant differences were observed between the 2 groups in relation to the 2 success rate criteria (ASES minimal clinically important difference or MCID greater than 17, Constant score MCID greater than 10.4), as well as pain relief and ROM 12 months after surgery. The authors concluded that arthroscopic partial repair, either with or without ISB implantation, resulted in significantly improved clinical and functional short-term outcomes for the treatment of MRCT. Patients who were treated with combined partial repair and ISB implantation had a potential propensity toward better functional outcomes and higher patient satisfaction compared to the single-partial-repair-treated group. However, given that these differences were not significant, these researchers stated that further studies are needed to clarify the potential therapeutic value of ISB implantation in the treatment of irreparable MRCT. Level of Evidence = III.

Ozturk et al (2021) noted that the treatment of massive, irreparable rotator cuff tears remains controversial today because there is no consensus on the ideal therapeutic option. In a prospective, randomized trial, these investigators compared the outcomes of arthroscopy-assisted LDT and SCR in the treatment of massive, irreparable rotator cuff tears. A total of 42 patients at an average age of 62.8 years with massive, irreparable rotator cuff tears were randomized into 2 treatment groups – 21 patients underwent arthroscopy-assisted LDT, and 21 patients underwent arthroscopy-assisted SCR. Subjects were followed-up for 31 months on average; 1 patient in the SCR group was lost to follow-up. The outcomes were evaluated with ASES, Western Ontario Rotator Cuff Index (WORC), VAS, and Constant scores clinically and with AHD measurements radiologically. Both groups displayed improved results in ASES, WORC, Constant, and VAS scores in the final follow-up (p < 0.001). The LDT group had significantly better results in AHD (p = 0.006), whereas the SCR group yielded significantly higher improvements in ASES (p = 0.007) and Constant scores (p = 0.008). The rate of successful pseudo-paralysis treatment was 45 % (5/11) in the LDT group and 92 % (12/13) in the SCR group (p = 0.011). The graft failure rate was 5 % (1 patient) in each group post-operatively; 1 patient in the SCR group had a traumatic graft rupture and 1 patient in the LDT group was complicated with septic arthritis, which required graft removal. The authors concluded that both SCR and LDT yielded promising short-term results in treatment of massive, irreparable rotator cuff tears in this study. The SCR group displayed better overall outcomes clinically, especially in the pseudo-paralytic shoulders, whereas the LDT group displayed better radiologic results.

The authors stated that this study had several drawbacks. The main limitation was the limited number of patients. A larger group of patients would yield more precise information on the overall evaluation of the 2 techniques. The short-term follow-up 9average of 31 months) was another limiting factor that prevented observation of patients for progression of arthritic changes and possible future complications including graft failure. Because the outcomes of this study represented the results of a single sports fellowship–trained surgeon who was primarily involved in shoulder surgery, they may not be generalizable. The potential effect of additional procedures such as subscapularis repair and biceps tenodesis or tenotomy should also be acknowledged as a possible confounding factor. The patient choice (exclusion of patients with advanced arthritis, deltoid muscle dysfunction, irreparable subscapularis tears, and failed cuff surgeries) was another factor that probably had positive influence on the outcomes in this study. The lack of an a priori power analysis may be considered another limitation; however, the post-hoc power analysis showed that the achieved power for each outcome measure, which aided the interpretation of the results. These researchers stated that further studies with larger populations and longer follow-up along with inclusion of more complicated groups such as those mentioned above are needed to obtain more information on the effectiveness of these 2 techniques and the factors that influence the outcomes.

In a retrospective, comparative study, Bilsel et al (2022) compared the clinical and radiographic outcomes of partial rotator cuff repair (RCR) with and without implantation of a biodegradable subacromial spacer in the treatment of symptomatic irreparable MRCTs. Patients with MRCT who underwent arthroscopic partial repair alone (PR) or combined with subacromial spacer augmentation (PRS) were included. Patient-reported outcomes, including VAS, ASES, and Constant scores in addition to ROM were collected pre-operatively and at the final follow-up. Furthermore, these researchers determined the percentages of all of the patients in groups that achieved the minimal clinical important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) for the VAS, ASES, and Constant scores. Acromio-humeral distance (AHD) was determined as well. A total of 32 patients were included. Group PR included 20 patients with a median age of 68 years (range of 64 to 73) and median follow-up 28.0 months (14.0 to 60.0). Group PRS included 12 patients with a median age of 68.5 years (range of 63 to 74) and median follow-up of 17.0 months (12.0 to 32.0). At the final follow-up, the ASES, VAS, and Constant scores were significantly higher in the PRS group (75.5 [55 to 88.3], 1.0 [0 to 3], and 70.0 [43 to 79], respectively, compared to the PR group (55.0 [37.5 to 65], 2.0 [0 to 4], and 55.0 [31 to 79], respectively; p < 0.05). The only statistically significant differences were found between the PR and PRS groups in terms of the proportions of the patients who achieved MCID for the ASES (70 % versus 100 %; p = 0.04) and in terms of the proportions of the patients who achieved SCB for the ASES (60 % versus 100 %; p = 0.01). There was also statistically significant difference between the PR and PRS groups, in terms of the proportions of the patients who achieved PASS for the VAS and ASES ([30 % versus 66.7 %; p = 0.04] and [0 % versus 50 %; p = 0.001], respectively). AHD was also improved in the PRS group (8.4 [7 to 9.5] versus 7.85 [5.5 to 9.0]; p < 0.05). ROM was greater in the PRS group at final follow-up with median forward flexion degree, 140.0° (90° to 150°) versus 120.0° (80° to 153°) (p < 0.001) and median abduction degree, 100.0° (70° to 130°) versus 90.0° (70° to 110°). There was no difference in terms of external rotation between groups (3° [2° to 5°] versus 3.0° (2° to 4°); p = 0.4). The authors concluded that arthroscopic partial RCR with implantation of a subacromial spacer resulted in satisfactory clinical and radiographic outcomes in patients with symptomatic irreparable MRCT compared with patients treated with partial repair alone. Level of Evidence = III.

The authors stated that this study had several drawbacks in addition to those inherent to the retrospective design. First, there was no treatment group with subacromial spacer implantation alone, which could demonstrate the effect of partial RCR. This was due to the treating surgeon’s clinical preference for partial repair. However, the study provided sufficient information as to the effect of subacromial spacer on the outcome after partial RCR. Second, the follow-up for the PRS group was shorter than the PR group. Longer follow-up is needed to confirm the stability of difference in clinical and radiographic outcomes over time. However, the median follow-up of 1.5 years is sufficient to assess early outcome, given that Deranlot et al (2017) could not show a decrease in Constant score after 1 and 3 years of follow-up. Finally, a larger cohort with post-operative MRI to show healing integrity and fatty degeneration is needed to fully validate these findings.

In a single-blinded, multi-center, RCT, Verma et al (2022) examined the safety and effectiveness of a subacromial balloon spacer (InSpace implant) compared with arthroscopic partial repair in patients with irreparable, posterosuperior massive rotator cuff tears. Patients 40 years of age or older with symptomatic, irreparable, posterosuperior, massive rotator cuff tears and an intact subscapularis who underwent failed non-operative management were included in this RCT comparing the InSpace implant with partial repair. Clinical outcome data were collected at baseline through a 24-month follow-up. The primary outcome was improvement in the ASES scores. The secondary outcomes included change from baseline in the WORC score, the VAS pain score, the Constant-Murley shoulder score, the EuroQol-5 Dimensions-5-Level (EQ-5D-5L) score, active ROM, and operative time. Complications and re-operations for each group were also recorded. A total of 20 sites randomized 184 patients: 93 in the InSpace group and 91 in the partial repair group. Significant and clinically relevant improvements in the ASES score from baseline were noted in both groups at month 12 and were maintained at month 24. Overall, 83 % of patients in the InSpace group and 81 % of patients in the partial repair group achieved the ASES minimally clinically important difference threshold, and 82 % of patients in the InSpace group and 79 % of patients in the partial repair group achieved the substantial clinical benefit threshold. Forward elevation was significantly greater in the InSpace group compared with the partial repair group at day 10 (p = 0.04), week 6 (p = 0.0001), month 12 (p = 0.005), and month 24 (p = 0.003). The operative time was significantly shorter in the InSpace group (p < 0.0001). No device-related surgical complications were noted, and 4 re-operations after InSpace implantation and 3 re-operations after partial repair were required. The authors concluded that the InSpace implant was an appropriate alternative to partial repair in patients with irreparable posterosuperior massive rotator cuff tears and an intact subscapularis. Notable benefits included early functional recovery and pain relief combined with a shorter operative time. Level of Evidence = I.

These investigators noted that study drawbacks included the lack of standardization with respect to the concomitant procedures carried out in both groups and the repair techniques in the partial repair group and evaluators of the physical examination not being blinded to treatment group, which may have been a potential source of detection bias. Although the study presented results on intermediate-term follow-up at 2 years, longer-term follow-up is needed to examine the duration of benefit. More importantly, the role of the implant in patients with true pseudo-paralysis unrelated to pain remained unknown and was beyond the scope of this study.

In an editorial that accompanied the afore-mentioned study by Verma et al (2022), Dey Hazra et al (2022) believed that “in young, active patients with an irreparable massive rotator cuff tear, the more surgically demanding superior capsular reconstruction provides the best salvage option. With regard to the clinical results reported by Verma et al, one could consider augmenting partial repairs with a balloon to secure the construct and provide the possibility of early mobilization. In elderly patients, it is our opinion that the balloon should be considered alongside non-operative treatment and reverse shoulder arthroplasty. Further long-term studies with radiographic imaging, histologically analyzed intraoperative biopsies, and comparative randomized clinical studies of competing treatment options are necessary to answer these questions”.

Lapner et al (2022) noted that there is ongoing controversy regarding optimal treatment for full-thickness rotator cuff tears. Given that the evidence surrounding the use of various therapeutic options has expanded, an overall assessment is needed. On behalf of the Canadian Shoulder and Elbow Society, these investigators compared the following to determine which resulted in improved patient-reported function, pain, and re-operation rates for each: (i) double-row (DR) fixation and single-row (SR) fixation in arthroscopic cuff repair; (ii) latissimus dorsi transfer (LDT) with lower trapezius transfer (LTT), partial rotator cuff repair, and SCR; and (iii) early and late surgical intervention. Medline, Embase, and Cochrane were searched through to April 20, 2021. Additional studies were identified from reviews. The following were included: (i) All English-language randomized controlled trials (RCTs) in patients 18 years of age or older comparing SR and DR fixation, (ii) observational studies comparing LDT with LTT, partial repair, and SCR, and (iii) observational studies comparing early versus late treatment of full-thickness rotator cuff tears. A total of 15 RCTs (n = 1,096 randomized patients) were included in the meta-analysis of SR versus DR fixation. No significant standardized mean differences in function (0.08, 95 % confidence interval [CI]: -0.09 to 0.24) or pain (-0.01, 95 % CI: -0.52 to 0.49) were observed. There was a difference in re-tear rates in favor of DR compared with SR fixation (RR 1.56, 95 % CI: 1.06 to 2.29). A total of 4 studies were included in the systematic review of LDT compared with a surgical control. LDT and partial repair did not reveal any differences in function (-1.12, 95 % CI: -4.02 to 1.78) on comparison. A single study compared arthroscopically assisted LDT to LTT and observed a non-statistical difference in the Constant score of 14.7 (95 % CI: -4.06 to 33.46). A single RCT compared LDT with SCR and revealed a trend toward superiority for the Constant score with SCR with a mean difference (MD) of -9.6 (95 % CI: -19.82 to 0.62). Comparison of early versus late treatment revealed a paucity of comparative studies with varying definitions of "early" and "late" treatment, which made meaningful interpretation of the results difficult. The authors concluded that DR fixation resulted in similar improvement in function and pain compared with SR fixation and results in a higher healing rate. LDT transfer yielded results similar to those from partial repair, LTT, and SCR in functional outcomes. Moreover, these researchers stated that further study is needed to determine the optimal timing of treatment and to increase confidence in these findings. They also stated that future trials of high methodologic quality comparing LDT with LTT and SCR are needed.

Broida et al (2022) stated that functionally irreparable rotator cuff tears (FIRCTs) present an ongoing challenge to the orthopedic surgeon. In a systematic review, these investigators compared the outcomes of 3 LDT techniques and 2 SCR techniques in treatment of FIRCTs. They carried out a systematic review of studies examining the outcome of FIRCT treatment via a search of 4 databases in April 2020. Each included study was reviewed in duplicate by 2 reviewers for evaluation of methodological quality. The treatments analyzed were arthroscopic LDT (aLDT), open LDT Gerber technique (oLDTG), open LDT L'Episcopo technique (oLDTL), SCR with allograft (SCR-Allo), and SCR with autograft (SCR-TFL). Demographics, ROM, patient-reported outcome measures (PROMs), radiographic AHD, treatment failures, and revisions were recorded. A total of 46 studies (1,287 shoulders) met criteria for inclusion; 23 studies involved open latissimus transfer, with 445 shoulders undergoing oLDTG with mean follow-up of 63.2 months and 60 patients undergoing oLDTL with mean follow-up (F/U) of 51.8 months; 10 studies (n = 369, F/U 29.2 months) reported on aLDT; 7 studies (n = 253, F/U 16.9 months) concerned SCR-Allo, and 6 studies (n = 160, F/U 32 months) reported on SCR-TFL. ROM and subjective outcome scores improved in all techniques with no differences across treatments. Both SCR methods provided greater improvement in AHD than open LDT methods (p < 0.01). The re-tear rates were lower in both oLDT groups compared to the SCR groups (p = 0.03). Clinical failure rates were higher in the SCR-Allo and oLDTG groups, while overall treatment failures were lowest in oLDTL compared to all 4 other groups. The authors concluded that in this systematic review comparing arthroscopic-assisted LDT, 2 techniques of open LDT, and 2 techniques of SCR, all of these joint-preserving reconstructions resulted in improved clinical outcomes and pain relief compared to pre-operative levels. There were no major differences between the 5 techniques when examining the improvements in active shoulder ROM, pain, or PROMs. Radiographically, the SCR techniques were associated with slightly improved rates of AHD, while the open and arthroscopic-assisted LDT techniques had slightly lower rates of tendon re-tears, revision surgery, and overall treatment failure. Ultimately, many patient and technical factors play an important role in the outcomes after these technically demanding procedures. These researchers stated that future prospective, high-quality studies are needed to compare and delineate many of these considerations. Level of Evidence = IV.

Computer-Assisted Navigation in Reverse Shoulder Arthroplasty

Garcia and Abdo (2022) stated that navigation technologies have improved the accuracy and precision in positioning glenoid components during shoulder arthroplasty. The influence of navigation on baseplate screw placement has not been independently examined. In a systematic review and meta-analysis, these investigators examined the best scientific evidence on the influence of intra-operative navigation on the length and number of screws for primary base-plate fixation in RTSA procedures. In August 2022, PubMed, Scopus, and Embase databases were accessed. These researchers analyzed the screw purchase length, the number of screws needed for the fixation of the baseplate, and the proportion of cases fixed with 2 screws in all clinical trials, comparing navigation to standard instrumentation for reverse shoulder arthroplasty. Following an evaluation of the heterogeneity of the studies, DerSimonian-Laird random-effects models were employed to merge data from separate studies. The systematic search revealed a total of 2,034 articles. After excluding duplicates and irrelevant studies, 633 shoulder arthroplasties from 6 trials were included in the analysis. The pooled MD in screw purchase length was 5.839 mm (95 % CI: 4.496 to 7.182) in favor of navigation (p < 0.001). Furthermore, significant differences were also found in the number of screws per case (- 0.547, 95 % CI: -0.890 to -0.203, p = 0.002) and in the proportion of cases fixed with 2 screws (OR 3.182; 95 % CI: 1.057 to 9.579, p = 0.040) in favor of the navigation group. The authors concluded that intra-operative navigation improved the baseplate screw placement, allowing for a greater screw purchase length and fewer screws to achieve primary fixation of the glenoid component during reverse shoulder arthroplasty. However, it is unclear whether these improvements would increase the longevity of the prosthesis or the clinical outcomes of the patients.

Custom Instrumentation / Patient-Specific Instrumentation

Navarro et al (2023) noted that ongoing innovation results in a continuous influx of new technologies related to shoulder arthroplasty. These are made available to surgeons and marketed to both healthcare providers and patients with the hope of improving outcomes. In a retrospective, observational study, these investigators examined how pre-operative planning technologies for shoulder arthroplasty would affect outcomes. This trial was carried out using data from an integrated healthcare system’s shoulder arthroplasty registry. Adult patients who underwent primary elective anatomic or reverse total shoulder arthroplasty (TSA) (2015 to 2020) were identified. Pre-operative planning technologies were identified as a computed tomography (CT) scan and patient-specific instrumentation (PSI). Multi-variable Cox regression and logistic regression were employed to compare the risk of aseptic revision and 90-day adverse events (AEs), respectively, between procedures for which technologies were and were not used. The study sample included 8,117 procedures (in 7,372 patients) with an average follow-up of 2.9 years (maximum, 6 years). No reduction in the risk of aseptic revision was observed for patients having either pre-operative CT scans (hazard ratio [HR] = 1.22; 95 % CI: 0.87 to 1.72) or PSI (HR = 1.44; 95 % CI: 0.71 to 2.92). Patients having CT scans had a lower likelihood of 90-day emergency department visits (OR = 0.84; 95 % CI: 0.73 to 0.97) but a higher likelihood of 90-day venous thromboembolic events (VTE) (OR = 1.79; 95 % CI: 1.18 to 2.74). Patients with PSI use had a higher likelihood of 90-day deep infection (OR = 7.74; 95 % CI: 1.11 to 53.94). The authors found no reduction in the risk of aseptic revision with the use of these technologies. Patients having CT scans and PSI use had a higher likelihood of venous thromboembolism and deep infection, respectively. Moreover, these researchers stated that the findings of a higher likelihood of VTE and deep infection associated with the use of CT and PSI warrant further study with extended follow to examine the effects of these technologies on patient outcomes. The orthopedic community is eager for new technologies to be validated by patient-reported outcomes. It remains to be seen whether clinical benefit of these innovations will be realized and whether their use is justified in view of their cost in money and time. Level of Evidence = III.

The authors stated that this study had several drawbacks. First, only associations were reported in this observational study. Challenging cases were possibly planned with the use of CT scans or PSI; thus, selection bias may be present. These researchers attempted to address potential confounding but were limited to information collected in the registry; there is the potential for residual confounding due to unmeasured factors. Second, only pre-operative planning for the glenoid was evaluated, as technology for humeral planning was not available during the period. Third, as only 1 implant with PSI technology was examined, the findings may not be generalizable to other implants with PSI technology. Fourth, other outcomes of clinical relevance, including patient-reported outcomes, ROM, pain, post-operative medical conditions, and cost-effectiveness, could not be evaluated as this information is not collected by the registry. Fifth, not every CT scan may have been associated with the use of enhanced proprietary pre-operative planning or PSI, as some surgeons may have ordered a CT scan to study the glenoid morphology without using enhanced proprietary pre-operative planning or the creation of PSI. Sixth, not every procedure that used PSI may have been captured via the registry. However, this misclassification would bias the effect estimates toward the null value of 1; therefore, the reported results may be conservative. Furthermore, these investigators restricted the PSI analysis to only procedures for which an implant with PSI capability was used and did not differentiate between the use of software and obtaining an actual 3D-printed guide for pin placement. Finally, reasons for a return to the ED and/or re-admission were not collected by the registry and could not be compared.

Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit

Hones et al (2023) stated that latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing RSA who have pre-operative combined loss of forward elevation (FE) and ER. In a systematic review, these investigators examined available evidence for the functional outcomes and complications following RSA with LDT. In addition, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied. They caried out a systematic review according to the PRISMA guidelines. These researchers queried PubMed/Medline, Embase, Web of Science, and Cochrane databases to identify studies reporting on LDT with RSA to restore ER. The primary outcomes were ER, FE, Constant score, and complication incidence. Secondary outcomes included post-operative IR, and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed. A total of 19 studies were evaluated; functional outcomes were assessed in 16 studies reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly rotator cuff tear arthropathy and massive irreparable cuff tear. Mean ER was -12° pre-operatively and 25° post-operatively, FE was 72° pre-operatively and 141° post-operatively. Mean post-operative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25 % reported a mean post-operative IR of L3 or greater. Sub-analysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed showed no significant difference in post-operative ER, FE, and Constant score, nor pre-operative to post-operative improvement in ER and FE. The complication rate was 14.1 % (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9). The authors concluded that RSA with LDT was a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes. Level of Evidence = IV.

Subscapularis Repair for Reverse Shoulder Arthroplasty

In a systematic review and meta-analysis, Bethell et al (2023) examined the importance of subscapularis repair in patients who underwent RSA. These investigators performed a systematic search of studies in PubMed, Embase, and the Cochrane Library databases according to the PRISMA guidelines. Cohort studies comparing RSA with subscapularis repair versus RSA without subscapularis repair were included. All statistical analysis was conducted using Review Manager; and a p-value of < 0.5 was considered to be statistically significant. A total of 17 studies with 2,620 patients were included. Subscapularis repair resulted in less instability compared to without subscapularis repair (0.8 % versus 4.2 %, p = 0.04) and there were no significant differences in rate of instability with lateralization (0.6 % versus 1.6 %, p = 0.40), revision rates (2.6 % versus 3.9 %, p = 0.62) and complication rates (7.7 % versus 4.9 %, p = 0.21). Subscapularis repair had improved ASES scores (83.6 versus 80.2, p = 0.02) and constant scores (72.6 versus 68.9, p < 0.01); however, there was no significant differences in VAS pain scores (1.2 versus 1.6, p = 0.11). Subscapularis repair had a significant difference in forward flexion (140° versus 137°, p = 0.04) and internal rotation score (5.5 versus 4.6, p = 0.001); however, there was no significant different in external rotation (35° versus 35°, p = 0.80) and abduction (117° versus 123°, p = 0.13). The authors concluded that this study found that RSA with subscapularis repair showed a reduction in the occurrence of implant instability with medialized implants; however, subscapularis repair did not yield improvements in revision rates, complications, or instability with lateralized implants. Furthermore, other outcome measures such as ASES, Constant score, and ROM exhibited statistically significant improvements with subscapularis repair but did not surpass clinically significant thresholds.

Glossary of Terms

Table: Glossary of Terms
Term	Definition
Conservative therapy	Non-surgical medical management
Range of motion	Elevation/flexion

References

The above policy is based on the following references:

Alentorn-Geli E, Samitier G, Torrens C, Wright TW. Reverse shoulder arthroplasty. Part 2: Systematic review of reoperations, revisions, problems, and complications. Int J Shoulder Surg. 2015;9(2):60-67.
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Last Review 11/21/2023

Effective: 01/18/2013

Next Review: 09/26/2024
Review History
Definitions

Shoulder Arthroplasty and Arthrodesis

Table Of Contents

Policy

Scope of Policy

Medical Necessity

Experimental and Investigational

Policy Limitations and Exclusions

Related CMS Coverage Guidance

Code of Federal Regulations (CFR):

Internet-Only Manual (IOM) Citations:

Medicare Coverage Determinations:

Related Policies

Applicable CPT / HCPCS / ICD-10 Codes

CPT codes not covered for indications listed in the CPB:

Total shoulder arthroplasty:

CPT codes covered if selection criteria are met :

CPT codes not covered for indications listed in the CPB:

Other HCPCS codes related to the CPB:

HCPCS codes covered if selection criteria are met :

HCPCS codes not covered if selection criteria are met:

ICD-10 codes covered if selection criteria are met :

ICD-10 not covered for indications listed in the CPB:

Reverse shoulder arthroplasty:

CPT codes covered if selection criteria are met :

CPT codes not covered for indications listed in the CPB:

HCPCS codes covered if selection criteria are met :

ICD-10 codes covered if selection criteria are met :

Shoulder Hemiarthroplasty:

CPT codes covered if selection criteria are met :

CPT codes not covered for indications listed in the CPB:

HCPCS codes covered if selection criteria are met :

ICD-10 codes covered if selection criteria are met :

Revision or replacement of shoulder arthroplasty prosthesis:

CPT codes covered if selection criteria are met :

CPT codes not covered for indications listed in the CPB:

HCPCS codes covered if selection criteria are met :

ICD-10 codes covered if selection criteria are met :

Shoulder arthrodesis:

CPT codes covered if selection criteria are met :

CPT codes not covered for indications listed in the CPB:

ICD-10 codes covered if selection criteria are met :

ICD-10 codes not covered for indications listed in the CPB:

Subacromial balloon spacer and superior capsular reconstruction:

HCPCS codes not covered for indications listed in the CPB:

ICD-10 codes not covered for indications listed in the CPB:

Background

Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures

Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears

Microfracturing of the Shoulder

Use of Acellular Dermal Extracellular Matrix for Shoulder Capsular Reconstruction

Rehabilitation Following Anatomic and Reverse Shoulder Arthroplasty

Total Shoulder Arthroplasty for Ochronotic Arthritis

Total Shoulder Arthroplasty with a Cage Glenoid

Reverse Total Shoulder Arthroplasty for Oncologic Reconstruction of the Proximal Humerus

Stemless Shoulder Arthroplasty

Three-Dimensional Pre-Operative Imaging for Total Shoulder Arthroplasty

Subacromial Balloon Spacer / Superior Capsular Reconstruction for the Treatment of Rotator Cuff Tears

Computer-Assisted Navigation in Reverse Shoulder Arthroplasty

Custom Instrumentation / Patient-Specific Instrumentation

Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit

Subscapularis Repair for Reverse Shoulder Arthroplasty

Glossary of Terms

References

Policy History

Additional Information