The outcomes of shoulder arthroplasties in younger patients (55 years or younger) are not as reliable compared with those of the general population. Greater risk of revision and higher complication rates in younger patients present direct costs to the healthcare system and indirect costs to the patient in terms of quality of life. Previous studies have suggested an increased demand for shoulder arthroplasties overall, but to our knowledge, the demand in younger patients has not been explored. We asked: (1) What was the demand for shoulder arthroplasties between 2002 and 2011 in the United States for all patients and a specific subpopulation of patients who were 55 years old or younger? (2) How is the demand for shoulder arthroplasties in younger patients projected to change through 2030? (3) How is procedural demand projected to change in younger patients through 2030, and specifically, what can we anticipate in terms of hemiarthroplasty volume compared with that of total shoulder arthroplasty? We used the National Inpatient Sample database to identify primary shoulder arthroplasties performed between 2002 and 2011. A Poisson regression model was developed using the National Inpatient Sample data and United States Census Bureau projections on future population changes to predict estimated national demand for total shoulder arthroplasties and hemiarthroplasties in all patients and in the subpopulation 55 years old or younger. This model was projected until 2030, with associated 95% CIs. We then specifically analyzed the projected demand of hemiarthroplasties and compared this with demand for all arthroplasty procedures in the younger patient population. Demand for shoulder arthroplasties in patients 55 years or younger is increasing at a rate of 8.2% per year (95% CI, 7.06%–9.35%), compared with a growth rate of 12.1% (95% CI, 8.35%–16.02%) per year for patients older than 55 years. In 2002, 15.9% (3587 of 22,617 captured in the National Inpatient Sample) of primary shoulder arthroplasties were performed in patients 55 years old or younger. In 2011, the relative size of the younger patient population had decreased to 11.0% (7001 of 63,784) of all recipients of shoulder arthroplasties. The demand for primary shoulder arthroplasties among younger patients is projected to increase by 333.3% (95% CI, 257.0%–432.5%) from 2011 to 2030. However, in patients older than 55 years demand is projected to increase by 755.4% (95% CI, 380.7%–1511.1%). Therefore, despite the increased predicted demand for shoulder arthroplasties in younger patients, they are predicted to account for only 4% of all recipients by 2030. The rate of hemiarthroplasties in patients 55 years or younger showed a 16.5% decline per year (95% CI, 16.1%–17.1%) from 2002 (53.6% of all arthroplasties) to 2011 (34.2% of all arthroplasties). By 2030, hemiarthroplasties are projected to account for only 23.5% of all shoulder arthroplasties in patients 55 years or younger. The demand for shoulder arthroplasties in younger patients continues to increase in the United States; however, rates of hemiarthroplasties are declining. The demand has substantial implications for future revision arthroplasties, which include the direct healthcare costs of revision arthroplasty, the indirect societal burden of missed productivity owing to time away from work, and the increased burden of the need for qualified surgeons to meet the demand. Despite the increasing rate of arthroplasties performed in younger patients, current and projected demands remain greater for older patients, indicating a disproportionately greater need for shoulder arthroplasties in older patients. This is in contrast to the trends observed in the literature regarding hip and knee arthroplasties that show projected demands to be greater in younger patients. Factors responsible for the difference in demand require further investigation but may be related to changing indications, reported poorer outcomes in younger patients, the increased popularity of reverse shoulder arthroplasties in the elderly, or the evolution of nonarthroplasty options. Level III, prognostic study.

Complex proximal humeral fractures that are not amenable to surgical fixation represent a difficult treatment problem. The purpose of this systematic review was to critically examine the outcomes of reverse shoulder arthroplasty and hemiarthroplasty (with use of a fracture-specific stem) for the treatment of proximal humeral fractures. A systematic review of the literature was performed by means of a search of electronic databases. Two reviewers independently assessed the methodological quality and extracted relevant data from each included study. When outcomes data were similar among studies, the data were pooled by means of frequency-weighted values to generate summary outcomes. Fourteen studies fulfilled all inclusion and exclusion criteria and were included. Patients were followed for a frequency-weighted mean of 43.5 months in the reverse arthroplasty group and 31.1 months in the hemiarthroplasty group (p = 0.228). Subjective outcomes (including the Constant score, Constant pain subscore, and American Shoulder and Elbow Surgeons [ASES] score) and range-of-motion parameters (including active forward elevation, abduction, and external rotation) were similar between the two groups. Compared with hemiarthroplasty, reverse arthroplasty was associated with 4.0 times greater odds of a postoperative complication. The compiled data and frequency-weighted means demonstrated improvement in function, pain, and range of motion after reverse arthroplasty and hemiarthroplasty. Patients and physicians should consider projected functional outcomes, implant costs, and complication rates when selecting an appropriate arthroplasty technique for this indication.

Background The incidence of humeral shaft fractures has been increasing over time. This represents a growing public health concern in a climate of cost containment. The purpose of this study is to analyze national trends in surgical management of humeral shaft fractures and determine factors predictive of surgical intervention. Materials and methods Humeral shaft fractures were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification codes 812.21 and 812.31 in the United States Nationwide Inpatient Sample from 2002 to 2011. Open reduction and internal fixation (ORIF) was identified by code 79.31 (ORIF, humerus). Other case codes analyzed were 79.01 (closed reduction without internal fixation), 79.11 (closed reduction with internal fixation), and 79.21 (open reduction without internal fixation). Multivariate regression analysis was utilized to determine predictive factors for utilization of ORIF. Results 27,908 humeral shaft fractures were identified. Utilization of ORIF increased from 47.2% of humeral shaft fractures in 2002 to 60.3% in 2011. Demographically, patients who underwent ORIF were younger (51.5 versus 59.7 years, p < 0.001; odds ratio 0.87 per decade of age). There were modest increases in ORIF usage with private insurance, open fracture, and hospital size, which persisted with multivariate regression analysis. Surprisingly, there was a tendency to shift from a slight increase in ORIF for males with the bivariate case to a slight preference for females in the multivariate case. Conclusion Utilization of ORIF for humeral shaft fractures has been steadily increasing with time. Surgical intervention was more common with younger patients, female gender, private insurance, and larger hospital size. The increasing incidence of surgical management for humeral shaft fractures may represent a public health burden given the historical success of non-operative management. Level of evidence IV.

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this 2-part study was to systematically review each of the most common complications of RSA, limiting each search to publications in 2010 or later. In this part (part I), we examined (1) scapular notching (SN), (2) periprosthetic infection (PJI), (3) mechanical failure (glenoid or humeral component), and (4) neurologic injury (NI). Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Overall, 113 studies on SN, 62 on PJI, 34 on mechanical failure, and 48 on NI were included in our reviews. Univariate analysis was performed with the χ2 or Fisher exact test. The Grammont design had a higher SN rate vs. all other designs combined (42.5% vs. 12.3%, P < .001). The onlay humeral design had a lower rate than the lateralized glenoid design (10.5% vs. 14.8%, P < .001). The PJI rate was 2.4% for primary RSA and 2.6% for revision RSA. The incidence of glenoid and humeral component loosening was 2.3% and 1.4%, respectively. The Grammont design had an increased NI rate vs. all other designs combined (0.9% vs. 0.1%, P = .04). Focused systematic reviews of the recent literature with a large volume of RSAs demonstrate that with the use of non-Grammont modern prosthesis designs, complications including SN, PJI, glenoid component loosening, and NI are significantly reduced compared with previous studies. As the indications for RSA continue to expand, it is imperative to accurately track the rates and types of complications to justify its cost and increased indications.