Joint Maximum Likelihood of Phylogeny and Ancestral States Is Not Consistent

Maximum likelihood estimation in phylogenetics requires a means of handling unknown ancestral states. Classical maximum likelihood averages over these unknown intermediate states, leading to provably consistent estimation of the topology and continuous model parameters. Recently, a computationally efficient approach has been proposed to jointly maximize over these unknown states and phylogenetic parameters. Although this method of joint maximum likelihood estimation can obtain estimates more quickly, its properties as an estimator are not yet clear. In this article, we show that this method of jointly estimating phylogenetic parameters along with ancestral states is not consistent in general. We find a sizeable region of parameter space that generates data on a four-taxon tree for which this joint method estimates the internal branch length to be exactly zero, even in the limit of infinite-length sequences. More generally, we show that this joint method only estimates branch lengths correctly on a set of measure zero. We show empirically that branch length estimates are systematically biased downward, even for short branches.

Deep generative models for T cell receptor protein sequences

Probabilistic models of adaptive immune repertoire sequence distributions can be used to infer the expansion of immune cells in response to stimulus, differentiate genetic from environmental factors that determine repertoire sharing, and evaluate the suitability of various target immune sequences for stimulation via vaccination. Classically, these models are defined in terms of a probabilistic V(D)J recombination model which is sometimes combined with a selection model. In this paper we take a different approach, fitting variational autoencoder (VAE) models parameterized by deep neural networks to T cell receptor (TCR) repertoires. We show that simple VAE models can perform accurate cohort frequency estimation, learn the rules of VDJ recombination, and generalize well to unseen sequences. Further, we demonstrate that VAE-like models can distinguish between real sequences and sequences generated according to a recombination-selection model, and that many characteristics of VAE-generated sequences are similar to those of real sequences.

Per-sample immunoglobulin germline inference from B cell receptor deep sequencing data

The collection of immunoglobulin genes in an individual's germline, which gives rise to B cell receptors via recombination, is known to vary significantly across individuals. In humans, for example, each individual has only a fraction of the several hundred known V alleles. Furthermore, the currently-accepted set of known V alleles is both incomplete (particularly for non-European samples), and contains a significant number of spurious alleles. The resulting uncertainty as to which immunoglobulin alleles are present in any given sample results in inaccurate B cell receptor sequence annotations, and in particular inaccurate inferred naive ancestors. In this paper we first show that the currently widespread practice of aligning each sequence to its closest match in the full set of IMGT alleles results in a very large number of spurious alleles that are not in the sample's true set of germline V alleles. We then describe a new method for inferring each individual's germline gene set from deep sequencing data, and show that it improves upon existing methods by making a detailed comparison on a variety of simulated and real data samples. This new method has been integrated into the partis annotation and clonal family inference package, available at https://github.com/psathyrella/partis, and is run by default without affecting overall run time.

Survival analysis of DNA mutation motifs with penalized proportional hazards

Antibodies, an essential part of our immune system, develop through an intricate process to bind a wide array of pathogens. This process involves randomly mutating DNA sequences encoding these antibodies to find variants with improved binding, though mutations are not distributed uniformly across sequence sites. Immunologists observe this nonuniformity to be consistent with "mutation motifs", which are short DNA subsequences that affect how likely a given site is to experience a mutation. Quantifying the effect of motifs on mutation rates is challenging: a large number of possible motifs makes this statistical problem high dimensional, while the unobserved history of the mutation process leads to a nontrivial missing data problem. We introduce an ℓ 1-penalized proportional hazards model to infer mutation motifs and their effects. In order to estimate model parameters, our method uses a Monte Carlo EM algorithm to marginalize over the unknown ordering of mutations. We show that our method performs better on simulated data compared to current methods and leads to more parsimonious models. The application of proportional hazards to mutation processes is, to our knowledge, novel and formalizes the current methods in a statistical framework that can be easily extended to analyze the effect of other biological features on mutation rates.

Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation

BACKGROUND

It has been documented that the smooth and move procedure-smoothing the proximal humeral surface while maintaining the coracoacromial arch-can provide clinically significant long-term improvement in function for patients having irreparable rotator cuff tears with retained active elevation. This study sought to demonstrate that clinically significant gains in comfort, function, and active motion can be realized as early as 6 weeks after this procedure.

METHODS

We conducted a prospective cohort study of the 6-week clinical outcomes for 48 patients enrolled prior to a smooth and move procedure for irreparable rotator cuff tears. Prior rotator cuff repair had been attempted in 28 (70%).

RESULTS

In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID). The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus. In 30 patients with preoperative and 6-week postoperative objective measurements of active motion, the average abduction improved from 93(± 43) to 123(± 47)° (p = 0.005) and the average flexion improved from 102(± 46) to 126(± 44)° (p = 0.023).

CONCLUSIONS

In addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.

Using Genotype Abundance to Improve Phylogenetic Inference

Modern biological techniques enable very dense genetic sampling of unfolding evolutionary histories, and thus frequently sample some genotypes multiple times. This motivates strategies to incorporate genotype abundance information in phylogenetic inference. In this article, we synthesize a stochastic process model with standard sequence-based phylogenetic optimality, and show that tree estimation is substantially improved by doing so. Our method is validated with extensive simulations and an experimental single-cell lineage tracing study of germinal center B cell receptor affinity maturation.

Clinical effectiveness and safety of the extended humeral head arthroplasty for selected patients with rotator cuff tear arthropathy

BACKGROUND

Cuff tear arthropathy is commonly managed with a reverse total shoulder arthroplasty (RTSA). A humeral hemiarthroplasty with an extended humeral head may provide a less invasive alternative for selected patients with cuff tear arthropathy if the shoulder has preserved active elevation. Because evidence regarding this procedure is limited, we investigated its safety and efficacy in treating selected patients with cuff tear arthropathy.

METHODS

We analyzed the preoperative characteristics, surgical findings, and clinical outcomes for patients selected for extended head hemiarthroplasty.

RESULTS

For 42 patients with 2-year follow-up, there were no complications or revisions. The Simple Shoulder Test score improved from a median of 3.0 to 8.0 (P < .001). The median percentage of maximal possible improvement was 50% (P < .001). The percentage of patients able to perform each of the functions of the Simple Shoulder Test was significantly improved; for example, the ability to sleep comfortably increased from 19% to 71%, and the ability to place a coin on the shelf at shoulder level increased from 38% to 86% (P < .001).

CONCLUSIONS

There are circumstances in which RTSA is clearly the preferred procedure for cuff tear arthropathy, including pseudoparalysis, anterosuperior escape, and glenohumeral instability; however, in shoulders with preserved active motion and stability of the humeral head provided by an intact coracoacromial arch, the extended head humeral arthroplasty can enable selected patients to realize improved comfort and function without the potential risks of RTSA. Extended humeral head hemiarthroplasty can provide a safe and effective alternative for the management of selected patients with rotator cuff tear arthropathy and preserved active motion.

Analysis of 4063 complications of shoulder arthroplasty reported to the US Food and Drug Administration from 2012 to 2016

BACKGROUND

Most of the literature on shoulder arthroplasty failure comes from high-volume centers. These reports tend to exclude the experience of community orthopedic surgeons, who perform most of the shoulder joint replacements.

METHODS

We analyzed the failure reports mandated by the US Food and Drug Administration for all hospitals. Each reported event from 2012 to 2016 was characterized by implant, failure mode, and year of surgery.

RESULTS

For the 1673 anatomic arthroplasties, the most common failure modes were glenoid component failure (20.4%), rotator cuff/subscapularis tear (15.4%), pain/stiffness (12.9%), dislocation/instability (11.8%), infection (9%), and humeral component loosening (5.1%). For the 2390 reverse arthroplasties, the most common failure modes were dislocation/instability (32%), infection (13.8%), glenosphere-baseplate dissociation (12.2%), failed/loosened baseplate (10.4%), humeral component dissociation/tray fracture (5.5%), difficulty inserting the baseplate (4.8%), and difficulty inserting the glenosphere (4.2%). Although the percentage distribution among the different failure modes was relatively consistent over the years of this study, the percentage distribution of these failure modes differed substantially among different implant manufacturers.

CONCLUSIONS

The Food and Drug Administration database reveals modes of shoulder arthroplasty failure that are not emphasized in the published literature, such as rotator cuff tear, infection, and postoperative pain/stiffness for anatomic total shoulder arthroplasty and implant dissociation and baseplate failure for reverse shoulder arthroplasty. Knowledge of these failure modes may help inform surgical technique and implant design in ways that will lower the risk of implant failure in the future.

Benchmarking Tree and Ancestral Sequence Inference for B Cell Receptor Sequences

B cell receptor sequences evolve during affinity maturation according to a Darwinian process of mutation and selection. Phylogenetic tools are used extensively to reconstruct ancestral sequences and phylogenetic trees from affinity-matured sequences. In addition to using general-purpose phylogenetic methods, researchers have developed new tools to accommodate the special features of B cell sequence evolution. However, the performance of classical phylogenetic techniques in the presence of B cell-specific features is not well understood, nor how much the newer generation of B cell specific tools represent an improvement over classical methods. In this paper we benchmark the performance of classical phylogenetic and new B cell-specific tools when applied to B cell receptor sequences simulated from a forward-time model of B cell receptor affinity maturation toward a mature receptor. We show that the currently used tools vary substantially in terms of tree structure and ancestral sequence inference accuracy. Furthermore, we show that there are still large performance gains to be achieved by modeling the special mutation process of B cell receptors. These conclusions are further strengthened with real data using the rules of isotype switching to count possible violations within each inferred phylogeny.

Predicting B cell receptor substitution profiles using public repertoire data

B cells develop high affinity receptors during the course of affinity maturation, a cyclic process of mutation and selection. At the end of affinity maturation, a number of cells sharing the same ancestor (i.e. in the same “clonal family”) are released from the germinal center; their amino acid frequency profile reflects the allowed and disallowed substitutions at each position. These clonal-family-specific frequency profiles, called “substitution profiles”, are useful for studying the course of affinity maturation as well as for antibody engineering purposes. However, most often only a single sequence is recovered from each clonal family in a sequencing experiment, making it impossible to construct a clonal-family-specific substitution profile. Given the public release of many high-quality large B cell receptor datasets, one may ask whether it is possible to use such data in a prediction model for clonal-family-specific substitution profiles. In this paper, we present the method “Substitution Profiles Using Related Families” (SPURF), a penalized tensor regression framework that integrates information from a rich assemblage of datasets to predict the clonal-family-specific substitution profile for any single input sequence. Using this framework, we show that substitution profiles from similar clonal families can be leveraged together with simulated substitution profiles and germline gene sequence information to improve prediction. We fit this model on a large public dataset and validate the robustness of our approach on two external datasets. Furthermore, we provide a command-line tool in an open-source software package (https://github.com/krdav/SPURF) implementing these ideas and providing easy prediction using our pre-fit models.

Antibody engineering can be greatly informed by knowledge about the underlying affinity maturation process. As such this can be probed by sequencing, but unfortunately, in practice often only one member of the clonal family is sequenced, making it difficult to determine a set of possible amino acid mutations that would retain the original antibody antigen binding affinity. We overcome this data sparsity by developing a statistical learning approach that leverages vast information about amino acid preferences available in public immune system repertoire data. We use a penalized regression approach to devise a flexible statistical model that integrates multiple sources of information into a coherent prediction framework and validate our prediction algorithm using subsampling and held out data.

Human T cell receptor occurrence patterns encode immune history, genetic background, and receptor specificity

The T cell receptor (TCR) repertoire encodes immune exposure history through the dynamic formation of immunological memory. Statistical analysis of repertoire sequencing data has the potential to decode disease associations from large cohorts with measured phenotypes. However, the repertoire perturbation induced by a given immunological challenge is conditioned on genetic background via major histocompatibility complex (MHC) polymorphism. We explore associations between MHC alleles, immune exposures, and shared TCRs in a large human cohort. Using a previously published repertoire sequencing dataset augmented with high-resolution MHC genotyping, our analysis reveals rich structure: striking imprints of common pathogens, clusters of co-occurring TCRs that may represent markers of shared immune exposures, and substantial variations in TCR-MHC association strength across MHC loci. Guided by atomic contacts in solved TCR:peptide-MHC structures, we identify sequence covariation between TCR and MHC. These insights and our analysis framework lay the groundwork for further explorations into TCR diversity.

The Bayesian optimist's guide to adaptive immune receptor repertoire analysis

Probabilistic modeling is fundamental to the statistical analysis of complex data. In addition to forming a coherent description of the data-generating process, probabilistic models enable parameter inference about given datasets. This procedure is well developed in the Bayesian perspective, in which one infers probability distributions describing to what extent various possible parameters agree with the data. In this paper, we motivate and review probabilistic modeling for adaptive immune receptor repertoire data then describe progress and prospects for future work, from germline haplotyping to adaptive immune system deployment across tissues. The relevant quantities in immune sequence analysis include not only continuous parameters such as gene use frequency but also discrete objects such as B-cell clusters and lineages. Throughout this review, we unravel the many opportunities for probabilistic modeling in adaptive immune receptor analysis, including settings for which the Bayesian approach holds substantial promise (especially if one is optimistic about new computational methods). From our perspective, the greatest prospects for progress in probabilistic modeling for repertoires concern ancestral sequence estimation for B-cell receptor lineages, including uncertainty from germline genotype, rearrangement, and lineage development.

Consistency and convergence rate of phylogenetic inference via regularization

It is common in phylogenetics to have some, perhaps partial, information about the overall evolutionary tree of a group of organisms and wish to find an evolutionary tree of a specific gene for those organisms. There may not be enough information in the gene sequences alone to accurately reconstruct the correct "gene tree." Although the gene tree may deviate from the "species tree" due to a variety of genetic processes, in the absence of evidence to the contrary it is parsimonious to assume that they agree. A common statistical approach in these situations is to develop a likelihood penalty to incorporate such additional information. Recent studies using simulation and empirical data suggest that a likelihood penalty quantifying concordance with a species tree can significantly improve the accuracy of gene tree reconstruction compared to using sequence data alone. However, the consistency of such an approach has not yet been established, nor have convergence rates been bounded. Because phylogenetics is a non-standard inference problem, the standard theory does not apply. In this paper, we propose a penalized maximum likelihood estimator for gene tree reconstruction, where the penalty is the square of the Billera-Holmes-Vogtmann geodesic distance from the gene tree to the species tree. We prove that this method is consistent, and derive its convergence rate for estimating the discrete gene tree structure and continuous edge lengths (representing the amount of evolution that has occurred on that branch) simultaneously. We find that the regularized estimator is "adaptive fast converging," meaning that it can reconstruct all edges of length greater than any given threshold from gene sequences of polynomial length. Our method does not require the species tree to be known exactly; in fact, our asymptotic theory holds for any such guide tree.

Preoperative skin cultures are predictive of Propionibacterium load in deep cultures obtained at revision shoulder arthroplasty

BACKGROUND

Propionibacterium-specific cultures are commonly positive in revised shoulders without obvious signs of infection. To help identify patients at risk for these "stealth" presentations of positive Propionibacterium cultures, we assessed the value of a preoperative skin culture in predicting the results of deep cultures obtained at the time of revision shoulder arthroplasty in patients without clinical evidence of infection.

METHODS

The study enrolled 60 patients undergoing revision for a prior shoulder arthroplasty without clinical evidence of infection. A preoperative culture of the skin surface was taken before skin preparation. At surgery, multiple (mean 5.9 ± standard deviation 1.6) deep tissue and explant cultures were harvested from the shoulder. Each culture was semiquantitatively reported as the specimen Propionibacterium value (SpPV). All SpPVs from the deep specimens from each patient were summed as the total shoulder Propionibacterium score (ShPS). The averaged ShPS was the total ShPS divided by the number of deep specimens harvested.

RESULTS

A multivariate analysis demonstrated that the preoperative skin SpPV was predictive of the Propionibacterium load in the revised shoulders as indicated by the total ShPS (P = .004) and averaged ShPS (P = .003).

CONCLUSIONS

In this series of patients, a preoperative culture of the unprepared skin was strongly predictive of the Propionibacterium load in revised shoulder arthroplasties without clinical evidence of infection. This result suggests that the results of skin cultures taken before revision surgery may help inform operative management with respect to the need for prosthesis exchange and extended postoperative antibiotic treatment.

Preoperative Skin-Surface Cultures Can Help to Predict the Presence of Propionibacterium in Shoulder Arthroplasty Wounds

Background:

Propionibacterium species are commonly cultured from specimens harvested at the time of revision shoulder arthroplasty. These bacteria reside in normal sebaceous glands, out of reach of surgical skin preparation. The arthroplasty incision transects these structures, which allows Propionibacterium to inoculate the wound and to potentially lead to the formation of a biofilm on the inserted implant. To help identify patients who are at increased risk for wound inoculation, we investigated whether preoperative cultures of the specimens from the unprepared skin surface were predictive of the results of intraoperative cultures of dermal wound-edge specimens obtained immediately after incision of the surgically prepared skin.

Methods:

Sixty-six patients (mean age, 66.1 ± 9.4 years [range, 37 to 82 years]; 73% male) undergoing primary shoulder arthroplasty had preoperative cultures of the unprepared skin surface and intraoperative cultures of the freshly incised dermis using special culture swabs. For the first 50 patients, a control swab was opened to air during the same time that the dermal specimen was obtained. The results for female and male patients were characterized as the Specimen Propionibacterium Value (SpPV). We then determined the degree to which the results of cultures of the skin surface specimens were predictive of the results of culture of the dermal specimens.

Results:

The skin-surface SpPV was ≥1 in 3 (17%) of the 18 female patients and 34 (71%) of the 48 male patients (p < 0.001). The dermal SpPV was ≥1 in 0 (0%) of the 18 female patients and 19 (40%) of the 48 male patients (p < 0.001). None of the control samples had an SpPV of ≥1. The predictive characteristics of a skin-surface SpPV of ≥1 for a dermal SpPV of ≥1 were as follows: sensitivity, 1.00 (95% confidence interval [CI], 0.82 to 1.00); specificity, 0.62 (95% CI, 0.46 to 0.75); positive predictive value, 0.51 (95% CI, 0.34 to 0.68); and negative predictive value, 1.00 (95% CI, 0.88 to 1.00).

Conclusions:

A preoperative culture of the unprepared skin surface can help to predict whether the freshly incised dermal edge is likely to be positive for Propionibacterium. This test may help to identify patients who may merit more aggressive topical and systemic antibiotic prophylaxis.

Clinical Relevance:

This study shows that surgeons have the opportunity to use preoperative skin cultures to determine the likelihood that the shoulder arthroplasty wound will be culture-positive for Propionibacterium.

Tanglegrams: A Reduction Tool for Mathematical Phylogenetics

Many discrete mathematics problems in phylogenetics are defined in terms of the relative labeling of pairs of leaf-labeled trees. These relative labelings are naturally formalized as tanglegrams, which have previously been an object of study in coevolutionary analysis. Although there has been considerable work on planar drawings of tanglegrams, they have not been fully explored as combinatorial objects until recently. In this paper, we describe how many discrete mathematical questions on trees "factor" through a problem on tanglegrams, and how understanding that factoring can simplify analysis. Depending on the problem, it may be useful to consider a unordered version of tanglegrams, and/or their unrooted counterparts. For all of these definitions, we show how the isomorphism types of tanglegrams can be understood in terms of double cosets of the symmetric group, and we investigate their automorphisms. Understanding tanglegrams better will isolate the distinct problems on leaf-labeled pairs of trees and reveal natural symmetries of spaces associated with such problems.

Functional Outcomes of the Ream-and-Run Shoulder Arthroplasty: A Concise Follow-up of a Previous Report

We previously reported the results at an average of 4.5 years after treatment of 176 patients with the ream-and-run arthroplasty. In the present study, we present the patient self-reported functional outcomes and clinical implant survival of the original cohort at a mean of 10 years (range, 5 to 16 years). Twenty-eight (16%) of the 176 patients had a subsequent procedure, 11 (6%) died, and 30 (17%) had <5 years of follow-up. The Simple Shoulder Test (SST) score at the time of the latest follow-up was a median of 11 points (interquartile range, 9 to 12 points) and a mean (and standard deviation) of 10 ± 2.6 points, out of a possible 12 points. The present study demonstrates that the improvement in function and comfort derived from the ream-and-run procedure can be sustained at the time of mid-term follow-up.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?

BACKGROUND

While glenoid retroversion and posterior humeral head decentering are common preoperative features of severely arthritic glenohumeral joints, the relationship of postoperative glenoid component retroversion to the clinical results of total shoulder arthroplasty (TSA) is unclear. Studies have indicated concern for inferior outcomes when glenoid components are inserted in 15° or more retroversion.

QUESTIONS/PURPOSES

In a population of patients undergoing TSA in whom no specific efforts were made to change the version of the glenoid, we asked whether at 2 years after surgery patients having glenoid components implanted in 15° or greater retroversion had (1) less improvement in the Simple Shoulder Test (SST) score and lower SST scores; (2) higher percentages of central peg lucency, higher Lazarus radiolucency grades, higher mean percentages of posterior decentering, and more frequent central peg perforation; or (3) a greater percentage having revision for glenoid component failure compared with patients with glenoid components implanted in less than 15° retroversion.

METHODS

Between August 24, 2010 and October 22, 2013, information for 201 TSAs performed using a standard all-polyethylene pegged glenoid component were entered in a longitudinally maintained database. Of these, 171 (85%) patients had SST scores preoperatively and between 18 and 36 months after surgery. Ninety-three of these patients had preoperative radiographs in the database and immediate postoperative radiographs and postoperative radiographs taken in a range of 18 to 30 months after surgery. Twenty-two patients had radiographs that were inadequate for measurement at the preoperative, immediate postoperative, or latest followup time so that they could not be included. These excluded patients did not have substantially different mean age, sex distribution, time of followup, distribution of diagnoses, American Society of Anesthesiologists class, alcohol use, smoking history, BMI, or history of prior surgery from those included in the analysis. Preoperative retroversion measurements were available for 11 (11 shoulders) of the 22 excluded patients. For these 11 shoulders, the mean (± SD) retroversion was 15.8° ± 14.6°, five had less than 15°, and six had more than 15° retroversion. We analyzed the remaining 71 TSAs, comparing the 21 in which the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°) with the 50 in which it was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°). At the 2-year followup (mean ± SD, 2.5 ± 0.6 years; range, 18-36 months), we determined the latest SST scores and preoperative to postoperative improvement in SST scores, the percentage of maximal possible improvement, glenoid component radiolucencies, posterior humeral head decentering, and percentages of shoulders having revision surgery. Radiographic measurements were performed by three orthopaedic surgeons who were not involved in the care of these patients. The primary study endpoint was the preoperative to postoperative improvement in the SST score.

RESULTS

With the numbers available, the mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The mean difference in improvement between the two groups was 0.9 (95% CI, - 2.5 to 0.7; p = 0.412). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%). The mean difference between the two groups was 3% (95% CI, - 18% to 12%; p = 0.857). The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, - 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. With the numbers available, the radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4-6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). With the numbers available, the percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids (three of 50; [6%]; p = 0.251).

CONCLUSION

In this small series of TSAs, postoperative glenoid retroversion was not associated with inferior clinical results at 2 years after surgery. This suggests that it may be possible to effectively manage arthritic glenohumeral joints without specific attempts to modify glenoid version. Larger, longer-term studies will be necessary to further explore the results of this approach.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity

BACKGROUND

The rationale for rotator cuff repair surgery is that better integrity of the cuff should be associated with better comfort and function. However, in patients with cuff disease, there is not good evidence that the degree of rotator cuff integrity is closely associated with the shoulder's comfort, function, or active motion. The goal of this study was to explore these relationships in shoulders with surgically documented cuff disease.

METHODS

In 55 shoulders having surgery for cuff-related symptoms, we correlated the preoperative Simple Shoulder Test score with the objectively measured preoperative active shoulder motion and with the integrity of the cuff observed at surgery.

RESULTS

The 16 shoulders with tendinosis or partial-thickness tears had an average Simple Shoulder Test score of 3.7 ± 3.3, active abduction of 111° ± 38°, and active flexion of 115° ± 36°. The corresponding values were 3.6 ± 2.8, 94° ± 47°, and 94° ± 52° for the 22 full-thickness supraspinatus tears and 3.9 ± 2.7, 89° ± 39°, and 100° ± 39° for the 17 supraspinatus and infraspinatus tears.

CONCLUSION

In this study, surgically observed cuff integrity was not strongly associated with the shoulder's comfort or function. Whereas surgeons often seek to improve the integrity of the rotator cuff, the management of patients with rotator cuff disorders needs to be informed by a better understanding of the factors other than cuff integrity that influence the comfort and functioning of shoulders with cuff disease.

Is the Simple Shoulder Test a valid outcome instrument for shoulder arthroplasty?

BACKGROUND

The Simple Shoulder Test (SST) is a brief, inexpensive, and widely used patient-reported outcome tool, but it has not been rigorously evaluated for patients having shoulder arthroplasty. The goal of this study was to rigorously evaluate the validity of the SST for outcome assessment in shoulder arthroplasty using a systematic review of the literature and an analysis of its properties in a series of 408 surgical cases.

METHODS

SST scores, 36-Item Short Form Health Survey scores, and satisfaction scores were collected preoperatively and 2 years postoperatively. Responsiveness was assessed by comparing preoperative and 2-year postoperative scores. Criterion validity was determined by correlating the SST with the 36-Item Short Form Health Survey. Construct validity was tested through 5 clinical hypotheses regarding satisfaction, comorbidities, insurance status, previous failed surgery, and narcotic use.

RESULTS

Scores after arthroplasty improved from 3.9 ± 2.8 to 10.2 ± 2.3 (P < .001). The change in SST correlated strongly with patient satisfaction (P < .001). The SST had large Cohen's d effect sizes and standardized response means. Criterion validity was supported by significant differences between satisfied and unsatisfied patients, those with more severe and less severe comorbidities, those with workers' compensation or Medicaid and other types of insurance, those with and without previous failed shoulder surgery, and those taking and those not taking narcotic pain medication before surgery (P < .005).

CONCLUSION

These data combined with a systematic review of the literature demonstrate that the SST is a valid and responsive patient-reported outcome measure for assessing the outcomes of shoulder arthroplasty.