Stephen D. Gill

Background: Total shoulder arthroplasty (TSA) is increasingly used to treat a range of shoulder disorders. Although TSA improves pain and function, its cost-effectiveness remains uncertain. This systematic review evaluated the cost-effectiveness of TSA for glenohumeral arthritis, rotator cuff arthropathy, massive rotator cuff tears and proximal humerus fractures. Methods: We systematically searched MEDLINE, Embase, and CINAHL from inception to July 2025 for full economic evaluations comparing TSA with surgical or non-operative alternatives. Eligible studies included primary anatomical total shoulder arthroplasty (ATSA) or reverse total shoulder arthroplasty (RTSA). Studies could be randomised, observational or model-based, and had to provide costs and outcomes to allow determination of an incremental cost-effectiveness ratio or equivalent expression. Study quality was assessed with the Drummond checklist. Given study heterogeneity, results were synthesised narratively. Results: Of 308 potentially eligible studies, 26 were included, comprising 15,163 patients, all of which were conducted in high-income countries. Fifteen studies were modelled, relying on published literature for costs and outcomes. Most studies were rated as fair (58%) or good (38%) quality. In four studies regarding osteoarthritis, ATSA was consistently cost-effective or dominant (more effective and less costly) over hemiarthroplasty. In three studies regarding osteoarthritis with intact rotator cuff, ATSA and RTSA were similarly effective, and costs were similar or less for ATSA, depending on patient age. In four studies regarding proximal humerus fractures, RTSA was cost-effective or dominant over hemiarthroplasty. In three studies regarding massive rotator cuff tears, cuff repair was always substantially less costly and marginally more effective than RTSA. Conclusions: Despite the increasing use of TSA, evidence regarding its cost-effectiveness is limited to a small number of studies from high-income countries. Although TSA might be cost-effective for selected indications, high-quality, randomised, prospective economic evaluations from a diverse range of settings are needed to provide rigorous evidence to guide value-based care in shoulder arthroplasty.

Background: The COVID-19 pandemic produced a substantial reduction in arthroplasties, which could have affected patient quality of life. This study investigated quality of life in Australians undergoing elective arthroplasty before and during the COVID-19 pandemic. Methods: Using data from the Australian Orthopaedic Association National Joint Replacement Registry, quality of life was assessed in patients before and six months after primary total hip arthroplasty (THA), total knee arthroplasty (TKA) and reverse total shoulder arthroplasty (RTSA) using the EQ-5D-5L instrument. Patients with an EQ-5D Utility score less than zero were considered to have a quality of life worse than dead. Secondary outcomes included Oxford Scores, joint-specific pain, patient perceived change, responder status and patient satisfaction. Quality of life was compared before (1 July 2018–10 March 2020) and during the pandemic (11 March 2020–10 March 2023) using linear or logistic regression models. Results: The analysis included preoperative data for more than 24,000 THA patients, 20,000 TKA patients and 1,100 RTSA patients. Compared to the pre-pandemic period, preoperative and postoperative quality of life significantly reduced during the pandemic for THA and TKA, but not by a meaningful amount (adjusted mean difference ≤ 0.03 points, p < 0.001). The likelihood of having quality of life worse than dead increased during the pandemic but was only significant for preoperative THA (ORs 1.24 to 1.40, p < 0.02). For secondary outcomes, joint-specific scores deteriorated, and joint pain increased to a small degree during the pandemic for THA and TKA ( p < 0.05), but not for RTSA. The proportion of THA and TKA patients satisfied with their surgery outcome increased modestly during the pandemic by approximately five percentage points, compared to pre-pandemic. Conclusion: The COVID-19 pandemic was not associated with a clinically meaningful deterioration in pre- or post-operative quality of life, on average, for patients undergoing THA, TKA or RTSA in Australia.

Genicular artery embolization (GAE) is an emerging, minimally invasive procedure for treating knee osteoarthritis (OA) that targets pain-producing neovessels and inflammation. Over the last decade, interest in GAE has grown rapidly. This descriptive review synthesizes key evidence regarding GAE's proposed mechanisms of effect, procedural techniques, effectiveness and safety. Single-arm studies and meta-analyses consistently report significant improvements in pain and function following GAE, however these are limited by the absence of comparison groups. Three placebo-controlled randomized trials have yielded mixed results, with two studies suggesting strong nonspecific effects. Effectiveness appears greater in early-stage OA, with diminishing effects in advanced disease. Animal studies and preliminary human imaging data support anti-inflammatory effects, although causal links in humans remain unconfirmed. Procedural variables such as embolic agent type and number of arteries treated appear to influence outcomes and adverse events. Biodegradable agents may offer improved safety profiles compared to permanent materials, though conclusive comparative data are lacking. Most complications reported to date have been minor and self-limiting, including transient skin ischemia and procedural pain. Looking ahead, carefully designed, large-scale trials with standardized protocols, biomarkers, and longer follow-up are needed to define GAE's role in OA management and to determine whether it provides benefits beyond placebo.

Gill SD, et al. Clin Orthop Surg. 2026 Apr;18(2):380. https://doi.org/10.4055/cios25052corr

Metabolic syndrome (MetS) associated with Osteoarthritis (OA) is an increasingly recognised entity. Whilst the degenerative pattern in cuff-tear arthropathy (CTA) has been well documented, the biological processes behind primary shoulder OA and CTA remain less understood. This study investigates transcriptomic differences in these conditions, alongside the impact of MetS in patients undergoing total shoulder replacement. In a multi-centre study, 20 OA patients undergoing total shoulder replacement were included based on specific treatment indications for OA and cuff-tear arthropathy as well as 25 patients undergoing rotator cuff repair (RCR) as a comparator group. Tissues from subchondral bone, capsule (OA and RCR), and synovium were biopsied, and RNA sequencing was performed using Illumina platforms. Differential gene expression was conducted using DESeq2, adjusting for demographic factors, followed by pathway enrichment using the mitch package. Gene expressions in CTA and primary OA was differentially affected. CTA showed mitochondrial dysfunction, GATD3A downregulation, and increased cartilage degradation, while primary OA was marked by upregulated inflammatory and catabolic pathways. The effect of MetS on these pathologies was further shown. MetS further disrupted WNT/β-catenin signalling in CTA, and in OA. Genes such as ACAN, PANX3, CLU, and VAT1L were upregulated, highlighting potential biomarkers for early OA detection. This transcriptomic analysis reveals key differences between end-stage CTA and primary glenohumeral OA. CTA shows heightened metabolic/protein synthesis activity with less immune-driven inflammation. Under MetS, mitochondrial dysfunction (including GATD3A downregulation) and altered Wnt/β-catenin signalling intensify cartilage and bone damage. In contrast, primary OA features strong complement activation, inflammatory gene expression, and collagen remodelling. MetS worsens both conditions via oxidative stress, advanced glycation end products, and ECM disruption—particularly, increased CS/DS degradation. These distinctions support targeted treatments, from antioxidants and Wnt modulators to aggrecanase inhibitors or clusterin augmentation. Addressing specific molecular disruptions, especially those amplified by MetS, may preserve shoulder function, delay surgical intervention, and improve long-term patient outcomes.

Background: COVID‐19 affected access to healthcare. Victoria, Australia was heavily affected. Hospitals deferred non‐urgent operations and preserved health resources to manage people with COVID‐19. Elective orthopaedic surgery was directly impacted. This study investigated changes to orthopaedic procedures and the elective surgery waitlist during the COVID‐19 at a large regional health service in Victoria.Methods: Data were acquired from University Hospital Geelong, a publicly funded regional health service in Victoria, Australia. Orthopaedic surgeries and waitlist numbers were collated for financial years ending (FYE) 2020–2023. Procedures were displayed as total, planned and unplanned (i.e., trauma).Results: From FYE 2020 to 2023 there was 8244 orthopaedic surgery cases with 8850 procedures. Planned joint replacements of knee, hip and shoulder decreased collectively by 19% in FYE 2022 and increased by 66% in FYE 2023. Waiting lists rose from 247 in FYE 2020 and peaked at 786 in FYE 2022, before falling to 390 in FYE 2023. The number of fractured neck of femur procedures were consistent each year (average 152/year), while ankle and wrist fractures declined by 55% and 43% during FYE 2022 and increased in FYE 2023 by 106% and 159% respectively.Conclusion: Changes to planned orthopaedic procedures and waitlists in a regional centre were evident throughout the pandemic. These results can help to inform strategies to optimize the provision of orthopaedic surgery during future major disruptive events.

Gill SD, et al. Clin Orthop Surg. 2025 Oct;17(5):779-786. https://doi.org/10.4055/cios25052

Background With advances in health state valuation methods, new value sets may be developed for some countries. Quantifying the impact of moving between existing and new value sets is critical for guiding decisions around utility score interpretation, reporting and comparison with published scores. Objectives The aim of this study is to examine, using large-scale national registry data, how the new Australian EQ-5D-5L value set impacts utility scores for patients undergoing joint replacement. Methods Data from the Australian Orthopaedic Association National Joint Replacement Registry were used for this analysis. All primary total hip (THR), knee (TKR), and shoulder replacement (TSR) procedures between 2018 and 2022 with pre-operative and 6-month post-operative EQ-5D-5L data were included. Utility scores were generated using the 2013 and 2023 Australian value sets (‘previous’ and ‘new’ value sets, respectively) and analysed descriptively for each joint replacement cohort. Agreement between the two utility score sets was evaluated using concordance correlation coefficients and Bland–Altman plots. Results EQ-5D-5L data were available for 17,576 THR, 23,010 TKR, and 1667 TSR procedures. The new value set produced a lowest possible EQ-5D-5L utility score of −0.30 (compared with −0.68 previously) and fewer patients had ‘worse-than-dead’ quality of life (score < 0.00) before surgery. Mean pre-operative scores were 0.21 (THR), 0.19 (TKR), and 0.17 (TSR) units higher with the new value set, and mean post-operative scores were 0.11–0.14 units higher. The new value set resulted in smaller effect sizes for the THR (1.08 versus 1.23) and TKR cohorts (0.86 versus 0.92). There was moderate-to-good overall agreement (coefficients: 0.70–0.80), but concordance varied by time point. Conclusion Although acceptable agreement was evident, the new Australian value set produces less extreme negative utility scores and markedly higher group-level scores. Transition to reporting new EQ-5D-5L utility scores will require accompanying explanation to signal measurement modifications rather than better quality of life.