Factors predicting complication rates after primary shoulder arthroplasty

[Survival rate and complications of stemmed shoulder prostheses in primary osteoarthritis]

Survivorship and survival rate of shoulder prostheses can be affected by a large number of possible complications. An evaluation of the current literature and the prosthesis register, however, shows an overall low revision (1.39 revisions per 100 observation years) and loosening rates (implant-related 10-year survival rate up to 99%), comparable to that of hip and knee endoprostheses. It must be emphasized that cementless stems more often cause problems than cemented components (4.34 compared to 0.77 revisions per 100 observation years) and that secondary rotator cuff rupture (4.6%; functional deficit up to 30%) occurs more frequently than was generally assumed and is often not diagnosed or treated adequately. The infection rate amounts to approximately 1% and according to latest literature the dislocation rate is regressive and is estimated to be approximately 5%.The low complication and revision rates do not justify the replacement of stemmed prostheses by stemless implants and short stem prostheses and the preference given to the new implants is attributed more to the better revision possibilities and easier convertibility into inverse prostheses.

What are the factors influencing outcome among patients admitted to a hospital with a proximal humeral fracture?

BACKGROUND

Fracture of the proximal humerus is common in older patients during the decline of their physical health.

QUESTIONS/PURPOSES

Our purpose was to evaluate the association between specific risk factors in patients with fractures of the proximal humerus and any inpatient adverse events, mortality, and discharge to a short-term or long-term care facility.

METHODS

The National Hospital Discharge Survey (NHDS) provided estimates of all adult patients who were admitted to hospitals after fractures of the proximal humerus in the United States between 1990 and 2007. The influences of sex, age, days of care, diagnosis and procedures (based on ICD-9 codes) on inpatient adverse events and death, and discharge to a short-term or long-term care facility, were studied in bivariate and multivariable analyses.

RESULTS

Among an estimated 867,282 patients admitted for proximal humerus fractures, 20% experienced adverse events, and 2.3% died in the hospital. Older age, concomitant femur and femoral neck fractures or head trauma, operative fracture care, congestive heart failure, and chronic alcoholism were associated with inpatient adverse events. Intubation, acute myocardial infarctions, malignancies, and skull fractures were associated with inpatient deaths. Older age, lower limb fractures, specific comorbidities (obesity, congestive heart failure, dementia), and inpatient adverse events (pneumonia, anemia treated with transfusion) were associated with discharges to short-term or long-term care facilities.

CONCLUSIONS

Knowledge of risk factors for inpatient adverse events, mortality, and discharge to facilities can help make treatment decisions, improve overall care, discharge planning, and resource utilization for patients with proximal humeral fractures.

Shoulder arthroplasty in osteoarthritis: correlation between function and radiographic parameters

OBJECTIVES

To evaluate the correlation between radiographic parameters and functional assessments of patients with osteoarthritis of the shoulder who underwent shoulder arthroplasty and to describe the functional outcomes of this procedure in our institution.

METHODS

We evaluated 21 patients (22 shoulders) who underwent shoulder arthroplasty between 1998 and 2010 and with a minimum follow-up of 12 months. Clinical evaluation was performed using the Constant-Murley scale, UCLA, EVA and by measuring the active motion. We analysed preoperative (distance between the top of the head and the humerus and the acromion, superior migration, neck angulation, medial "offset", subluxation, glenoid erosion) and postoperative radiographic parameters (rod inclination, migration of components and loosening).

RESULTS

PATIENTS SHOWED SIGNIFICANT IMPROVEMENT IN ALL PARAMETERS: flexion (p = 0.0083), abduction (p = 0.0266), external rotation (p = 0.0062), Constant-Murley (p = 0.0001 ), UCLA (p <0.0001) and VAS (p = 0.0002). The superior migration of the humerus showed a significant correlation with UCLA and Constant-Murley scores (p = 0.0480 and p = 0.0110, respectively). The other radiographic parameters showed no correlation with the clinical outcomes.

CONCLUSION

The superior migration of the humerus is related to worse clinical scores. Level of Evidence IV, Case Series.

Impact of prosthetic design on clinical and radiologic outcomes of total shoulder arthroplasty: a prospective study

BACKGROUND

This prospective longitudinal study compared clinical and radiologic outcomes of total shoulder arthroplasty (TSA) using 3 different prosthetic designs, the Neer II system, the Bigliani-Flatow (BF), and a stemless prosthesis, the Total Evolutive Shoulder System (TESS).

MATERIALS AND METHODS

Patients with advanced osteoarthritis 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.

RESULTS

Seventy-four 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 < .0001). Active external rotation at 90° abduction was statistically significantly lower in the Neer II group (P = .001). The incidence of lucent lines around the glenoid component was higher in the Neer II group (P = .0002). No statistically significant relationship was seen between type of prosthesis and patient satisfaction (P > 0.05).

CONCLUSIONS

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.

Late prosthetic shoulder hemiarthroplasty after failed management of complex proximal humeral fractures

Background. The purpose of this study was to report our experience with shoulder hemiarthroplasty in the context of old trauma. Methods. 33 patients with failed treatment for a complex proximal humeral fracture underwent prosthetic hemiarthroplasty. There were 15 men and 18 women with a mean age of 58.1 years. The average period from initial treatment was 14.9 months. Sequelae included 11 malunions, 4 nonunions, 15 cases with avascular necrosis (AVN) and 3 neglected posterior locked dislocations. Follow up investigation included radiological assessment and clinical evaluation using the Constant score and a visual analogue pain scale. Results. After a mean follow up of 82.5 months the median Constant score was 75.7 points, improved by 60% in comparison to preoperative values. Greater tuberosity displacement, large cuff tears and severe malunion were the factors most affected outcome. No cases of stem loosening or severe migration were noted. 60% of the patients were able to do activities up to shoulder level compared with 24% before reconstruction. Conclusions. Late shoulder hemiarthroplasty is technically difficult and the results are inferior to those reported for acute humeral head replacement, nonetheless remains a satisfactory reconstructive option when primary treatment fails.

Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures

BACKGROUND

Complex acute proximal humeral fractures may require prosthetic replacement of the proximal humerus. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative to hemiarthroplasty in the management of such fractures. This study compared the functional outcomes of RSA with hemiarthroplasty in patients with acute proximal humeral fractures.

MATERIALS AND METHODS

All patients who underwent RSA or shoulder hemiarthroplasty for acute proximal humeral fractures between January 1, 1999, and December 31, 2010 were identified from The New Zealand Joint Registry. Baseline information, operative characteristics, and postoperative outcomes (Oxford Shoulder Score [OSS] at 6 months and 5 years, revision rate, and mortality rate) were examined and compared between the study groups.

RESULTS

During the study period, 55 patients underwent RSA and 313 underwent shoulder hemiarthroplasty for acute proximal humeral fractures. Compared with hemiarthroplasty patients, RSA patients were significantly older (mean age, 79.6 vs 71.9 years; P < .001) and more often women (93% vs 78%, P = .013). The 6-month OSS was 28.1 for RSA and 27.9 for hemiarthroplasty, which was not significantly different (P = .923); however, the RSA group had a significantly better 5-year OSS than the hemiarthroplasty group (41.5 vs 32.3; P = .022). There was no significant difference between the RSA and hemiarthroplasty groups in revision rate per 100 component-years (1.7 vs 1.1; P = .747) or in 1-year mortality (3.5% vs 3.6%; P > .99).

CONCLUSIONS

Patients with acute proximal humeral fractures who undergo RSA appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty.

The venous thromboembolic complications of shoulder and elbow surgery

We investigated the incidence of and risk factors for venous thromboembolism (VTE) following surgery of the shoulder and elbow and assessed the role of thromboprophylaxis in upper limb surgery. All papers describing VTE after shoulder and elbow surgery published in the English language literature before 31 March 2012 were reviewed. A total of 14 papers were available for analysis, most of which were retrospective studies and case series. The incidence of VTE was 0.038% from 92 440 shoulder arthroscopic procedures, 0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures for fractures of the proximal humerus (open reduction and internal fixation or hemiarthroplasty). The incidence following replacement of the elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid arthritis and ischaemic heart disease were identified as the major risk factors.

The evidence that exists on thromboprophylaxis is based on level III and IV studies, and we therefore cannot make any recommendations on prophylaxis based on the current evidence. It seems reasonable to adopt a multimodal approach that involves all patients receiving mechanical prophylaxis, with chemical prophylaxis reserved for those who are at high risk for VTE.

Cite this article: Bone Joint J 2013;95-B:70–4.

Stemless shoulder prosthesis versus conventional anatomic shoulder prosthesis in patients with osteoarthritis: a comparison of the functional outcome after a minimum of two years follow-up

Background

The stemless shoulder prosthesis is a new concept in shoulder arthroplasty. To date, only a few studies have investigated the results of this prosthesis. The aim of this study was to investigate the clinical and radiological midterm results of this implant in comparison with a standard anatomic stemmed shoulder prosthesis.

Materials and methods

The Constant score, the DASH score, the active range of motion (abduction, anteversion, external rotation), and the radiological results were examined in 82 patients with primary osteoarthritis of the shoulder treated with either the Total Evolutive Shoulder System^® (Biomed, France) stemless shoulder prosthesis or the Affinis^® (Mathys, Switzerland) stemmed shoulder prosthesis to detect possible differences in the functional outcome and to evaluate radiological properties of the implants. Patients were examined before and 32 ± 4 months after surgery.

Results

There was no significant difference in the Constant scores of the groups treated with the stemless shoulder prosthesis (65.0 ± 11.0 points) and the stemmed shoulder prosthesis (73.2 ± 11.3 points; P = 0.162). The estimated blood loss (P = 0.026) and the mean operative time (P = 0.002) were significantly lower in the group with the stemless shoulder prosthesis.

Conclusions

The use of the stemless shoulder prosthesis yielded good results which, in a mid-term follow-up, were comparable with those provided by a standard anatomic shoulder prosthesis. Further investigations are needed regarding the long-term performance of this prosthesis.

Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.

Results of the Total Evolutive Shoulder System (TESS): a single-centre study of 56 consecutive patients

BACKGROUND

Shoulder arthroplasty surgery has undergone remarkable progress. New concepts like reverse and stemless shoulder prostheses have been widely used. The Total Evolutive Shoulder System (TESS) is a new innovative system that provides the surgeon with different prosthetic versions. The purpose of the present study was to evaluate our short-term results and complications of the TESS.

PATIENTS AND METHODS

56 consecutive patients were operated with one of the two versions of TESS (anatomical or reverse) between October 2007 and December 2009. Preoperative and postoperative evaluation of the function and life quality was achieved by the Quick Disability of the Arm, Shoulder and Hand (DASH) index and EQ-5D self-report questionnaire, respectively. Radiographic follow-up by anteroposterior, axillary and lateral views was done. The anterosuperior approach was used in all cases. We compared the outcome in fracture patients with other categories.

RESULTS

49 patients were available for 9-24 months (mean 14) clinical and radiographic postoperative follow-up. The mean of quick DASH improved from 56 preoperatively to 34 postoperatively (p < 0.001) and EQ-5D from 0.36 preoperatively to 0.73 postoperatively (p < 0.001). The complications were few and we had no radiolucencies or scapular notching during the study period. Fracture patients did worse compared to other categories.

CONCLUSIONS

TESS prosthesis showed promising short-term results with few complications. The reverse version could be implanted without stem if initial stability was adequate. Long-term follow-up is required to confirm the results of this innovative system in the long run.