National trends and perioperative outcomes in primary and revision total shoulder arthroplasty: Trends in total shoulder arthroplasty

After Primary Total Shoulder Arthroplasty, Factors Associated with Returning to the Same Surgeon for Subsequent Total Shoulder Arthroplasty

BACKGROUND

Total shoulder arthroplasty (TSA) is commonly done for degenerative conditions. Patients may need additional contralateral TSA or ipsilateral revision TSA. As a marker of patient satisfaction and practice integrity, factors associated with return to the same or different surgeon are of interest.

METHODS

Patients undergoing TSA were abstracted from the PearlDiver data set. Subsequent TSA within 2 years was identified. Factors analyzed included age, sex, comorbidity burden, prior depression diagnosis, insurance type, reverse versus anatomic TSA, ipsilateral versus contralateral surgery, and postoperative adverse events. Patients returning to the same surgeon versus different surgeon were compared with multivariable analysis.

RESULTS

98,048 TSA patients were identified, with 8483 patients (8.7%) undergoing subsequent TSA within 2 years. Of those, 1,237 (14.6%) chose a different surgeon. Factors associated with changing surgeons were revision surgery on the ipsilateral shoulder (OR:2.47), Medicaid insurance (OR:1.46), female sex (OR:1.36), any adverse events (OR:1.23), and higher Elixhauser Comorbidity Index (OR:1.07 per point), while prior depression diagnosis was associated with decreased odds (OR:0.74) of changing surgeon (P < 0.05 for all).

DISCUSSION

When pursuing a subsequent TSA, only a minority of patients changed to a different surgeon. Factors identified associated with changing to a different surgeon may help guide measures to improve patient satisfaction and practice integrity.

The association of hyponatremia and early postoperative complications in aseptic revision total shoulder arthroplasty

PURPOSE

This study investigates the association between preoperative serum sodium levels and 30-day postoperative complications following aseptic revision total shoulder arthroplasty (TSA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent aseptic revision TSA from 2015 to 2022. The study population was divided into two groups based on preoperative serum sodium levels: eunatremia (135-144 mEq/L) and hyponatremia (< 135 mEq/L). Logistic regression analysis was performed to investigate the relationship between hyponatremia and early postoperative complications.

RESULTS

Compared to eunatremia, hyponatremia was independently associated with a significantly greater likelihood of experiencing any complication (odds ratio [OR] 1.65, 95% confidence interval [CI] 1.14-2.40; P = .008), blood transfusions (OR 2.45, 95% CI 1.24-4.83; P = .010), unplanned reoperation (OR 2.27, 95% CI 1.07-4.79; P = .032), and length of stay > 2 days (OR 1.63, 95% CI 1.09-2.45; P = .017).

CONCLUSION

Hyponatremia was associated with a greater rate of early postoperative complications following noninfectious revision TSA. This study sheds light on the role of preoperative hyponatremia as a risk factor for postoperative complications and may help surgeons better select surgical candidates and improve surgical outcomes in the setting of revision TSA.

Imaging in shoulder arthroplasty: Current applications and future perspectives

Shoulder arthroplasty has become a standard surgical procedure for treating a variety of complex shoulder disorders, including those with degenerative and traumatic aetiologies. The ever-improving success rates of shoulder arthroplasty could be attributed to advancements in endoprosthesis design, improvements in the biomechanics of endoprosthetic components, and improvements in surgical techniques. It improves patient outcomes and helps restore shoulder joint function and mobility. Imaging plays a vital role by enabling surgeons to plan arthroplasty procedures, help guide endoprosthesis placement, and monitor postoperative outcomes. In addition, imaging plays a role in assessing the residual bone stock and status of rotator cuff integrity and in correcting the placement of prosthetic components to restore shoulder mobility. CT-guided navigation aids surgeons by helping them choose appropriate components for implants and ensuring that implants are placed optimally during surgery. It can lead to better surgical results with reduced patient morbidity and a longer duration of prosthetic stability. After surgery, it is crucial to use imaging techniques to detect issues such as periprosthetic loosening, infections, or fractures to start effective management strategies to enhance patient recovery. This article aims to provide orthopaedic surgeons and radiologists with knowledge on the imaging methods used in shoulder arthroplasty and their role in presurgical planning, intraoperative guidance and postoperative assessment. In this study, we aimed to investigate the rationale behind utilising various types of shoulder replacements: total shoulder replacement (TSA), reverse total shoulder arthroplasty (RTSA), and hemiarthroplasty; methods, their respective advantages and limitations; and outcomes. Our objective is to comprehensively analyse the procedures mentioned above and highlight their unique features and benefits to facilitate a better understanding of these approaches. Additionally, we will discuss how these imaging techniques help identify issues such as loose components, fractures around the implant site, joint instability and infections.

Revision of failed reverse total shoulder arthroplasty with reverse: short-term clinical outcomes

BACKGROUND

The prevalence of failed reverse total shoulder arthroplasty (rTSA) is increasing. This can often present a challenging clinical situation with substantial bone loss and limited reconstruction options. This study reports a single tertiary referral center's experience with revision of failed rTSA managed with revision rTSA of bone-interfacing components.

METHODS

After institutional review board approval, all revision shoulder arthroplasty cases performed at a single institution between 2012 and 2020 were reviewed. Cases in which rTSA was revised to a new rTSA construct with revision of at least 1 bone-interfacing implant (humeral stem and/or baseplate) with a minimum 2-year follow-up were identified. Characteristics of revision cases-including indications, bony stock, revised components, and use of bone graft-were collected. All patients were contacted for patient-reported outcome measures at a minimum of 2 years after surgery. In addition, the incidence and indication for any reoperation after revision were determined.

RESULTS

Thirty-three patients with an average age of 66 years (range: 46-82 years), with 19 (58%) being female, met the inclusion criteria and had a mean follow-up of 4.2 years (range: 2-8 years). The most common indication for revision rTSA included humeral component loosening (33%; 11/33), baseplate loosening (27%; 9/33), and instability (21%; 7/33). Prerevision infectious workup demonstrated no cases of periprosthetic shoulder infection. Thirteen cases had massive bone loss-5 treated with humeral allograft prosthetic composite, 5 with glenoid bone grafting, and 3 with custom glenoid implant. In total, 10 of 33 cases (30%) required reoperation at a mean of 13 months (range: 1-44 months) for instability (4), humeral loosening (2), infection (1), baseplate loosening (1), or periprosthetic fracture (1). The reoperation rate for patients with revised baseplates only, humerus only, or combined was 23% (3/13), 28% (5/18), and 27% (3/11), respectively. Overall, the visual analog scale pain score improved from 6.5 preoperatively to 2.0 (P < .001), and the American Shoulder and Elbow Surgeons score improved from 30.7 to 67.5 (P < .001). However, the postoperative Single Assessment Numeric Evaluation score averaged only 51.2% (range: 2-100%).

CONCLUSION

This study demonstrates that failed rTSA can be salvaged with a revision rTSA. However, patient expectations for functional improvements should be tempered, and a high reoperation rate should be expected.

Components of metabolic syndrome as significant risk factors for postoperative complications following total shoulder arthroplasty: hypertension, diabetes, and obesity

Background

Metabolic syndrome (MetS) is a known risk factor for adverse postoperative outcomes. However, the literature surrounding the effects of MetS on orthopedic surgery outcomes following total shoulder arthroplasty (TSA) remains understudied. The purpose of this study is to investigate the effect of MetS on postoperative 30-day adverse outcomes following TSA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2020. After exclusion criteria, patients were divided into MetS and no MetS cohorts. MetS patients were defined as presence of hypertension, diabetes, and body mass index > 30 kg/m2. Bivariate logistic regression was used to compare patient demographics, comorbidities, and complications. Multivariate logistic regression, adjusted for all significant patient demographics and comorbidities, was used to identify the complications independently associated with MetS.

Results

A total of 26,613 patients remained after exclusion criteria, with 23,717 (89.1%) in the no MetS cohort and 2896 (10.9%) in the MetS cohort. On multivariate analysis, MetS was found to be an independent predictor of postoperative pneumonia (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.02-2.55; P = .042), renal insufficiency (OR 4.09, 95% CI 1.67-10.00; P = .002), acute renal failure (OR 4.17, 95% CI 1.13-15.31; P = .032), myocardial infarction (OR 2.11, 95% CI 1.21-3.69; P = .009), nonhome discharge (OR 1.41, 95% CI 1.24-1.60; P < .001), and prolonged hospital stay > 3 days (OR 1.44, 95% CI 1.25-1.66; P < .001).

Conclusion

MetS was identified as an independent risk factor for postoperative pneumonia, renal insufficiency, acute renal failure, myocardial infarction, nonhome discharge, and prolonged hospital stay following TSA. These findings encourage physicians to medically optimize MetS patients prior to surgery to limit adverse outcomes.

Primary Total Shoulder Arthroplasty is Superior to Hemiarthroplasty for the Treatment of Glenohumeral Arthritis: Analysis of 5-year Outcomes in a Large Surgical Database

Background

Total shoulder arthroplasty (TSA) is the preferred treatment for glenohumeral arthritis refractory to nonoperative measures. However, some surgeons have argued for a role for hemiarthroplasty (HA) in the setting of a smooth glenoid that articulates appropriately with the humeral head. The purpose of this study is to evaluate long-term revision rates and short-term postoperative complications in patients undergoing either HA or TSA for glenohumeral arthritis.

Methods

A retrospective review of patients who underwent HA and TSA was conducted using a commercially available national database. Demographics, postoperative complications, risk factors, revision rates, and costs were analyzed using 2 sample t-tests, chi-squared tests, and multivariate logistic regressions.

Results

Patients were stratified by operation: (1) HA (n = 1615) or 2) TSA (n = 7845). Patients undergoing primary TSA had higher rates of prior ipsilateral rotator cuff repair and corticosteroid injections. At 2 years, patients who underwent HA, 3.0% of patients had revision surgery, compared to 1.6% of patients who underwent TSA (P = .002); at 5 years, 3.7% of the HA cohort (P < .0001) had revision surgery, compared to 1.9% of patients who underwent TSA.

Conclusions

Patients undergoing TSA or RTSA for glenohumeral arthritis had higher preoperative co-morbidities but had no difference in short-term complication rates with a lower risk of revision surgery at both 2-year and 5-year follow-up when compared to HA. Increasing age, female sex, hyperlipidemia, postoperative infection, shoulder instability, and thromboembolism all independently increased odds for revision shoulder arthroplasty for glenohumeral arthritis.

Level of evidence Level

III.

Trends in outcomes following aseptic revision shoulder arthroplasty

PURPOSE

As the incidence of anatomic and reverse total shoulder arthroplasty (TSA, RSA) increases, revision procedures will also increase with a corresponding need for counseling patients regarding outcomes. We hypothesized that different revision categories would have different complication profiles depending on both the indication as well as the nature of the prior hardware.

METHODS

A retrospective review of 1773 cases performed at a single tertiary health system utilized case postings and diagnoses to identify revision shoulder arthroplasty cases. Revisions were classified based on the prior hardware present, with basic demographics and other perioperative and postoperative outcomes recorded within the limits of available follow-up.

RESULTS

166 surgical cases involving revision of prior shoulder arthroplasty metal hardware were identified with an average follow-up of 1.0 years. Immediate perioperative outcomes of revision cases were similar relative to the companion cohort of 1607 primary cases. 137 cases (83%) required no further revision surgery, while 19 cases (11%) underwent aseptic revision, and 10 cases (6%) were revised for periprosthetic infection. RSA hardware revised to another RSA had the highest repeat revision rate relative to the other revision categories (32% vs < 14%).

CONCLUSIONS

Revision of reverse shoulder arthroplasty to a repeat reverse has the highest rate of subsequent all-cause revision, and these repeat revisions often occurred for periprosthetic infection. Despite a relatively high long-term complication rate following revision shoulder arthroplasty, immediate perioperative outcomes remain similar to primary cases, providing some preliminary evidence for policymakers considering inclusion in future value-based care models.

LEVEL OF EVIDENCE

Level III Treatment Study.

Development of a machine learning algorithm to identify total and reverse shoulder arthroplasty implants from X-ray images

Introduction

Demand for total shoulder arthroplasty (TSA) has risen significantly and is projected to continue growing. From 2012 to 2017, the incidence of reverse total shoulder arthroplasty (rTSA) rose from 7.3 cases per 100,000 to 19.3 per 100,000. Anatomical TSA saw a growth from 9.5 cases per 100,000 to 12.5 per 100,000. Failure to identify implants in a timely manner can increase operative time, cost and risk of complications. Several machine learning models have been developed to perform medical image analysis. However, they have not been widely applied in shoulder surgery. The authors developed a machine learning model to identify shoulder implant manufacturers and type from anterior-posterior X-ray images.

Methods

The model deployed was a convolutional neural network (CNN), which has been widely used in computer vision tasks. 696 radiographs were obtained from a single institution. 70% were used to train the model, while evaluation was done on 30%.

Results

On the evaluation set, the model performed with an overall accuracy of 93.9% with positive predictive value, sensitivity and F-1 scores of 94% across 10 different implant types (4 reverse, 6 anatomical). Average identification time was 0.110 s per implant.

Conclusion

This proof of concept study demonstrates that machine learning can assist with preoperative planning and improve cost-efficiency in shoulder surgery.

Outcomes of different stem sizes in shoulder arthroplasty

Background

The successive refinement in implant design and operative technique alongwith improved understanding has resulted in increased incidence of total shoulder arthroplasty (TSA). Simultaneously, the indications of TSA have widened and include a range of shoulder pathologies.

Methods

Using the keywords and relevant literature, we have described an overview of the different stem sizes used in shoulder arthroplasty. Relevant description of clinical and radiological outcome is done with regards to different stem sizes.

Discussion

There are plethora of shoulder replacement systems, based on unique philosophy and having their own advantages and disadvantages. Additionally, the rise in ageing population had increased the need for revision TSA, thereby necessitating the judicious choice of implant at primary TSA. We further present the role of cemented and uncemented humeral stems and discuss the findings of finite element analysis. The choice of humeral stem size and use of cemented or uncemented stems have been reported to affect the clinical and radiological outcomes.

Pectoralis-major-pedicled bone window for revision of a shoulder arthroplasty

PURPOSE

The aim of this study is to review our experience with the pectoralis-major-pedicled bone window for the revision of shoulder arthroplasty.

METHODS

This study used the retrospective case series of six patients who underwent a pectoralis-major-pedicled bone window for revision of shoulder arthroplasty, with a minimum follow-up of 2 years. Demographic, clinical, and radiological data were analyzed.

RESULTS

The mean age of the included patients was 72.6 years old (standard deviation (SD) 4.7), and 83.3% were women (5/1). The mean follow-up was 36.6 months (range 25-48 months). Five patients had a shoulder hemiarthroplasty and one patient a reverse shoulder arthroplasty. The indications for revision were pain in five patients and recurrent dislocation in one patient. No intraoperative complications were found. One patient developed a wound infection that required debridement and a two-stage revision. Despite complications, 2 years after surgery, the range of motions and functional scores were improved from preoperative levels. The difference between preoperative and postoperative VAS pain scores was 7.1 points (p < 0.001). The difference between preoperative and postoperative CSS and ASES questionnaires were 32 and 31.6 points, respectively (p < 0.001). At the final follow-up, all radiographs showed bone union of the osteotomy, good fixation of all components, without evidence of prosthetic loosening or migration.

CONCLUSIONS

Revision of a shoulder arthroplasty using a pectoralis-major-pedicled bone window can be an effective treatment that can yield pain relief; however, improvements in motion and function were difficult to achieve.

Factors Associated With Elevated Inflammatory Markers Prior to Shoulder Arthroplasty

Background: Preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) ranges for several shoulder arthroplasty indications are not well understood. Purpose: We sought to compare preoperative ESR and CRP values for a variety of shoulder arthroplasty indications and evaluate risk factors for elevated preoperative ESR and CRP values. Methods: We conducted a retrospective cohort study of shoulder arthroplasty cases performed at a single academic medical institution from 2013 to 2018. Preoperative ESR and CRP values for 235 shoulder arthroplasties with various indications were recorded. Independent risk factors for elevated values (CRP > 10.0 mg/L and ESR > 30.0 mm/h) were determined via multiple variable logistic regression. Results: Patients undergoing shoulder arthroplasty for osteoarthritis had an ESR (mean ± SD) of 22.6 ± 17.8, with 29.8% of patients elevated, and a CRP of 6.5 ± 6.4, with 25.5% of patients elevated. Arthroplasty for acute fracture and prosthetic joint infection (PJI) had higher preoperative ESR and CRP values. Multivariate analysis identified several predictors of elevated ESR, including infection, acute fracture, diabetes, and female sex. It also identified predictors of elevated CRP, including infection, acute fracture, and younger age. Conclusions: Preoperative ESR and CRP values may be elevated in 25% to 30% of patients undergoing primary shoulder arthroplasty. Arthroplasty for both acute fracture and PJI, along with several other patient factors, was associated with elevated preoperative ESR and CRP. Thus, routine collection of ESR and CRP preoperatively may not be of benefit, as elevated values are common. Further study is warranted.

Outcomes of shoulder arthroplasty by year of index procedure: are we getting better?

BACKGROUND

The purpose of this study was to determine whether postoperative patient-reported outcomes improved over time following anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

We performed a retrospective analysis of prospectively collected patient-reported outcomes from our institution's registry between 2008 and 2018 (N = 1899). American Shoulder and Elbow Surgeons (ASES) scores at a minimum of 2 years postoperatively were required. Univariable linear models were used to test the association between year of surgery and improvement in ASES scores at 2- and 5-year follow-up, as well as any association with age, sex, primary or revision surgery, hand dominance, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, and Walch classification. Multivariable models were created to analyze ASES score improvement by index year while controlling for significant factors.

RESULTS

In the univariable analysis, 5-year ASES difference scores increased each year by a mean of 1.65 (P < .001; 95% confidence interval [CI], 0.75-2.55) for TSA, 2.50 (P = .014; 95% CI, 0.52-4.49) for RTSA, and 1.64 (P < .001; 95% CI, 0.81-2.47) for the overall population. Patient sex, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, Walch classification, and revision procedures were also significant factors affecting ASES scores. On multivariable analysis controlling for these factors, 5-year ASES difference scores were still significantly associated with year of surgery, increasing each year by a mean of 2.20 (P < .001; 95% CI, 0.91-3.50) for TSA, 4.83 (P < .001; 95% CI, 1.17-8.49) for RTSA, and 1.66 (P < .001; 95% CI, 0.81-2.51) for the entire population.

CONCLUSION

Both anatomic TSA and RTSA patients reported increasing ASES difference scores at 5-year follow-up as time passed. These findings may indicate that advances in shoulder arthroplasty have resulted in better patient outcomes over time. Further research is needed to clarify which factors influence improvements in outcomes, particularly for revision procedures.

Surgical Trends of Shoulder Arthroplasty: Nationwide Epidemiologic Study in South Korea

Background

The aim of this study was to determine the nationwide shoulder arthroplasty trends in South Korea based on an analysis of nationwide data acquired from the Korean Health Insurance Review and Assessment Service (HIRA).

Methods

We analyzed a nationwide database acquired from the HIRA that covered 2008 to 2017. International Classification of Diseases, 10th Revision (ICD-10) codes and procedure codes were used to identify patients who underwent shoulder arthroplasty, including total shoulder arthroplasty (TSA), hemiarthroplasty (HA), and revision shoulder arthroplasty.

Results

From 2008 to 2017, a total of 19,831 shoulder arthroplasties were performed; there were 16,162 TSAs and 3,669 hemiarthroplasties. During the 10-year study period, there was an exponential increase in the incidence of TSA (from 513 cases in 2008 to 3,583 cases in 2017), while the number of hemiarthroplasties remained steady. The most common diagnoses for TSA were rotator cuff tears (6,304 cases, 39.0%) and osteoarthritis (6,589 cases, 40.8%) for all 9 years. Osteoarthritis was the most common reason for TSA during the first 3 years (2008-2010), but rotator cuff tears ultimately surpassed osteoarthritis during the last 3 years (2015-2017). HA was performed to treat proximal humerus fracture (1,770 cases, 48.2%) and osteoarthritis (774 cases, 21.1%). In terms of hospital types, the rate of TSA in hospitals with 30-100 inpatient beds increased from 21.83% to 46.27%, while the rates of the other types of surgery decreased. A total of 430 revision surgeries were performed during the study period, and infection (152 cases, 35.3%) was the most common reason for revision surgery.

Conclusions

Overall, the total count and incidence of TSA, unlike HA, increased rapidly between 2008 and 2017 in South Korea. Moreover, at the end of the study period, nearly half of the TSAs were performed in small hospitals (30 to 100 beds). Rotator cuff tears were the leading cause of TSA at the end of the study period. These findings revealed an explosive increase in reverse TSA surgery.

Projections of Primary and Revision Shoulder Arthroplasty until 2040: Facing a Massive Rise in Fracture-Related Procedures

Although the demand for shoulder arthroplasties has reached its highest number worldwide, there remains a lack of epidemiologic data regarding recent and future trends. In this study, data for all shoulder arthroplasties (hemiarthroplasty, reverse/anatomic shoulder arthroplasty) from the nationwide inpatient statistics of Germany (2010–2019) and population forecasts until 2040 were gathered. A Poisson and a negative binomial approach using monotone B-splines were modeled for all types of prostheses to project the annual number and incidence of primary and revision arthroplasty. Additionally, trends in main indicators were also gathered and expected changes were calculated. Overall, the number of primary shoulder replacements is set to increase significantly by 2040, reaching at least 37,000 (95% CI 32,000–44,000) procedures per year. This trend is mainly attributable to an about 10-fold increased use of fracture-related reverse shoulder arthroplasty in patients over 80 years of age, although the number of procedures in younger patients will also rise substantially. In contrast, hemiarthroplasties will significantly decrease. The number of revision procedures is projected to increase subsequently, although the revision burden is forecast to decline. Using these country-specific projection approaches, a massive increase of primary and revision shoulder arthroplasties is expected by 2040, mainly due to a rising number of fracture-related procedures. These growth rates are substantially higher than those from hip or knee arthroplasty. As these trends are similar in most Western countries, this draws attention to the international issue, of: if healthcare systems will be able to allocate human and financial resources adequately, and if future research and fracture-prevention programs may help to temper this rising burden in the upcoming decades.

Humeral Head Morphology Influences Outcomes of Arthroscopic Interposition Glenoid Patch Allograft for Glenohumeral Arthritis

Purpose

To determine short- to midterm patient-reported outcomes of arthroscopic soft-tissue interposition arthroplasty using acellular dermal allograft with a minimum follow-up of 1 year and to assess outcomes in patients with and without flattening of the humeral head.

Methods

Patients with a diagnosis of primary glenohumeral arthritis who underwent arthroscopic soft-tissue interposition arthroplasty with an acellular dermal allograft from July 2010 to November 2019 were retrospectively enrolled. Inclusion criteria were a primary diagnosis of glenohumeral arthritis and Outerbridge 4 full-thickness cartilage loss of ≥50% of the glenoid articular surface. Patients underwent arthroscopic debridement, microfracture, and biological arthroscopic soft-tissue interposition arthroplasty with an acellular dermal matrix. Postoperative outcomes included American Shoulder and Elbow Surgeon (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Penn Shoulder Score (PSS), numeric rating scale (NRS) pain score, analgesic use, and conversion to total shoulder arthroplasty (TSA). Results were stratified according to humeral head morphology on preoperative radiographs.

Results

A total of 25 patients were included, with a mean age of 56.0 years (range 19.2 to 74.8) and a mean follow-up of 3.36 years (range 1.03 to 8.98). The mean postoperative ASES score was 64.1 (range 11.7 to 100.0), SANE score was 62% (range 5% to 100%), and PSS was 61.2 (range 10.6 to 97.9). Additionally, 56% of patients rated their shoulder function as improved or much improved, and 36% of patients converted to TSA at a mean of 2.35 years. Patients with and without humeral flattening had similar postoperative ASES scores (P = .44), SANE scores (P = .90), PSS (P = .73), and conversions to TSA (P = .83). Patients with humeral flattening were more likely to have shoulder pain at night (83.3% versus 28.6%, P = .02).

Conclusion

Arthroscopic soft-tissue interposition arthroplasty with an acellular dermal allograft resulted in satisfactory short- to mid-term postoperative outcomes for younger patients with glenohumeral arthritis but demonstrated a TSA conversion rate of 36%. Patients with humeral head flattening also had satisfactory shoulder function but were more likely to experience shoulder pain at night.

Level of Evidence

Level IV, therapeutic case series

Undergoing an Arthroscopic Procedure Prior to Shoulder Arthroplasty is Associated With Greater Risk of Prosthetic Joint Infection

PURPOSE

To utilize a national all-payer claims dataset to understand whether a history of a prior shoulder arthroscopy is associated with adverse outcomes or complications after the index shoulder arthroplasty itself.

METHODS

The Symphony Integrated DataVerse, an all-payer claims database, was used to identify patients undergoing primary shoulder arthroplasty (hemiarthroplasty, anatomic total shoulder arthroplasty, or reverse total shoulder arthroplasty) between 2017 to 2018. Current Procedural Terminology codes were used to identify patients who had undergone a shoulder arthroscopic procedure on the ipsilateral side within 2 years before the arthroplasty. Multivariate logistic regression analyses were used to assess whether prior shoulder arthroscopy was associated with higher risks of wound complications, postoperative stiffness, mechanical complications, prosthetic joint infection, revision surgery and readmissions within 90 days of the arthroplasty.

RESULTS

In total, 19,429 patients were included, of which 837 (4.3%) had undergone shoulder arthroscopy within 2 years before the arthroplasty. Prior shoulder arthroscopy was associated with a significantly higher risk of prosthetic joint infection (odds ratio [OR] 2.74 [95% confidence interval {CI} 1.51-4.69]; P < .001) within 90 days of the arthroplasty. The greatest risk of prosthetic joint infection was associated with arthroscopies that took place within 3 months before the arthroplasty (OR 5.32 [95% CI 1.42-15.14]; P = .005).

CONCLUSIONS

Undergoing an arthroscopic procedure of the ipsilateral shoulder before undergoing an arthroplasty was associated with greater risk of prosthetic joint infection. Furthermore, it appears that patients who received arthroscopy within the 3 months before arthroplasty had the highest risk of prosthetic joint infections. Physicians should not only anticipate possible inferior outcomes in patients who have had prior arthroscopy, but also consider delaying the arthroplasty by at least 3 months after the arthroscopy to mitigate the risks of experiencing this costly adverse event.

LEVEL OF EVIDENCE

III.

Chronic Kidney Disease Is Associated with High Mortality Risk in Patients with Diabetes after Primary Shoulder Arthroplasty: A Nationwide Population-Based Cohort Study

The number of diabetic patients with chronic kidney disease (CKD) undergoing shoulder arthroplasty is growing. This study aims to compare perioperative outcomes of shoulder arthroplasty in diabetic patients at different renal function stages. Between 1998 and 2013, a total of 4443 diabetic patients with shoulder arthroplasty were enrolled: 1174 (26%) had CKD without dialysis (CKD group), 427 (9%) underwent dialysis (dialysis group), and 3042 (68%) had no CKD (non-CKD group). Compared with the non-CKD group, the CKD (odds ratio [OR], 4.69; 95% confidence interval [CI], 2.02–10.89) and dialysis (OR, 6.71; 95% CI, 1.63–27.73) groups had a high risk of in-hospital death. The dialysis group had a high risk of infection after shoulder arthroplasty compared with the CKD (subdistribution hazard ratio [SHR], 1.69; 95% CI, 1.07–2.69) and non-CKD (SHR, 1.76; 95% CI, 1.14–2.73) groups. The dialysis group showed higher risks of all-cause readmission and mortality than the CKD and non-CKD groups after a 3-month follow-up. In conclusion, CKD was associated with worse outcomes after shoulder arthroplasty. Compared with those without CKD, CKD patients had significantly increased readmission and mortality risks but did not have an increased risk of surgical complications, including superficial infection or implant removal.

Reassessment of Relative Value in Shoulder and Elbow Surgery: Do Payment and Relative Value Units Reflect Reality?

BACKGROUD

Many U.S. health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. A major determinant of payment and wRVU assignments is operative time. We sought to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common shoulder/elbow procedures.

METHODS

We collected data on wRVUs, payments, and operative times from CMS for 29 types of isolated arthroscopic and open shoulder/elbow procedures. Using regression analysis, we compared relationships between these variables, in addition to median operative times reported by NSQIP (2013-2016). We then determined the relative valuation of each procedure based on operative time.

RESULTS

Seventy-nine percent of CMS operative time were longer than NSQIP time (R2 = 0.58), including, but not limited to, shoulder arthroplasty and arthroscopic shoulder surgery. The correlation between payments and operative times was stronger between CMS data (R2 = 0.61) than NSQIP data (R2 = 0.43). Similarly, the correlation between wRVUs and operative times was stronger when using CMS data (R2 = 0.87) than NSQIP data (R2 = 0.69). Nearly all arthroscopic shoulder procedures (aside from synovectomy, debridement, and decompression) were highly valued according to both datasets. Per NSQIP, compensation for revision total shoulder arthroplasty ($10.14/min; 0.26 wRVU/min) was higher than that for primary cases ($9.85, 0.23 wRVU/min) and nearly twice the CMS rate for revision cases ($5.84/min; 0.13 wRVU/min).

CONCLUSIONS

CMS may overestimate operative times compared to actual operative times as recorded by NSQIP. Shorter operative times may render certain procedures more highly valued than others. Case examples show that this can potentially affect patient care and incentivize higher compensating procedures per operative time when less-involved, shorter operations have similar patient-reported outcomes.

Early revision in anatomic total shoulder arthroplasty in osteoarthritis: a cross-registry comparison

BACKGROUND

We evaluated anatomic total shoulders undergoing early revision (less than two years) in the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Kaiser Permanente Shoulder Arthroplasty Registry (KPSAR).

METHODS

A cross-sectional comparison of both registries was performed between the years of 2009 and 2012. Only patients who underwent anatomic total shoulder arthroplasty for a primary diagnosis of osteoarthritis were included. Aggregate-level data of patients undergoing early revisions done within two years of index arthroplasty were evaluated, and descriptive analysis was conducted.

RESULTS

During the study period, 4614 patients were identified in the AOANJRR compared to 2036 in the KPSAR. Rotator cuff pathology, component loosening, and prosthetic instability were among the most common reasons for revision in both registries. A higher rate of revision in the AOANJRR was found to be secondary to the failure of one specific prosthesis, which has since been discontinued.

DISCUSSION

Comparing reasons for early revision in total shoulder arthroplasty revealed several similarities between the AOANJRR and KPSAR. Differences were also noted, and this study served to highlight the importance prosthesis selection can play in determining outcomes. Cooperation among registries may allow for earlier identification of risk factors for failure in shoulder arthroplasty.

Risk Factors for Re-Revision Surgery in Shoulder Arthroplasty

INTRODUCTION

Revision shoulder arthroplasty is an expensive undertaking with notable morbidity to the patient and less predictable outcomes. Therefore, it is important to avoid even further surgery in these patients. We sought to report the annual revision burden from a large integrated healthcare system and identify patient and operative factors that may predispose patients to revision failure, necessitating further surgery.

METHODS

Annual revision burden as a proportion of the overall shoulder arthroplasties performed from 2005 to 2017 was obtained. Patients who underwent aseptic revision between 2005 and 2017 comprised the study sample. Patient characteristics evaluated for re-revision risk included age, sex, body mass index (BMI), race, and diabetes status, whereas surgical characteristics included surgeon cumulative revision volume, revision procedure type, and top reason for revision by primary procedure type. Multivariable Cox proportional hazards regression was used to evaluate the association between the specified factors and re-revision risk.

RESULTS

From 2005 to 2017, revisions represented 5.3% to 7.8% of all shoulder arthroplasty procedures performed. Factors associated with re-revision surgery risk by procedure type included increasing BMI and hemiarthroplasty revision procedure compared with reverse total shoulder arthroplasty (RTSA) revision procedure for hemiarthroplasty primaries; diabetes, revision because of instability, and lower cumulative surgeon revision procedure volume for RTSA primaries; and TSA revision procedure compared with RTSA revision procedure for TSA primaries.

CONCLUSION

The annual revision shoulder arthroplasty volume increased over the study period. Patient factors, including BMI and diabetes were associated with higher re-revision risks for hemiarthroplasty and RTSA primaries, respectively. RTSA revised for instability had a higher risk of re-revision compared with other indications. TSA and hemiarthroplasty requiring aseptic revision may be best treated with RTSA as opposed to another TSA or hemiarthroplasty. Further studies are needed to verify these findings and identify how the mechanism of failure may affect the procedure selection in the revision setting.

LEVEL OF EVIDENCE

Level III.

The association between glenoid component design and revision risk in anatomic total shoulder arthroplasty

INTRODUCTION

Anatomic total shoulder arthroplasty (TSA) is a proven treatment for glenohumeral joint osteoarthritis, with superior results compared with hemiarthroplasty. However, glenoid component loosening remains a problem and is one of the most common causes of failure in TSA. Multiple component designs have been developed in an attempt to reduce loosening rates. The purpose of this study was to evaluate risk of revision after anatomic TSA according to the glenoid component design.

METHODS

We conducted a cohort study including patients aged ≥18 years who underwent primary elective TSA for the diagnosis of osteoarthritis between 2010 and 2017. Patients with missing implant information, who received stemless humeral implants, or who received augmented glenoid implants, were excluded. Glenoid component designs used were categorized into 4 mutually exclusive treatment groups: polyethylene central-pegged ingrowth, polyethylene-metal hybrid, polyethylene all-cemented pegged, and polyethylene cemented keeled. Multivariable competing risk regression was used to evaluate the risk of glenoid loosening as a cause-specific revision by the glenoid component design.

RESULTS

Of the 5566 TSA included in the final cohort, 39.2% of glenoid implants were polyethylene central-pegged ingrowth, 31.1% were polyethylene-metal hybrid, 26.0% were polyethylene all-cemented pegged, and 3.6% were polyethylene cemented keeled. At 6-year final follow-up, 4.1% of TSA were revised for any cause, and 1.4% for glenoid loosening. Compared with the polyethylene central-pegged ingrowth design, no difference in glenoid loosening revision risk was observed for the polyethylene-metal hybrid design (hazard ratio [HR] = 1.15, 95% confidence interval [CI] = 0.42-3.20). However, both the polyethylene all-cemented pegged (HR = 2.48, 95% CI = 1.08-5.66) and polyethylene cemented keeled (HR = 3.84, 95% CI = 1.13-13.00) designs had higher risks for revision due to glenoid loosening.

CONCLUSIONS

We observed glenoid component designs to be associated with differential risks in revision due to glenoid loosening with polyethylene all-cemented pegged glenoids and polyethylene cemented keeled glenoids having higher risks when compared with polyethylene central-pegged ingrowth glenoids. Surgeons may want to consider the glenoid component design when performing anatomic TSA.

Risk Factors and Complications for Revision Shoulder Arthroplasty

BACKGROUND

Revision shoulder arthroplasty has become increasingly common as primary arthroplasty has become more widespread.

QUESTIONS/PURPOSES

We sought to answer two questions: What are the risks factors for revision shoulder arthroplasty? What are the complications associated with revision shoulder arthroplasty?

METHODS

A retrospective search of a national insurance database from the years 2013 to 2016 was undertaken for billing codes of patients undergoing revision shoulder arthroplasty. The odds ratios for revision of various patient demographic characteristics and comorbidities were determined. The incidences of various complications within 90 days of revision were determined.

RESULTS

A total of 824 cases of revision shoulder arthroplasty were found. Eighty-seven patients (10.5%) had infections prior to revision and 133 patients (16.1%) had dislocations prior to revision. Of the risk factors examined, smoking status was associated with the highest odds ratio for revision (8.1). Additionally, depression, Charlson Comorbidity Index (CCI), male gender, renal failure, and diabetes were significant risks factors for revision. The most common complication of revision shoulder arthroplasty was found to be surgical site infection, affecting 10.9% of patients. In the time period studied, 89 patients underwent more than one revision shoulder arthroplasty.

CONCLUSION

Despite limitations inherent in database studies, this data may have utility for surgeons in pre-operative counseling of patients on their risk.

A Point-Based Model to Predict Absolute Risk of Revision in Anatomic Shoulder Arthroplasty

Background

Total shoulder arthroplasty (TSA) has demonstrated good long-term survivorship but early implant failure can occur. This study identified factors associated with shoulder arthroplasty revision and constructed a risk score for revision surgery following shoulder arthroplasty.

Methods

A validated algorithm was used to identify all patients who underwent anatomic TSA between 2002 and 2012 using population-based data. Demographic variables included shoulder implant type, age and sex, Charlson comorbidity score, income quintile, diagnosis, and surgeon arthroplasty volume. The associations of covariates with time to revision were measured while treating death as a competing risk and were expressed in the Shoulder Arthroplasty Revision Risk Score (SARRS).

Results

During the study period, 4079 patients underwent TSA. Revision risk decreased in a nonlinear fashion as patients aged and in the absence of osteoarthritis with no influence from surgery type or other covariables. The SARRS ranged from −21 points (5-year revision risk 0.75%) to 30 points (risk 11.4%). Score discrimination was relatively weak 0.55 (95% confidence interval: 0.530.61) but calibration was very good with a test statistic of 5.77 (df = 8, P = .762).

Discussion

The SARRS model accurately predicted the 5-year revision risk in patients undergoing TSA. Validation studies are required before this score can be used clinically to predict revision risk. Further study is needed to determine if the addition of detailed clinical data including functional outcome measures and the severity of glenohumeral arthrosis increases the model’s discrimination.

Shoulder Arthroplasty for Posttraumatic Arthritis Is Associated With Increased Transfusions and Longer Operative Times

Introduction:

Posttraumatic arthritis (PTA) is a common sequela of proximal humerus fractures that is commonly managed with anatomic or reverse total shoulder arthroplasty (TSA). TSA for PTA is more challenging than that performed for primary osteoarthritis and frequently leads to worse patient outcomes. CPT uniformly classifies all cases of primary TSA, irrespective of procedural complexity and resource utilization. This study analyzes intraoperative differences and 30-day outcomes for anatomic and reverse TSA performed in the posttraumatic shoulder.

Methods:

Patients undergoing TSA from 2008 to 2015 were selected from the National Surgical Quality Improvement Program database and stratified according to concurrent procedures and administrative codes indicating posttraumatic diagnoses. Perioperative parameters and 30-day complications were recorded; multivariate analyses were performed to determine whether PTA was a risk factor for poor outcomes.

Results:

A total of 8508 primary and 243 posttraumatic TSAs were identified. Posttraumatic TSA patients were slightly younger ( P = .003), more likely to be female ( P < .001), smokers ( P = .029), and diabetic ( P =  .003). Diagnosis of PTA was an independent risk factor for prolonged operative times ≥160 minutes (≥1 standard deviation above the mean, P =  .003; odds ratio [OR]: 1.718; 95% confidence interval [CI]: 1.204–2.449) and increased bleeding requiring transfusion ( P <  .001; OR: 2.719; 95% CI: 1.607–4.600). Although posttraumatic TSA had a tendency for longer hospital admissions, 30-day readmissions were not significantly different between cohorts.

Conclusions:

Compared with primary osteoarthritis, a preoperative diagnosis of PTA is an independent risk factor for prolonged operative times and postoperative transfusion in anatomic or reverse TSA patients; such patients may be less than optimal candidates for same-day discharges or outpatient shoulder arthroplasty.

Patient Outcomes After Revision of Anatomic Total Shoulder Arthroplasty to Reverse Shoulder Arthroplasty for Rotator Cuff Failure or Component Loosening: A Matched Cohort Study

PURPOSE

To compare outcomes after conversion of anatomic total shoulder arthroplasty (aTSA) to reverse total shoulder arthroplasty (RTSA) and a matched cohort.

METHODS

Patients converted from aTSA to RTSA for rotator cuff failure or component loosening and a primary RTSA matched cohort were retrospectively identified from a prospective database. Demographics and preoperative and postoperative outcomes were obtained and compared.

RESULTS

Age, sex, body mass index, follow-up length, and preoperative function were similar between revision (n = 35) and primary (n = 70) groups. At final follow-up, visual analog scale pain (2.4 ± 2.8 versus 1.7 ± 2.8; P = 0.24) and American Shoulder and Elbow Surgeons (68 ± 26 versus 76 ± 24; P = 0.14) scores were similar. The revision group had worse subjective shoulder value scores (63 ± 30 versus 79 ± 21; P = 0.002), satisfaction (74% versus 90%; P = 0.03), and more complications (31% versus 13%; P = 0.02).

CONCLUSION

Revision of aTSA to RTSA for component loosening or rotator cuff failure results in function comparable to primary RTSA; however, more complications, worse subjective shoulder value scores, and lower patient satisfaction should be expected.

LEVEL OF EVIDENCE

Level III, retrospective comparative.

The role of the subscapularis tendon in a lateralized reverse total shoulder arthroplasty: repair versus nonrepair

PURPOSE

The reverse shoulder prost hesis (rTSA) is now implanted by the same percentage of anatomic shoulder prosthesis in the USA. Scapular notching and loss of extrarotation have been underlined as complication at long-term follow-up due to the Grammont design. The current trend to reduce those limits is to position both components lateralized. As the role of the subscapularis tendon in this new rTSA design is unclear, the purpose of this study is to quantify rTSA outcomes in patients with or without subscapularis tendon suture.

METHODS

The surgery was performed by the same orthopaedic surgeon (F.F.), using a Aequalis Ascend™ Flex prosthesis (Tornier, Montbonnot, France) with a bone autograft. Forty-four patients underwent surgery with the tendon sutured, whereas 40 patients underwent the same surgery without repairing it. Patients were evaluated pre-operatively and at the last follow-up using Constant score, VAS, and ROM. The minimum and mean follow-ups were six and 16.6 months, respectively.

RESULTS

All patients showed statistically significant improvement in pain and joint function following surgery. This study highlighted significant higher values in intrarotation and abduction, respectively, with and without suturing the subscapularis tendon. However, no significant differences were underlined in Constant score, VAS, forward flexion, extrarotation at 0° and 90° of abduction, and rate of instability.

CONCLUSIONS

As predicted, significant clinical improvements were observed in both groups with some differences. These clinical results showed that the use of rTSA with lateralized humerus and bony increase offset leads to realistic clinical improvements with a low risk of instability without the need for compression and stabilization of the tendon.

Shoulder Arthroplasty Outcomes After Prior Non-Arthroplasty Shoulder Surgery

BACKGROUND

The purpose of this retrospective study was to compare outcomes and complications in patients with and patients without a history of non-arthroplasty surgery on the ipsilateral shoulder who later underwent total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). We hypothesized that patients who had undergone prior surgery would have more complications and worse clinical outcomes.

METHODS

Consecutive patients who had undergone shoulder arthroplasty and had been followed for a minimum of 2 years were evaluated with the American Shoulder and Elbow Society scoring system (ASES), Simple Shoulder Test (SST), and Visual Analog Scale (VAS) assessments and with physical examination, including range-of motion assessments. Complications and outcomes in patients who had undergone prior surgery on the ipsilateral shoulder (PS group) were compared with those in patients without such a history (NPS group).

RESULTS

Data on 506 shoulder arthroplasties (263 TSA and 243 RTSA) were available for analysis. A total of 144 patients (28%) had an average of 1.9 ± 1.0 surgical procedures on the ipsilateral shoulder before arthroplasty. The average age in the PS group was significantly younger at the time of arthroplasty compared with the NPS group (61.6 ± 10.2 years compared with 68.2 ± 8.6 years, p = 0.035). At an average follow-up of 42.8 ± 16.4 months, both groups had significant improvements in ASES, SST, VAS, and range-of-motion values (p < 0.05 for all). All outcome scores in the PS group were significantly lower than those in the NPS group (p < 0.001 for all). The PS group also had a significantly higher complication rate than the NPS group (19.4% compared with 4.4%, p < 0.001), and multivariate regression analysis revealed that prior surgery was a significant independent predictor of postoperative complications. There were no differences between the PS and NPS groups in the number of postoperative infections (p = 0.679), reoperations (p = 0.553), or transfusions (p = 0.220).

CONCLUSIONS

Patients who have a history of prior surgery on the ipsilateral shoulder derive benefit from shoulder arthroplasty, but their magnitude of improvement and final scores are lower than those of patients who do not have such a history. This information can be used to counsel this challenging patient population on expected outcomes following shoulder arthroplasty.

LEVEL OF EVIDENCE

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

Perioperative Factors Affecting the Length of Hospitalization After Shoulder Arthroplasty

Objective:

To determine factors related to length of hospitalization after shoulder arthroplasty.

Methods:

A retrospective review identified patients who underwent shoulder arthroplasty between 2009 and 2012 at our institution. Factors were evaluated for their association with hospitalization length in a univariate model. Diagnoses were categorized into four groups: (1) osteoarthritis, cuff tear arthropathy, massive rotator cuff tear, or osteonecrosis; (2) acute fracture or fracture sequelae; (3) inflammatory arthropathy; and (4) failed shoulder arthroplasty. Significant factors were then evaluated using a multivariate model.

Results:

Four hundred twenty-five shoulder arthroplasties were identified (average age, 66.9 years). Arthroplasty type significantly affected hospitalization length. Significant factors for increased hospitalization using multivariate analysis were diabetes mellitus, American Society of Anesthesiologists score of 3 or 4, acute fracture or fracture sequelae diagnosis, inflammatory arthropathy, and a blood transfusion.

Discussion:

Independent factors using multivariate analysis are diabetes, an American Society of Anesthesiologists score ≥3, fracture or fracture sequelae, inflammatory arthritis, and a perioperative blood transfusion.

Level of Evidence:

Level III therapeutic study

Good functional outcomes expected after shoulder arthroplasty irrespective of body mass index

BACKGROUND

This study evaluated how body mass index (BMI) factors into functional outcomes and complications after shoulder arthroplasty.

METHODS

A retrospective analysis was performed of age-matched patients with a minimum 2-year follow-up after total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), or hemiarthroplasty (HA). Patient-reported outcome (PRO) scores, range of motion (ROM), and complications were assessed. Forty-nine patients were classified into the following groups: normal (BMI <24.9 kg/m²), overweight (BMI 25-29.9 kg/m²), class I obese (BMI 30-34.9 kg/m2), class II obese (BMI 35-39.9 kg/m²), and class III morbid obese (BMI ≥40 kg/m²).

RESULTS

A total of 245 patients (134 women, 111 men; average age, 64 ± 8 years) were evaluated at an average follow-up of 48 ± 18 months. TSA was performed in 122 patients (50%), RTSA was performed in 103 (42%), and HA was performed in 20 (8%). No significant difference was found among the 5 BMI groups in arthroplasty type (P = .108) or in complications, including reoperations (P = .27). All groups had significant postoperative improvements in PROs and ROM (P < .001 for both). There were no significant differences among the BMI groups in postoperative ROM or PROs.

DISCUSSION

This study demonstrates that patients undergoing TSA, RTSA, and HA can expect good functional outcomes, with improvements in pain, function and outcome scores, irrespective of BMI.

Effects of cemented versus press-fit primary humeral stem fixation in the setting of revision shoulder arthroplasty

BACKGROUND

The influence of primary humeral stem fixation method (cemented or press fit) on intraoperative or postoperative outcomes in the setting of revision shoulder arthroplasty is unknown.

METHODS

A retrospective analysis of a prospectively collected cohort of revision shoulder arthroplasty patients from a single tertiary center was performed. Demographic variables, intraoperative data, and 90-day complication rates were compared between cemented and press-fit primary stem fixation cohorts. Follow-up radiographs were graded and compared using a modified Gruen system for humeral lucencies.

RESULTS

Eighty-six primary shoulder replacements (34 hemiarthroplasties, 39 anatomic total shoulder arthroplasties, 13 reverse total shoulder arthroplasties) underwent revision arthroplasty with humeral stem removal between 2004 and 2017. Forty-five patients had cemented primary humeral fixation and 41 had press-fit fixation. The cemented cohort was older than the cementless cohort (66.6 vs. 61.4 years; P = .03) but otherwise demonstrated no difference in gender, body mass index, type of primary prosthesis (hemi, total, or reverse), or time between primary and revision operations. The cemented and cementless cohorts showed similar rates of humeral osteotomy (28.9% vs. 29.3%; P = .97), operative time (133.5  vs. 121.3 minutes; P = .16), and 90-day complication rates (13.3% vs. 9.8%; P = .61). Cemented vs. press-fit primary stems also had similar rates of humeral lucencies seen on follow-up radiographs after revision (77.1% vs. 60.6%; P = .14).

CONCLUSION

Humeral stem fixation with or without cement during primary shoulder arthroplasty demonstrated similar operative time, need for intraoperative humeral osteotomy, and postoperative complication rates in the setting of revision arthroplasty.

Relative Complications and Trends of Outpatient Total Shoulder Arthroplasty

Outpatient arthroplasty is an appealing option among select patient populations as a mechanism for reducing health care expenditure. The purpose of this study was to determine the nationwide trends and complication profile of outpatient total shoulder arthroplasty (TSA). The authors reviewed a national administrative claims database to identify patients undergoing TSA as outpatients and inpatients from 2007 to 2016. The incidence of perioperative surgical and medical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Multivariate logistic regression adjusted for age, sex, and Charlson Comorbidity Index was used to calculate odds ratios of complications among outpatients relative to inpatients undergoing TSA. The query identified 1555 patients who underwent outpatient TSA and 15,987 patients who underwent inpatient TSA. The median age was in the 70 to 74 years age group in both the outpatient and the inpatient cohorts, and the age distribution was comparable between the 2 cohorts (P=.287). The incidence of both outpatient (P<.001) and inpatient (P<.001) TSA increased during the study period. On adjustment for age, sex, and comorbidities, patients undergoing outpatient TSA had significantly lower rates of stiffness requiring manipulation under anesthesia (outpatient, 1.09%; inpatient, 2.35%; odds ratio, 0.52; 95% confidence interval, 0.38-0.71; P<.001) and higher rates of postoperative surgical site infections requiring reoperation (outpatient, 0.90%; inpatient, 0.65%; odds ratio, 1.65; 95% confidence interval, 1.15-2.35; P<.001) at 1 year. Rates of all other postoperative complications were comparable. Ambulatory TSA is increasing in incidence nationwide and is associated with an overall favorable postoperative complication profile. [Orthopedics. 2018; 41(3):e400-e409.].

Optimal management of glenohumeral osteoarthritis

Glenohumeral osteoarthritis (OA) is defined as progressive loss of articular cartilage, resulting in bony erosion, pain, and decreased function. This article provides a gross overview of this disease, along with peer-reviewed research by experts in the field. The pathology, diagnosis, and classification of this condition have been well described. Treatment begins with non-operative measures, including oral and topical anti-inflammatory agents, physical therapy, and intra- articular injections of either a corticosteroid or a viscosupplementation agent. Operative treatment is based on the age and function of the affected patient, and treatment of young individuals with glenohumeral OA remains controversial. Various methods of surgical treatment, ranging from arthroscopy to resurfacing, are being evaluated. The roles of hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty are similarly reviewed with supporting data.

Revision Total Shoulder Arthroplasty is Associated with Increased Thirty-Day Postoperative Complications and Wound Infections Relative to Primary Total Shoulder Arthroplasty

BACKGROUND

With an increasing volume of primary total shoulder arthroplasties (TSA), the number of revision TSA cases is expected to increase as well. However, the postoperative medical morbidity of revision TSA has not been clearly described.

QUESTIONS/PURPOSES

The purpose of this study was to determine the rate of postoperative complications following revision TSA, relative to primary TSA. In addition, we sought to identify independent predictors of complications, as well as to compare operative time and postoperative length of stay between primary and revision TSA.

METHODS

Patients who underwent primary/revision TSA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Differences in complications, readmission rates, operative time, length of stay, and predictors of complications were evaluated using bivariate and multivariate analyses.

RESULTS

A total of 10,371 primary TSA (95.4%) and 496 revision TSA cases (4.6%) were identified. The overall complication rate was 6.5% in primary and 10.7% in revision TSA patients (p < 0.001). Multivariate analysis identified an increased risk of any complication (odds ratio 1.73, p < 0.001), major complication (2.08, p = 0.001), and wound infection (3.45, p = 0.001) in revision TSA patients, relative to primary cases. Operative time was increased in revision cases (mean ± standard deviation, 125 ± 62.5), relative to primary (115 ± 47.7, p < 0.001). Age > 75, female sex, history of diabetes or chronic obstructive pulmonary disease, and American Society of Anesthesiologists classification ≥ 3 were associated with increased risk of any complication. Smoking history was the only significant predictor of wound infection.

CONCLUSION

Revision TSA, in comparison to primary, poses an increased risk of postoperative complications, particularly wound infections. A history of smoking was an independent predictor of wound infections.

The effect of patient gender on outcomes after reverse total shoulder arthroplasty

BACKGROUND

Gender differences may exist for patients undergoing shoulder arthroplasty. Limited data suggest that women may have worse preoperative disability and outcomes. Our objective was to determine whether gender influences preoperative disability and patient-reported outcomes after reverse total shoulder arthroplasty.

METHODS

Data were prospectively collected for patients who underwent reverse total shoulder arthroplasty for rotator cuff arthropathy or osteoarthritis with a rotator cuff tear at a single institution between 2009 and 2015. Range of motion, visual analog scale, 12-Item Short Form Health Survey (SF-12), and American Shoulder and Elbow Surgeons (ASES) scores were collected at the preoperative, 1-year, and 2-year postoperative time points. Data were analyzed using multivariate mixed-effect regression analysis.

RESULTS

There were 117 patients included. Men and women had similar demographics, preoperative range of motion, pain, and function. Length of stay was similar (men, 2.32 days; women, 2.58 days; P = .18). Controlling for patient variables, men achieved higher ASES function (P = .009) and SF-12 Physical Component Summary (P = .008) scores compared with women. There was no difference between men and women in ASES pain and SF-12 Mental Component Summary scores, visual analog scale score, or range of motion.

CONCLUSION

Improvements in pain and range of motion were similar in men and women; however, men achieved higher ASES function and SF-12 Physical Component Summary scores. Women may be more functionally impaired on the basis of differences in activities of daily living. These results may be used to guide discussion about expected benefits after reverse shoulder arthroplasty.

The hospital cost of two-stage reimplantation for deep infection after shoulder arthroplasty

Background

The cost of treating infection after hip and knee arthroplasty is well documented in the literature. The purpose of this study was to determine the cost of two-stage reimplantation for deep infection after shoulder arthroplasty.

Methods

Between 2003 and 2012, 57 shoulders (56 patients) underwent a two-stage reimplantation for deep periprosthetic shoulder infection; implants placed at reimplantation included anatomic total shoulder arthroplasty (a-TSA) in 58%, reverse total shoulder arthroplasty (r-TSA) in 40%, and hemiarthroplasty (HA) in 2%. During the same timeframe, 2953 primary shoulder arthroplasties (2589 patients) were performed at the same institution (a-TSA in 55%, r-TSA in 28%, and HA in 17%). Total direct medical costs were calculated by using standardized, inflation-adjusted costs for services and procedures billed during hospitalization and were adjusted to nationally representative unit costs in 2013 inflation-adjusted dollars.

Results

The mean hospital cost (per shoulder) for two-stage reimplantation was $35,824 (95% CI: 33,363 to 38,285) and was significantly higher than for primary procedures (mean: $16,068; 95% CI: 15,823 to 16,314). Both Part A and Part B costs were significantly higher in two-stage reimplantation (p < 0.001). For part A (hospital services), the mean cost for two-stage reimplantation was $29,851 (95% CI: 27,741 to 31,960), compared to $13,508 (95% CI: 13,302 to 13,715) for primaries. For part B (professional costs), mean costs were $5973 (95% CI: 5493 to 6453) versus 2560 (95% CI: 2512 to 2608) respectively.

Conclusions

The hospital cost of two-stage reimplantation for the treatment of an infected shoulder arthroplasty is about two times higher than the cost of a primary shoulder arthroplasty.

Legal and psychological considerations for obtaining informed consent for reverse total shoulder arthroplasty

This paper seeks to outline recent legal developments and requirements pertinent to obtaining informed consent. We argue that this is of particular relevance to patients considering a reverse total shoulder arthroplasty, due to the high complication rate associated with this procedure. By examining the cognitive processes involved in decision-making, and other clinician-related factors such as delivery of information, gender bias and conflict of interest, we explore some of the barriers that can undermine the processes of shared decision-making and obtaining genuine informed consent. We argue that these issues highlight the importance for surgeons in understanding the cognitive processes and other influential factors involved in patients' comprehension and decision-making. We recommend, based on strong evidence, that decision aids could prove useful in overcoming such challenges and could provide one way of mitigating the ethical, professional and legal consequences of failing to obtain proper informed consent. They are not widely used in orthopaedics at present, although it would be in the interests of both the surgeon and patient for such measures to be explored.

Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends

BACKGROUND

Patients with human immunodeficiency virus (HIV) infection were previously at substantial risk for immunosuppression-related complications. As a result of highly active antiretroviral therapy, HIV-infected patients are living longer and are presenting for elective surgery. Outcomes in HIV-infected patients are well described for hip and knee arthroplasty but not for total shoulder arthroplasty (TSA). The purpose of this study was to examine postoperative complications of TSA in HIV-positive patients.

METHODS

We queried the entire 2005 to 2012 Medicare database. Current Procedural Terminology and International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify the procedure, demographics, comorbidities, and postoperative complications. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

The query returned 2528 HIV-positive patients who underwent TSA or reverse TSA (RTSA). There was increased utilization of TSA and RTSA in this population from 2005 to 2012; 1353 patients had 2-year follow-up. These patients were slightly older and had higher prevalence of comorbidities, suggesting a sicker cohort. HIV-positive patients had alarmingly higher rates of 90-day cerebrovascular accident (OR, 35.98; CI, 30.34-42.67). HIV-positive patients had higher overall rates of broken prosthetic joints (OR, 1.72; CI, 1.20-2.47), periprosthetic infection (OR, 1.36; CI, 1.01-1.82), and TSA revision or repair (OR, 2.44; CI, 1.81-3.28).

CONCLUSIONS

To our knowledge, this is the first study that directly examines the postoperative outcomes of HIV-positive patients after TSA or RTSA. As more of these patients present for surgery, surgeons should be aware that these patients might be at increased risk for certain postoperative surgical and medical complications.

Shoulder Arthroplasty Outcomes in Patients With Multiple Reported Drug Allergies: Does Number of Drug Allergies Have an Effect on Outcome?

Background:

The presence of multiple allergies has been correlated with worse outcomes for patients undergoing hip and knee arthroplasty, but the effect of allergies has not yet been elucidated with respect to shoulder arthroplasty.

Purpose/Hypothesis:

The purpose of this study is to identify any discrepancies in shoulder arthroplasty outcomes with respect to reported drug allergies. We hypothesized that patients with multiple drug allergies would have inferior outcomes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included in the analysis were a single surgeon’s cases between 2009 and 2014 of primary total shoulder arthroplasty with a minimum of 180 days of follow-up. Cases with fracture as the indication were excluded. Preoperative and postoperative metrics included visual analog scale (VAS) for pain, forward flexion range of motion, and Simple Shoulder Test (SST) results, and postoperative patient satisfaction scores were also collected. Chi-square and 1-way analysis of variance with Tukey post hoc analyses were performed when appropriate.

Results:

A total of 98 patients were included (no allergies, n = 51; single allergy, n = 21; multiple allergies, n = 26). The proportion of females was greater with increasing number of allergies (no allergies, 31%; single allergies, 47%; multiple allergies, 88%; Pearson χ² = 22.5; P < .0001). Both preoperatively and postoperatively, no difference was found between cohorts with respect to SST score, VAS score, or forward flexion. There was also no difference in postoperative satisfaction between cohorts. No difference between cohorts was identified when comparing the pre- to postoperative change in SST scores, VAS scores, or forward flexion.

Conclusion:

The presence of single or multiple allergies is not correlated with worse outcomes after primary anatomic total shoulder arthroplasty.

Preoperative patient-reported scores can predict postoperative outcomes after shoulder arthroplasty

BACKGROUND

Total shoulder arthroplasty and reverse total shoulder arthroplasty are increasingly used to improve pain and function in patients with glenohumeral arthritis or cuff tear arthropathy. Our objective was to determine if preoperative patient-reported outcome measures predict which patients will achieve clinically meaningful improvements after shoulder arthroplasty.

METHODS

Preoperative and 1-year postoperative 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and American Shoulder and Elbow Surgeons (ASES) pain and function scores were prospectively collected from 107 patients who underwent total or reverse shoulder arthroplasty. The minimum clinically important difference (MCID) defined meaningful clinical improvement. Receiver operating characteristic analysis was used to calculate threshold values and C statistic. Multivariate logistic regression analysis was performed to determine preoperative measures that were indicative of achieving the MCID postoperatively.

RESULTS

Threshold values below which patients were more likely to achieve MCID were 12 for ASES function, 25 for ASES pain, 46 for SF-12 PCS, and 42 for SF-12 MCS. Multivariate analysis revealed that preoperative ASES function (area under the curve, 0.79; P = .006) and ASES pain (area under the curve, 0.90; P < .001) measures were predictive of achieving the MCID postoperatively. Patients with higher preoperative SF-12 MCS scores had a higher likelihood of achieving MCID for each measure.

CONCLUSION

We determined threshold values that predict clinically meaningful improvement after shoulder arthroplasty. Patients with higher preoperative mental health scores and lower physical function and pain scores were more likely to gain significant benefits from surgery. These results can be used to facilitate shared decision-making and to forecast expected benefits after shoulder arthroplasty.

Shoulder arthroplasty in New York State, 1991 to 2010: changing patterns of utilization

BACKGROUND

Shoulder arthroplasty is now used to treat an expanding variety of glenohumeral disorders.

METHODS

This study assessed the demographic patterns and utilization rates of shoulder hemiarthroplasty (HA) and anatomic or reverse total shoulder arthroplasty (TSA) within New York State (NYS) from 1991 to 2010. Using the New York Statewide Planning and Research Cooperative System database, all shoulder arthroplasty procedures that occurred within NYS during the study period were retrospectively identified and analyzed.

RESULTS

During the 20-year period, 24,040 shoulder arthroplasty procedures were performed. During the second decade (2001-2010), there was a 393% increase in utilization of TSA with a 98% increase in HA. This disproportionate increase is likely due to the introduction and expanding indications of reverse TSA as an effective procedure in place of HA for the treatment of proximal humerus fractures and rotator cuff arthropathy, as rotator cuff arthropathy as a primary indication for HA was significantly less prevalent in period 2. Also notable was an identifiable disparity in race; whites represented approximately 80% of the shoulder arthroplasty procedures in both decades, whereas African Americans made up <5%. This is significantly different from the general racial demographics of NYS during both periods analyzed.

DISCUSSION

It is clear that the volume of shoulder arthroplasty procedures performed in NYS is increasing, mirroring the national experience. This trend reflects the expanding indications, the general success of these procedures, the aging demographic of our population, and a greater desire and willingness of patients to consider operative management to maintain or to improve quality of life.