Reverse shoulder arthroplasty for rheumatoid arthritis since the introduction of disease-modifying drugs

Mitigating the Risk of Instability After Reverse Shoulder Arthroplasty: A Critical Analysis Review of Patient and Surgical Factors

» Instability and dislocation after reverse shoulder arthroplasty may occur in up to 31% of patients.

» Clinical risk factors for instability include younger age, male sex, increased body mass index, preoperative diagnosis of proximal humerus fracture or rotator cuff pathology, history of instability of the native shoulder or after surgery, and a medical history of Parkinson's disease.

» Patients with rheumatoid arthritis and decreased proximity to the coracoid may also be at greater risk.

» In patients at a high risk of instability, surgeons should consider a more lateralized prosthesis (particularly in patients with an incompetent rotator cuff), repairing the subscapularis (particularly when using a medialized prosthesis), and upsizing the glenosphere (>40 mm in male and 38-40 mm in female patients).

» While potentially useful, less evidence exists for the use of a constrained liner (particularly with a lateralized glenosphere and/or in low-demand patients) and rotating the polyethylene liner posteriorly to avoid impingement.

Clinical outcomes of over-the-top subscapularis repair in reverse shoulder arthroplasty

Background

Biomechanical research demonstrates increased subscapularis abduction range of motion (ROM) when the tendon's upper two-thirds is repaired over-the-top of the center of rotation during reverse shoulder arthroplasty (RSA). This study compares the clinical outcomes of patients undergoing RSA with over-the-top subscapularis repair (OTTR) to patients without repair.

Methods

We retrospectively reviewed 97 consecutive RSAs with either OTTR of the subscapularis (N = 75) or no repair (N = 22). Repair was attempted in all patients but not performed if the subscapularis could not be brought to the over-the-top position in 20° of external rotation (ER) and 30° of abduction. Improvements in ROM were compared to the minimal clinically important difference for RSA.

Results

The mean follow-up was 3.8 ± 1.6 years. Demographics were similar between groups. Preoperatively, patients undergoing repair had greater ER when compared to those without repair (15 ± 16° vs. 5 ± 12°, P = .003). Postoperatively, patients undergoing repair had greater forward elevation (132 ± 21° vs. 126 ± 22°, P = .268) and abduction (114 ± 26° vs. 106 ± 23°, P = .193) with both exceeding the minimal clinically important difference (-2.9° and -1.9°, respectively); however, not statistically significant. Patients with repair were more frequently able to reach the small of their back postoperatively (65% vs. 21%, P = .006) but had less improvement in ER (13 ± 20° vs. 24 ± 20°, P = .028). Postoperative outcome scores, complications, and reoperations were similar between groups.

Discussion

OTTR of the subscapularis in RSA had similar ROM and outcome scores compared to no repair, but a significantly larger proportion of patients with repair achieved functional internal rotation to the small of the back. ER limitations seen after conventional repair may also apply to this novel technique, but without a corresponding detrimental effect on forward elevation or abduction.

Long-Term Results of Primary Reverse Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears Without Glenohumeral Arthritis with a Mean Follow up of 9.4 Years

Background

The aim of this single-center study was to analyze the long-term clinical results of reverse shoulder arthroplasty in patients with massive, irreparable rotator cuff tears without glenohumeral arthritis.

Methods

A retrospective cohort study of 105 patients (115 shoulders) was conducted. The mean age of the patient group was 76 years (range, 65 to 87 years). The mean clinical follow-up was 9.4 years (range, 5 to 17 years). Pain, range of motion, and complication rates were analyzed pre-operatively and at the last follow-up.

Results

The mean Constant-Murley score increased from 29 points (range, 21 to 34 points) preoperatively to 68.1 points (range, 57 to 81 points) postoperatively (p<0.05). Scapular notching was present in 50 shoulders (43.5%) and it was grade 1 or 2 in 47 of 115 cases (40.9%) and grade 3 or 4 in 3 of 115 cases (2.6%). Complications occurred in 19 patients (17%). Seven patients (6%) underwent revision surgery. The mean satisfaction rate was 94%.

Conclusions

Reverse shoulder arthroplasty is a viable treatment for massive, irreparable rotator cuff tears without glenohumeral arthritis with satisfactory clinical outcomes and low complication and reoperation rates with a mean follow up of 9.4 years after surgery.

Comparison of reverse shoulder arthroplasty and total shoulder arthroplasty for patients with inflammatory arthritis

BACKGROUND

End-stage glenohumeral joint arthritis is common in patients with inflammatory arthritis. Reverse shoulder arthroplasty (RSA) and anatomic total shoulder arthroplasty (TSA) are both indicated in this setting. RSA is often considered based on the impacts of long-standing inflammatory arthritis including glenoid and humeral bone erosion and rotator cuff insufficiency. However, acromial and scapular spine fractures following RSA have been reported more commonly in these patients, which can have a significant impact on outcomes. Currently, no study has directly compared the efficacy and complication rates of RSA vs. TSA in patients with inflammatory arthritis. This study aimed to investigate differences in clinical outcomes and complications in patients undergoing RSA vs. TSA with glenohumeral inflammatory arthritis.

METHODS

We performed a retrospective review of 86 patients with inflammatory arthritis treated with primary RSA (n = 43) or TSA (n = 43) with a minimum of 2 years' follow-up. American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, visual analog scale scores for pain and function, active range of motion, and patient self-ratings of upper-extremity normality (Subjective Assessment of Normal Evaluation [SANE]) were collected preoperatively and at minimum 2-year follow-up. Radiographic classification of preoperative glenoid and humeral bone loss was performed, and postoperative complications were observed. Revision and complication details were compared.

RESULTS

The study cohort had an average age of 72.1 years (range, 31-92 years) and average follow-up period of 51.6 months (range, 22-159 months). Both the RSA and TSA cohorts demonstrated improvements in patient-reported outcome measures and ranges of motion; however, patients treated with TSA showed a greater postoperative final Simple Shoulder Test score (P < .001), visual analog scale score for function (P = .0347), active elevation (P = .0331), active external rotation (P < .001), active internal rotation (P = .005), and Single Assessment Numeric Evaluation (SANE) score (P = .0161). Analysis of complication rates demonstrated no statistically significant difference between cohorts. Four acromial fractures occurred in the RSA group. When RSA patients who sustained acromial fractures were removed from the analysis, there were minimal differences in outcomes between the RSA and TSA cohorts.

CONCLUSION

TSA in patients with inflammatory arthritis leads to improved clinical outcomes but higher early revision rates when compared with RSA. RSA outcomes are negatively impacted by a high rate of postoperative acromial fractures.

Perioperative management of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society for Rheumatology

BACKGROUND

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.

METHODS

After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.

RESULTS

The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.

CONCLUSION

Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.

[Perioperative management of treatment of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society of Rheumatology]

BACKGROUND

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.

METHODS

After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.

RESULTS

The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.

CONCLUSION

Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.

Reverse shoulder arthroplasty in rheumatoid arthritis: survival and outcomes

BACKGROUND

Despite its potential biomechanical advantages, reverse shoulder arthroplasty (RSA) is still considered to be particularly high risk in rheumatoid patients who are osteoporotic and immunodeficient. Our purpose was to report prosthesis survival, complications, and outcomes of RSA in patients with rheumatoid arthritis (RA) at minimum 5-year follow-up.

METHODS

We conducted a retrospective multicenter study including 65 consecutive primary RSAs performed in 59 patients with RA between 1991 and 2010. We excluded rheumatoid patients with previous failed anatomic shoulder arthroplasty. Age at surgery averaged 69 years (range, 46-86 years). A structural bone grafting was performed in 18 cases (45%), using the humeral head in 15 cases (BIO-RSA technique), the iliac crest in 2 cases (Norris technique), and an allograft in 1 case. The mean follow-up was 92 months (range, 60-147 months) or until revision surgery.

RESULTS

Revision-free survivorship, using Kaplan-Meier curves, was 96% at 7 years. Two patients had revision surgeries for infections, with associated glenoid loosening in 1 case. No humeral loosening was recorded. The mean adjusted Constant score improved from 36% ± 23% preoperatively to 90% ± 26% postoperatively, and mean Subjective Shoulder Value improved from 21% ± 13% to 85% ± 12%, respectively (P < .001). Active anterior elevation increased from 65° ± 43° to 132° ± 27°, active external rotation increased from 10° ± 26° to 22° ± 27°, and internal rotation improved from buttocks to waist (P < .001). Stable fixation of the baseplate was achieved in all cases (including the 6 patients with end-stage RA), and we did not observe bone graft nonunion or resorption. Preoperative radiologic pattern (centered, ascending, or destructive), presence of acromial fractures or tilt (4 cases, 10%), and scapular notching (55%) on final radiographs were not found to influence outcomes or complication rate. Patients with absent/atrophied teres minor had lower functional results. Overall, 95% of the patients were satisfied with the procedure.

CONCLUSION

RSA is a safe and effective procedure for the treatment of RA patients, with a low risk of complications and low rate of revision, regardless of the radiologic presentation and stage of the disease. Rheumatoid patients undergoing primary RSA, with or without glenoid bone grafting, can expect a revision-free survival rate of 96% at 7-year follow-up. RSA offers the benefit of solving 2 key problems encountered in rheumatoid shoulders: glenoid bone destruction and rotator cuff deficiency.

Does preoperative diagnosis impact patient outcomes following reverse total shoulder arthroplasty? A systematic review

BACKGROUND

The indications for reverse total shoulder arthroplasty (rTSA) have expanded to include the treatment of a wide variety of shoulder pathologies, and there may be significant differences in patient outcomes based on preoperative diagnosis.

METHODS

A systematic review of the orthopedic literature contained in the PubMed, Cochrane, and Embase databases was performed on November 14, 2019. Studies investigating rTSA indicated for 7 distinct preoperative diagnoses (massive rotator cuff tear [MCT] without glenohumeral osteoarthritis [GHOA], MCT with GHOA or cuff tear arthropathy, primary GHOA, inflammatory arthritis with MCT, failed shoulder arthroplasty, proximal humeral fracture [PHF], and sequelae following PHF) were included. The main outcomes of interest included functional outcomes (abduction, external rotation, and forward flexion) and patient-reported outcome measures (American Shoulder and Elbow Surgeons shoulder score and Constant-Murley score). Because of significant variation in measurement and reporting, data on internal rotation were not extracted. In addition, radiographic outcomes and complication rates were extracted and recorded for each of the included studies.

RESULTS

In total, 47 studies, comprising 2280 patients, met the inclusion criteria. Significant improvements in functional outcomes and patient-reported outcome measures were found across the preoperative diagnostic groups. There were no significant differences between the diagnostic groups regarding improvement between preoperative and postoperative values for the outcomes of interest, with the exception that the inflammatory arthropathy group had significantly less improvement in the Constant-Murley score than the primary GHOA and revision arthroplasty groups. Although there were few differences in improvement between groups, there were significant differences regarding the level of postoperative functional performance, which was not as consistent in the context of trauma or revision operations (ie, complex PHF, fracture sequela, and revision arthroplasty groups).

CONCLUSION

Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. The groups with primary GHOA and MCTs with or without GHOA demonstrated the most reliable postoperative functional outcomes of the examined diagnostic groups. Postoperative outcomes were not as consistent in the context of trauma or revision operations, and these groups may benefit from a variety of modern advancements in rTSA, although further research into these modalities for these groups is needed. Finally, rTSA remains an important treatment option in the context of rheumatoid arthritis, with similar outcomes and complication rates compared with the 6 other operative indications.

Midterm clinical outcomes of reverse shoulder arthroplasty in Japanese patients with rheumatoid arthritis using patient-reported outcome measures (Shoulder36)

Background

Reverse shoulder arthroplasty normally has adequate functional outcomes in patients with cuff tear arthropathy. The present study aimed to investigate the midterm clinical outcomes of reverse shoulder arthroplasty in Japanese patients with rheumatoid arthritis.

Methods

Between July 2014 and May 2016, reverse shoulder arthroplasty was performed in 14 rheumatic shoulders with joint destruction and rotator cuff tears. The range of motion, Constant score, and Shoulder36, which is a patient-reported outcome measure, were compared preoperatively and postoperatively. The prevalence of subscapular notching, subscapular osteophytes, postoperative fractures, and stress shielding of the humeral stem were evaluated by X-ray.

Results

Range of motion significantly improved from 77 to 122 degrees in flexion and from 67 to 111 degrees in abduction at four years. The Constant score significantly improved from 27 to 62, and each domain of Shoulder36 also significantly increased at four years. There was no dislocation, infection, or loosening of the prosthesis. Three shoulders presented scapular notching, and three cemented humeral stems showed stress shielding in the proximal humeral cortical bone.

Conclusion

Reverse shoulder arthroplasty performed in Japanese patients with rheumatoid arthritis not only decreased the pain and improved the function of the shoulder joint but also significantly improved patients' health and activity of daily living in midterm results.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II

Background

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous.

Methods

Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests.

Results

The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%.

Conclusions

Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.

Reverse Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: Early Outcomes, Pitfalls, and Challenges

Objective

To evaluate the early outcomes and risk factors of reverse shoulder arthroplasty (RSA) in patients with rheumatoid arthritis (RA).

Methods

A retrospective study was performed on RA patients who had undergone RSA between January 2016 and January 2018. Preoperative glenohumeral joint damage was evaluated according to two radiographic classification systems. The severity of joint damage was estimated using Larsen's method, while the Levigne‐Franceschi method was used to assess the type of destruction. Further, we recorded intra‐ and postoperative complications. Visual Analogue Scale (VAS) was used to assess the degree of shoulder pain while shoulder function was evaluated with the American Shoulder and Elbow Surgeons (ASES) Shoulder Score. In addition, patients' subjective outcome and range of shoulder motion were recorded. Radiographs were taken and examined during the follow‐up period. Paired t‐test was used to determine the difference in measurement data between preoperative and the last follow‐up. VAS was analyzed using the Wilcoxon matched‐pairs signed‐rank test.

Results

A total of 14 patients with 14 shoulders were included. All the patients were female with an average age of 60.29 years (range, 49–71 years) at the time of surgery and an average RA disease duration of 24.57 years (range, 5–40 years). Seven of the 14 patients had a history of joint surgery related to RA. Meanwhile, 11 of the 14 shoulders showed glenoid bone defect, and eccentric reaming was performed intraoperatively to avoid base plate malposition. The mean follow‐up period for the 14 patients was 2.76 years (range, 2–4 years). The mean VAS decreased from a value of 5.71 ± 1.10 preoperatively to 1.36 ± 0.61 postoperatively (P < 0.001). On the contrary, the ASES score showed an increase from 33.93 ± 6.89 to 76.67 ± 5.23 (P < 0.001). An increase in active forward elevation, abduction, and external rotation with the arm in 90° of abduction from 85.71° ± 17.61°, 77.14° ± 19.43°, and 17.14° ± 10.97° to 126.43° ± 5.23°, 106.42° ± 11.72°, and 38.57° ± 14.57°, respectively, was observed (P < 0.001). Subjective outcome assessment showed that 13 of the 14 patients were very satisfied or satisfied with the operation, while one patient was uncertain due to co‐existing ipsilateral elbow lesion. Notably, one patient acquired a humeral periprosthetic fracture during the operation. In this study, no major complications such as periprosthetic joint infection and dislocation or implant loosening were observed. Further, no patients underwent revision for any reason at the end of the follow‐up.

Conclusions

RSA could achieve good early outcomes without high complication rates in patients with RA. Glenoid bone defects and adjacent joints involvement were common in this patient group, which might increase the risk of surgery and affect postoperative satisfaction.

Conjoint tendon release for persistent anterior shoulder pain following reverse total shoulder arthroplasty

Background

Persistent anterior shoulder pain is an under-reported complication after reverse total shoulder arthroplasty (RTSA). The purpose of this study was to determine the effectiveness of open conjoint tendon release in patients with anterior shoulder pain due to conjoint tendinitis after RTSA.

Methods

Open conjoint tendon release was performed by the senior author from June 2014 to November 2018 in patients with persistent anterior shoulder pain after RTSA. Patients were evaluated preoperatively and at a minimum of 1 year postoperatively by phone interview with patient-reported outcome scores including a visual analog scale score for pain and the American Shoulder and Elbow Surgeons score.

Results

We evaluated 11 of 12 patients (92% follow-up) at a minimum of 1 year (average, 27 ± 11 months) after conjoint tendon release. American Shoulder and Elbow Surgeons and visual analog scale pain scores improved from 29.0 ± 22.1 and 7.3 ± 2.0, respectively, preoperatively to 58.2 ± 30.6 and 3.1 ± 3.5, respectively, postoperatively, after open conjoint tendon release (P = .02 and P = .003, respectively). Of the patients, 45% (5 of 11) reported improvement but with some coracoid pain after the release whereas 55% (6 of 11) reported no coracoid pain after the release. No complications occurred as a result of the release, and no patients required reoperation.

Conclusion

Our results suggest that conjoint tendinitis may be a cause of persistent postoperative anterior shoulder pain after RTSA and open conjoint tendon release is a successful treatment.