Long - Term survivorship and clinical and radiological follow - up of the primary uncemented Delta III reverse shoulder prosthesis

Functional and radiographic outcomes of reverse shoulder arthroplasty with a minimum follow-up of 10 years

BACKGROUND

The use of reverse shoulder arthroplasty (RSA) is becoming increasingly prevalent. However, few studies have been published reporting the long-term outcomes of RSA. This study aims to report the clinical, radiographic, and patient-reported outcomes of the Delta Xtend reverse shoulder prosthesis, performed by a single surgeon and with a minimum follow-up of 10 years.

METHODS

All RSA procedures performed between 2005 and 2012 were identified. Patients were contacted and invited for a follow-up visit including clinical assessment, radiographs, and patient-reported outcome measures. Patients with a follow-up of less than 10 years were excluded. The revision-free implant survival was calculated at 10 years. Between 2005 and 2012, 119 procedures in 116 patients meeting inclusion criteria were identified. Of these patients, 35 were deceased before reaching the 10-year follow-up and 23 could not be reached. In total, 63 RSAs could be included in 61 patients (response rate: 75%). The median follow-up was 11.7 years (interquartile range [IQR]: 10.5-13.2).

RESULTS

Of the 61 patients, 7 patients underwent a revision after a median of 3 years (IQR: 0.2-9.8) during the total follow-up period. The 10-year implant survival was 94% (95% confidence interval: 84-98). At final follow-up, the median anterior elevation was 135° (IQR: 130°-160°), the median abduction was 120° (IQR: 100°-135°), and the median level reached with internal rotation was L5 (IQR: sacrum-L5). The median Auto-Constant score was 68 (IQR: 53-78), the median Subjective Shoulder Value was 80 (IQR: 70-93), and the median pain score was 0.2/10 (IQR: 0-2). In total, radiographs could be obtained in 25 patients (40%). Scapular notching occurred in 10 patients (40%), which was classified as Sirveaux-Nerot grade IV in 3 patients (12%). Ossification occurred in 10 patients (40%), and stress shielding in 2 patients (8%). Radiolucencies were observed around the humeral component in 24 patients (96%) and around the glenoid component in 13 patients (52%).

CONCLUSION

The long-term results of RSA with a Delta Xtend prosthesis are favorable, with long-term improvement in range of motion and patient-reported outcome measures, and a satisfactory implant survival rate. Interestingly, the radiographical analysis showed high prevalence of signs associated with loosening, which did not seem to translate to high complication rates or inferior results.

Inverted-bearing reverse shoulder arthroplasty: long-term survivorship, complications, clinical, and radiological outcomes

BACKGROUND

Inverted-bearing reverse shoulder arthroplasty (IB-RSA) is characterized by a polyethylene glenosphere and a metallic humeral liner to minimize polyethylene wear and debris secondary to impingement between the humerus and glenoid neck. IB-RSA long-term survivorship, complication and revision rates, as well as clinical and radiographic outcomes have not been reported yet.

METHODS

This is a monocentric retrospective study on a consecutive series of 151 patients who underwent primary IB-RSA from January 2009 to September 2015 and were evaluated clinically and radiologically at the minimum 8-year follow-up. All complications and reoperations were recorded. Survivorship analysis with any revision surgery as endpoint was done using Kaplan-Meier survival curves.

RESULTS

Seventy-eight patients (follow-up rate 51.7%) were reviewed at a mean follow-up of 10.1 ± 1.9 years. At 10 years, the revision-free survival was 98.7% (95% confidence interval: 94.8-99.7). Sixteen complications (10.6%) were observed: 2 axillary nerve injuries, 2 infections, 2 glenoid loosening (which stabilized within 1 year), 2 cases of otherwise unexplained painful stiffness, 4 acromial fractures, 1 post-traumatic scapular pillar fracture, and 3 post-traumatic humeral periprosthetic fractures. Two patients were revised due to infection. No cases of late glenoid loosening and humeral loosening were observed. The revision rate was 1.3%. All the clinical scores and range of motion significantly improved at the last follow-up compared with preoperative status: final Constant score was 66.1 ± 17.4, Subjective Shoulder Value 79.1 ± 20.9, and the American Shoulder and Elbow Surgeons 82.2 ± 17.7. Scapular notching was observed in 51.4% of patients: only 1 case of grade 3 notching was observed in an early glenoid subsidence case.

CONCLUSIONS

Primary IB-RSA appears to be a safe and effective procedure and does not present specific implant-associated complications at long-term follow-up. Radiographic analysis showed that inverting the biomaterials leads to a distinct kind of notching with mainly mechanical features.

Midterm outcomes of primary reverse shoulder arthroplasty: a systematic review of studies with minimum 5-year follow-up

Background

Excellent short-term outcomes after reverse shoulder arthroplasty (RSA) have been reported, but longer term outcomes in the existing literature are sparse and vary widely. The purpose of this study is to systematically assess the existing literature to quantify functional outcomes and complication rates after RSA at a minimum of five years of follow-up.

Methods

A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant systematic literature search of the PubMed and Embase databases was undertaken. Studies reporting outcomes after primary RSA for nontrauma-related indications with a minimum of 5-year follow-up were included.

Results

Overall, 20 studies satisfied all inclusion criteria. This represented 1591 shoulders in 1556 patients (32.1% males), with a mean age of 70.2 ± 5.0 years and mean follow-up of 8.8 years, or 106.2 ± 30.1 months (60-243). At final follow-up, the mean reported Constant Murley score was 62.1 ± 5.0 (49.0-83.0). The mean adjusted Constant Murley score was 83.5 ± 12.5 (58-111.9). The mean American Shoulder and Elbow Surgeons score was 81.8 ± 4.6, while the mean subjective shoulder value was 74.6 ± 6.4. Overall, 88% of patients rated their satisfaction as either good or very good. The range of active forward flexion, abduction, external, and internal rotation were respectively, 126° ± 13°, 106° ± 11°, 22° ± 11°, and 6° ± 2°. The overall rate of revision surgery was 4.9% (0%-45.5%). Regarding complications, the rate of prosthetic joint infection was 4.3% (0%-26.7%), shoulder dislocation was 3.7% (0%-20.4%), and acromial fracture was 2.0% (0%-8.8%). At final follow-up, 30.9% of shoulders had some degree of scapular notching.

Conclusion

This systematic review shows that RSA results in high satisfaction rates, good clinical outcomes, as well as modest complication and revision rates at minimum 5-year follow-up.

A pilot-study focusing on internal rotation after reverse total shoulder arthroplasty using the Activities of Daily Living which require Internal Rotation (ADLIR) score

Background

Loss of internal rotation remains an issue after reverse total shoulder arthroplasty (RTSA). Our goal is to define the expected functional internal rotation after RTSA using the Activities of Daily Living which require Internal Rotation (ADLIR) score in a homogenous population of patients treated with RTSA.

Methods

35 patients with a minimum follow-up of two years after RTSA were evaluated using the ADLIR and Constant-Murley questionnaires. A correlation between the ADLIR and Constant score was investigated and the internal validity of the ADLIR score used in a RTSA patient population was measured using Cronbach's alpha coefficient. The impact of internal rotation on the total rotational arc of motion was defined.

Results

Excellent results were recorded for both the Constant score (79 ± 18) and ADLIR score (88 ± 16). Pearson's correlation coefficient was r = 0,84 (p-value <0,001). The ADLIR score showed a high reliability for all questions.

Conclusions

The ADLIR score has proven to be a useful addition in the post-operative evaluation of patients treated with RTSA. Further studies are needed to investigate the evolution of the ADLIR score from pre- to postoperatively in order to determine the clinical and predictive value of this score.

Level of evidence

Level IV - Observational study.

[Cuff Arthropathy - Inverse Total Shoulder Arthroplasty (iSTEP) - Biomechanical Principles, Complications and Outcomes]

The inverse total shoulder prosthesis is a standard treatment for cuff arthropathy. The number of implanted inverse total shoulder prostheses in Germany is significantly higher than that of the anatomical total shoulder prosthesis. Kaplan-Meier analyses show a 10-year result of inverse total shoulder prostheses after cuff arthropathy of 90%. The extent of the scapular notching correlates with the functional clinical outcome. The humeral anchoring principles of inverse total shoulder prosthesis differ considerably (from purely epiphyseal to diaphyseal). Inverse total shoulder prostheses show significant differences in humeral and glenoid offset as well as in shaft-neck angles. The large number of systems available differ considerably concerning anatomical and biomechanical parameters - the surgeons must be trained accordingly. Still, most shoulder replacements are implanted by surgeons who rarely perform this procedure.

Inverted-bearing reverse total shoulder arthroplasty: scapular notching does not affect clinical outcomes and complications at up to 7 years of follow-up

BACKGROUND

Scapular notching is a common complication of reverse total shoulder arthroplasty (RTSA). Inverted-bearing RTSA (IB-RTSA) systems, with polyethylene (PE) glenospheres and metal or ceramic humeral liners, reduce notching and PE wear compared with traditional Grammont prosthesis designs. However, whether notching after IB-RTSA influences clinical outcomes or complications remains unknown. Therefore, we evaluated the influence of notching on midterm clinical outcomes and complication rates after IB-RTSA.

METHODS

In our prospective multicenter, observational study, patients underwent IB-RTSA, using a prosthesis system with a PE glenosphere and a metal humeral component. We assessed patients clinically for functional scores, active range of motion, and pain and radiographically for notching.

RESULTS

Overall, 270 patients (284 shoulders) were treated with IB-RTSA. Of these, 229 shoulders were available for a mean follow-up of 86.7 months (range, 24.0-133.4 months). We observed notching in 35% of shoulders (28% grade 1; 3% grade 2; and 4% grade 3). IB-RTSA led to a distinct type of notching representing the mechanical indent of the humeral component into the scapular neck without PE-induced osteolysis. Patients with and without notching showed similar clinical outcomes (P ≥ .05), complication rates (P = .23), revision rates (P = .87), and survival of implant components after 10 years (P = .85).

CONCLUSIONS

Midterm results confirmed our hypothesis that patients with notching had equally good clinical outcomes and low complication rates as patients without notching. Additionally, we found a distinct type of notching without signs of PE-induced osteolysis.

Reconstruction or replacement? A challenging question in surgical treatment of complex humeral head fractures in the elderly

INTRODUCTION

Surgical treatment of complex humeral head fractures in the elderly is challenging due to osteoporotic bone, comorbidities and reduced compliance. The treatment strategy (reconstruction versus replacement) should allow for a functional aftercare and result in a high patient satisfaction. Major complications leading to surgical revision are crucial and should be avoided. The purpose of this study was to analyse the major complication rate leading to surgical revision and the patient-based outcome in complex humeral head fractures of the elderly population treated either using locking plate fixation (LCP) or reversed total shoulder arthroplasty (rTSA).

MATERIALS AND METHODS

All patients older than 65 years surgically treated due to a four-part fracture of the proximal humerus between 2003 and 2015 were enrolled in our retrospective study. Major complications and revision rates were recorded and functional outcome was assessed using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score.

RESULTS

A cohort of 103 patients with a mean age of 73.4 ± 6.2 years suffering from four-part fractures of the humeral head were enrolled. 63 patients were treated using the LCP fixation compared to 40 rTSAs. There were no significant differences in the patient-reported functional outcome. The revision rate was significantly higher in the LCP group (10/63; 15.9%) compared to the rTSA group (1/40; 2.5%). Reasons for revision were avascular head necrosis, cut-out of screws, secondary dislocation of the greater tuberosity and hypersensitivity to metal.

CONCLUSIONS

Reversed total shoulder arthroplasty and locking plate fixation are both established surgical procedures for the management of complex proximal humerus fractures in the elderly leading to similar functional results. However the revision rate in the rTSA group was significantly lower. Primary rTSA should, therefore, be favoured in multimorbid elderly patients with an increased complication risk to avoid repeated anaesthesia.

Reverse total shoulder arthroplasty in massive rotator cuff tears: does the Hamada classification predict clinical outcomes?

INTRODUCTION

Reverse total shoulder arthroplasty (RTSA) is a widely recognized treatment to reduce pain and improve shoulder function for patients in various disease stages of cuff tear arthropathy (CTA). However, it remains unclear whether outcomes after RTSA depend on the preoperative stage of CTA. Therefore, this study evaluated whether the Hamada classification influences midterm clinical outcomes after RTSA.

MATERIALS AND METHODS

In this multicenter observational study, patients underwent inverted bearing RTSA for massive rotator cuff tears or CTA. Shoulders were grouped into those with (Hamada grades 4a, 4b, and 5) and those without (Hamada grades 1, 2, and 3) glenohumeral arthritis. Clinical outcomes, including range of motion, Constant score, American Shoulder and Elbow Surgeons score, and visual analog scale for pain and satisfaction, were determined preoperatively and at 24 and > 30 months. All complications were recorded, and survival free from any implant component revision was calculated.

RESULTS

Overall, 202 patients (211 shoulders) were treated with RTSA at a mean age of 75.8 ± 6.6 years (range 41.9-91.6 years). Of these, 144 patients (151 shoulders) were available for a mean follow-up of 79.9 ± 24.7 months (range 30.2-132.3 months). No significant between-group differences were found for clinical outcomes at 24 and > 30 months (P > 0.05). Furthermore, the Hamada classification did not correlate with clinical outcomes at 24 (P = 0.98) and > 30 months (P = 0.29). Revision-free implant component survival was similar between groups (P = 0.17). Postoperative complications were found in 11 shoulders, of which 10 required revision.

CONCLUSIONS

Inverted bearing RTSA was found to be an effective treatment with similarly good midterm clinical outcomes, similar revision rates, and high implant survival rates in every stage of massive rotator cuff tears. Overall, the preoperative Hamada classification did not influence clinical outcomes or complications after RTSA.

Minimum five-year outcomes of reverse total shoulder arthroplasty using a trabecular metal glenoid base plate

AIMS

Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes.

METHODS

All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up.

RESULTS

The implant was revised in ten shoulders (5.2%) with a median time to revision of 21.2 months (interquartile range (IQR) 9.9 to 41.8). The Kaplan-Meier survivorship estimate at seven years was 95.9% (95% confidence interval (CI) 91.7 to 98; 35 RTSAs at risk) for aseptic mechanical failure of the glenoid and 94.8% (95% CI 77.5 to 96.3; 35 RTSAs at risk) for all-cause revision. Minimum five-year clinical and radiological outcomes were available for 103 and 98 RTSAs respectively with a median follow-up time of six years (IQR 5.2 to 7.0). Median postoperative Oxford Shoulder Score was 38 (IQR 31 to 45); median Constant and Murley score was 60 (IQR 47.5 to 70); median forward flexion 115° (IQR 100° to 125°); median abduction 95° (IQR 80° to 120°); and external rotation 25° (IQR 15° to 40°) Scapular notching was seen in 62 RTSAs (63.2%).

CONCLUSION

We present the largest and longest-term series of TM-backed glenoid implants demonstrating 94.8% all-cause survivorship at seven years. Specifically pertaining to glenoid loosening, survival of the implant increased to 95.9%. In addition, we report satisfactory minimum five-year clinical and radiological outcomes. Cite this article: Bone Joint J 2021;103-B(8):1333-1338.

Influence of humeral stem inclination in reverse shoulder arthroplasty on range of motion: a meta-analysis

Hypothesis

The reverse shoulder arthroplasty, as introduced by Grammont, has had many modifications over time. One of these modifications was reducing the neck-shaft angle (NSA) from 155 degrees to 135 degrees. Biomechanical studies indicated that lowering the NSA increases external rotation and reduces abduction and the incidence of scapular notching. The purpose of this study was to compare range of motion, functional outcome measures, and complications in patients undergoing reverse shoulder arthroplasty, depending on the NSA, through a systematic review and meta-analysis.

Methods

A literature search was conducted (articles published from January 1985 to January 2020) in the PubMed/MEDLINE, Embase, and CINAHL databases and the Cochrane library. All studies reporting outcomes after primary reverse shoulder arthroplasty for osteoarthritis and rotator cuff-related disease were included. Patients were divided into 2 groups: a medialized design (MD) with an NSA of 150-155 degrees and a lateralized design (LD) with an NSA of less than 150 degrees. Pooled effects were calculated in the form of mean differences and 95% confidence intervals (CIs). Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies - of Interventions tool for non-Randomized Controlled Trials and the Risk Of Bias 2 tool for Randomized Controlled Trials.

Results

A total of 21 studies and 3134 arthroplasties were included: 1366 with an MD and 1678 with an LD. The mean age was 73.0 years (MD 74.0 and LD 72.5). A direct comparative meta-analysis was not feasible, and therefore, all data were compared using the minimal clinically important difference. The MD group demonstrated a larger improvement in abduction (56.76°, 95% CI 37.03-76.49) than the LD group (48.52°, 95% CI 28.27-68.78), however the LD group demonstrated a larger improvement in external rotation with the arm at the side (MD: 7.69°, 95% CI 0.01-15.37; LD: 16.14° 95% CI 7.18-25.09). When looking at the postoperative range of motion, the MD group had more abduction than the LD group (MD: 136.28°, 95% CI 127.36-145.20; LD: 127.77° 95% CI 117.02-138.52). Both designs had a comparable improvement in the Constant Murley score (MD 42.04 points, LD 41.14 points). Lowering the NSA was accompanied by a decrease in dislocation rate (MD: 4.6%; LD: 1.4%; P value .037) and notching rate (MD: 40.3%; LD: 17.3%; P value <.0001).

Conclusion

In our analysis, lowering the NSA decreases the amount of abduction but increases the amount of external rotation. This change in range of motion is accompanied by less scapular notching and dislocations. There is no clear impact on functional outcome measures.

Reverse total shoulder arthroplasty

AIMS

This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH).

METHODS

A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and patient-reported outcome measures (PROMs). Meta-analysis was conducted on the reported proportion of complications, weighted by sample size, and PROMs were pooled using the reported standardized mean difference (SMD). Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROSPERO (CRD42020193041).

RESULTS

A total of 42 studies met the inclusion and exclusion criteria. Rates of scapular notching were found to be significantly higher in MGMH implants (52% (95% confidence interval (CI) 40 to 63)) compared with MGLH ((18% (95% CI 6 to 34)) and LGMH (12% (95% CI 3 to 26)). Higher rates of glenoid loosening were seen in MGMH implants (6% (95% CI 3 to 10)) than in MGLH implants (0% (95% CI 0 to 2)). However, strength of evidence for this finding was low. No significant differences were identified in any other complication, and there were no significant differences observed in PROMs between implant philosophies.

CONCLUSION

This systematic review has found significant improvement in PROMS and low complication rates across the implant philosophies studied. Scapular notching was the only complication found definitely to have significantly higher prevalence with the MGMH implant design. Cite this article: Bone Joint J 2021;103-B(5):813-821.

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 Total Shoulder Arthroplasty: Biomechanics and Indications

PURPOSE OF REVIEW

Over the past decade, our understanding of the biomechanics of the reverse total shoulder arthroplasty (RTSA) has advanced, resulting in design adjustments, improved outcomes, and expanding indications. The purpose of this review is to summarize recent literature regarding the biomechanics of RTSA and the evolving indications for its use.

RECENT FINDINGS

While Grammont's principles of RTSA biomechanics remain pillars of contemporary designs, a number of modifications have been proposed and trialed in later generations to address complications such as impingement and glenoid failure. Clinical and biomechanical literature suggest that less medialized, more inferior glenospheres result in less impingement and notching. On the humerus, a more vertical neck cut is associated with less impingement. Indications for RTSA continue to expand beyond the classic indication of cuff tear arthropathy (CTA). Patients without a functional cuff but no arthritis now have a reliable option in the RTSA. RTSA has also replaced hemiarthroplasty as the implant of choice for displaced three- and four-part proximal humerus fractures in the elderly. Finally, updated design options and modular components now allow for treatment of glenoid bone loss, failed arthroplasty, and proximal humerus tumors with RTSA implants. Reverse total shoulder arthroplasty design has been modernized on both the glenoid and humerus to address biomechanical challenges of early implants. As outcomes improve with these modifications, RTSA indications are growing to address complex bony pathologies such as tumor and bone loss. Longitudinal follow-up of patients with updated designs and novel indications is essential to judicious application of RTSA technology.