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A'Court JJ, Chatindiara I, Fisher R, Poon PC. Does the stemless reverse arthroplasty compare to a conventional stemmed implant? Clinical and radiographic evaluation at 2 years' minimum follow-up. J Shoulder Elbow Surg 2024; 33:1938-1945. [PMID: 38423251 DOI: 10.1016/j.jse.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Reverse shoulder arthroplasty (RSA) is a well-recognized treatment for many shoulder conditions, including rotator cuff arthropathy, primary glenohumeral joint arthritis, and rheumatoid arthritis, and can be used in both trauma and revision settings. Over the past 10 years, its popularity in New Zealand has been increasing, with a 6%-7% annual growth rate during this period. Stemless RSA designs have the following proposed advantages: They can preserve humeral bone stock, they can limit periprosthetic fractures, and they can be indicated in patients with abnormal diaphyseal humeral anatomy. To date, only 1 study has evaluated the outcomes of the Lima SMR Stemless implant. We present our data with an aim to report how the stemless reverse arthroplasty compares to a conventional stemmed implant. METHODS We performed a retrospective review of a consecutive series of patients treated at a single institution between 2015 and 2020. The endpoint was defined as final follow-up at a minimum of 2 years. Patients were excluded from the final analysis if they underwent revision. Thirty-three patients were identified as having undergone stemless RSA. Thirty patients had patient-reported outcome measures and radiographs at a minimum of 2 years' follow-up. Three patients had undergone revision within 2 years. The same sample size of stemmed RSAs (n = 33) was selected for comparison. RESULTS A total of 60 patients were included in the final analysis, of whom 30 underwent stemless RSA and 30 underwent stemmed RSA. The demographic characteristics of the 2 groups were comparable except age at operation, which showed a statistically significant difference (P = .001): 77 years (stemmed) vs. 65 years (stemless). The mean Oxford Shoulder Score was 40.1 in the stemless group vs. 40 in the stemmed group. The mean American Shoulder and Elbow Surgeons score was 72.9 in the stemless group vs. 79 in the stemmed group. Patient-reported outcome measures, pain scores, and satisfaction ratings were not statistically significantly different between the 2 groups. In terms of radiographic data, subsidence was observed in 2 patients in the stemless RSA group but the patients had no clinical symptoms. Also in the stemless RSA group, 1 patient had an acromial stress fracture and 1 patient had a superficial wound infection successfully treated with oral antibiotics. In terms of revisions in the stemless RSA group, 1 patient underwent revision owing to chronic infection, 1 underwent revision as a result of a periprosthetic fracture after a fall, and 1 underwent revision for gross instability. CONCLUSIONS The early results of sRSA are promising, and the stemless implant shows similar outcomes to a conventional stemmed implant.
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Affiliation(s)
- Jamie J A'Court
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand.
| | - Idah Chatindiara
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
| | - Rachael Fisher
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
| | - Peter C Poon
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
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Levin JM, Lorentz SG, Hurley ET, Lee J, Throckmorton TW, Garrigues GE, MacDonald P, Anakwenze O, Schoch BS, Klifto C. Artificial intelligence in shoulder and elbow surgery: overview of current and future applications. J Shoulder Elbow Surg 2024; 33:1633-1641. [PMID: 38430978 DOI: 10.1016/j.jse.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/10/2024] [Accepted: 01/14/2024] [Indexed: 03/05/2024]
Abstract
Artificial intelligence (AI) is amongst the most rapidly growing technologies in orthopedic surgery. With the exponential growth in healthcare data, computing power, and complex predictive algorithms, this technology is poised to aid providers in data processing and clinical decision support throughout the continuum of orthopedic care. Understanding the utility and limitations of this technology is vital to practicing orthopedic surgeons, as these applications will become more common place in everyday practice. AI has already demonstrated its utility in shoulder and elbow surgery for imaging-based diagnosis, predictive modeling of clinical outcomes, implant identification, and automated image segmentation. The future integration of AI and robotic surgery represents the largest potential application of AI in shoulder and elbow surgery with the potential for significant clinical and financial impact. This editorial's purpose is to summarize common AI terms, provide a framework to understand and interpret AI model results, and discuss current applications and future directions within shoulder and elbow surgery.
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Affiliation(s)
- Jay M Levin
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Samuel G Lorentz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Eoghan T Hurley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Julia Lee
- Department of Orthopedic Surgery, Sierra Pacific Orthopedics, Fresno, CA, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Germantown, TN, USA
| | | | - Peter MacDonald
- Section of Orthopaedic Surgery & The Pan Am Clinic, University of Manitoba, Winnipeg, MB, Canada
| | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Bradley S Schoch
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Christopher Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Ritter D, Denard PJ, Raiss P, Wijdicks CA, Bachmaier S. A stemless anatomic shoulder arthroplasty design provides increased cortical medial calcar bone loading in variable bone densities compared to a short stem implant. JSES Int 2024; 8:851-858. [PMID: 39035663 PMCID: PMC11258817 DOI: 10.1016/j.jseint.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Background Several studies have reported proximal bone resorption in stemless and press-fit short-stem humeral implants for anatomic total shoulder arthroplasty. The purpose of this biomechanical study was to evaluate implant and cortical bone micromotion of a cortical rim-supported stemless implant compared to a press-fit short stem implant during cyclic loading and static compression testing. Methods Thirty cadaveric humeri were assigned to 3 groups based on a previously performed density analysis, adopting the metaphyseal and epiphyseal and inferior supporting bone densities for multivariate analyses. Implant fixation was performed in stemless implant in low bone density (SL-L, n = 10) or short stem implant in low bone density (Stem-L, n = 10) and in stemless implant in high bone density (SL-H, n = 10). Cyclic loading with 220 N, 520 N, and 820 N over 1000 cycles at 1.5 Hz was performed with a constant valley load of 25 N. Optical recording allowed for spatial implant tracking and quantification of cortical bone deformations in the medial calcar bone region. Implant micromotion was measured as rotational and translational displacement. Load-to-failure testing was performed at a rate of 1.5 mm/s with ultimate load and stiffness measured. Results The SL-H group demonstrated significantly reduced implant micromotion compared to both low-density groups (SL-L: P = .014; Stem-L: P = .031). The Stem-L group showed significantly reduced rotational motion and variance in the test results at the 820-N load level compared to the SL-L group (equal variance: P = .012). Implant micromotion and reversible bone deformation were significantly affected by increasing load (P < .001), metaphyseal cancellous (P = .023, P = .013), and inferior supporting bone density (P = .016, P = .023). Absolute cortical bone deformation was significantly increased with stemless implants in lower densities and percentage reversible bone deformation was significantly higher for the SL-H group (21 ± 7%) compared to the Stem-L group (12 ± 6%, P = .017). Conclusion A cortical rim-supported stemless implant maintained proximally improved dynamic bone loading in variable bone densities compared to a press-fit short stem implant. Biomechanical time-zero implant micromotion in lower bone densities was comparable between short stem and stemless implants at rehabilitation load levels (220 N, 520 N), but with higher cyclic stability and reduced variability for stemmed implantation at daily peak loads (820 N).
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Affiliation(s)
- Daniel Ritter
- Arthrex Department of Orthopedic Research, Munich, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
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Ritter D, Denard PJ, Raiss P, Wijdicks CA, Bachmaier S. Preoperative 3-dimensional computed tomography bone density measures provide objective bone quality classifications for stemless anatomic total shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:1503-1511. [PMID: 38182017 DOI: 10.1016/j.jse.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/26/2023] [Accepted: 11/12/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Reproducible methods for determining adequate bone densities for stemless anatomic total shoulder arthroplasty (aTSA) are currently lacking. The purpose of this study was to evaluate the utility of preoperative computed tomography (CT) imaging for assessing the bone density of the proximal humerus for supportive differentiation in the decision making for stemless humeral component implantation. It was hypothesized that preoperative 3-dimensional (3-D) CT bone density measures provide objective classifications of the bone quality for stemless aTSA. METHODS A 3-part study was performed that included the analysis of cadaveric humerus CT scans followed by retrospective application to a clinical cohort and classification with a machine learning model. Thirty cadaveric humeri were evaluated with clinical CT and micro-CT (μCT) imaging. Phantom-calibrated CT data were used to extract 3-D regions of interest and defined radiographic scores. The final image processing script was applied retrospectively to a clinical cohort (n = 150) that had a preoperative CT and intraoperative bone density assessment using the "thumb test," followed by placement of an anatomic stemmed or stemless humeral component. Postscan patient-specific calibration was used to improve the functionality and accuracy of the density analysis. A machine learning model (Support vector machine [SVM]) was utilized to improve the classification of bone densities for a stemless humeral component. RESULTS The image processing of clinical CT images demonstrated good to excellent accuracy for cylindrical cancellous bone densities (metaphysis [ICC = 0.986] and epiphysis [ICC = 0.883]). Patient-specific internal calibration significantly reduced biases and unwanted variance compared with standard HU CT scans (P < .0001). The SVM showed optimized prediction accuracy compared with conventional statistics with an accuracy of 73.9% and an AUC of 0.83 based on the intraoperative decision of the surgeon. The SVM model based on density clusters increased the accuracy of the bone quality classification to 87.3% with an AUC of 0.93. CONCLUSIONS Preoperative CT imaging allows accurate evaluation of the bone densities in the proximal humerus. Three-dimensional regions of interest, rescaling using patient-specific calibration, and a machine learning model resulted in good to excellent prediction for objective bone quality classification. This approach may provide an objective tool extending preoperative selection criteria for stemless humeral component implantation.
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Affiliation(s)
- Daniel Ritter
- Department of Orthopedic Research, Arthrex GmbH, Munich, Germany; Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany.
| | | | | | - Coen A Wijdicks
- Department of Orthopedic Research, Arthrex GmbH, Munich, Germany
| | - Samuel Bachmaier
- Department of Orthopedic Research, Arthrex GmbH, Munich, Germany
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Caldaria A, Giovannetti de Sanctis E, Saccone L, Baldari A, Azzolina D, La Verde L, Palumbo A, Franceschi F. Bone Density Changes at the Origin of the Deltoid Muscle following Reverse Shoulder Arthroplasty. J Clin Med 2024; 13:3695. [PMID: 38999260 PMCID: PMC11242818 DOI: 10.3390/jcm13133695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 06/16/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Reverse total shoulder arthroplasty (RSA) significantly impacts deltoid length, tension, and structure. Studies have extensively investigated various modifications in deltoid characteristics, such as perfusion, elasticity, caliber, histological changes, and strength post-RSA. However, to date, there is a notable absence of research evaluating changes in bone mineral density (BMD) at the deltoid muscle origin after the RSA procedure. Methods: A retrospective analysis of a consecutive series of RSAs performed between May 2011 and May 2022 was conducted. Inclusion criteria comprised primary RSAs with both preoperative and last follow-up shoulder CT scans and a minimum follow-up of 12 months. Trabecular attenuation measured in Hounsfield units (HU) was calculated using a rapid region-of-interest (ROI) method. BMD analysis involved segmenting three ROIs in both pre- and postoperative CT scans of each patient: the acromion, clavicle, and spine of the scapula. Results: A total of 44 RSAs in 43 patients, comprising 29 women and 14 men, were included in this study. The mean follow-up duration was 49 ± 22.64 months. Significant differences were observed between preoperative and postoperative HU values in all analyzed regions. Specifically, BMD increased in the acromion and spine, while it decreased in the clavicle (p-values 0.0019, <0.0001, and 0.0088, respectively). Conclusions: The modifications in shoulder biomechanics and, consequently, deltoid tension post-implantation result in discernible variations in bone quality within the analyzed regions. This study underscores the importance of thorough preoperative patient planning. By utilizing CT images routinely obtained before reverse shoulder replacement surgery, patients at high risk for fractures of the acromion, clavicle, and scapular spine can be identified.
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Affiliation(s)
- Antonio Caldaria
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
- Faculty of Medicine and Surgery, UniCamillus-Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
| | - Edoardo Giovannetti de Sanctis
- Institut Universitaire Locomoteur et du Sport (IULS), Hôpital Pasteur 2, CHU de Nice, 30, Avenue Voie Romaine, 06000 Nice, France
| | - Luca Saccone
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
- Faculty of Medicine and Surgery, UniCamillus-Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario Campus Bio-Medico of Rome, 00128 Rome, Italy
| | - Angelo Baldari
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
- Faculty of Medicine and Surgery, UniCamillus-Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
| | - Danila Azzolina
- Department of Preventive and Environmental Science, University of Ferrara, 44131 Ferrara, Italy
| | - Luca La Verde
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
| | - Alessio Palumbo
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
- Faculty of Medicine and Surgery, UniCamillus-Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
| | - Francesco Franceschi
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
- Faculty of Medicine and Surgery, UniCamillus-Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
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Hiyama K, Takakuwa T, Yamaguchi R, Mochizuki T. Stemless total shoulder arthroplasty for multiple epiphyseal dysplasia in a 52-year-old patient: a case report. JSES Int 2024; 8:126-131. [PMID: 38312288 PMCID: PMC10837698 DOI: 10.1016/j.jseint.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Affiliation(s)
- Kanehiro Hiyama
- Department of Orthopedic Surgery, Shoulder Center, Tokyo KITA Medical Center, Tokyo, Japan
| | - Takuya Takakuwa
- Department of Orthopedic Surgery, Shoulder Center, Tokyo KITA Medical Center, Tokyo, Japan
| | - Reiko Yamaguchi
- Department of Orthopedic Surgery, Shoulder Center, Tokyo KITA Medical Center, Tokyo, Japan
| | - Tomoyuki Mochizuki
- Department of Orthopedic Surgery, Shoulder Center, Tokyo KITA Medical Center, Tokyo, Japan
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Hochreiter B, Selman F, Calek AK, Kriechling P, Götschi T, Grubhofer F, Wieser K, Bouaicha S. Why is female gender associated with poorer clinical outcomes after reverse total shoulder arthroplasty? J Shoulder Elbow Surg 2023; 32:2355-2365. [PMID: 37276918 DOI: 10.1016/j.jse.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION There is a lack of gender-specific research after reverse total shoulder arthroplasty (RTSA). Although previous studies have documented worse outcomes in women, a more thorough understanding of why outcomes may differ is needed. We therefore asked: (1) Are there gender-specific differences in preoperative and postoperative clinical scores, complications, surgery-related parameters, and demographics? (2) Is female gender an independent risk factor for poorer clinical outcomes after RTSA? (3) If so, why is female gender associated with poorer outcomes after RTSA? MATERIALS AND METHODS Between 2005 and 2019, 987 primary RTSAs were performed in our institution. After exclusion criteria were applied, data of 422 female and 271 male patients were analyzed. Clinical outcomes (absolute/relative Constant Score [a/rCS] and Subjective Shoulder Value [SSV]), complications (intra- and/or postoperative fracture, loosening), surgery-related parameters (indication, implant-related characteristics), and demographics (age, gender, body mass index, and number of previous surgeries) were evaluated. Preoperative and postoperative radiographs were analyzed (critical shoulder angle, deltoid-tuberosity index, reverse shoulder angle, lateralization shoulder angle, and distalization shoulder angle). RESULTS Preoperative clinical scores (aCS, rCS, SSV, and pain level) and postoperative clinical outcomes (aCS and rCS) were significantly worse in women. However, the improvement between preoperative and postoperative outcomes was significantly higher in female patients for rCS (P = .037), internal rotation (P < .001), and regarding pain (P < .001). Female patients had a significantly higher number of intraoperative and postoperative fractures (24.9% vs. 11.4%, P < .001). The proportion of female patients with a deltoid-tuberosity index <1.4 was significantly higher than males (P = .01). Female gender was an independent negative predictor for postoperative rCS (P = .047, coefficient -0.084) and pain (P = .017, coefficient -0.574). In addition to female sex per se being a predictive factor of worse outcomes, females were significantly more likely to meet 2 of the 3 most significant predictive factors: (1) significantly worse preoperative clinical scores and (2) higher rate of intra- and/or postoperative fractures. CONCLUSIONS Female sex is a very weak, but isolated, negative predictive factor that negatively affects the objective clinical outcome (rCS) after RTSA. However, differences did not reach the minimal clinically important difference, and it is not a predictor for the subjective outcome (SSV). The main reason for the worse outcome in female patients seems to be a combination of higher preoperative disability and higher incidence of fractures. To improve the outcome of women, all measures that contribute to the reduction of perioperative fracture risk should be used.
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Affiliation(s)
- Bettina Hochreiter
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Farah Selman
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Kriechling
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tobias Götschi
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Florian Grubhofer
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Samy Bouaicha
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Hatta T, Shinagawa K, Kawakami J, Kanazawa K, Hayakawa T, Yamamoto N, Yamakado K. A survey and biomechanical analysis of the feasibility of the thumb test for determining the cancellous bone quality for stemless shoulder prosthesis. J Orthop Surg (Hong Kong) 2023; 31:10225536231218869. [PMID: 38009331 DOI: 10.1177/10225536231218869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND The effect of the thumb test for assessing the cancellous bone quality at the resection plane of the proximal humerus on determining the application of a stemless shoulder prosthesis remains unclear. This study was conducted to survey the current utilization of the thumb test among surgeons and to investigate biomechanical features of the thumb test. METHOD A survey among shoulder surgeons who had experience with stemless prostheses was conducted to investigate the current utilization of preoperative assessments and intraoperative thumb test when applying stemless prosthesis. Biomechanical experiments for the thumb test using artificial bone models were performed to assess the compression force, contact pressure and area. According to the preliminary survey, three compression techniques were assessed: compression perpendicular to the surface with thumb pad (P-pad technique) or tip of the thumb (P-tip technique), or compression in the vertical direction simulating compression along the longitudinal axis of the humeral shaft with tip-pad of the thumb (H-axis technique). The contact area was separated into three subregions (proximal, middle and distal) to assess the distribution of contact pressure. RESULTS Among 38 surgeons, 66% utilized the thumb test intraoperatively. The P-pad technique was more frequently applied than the P-tip or H-axis techniques (80%, 4% and 16%, respectively). Although with wide variation among the examiners, biomechanical assessments revealed the P-pad technique showed larger contact area and less compression force than the P-tip technique. The P-pad technique provided no significant localized differences in the mean contact pressure on the compressed plane, whereas the P-tip and H-axis techniques showed significant differences among subregions. CONCLUSION This survey demonstrated relatively frequent application of the thumb test on applying the stemless shoulder prosthesis. Biomechanical assessment revealed the thumb test can hinder objective reproducibility among examiners; therefore, further investigations to identify feasible assessments of the bone quality is required.
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Affiliation(s)
- Taku Hatta
- Department of Orthopedic Surgery, Joint Surgery, Sports Clinic Ishinomaki, Ishinomaki, Japan
| | | | - Jun Kawakami
- Department of Orthopedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Kenji Kanazawa
- Department of Orthopedic Surgery, South Miyagi Medical Center, Shibata-gun, Japan
| | - Takashi Hayakawa
- Department of Orthopedic Surgery, Niigata Central Hospital, Niigata, Japan
| | - Nobuyuki Yamamoto
- Department of Orthopedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Kotaro Yamakado
- Department of Orthopedic Surgery, Fukui General Hospital, Fukui, Japan
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Hayden A, Cotter EJ, Hennick T, Hetzel S, Wollaeger J, Anderson S, Grogan BF. Bone quality in total shoulder arthroplasty: a prospective study correlating computed tomography Hounsfield units with thumb test and fracture risk assessment tool score. JSES Int 2023; 7:628-635. [PMID: 37426930 PMCID: PMC10328770 DOI: 10.1016/j.jseint.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Background To evaluate if Hounsfield units (HU) measured on preoperative computed tomography (CT) scans at the anatomic neck of the proximal humerus correlates with intraoperative findings of the "thumb test" in assessment of bone quality in shoulder arthroplasty patients. Methods Primary anatomic total shoulder and reverse total shoulder arthroplasty patients from 2019-2022 with an available preoperative CT scan of the operative shoulder were prospectively enrolled at a single center with 3 surgeons who perform shoulder arthroplasty. The "thumb test" was performed intraoperatively; a positive test signified "good bone." Demographic information, including prior dual x-ray absorptiometry scans, was extracted from the medical record. HU at the cut surface of the proximal humerus were calculated, as was cortical bone thickness on preoperative CT. Fracture risk assessment tool (FRAX) scores were calculated for 10-year risk of osteoporotic fracture. Results A total of 149 patients were enrolled. Mean age was 67.6 ± 8.5 years with 69 (46.3%) being males. Patients with a negative thumb test were significantly older (72.3 ± 6.6 vs. 66.5 ± 8.6 years; P < .001) than those with a positive thumb test. Males were more likely to have a positive thumb test than females (P = .014). Patients with a negative thumb test had significantly lower HUs on preoperative CT (16.3 ± 29.7 vs. 51.9 ± 35.2; P < .001). Patients with a negative thumb test had a higher mean FRAX score (14.1 ± 7.9 vs. 8.0 ± 4.8; P < .001). Receiver operator curve analysis was performed to identify a cut-off value for CT HU of 36.67, above which the thumb test is likely to be positive. Furthermore, receiver operator curve analysis also identified optimal cut-off values for 10-year risk of fracture by FRAX score of 7.75 HU, below which the thumb test is likely to be positive. Fifty patients were at high risk based on FRAX and HU; surgeons classified 21 (42%) as having "poor bone" quality through a negative thumb test. High-risk patients had a negative thumb test 33.8% (23/68) and 37.1% (26/71) of the time for HU and FRAX, respectively. Conclusions Surgeons are poor at identifying suboptimal bone quality at the anatomic neck of the proximal humerus based on intraoperative thumb test when referencing against CT HU and FRAX scores. The objective measures of CT HU and FRAX scoring may be useful metrics to incorporate into surgeons' preoperative plans for humeral stem fixation using readily available imaging and demographic data.
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Affiliation(s)
- Alexander Hayden
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Eric J. Cotter
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Terah Hennick
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - John Wollaeger
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Scott Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Brian F. Grogan
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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