Is stemless total shoulder arthroplasty indicated in elderly patients?

Clinical and radiological results of the SIMPLICITI* stemless shoulder arthroplasty: a twenty five patients retrospective cohort

PURPOSE

For preserving the humeral bone stock, some surgeons proposed a stemless humeral prosthetic component. This study reports the functional and radiologic results of the stemless anatomic prosthesis Simpliciti*(Tornier, Wright, Stryker), with the hypothesis that it can achieve a good metaphyseal fixation.

METHODS

28 patients underwent 30 shoulder replacements with the Simpliciti* humeral prosthesis followed for an average of three years (2 months to 8 years). The clinical outcome used the Constant-Murley score and the Bankes resistance and force evaluation. The radiologic assessment looked after radiolucent lines, signs of implant migration, osteolysis or loosening.

RESULTS

The Constant score improved from 19.03 preoperatively to 54.03 points post operatively. Radiographic analysis showed one early component loosening, and at the longer follow-up, one radiolucent line. All the other implants appeared well fixed.

CONCLUSION

This study verified the quality of the metaphyseal fixation of this stemless implant, with achieving a significant functional improvement.

LEVEL OF EVIDENCE

Level IV, Case Series, Treatment Study.

High revision rate of metal-backed glenoid component and impact on the overall revision rate of stemless total shoulder arthroplasty: a cohort study from the Danish Shoulder Arthroplasty Registry

BACKGROUND AND PURPOSE

There is controversy regarding the results of stemmed and stemless total shoulder arthroplasty (TSA) used for osteoarthritis. Therefore, we aimed to compare revision rates of stemmed and stemless TSA and to examine the impact of metal-backed glenoid components.

METHODS

We included all patients reported to the Danish Shoulder Arthroplasty Register from January 1, 2012 to December 31, 2022 with an anatomical TSA used for osteoarthritis. Primary outcome was revision (removal or exchange of components) for any reason.

RESULTS

3,338 arthroplasties were included. The hazard ratio for revision of stemless TSA adjusted for age and sex was 1.83 (95% confidence interval [CI] 1.21-2.78) with stemmed TSA as reference. When excluding all arthroplasties with a metal-backed glenoid component, the adjusted hazard ratio for revision of stemless TSA was 1.37 (CI 0.85-2.20). For the Eclipse stemless TSA system, the adjusted hazard ratio for revision of a metal-backed glenoid component was 8.75 (CI 2.40-31.9) with stemless Eclipse with an all-polyethylene glenoid component as reference.

CONCLUSION

We showed that the risk of revision of stemless TSAs was increased and that it was related to their combination with metal-backed glenoid components.

Influence of age-related bone density changes on primary stability in stemless shoulder arthroplasty: a multi-implant finite element study

BACKGROUND

Stemless implants were introduced to prevent some of the stem-related complications associated with the total shoulder arthroplasty. Although general requirements for receiving these implants include good bone quality conditions, little knowledge exists about how bone quality affects implant performance. The goal of this study was to evaluate the influence of age-induced changes in bone density, as a metric of bone quality, in the primary stability of five anatomic stemless shoulder implants using three-dimensional finite element (FE) models.

METHODS

The implant designs considered were based on the Global Icon, Sidus, Simpliciti, SMR, and Inhance stemless implants. Shoulder arthroplasties were virtually simulated in Solidworks. The density distributions of 20 subjects from two age groups, 20-40 and 60-80 years old, were retrieved from medical image data and integrated into three-dimensional FE models of a single humerus geometry, developed in Abaqus, to avoid confounding factors associated with geometric characteristics. For the designs which do not have a solid collar covering the entire bone surface, ie, the Sidus, Simpliciti, SMR, and Inhance implants, contact and noncontact conditions between the humeral head component and bone were considered. Primary stability was evaluated through the assessment of micromotions at the bone-implant interface considering eight load cases related to rehabilitation activities and demanding tasks. Three research variables, considering 20 μm, 50 μm, and 150 μm as thresholds for osseointegration, were used for a statistical analysis of the results.

RESULTS

The decreased bone density registered for the 60-80 age group led to larger micromotions at the bone-implant interface when compared to the 20-40 age group. The Global Icon-based and Inhance-based designs were the least sensitive to bone density, whereas the Sidus-based design was the most sensitive to bone density. The establishment of contact between the humeral head component and bone for the implants that do not have a solid collar led to decreased micromotions.

DISCUSSION

Although the age-induced decline in bone density led to increased micromotions in the FE models, some stemless shoulder implants presented good overall performance regardless of the osseointegration threshold considered, suggesting that age alone may not be a contraindication to anatomic total shoulder arthroplasty. If only primary stability is considered, the results suggested superior performance for the Global Icon-based and Inhance-based designs. Moreover, the humeral head component should contact the resected bone surface when feasible. Further investigation is necessary to combine these results with the long-term performance of the implants and allow more precise recommendations.

Patients 75 years or older with primary glenohumeral arthritis and an intact rotator cuff show similar clinical improvement after reverse or anatomic total shoulder arthroplasty

BACKGROUND

The optimal management of primary glenohumeral arthritis (GHOA) in the elderly is an ongoing topic of debate. The purpose of this study was to compare functional outcomes and complications in patients aged 75 years or older treated with anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) for primary GHOA with an intact rotator cuff.

METHODS

A retrospective study was performed on a prospectively maintained database which was queried for patients 75 years of age or older who underwent TSA or RSA for primary GHOA with an intact rotator cuff at a single institution between 2012 and 2021 with minimum 2-year follow-up. Patient-reported outcomes (PROs), including Visual Analog Scale for pain, American Shoulder and Elbow Surgeons, and Subjective Shoulder Value, as well as active range of motion including forward flexion, external rotation, internal rotation, were collected preoperatively and postoperatively. Complications, reoperations, and satisfaction were also recorded. The percentage of patients achieving clinically significant improvement was evaluated with the minimally clinical important difference, substantial clinical benefit, and patient acceptable symptomatic state for each PRO.

RESULTS

One-hundred and 4 patients were available for analysis, including 67 TSA patients and 37 RSAs with a mean follow-up of 39.4 months. Preoperative baseline characteristics, PROs, and range of motion were similar between groups. RSA was more commonly performed for eccentric glenoid wear (Walch B2/B3, 62% vs. 22%; P < .001). While clinical outcomes improved comparably in both groups, the TSA cohort showed significantly greater improvement in external rotation (36° vs. 26°; P = .013). Both cohorts had low revision (3% for TSA vs. 0% for RSA) and complication (7% for TSA vs. 5% for RSA; P = .677) rates. Satisfaction was similar in both groups (93% for TSA vs. 92% for RSA; P = .900). Clinically significant improvement was comparable between groups based on the American Shoulder and Elbow Surgeons score (minimally clinical important difference, 93% for TSA vs. 100% for RSA; substantial clinical benefit, 82% vs. 95%; patient acceptable symptomatic state, 67% vs. 78%; P > .05).

CONCLUSION

In this retrospective small sample size comparison study, TSA and RSA provide similar short-term clinical outcomes for patients 75 years and older with primary GHOA and an intact rotator cuff. Complication and revision rates are comparably low at short-term follow-up. Our data suggests that advanced age alone should not be used as a decision-making tool for TSA vs. RSA in the setting of primary GHOA with an intact rotator cuff.

Efficacy and safety of intravenous tranexamic acid in total shoulder arthroplasty: A meta-analysis

BACKGROUND

Total shoulder arthroplasty (TSA) results in a large amount of perioperative blood loss due to severe trauma.

AIM

To investigate the safety and efficacy of intravenous tranexamic acid (TXA) in TSA.

METHODS

We searched the PubMed, Cochrane Library, Embase and Web of Science databases for randomized controlled trials (RCTs) on the use of TXA in TSA. And all the results were checked and assessed by Reference Citation Analysis (https://www.referencecitationanalysis.com/). A meta-analysis was performed with Review Manager 5.3 to calculate the odds ratio (OR) or weighted mean difference (WMD) of related outcome indicators.

RESULTS

A total of 5 RCTs with level 1 evidence were included. There were 369 cases, with 186 in the TXA group and 183 in the placebo group. The meta-analysis showed that TXA can significantly reduce total blood loss during the perioperative period [WMD = -249.56, 95% confidence interval (CI): -347.6 to -151.52, P < 0.0001], and the incidence of adverse reactions was low (OR = 0.36, 95%CI: 0.16-0.83, P = 0.02). Compared with the placebo group, the TXA group had significantly less total haemoglobin loss (WMD = -34.39, 95%CI: -50.56 to -18.22), less haemoglobin fluctuation before and after the operation (WMD = -0.6, 95%CI: -0.93 to -0.27) and less 24-h drain output (WMD = -136.87, 95%CI: -165.87 to -106.49). There were no significant differences in the operation time (P = 0.11) or hospital length of stay (P = 0.30) between the two groups.

CONCLUSION

The application of intravenous TXA in the perioperative period of TSA can significantly reduce the total volume of perioperative blood loss and reduce the incidence of adverse reactions, so TXA is worthy of widespread clinical use.