Complications After Anatomic Shoulder Arthroplasty: Revisiting Leading Causes of Failure

Tendon transfers in the setting of shoulder arthroplasty

Background

Tendon transfers in conjunction with reverse total shoulder arthroplasty can significantly improve functional outcomes in patients with glenohumeral arthritis and irreparable rotator cuff deficiency. There have been multiple promising new techniques described within the last 20 years that shoulder surgeons should become familiar with.

Methods

The authors reviewed the literature on tendon transfers in the setting of reverse total shoulder arthroplasty. Procedures to restore various shoulder functions were described including surgical anatomy, techniques, pearls and pitfalls, and photos.

Results

Subscapularis insufficiency can be reconstructed with a pectoralis major transfer or latissimus dorsi transfer, with the latter having better clinical outcomes and a more anatomic line of pull. Posterosuperior rotator cuff deficiency can be reconstructed with a latissimus transfer (L'Episcopo transfer) or lower trapezius transfer, with the latter proving superior in biomechanical and short-term studies. Deltoid deficiency can be reconstructed with a pedicled upper pectoralis major transfer. Massive proximal humerus bone loss can be reconstructed with an allograft-prosthetic composite, and any of the aforementioned transfers can be utilized in this setting as well.

Conclusion

Tendon transfers in conjunction with reverse shoulder arthroplasty can significantly improve functional outcomes in patients with glenohumeral arthritis and irreparable rotator cuff deficiency. There have been multiple promising new techniques described within the last 20 years that shoulder surgeons should become familiar with.

Incidence and risk factors of in-hospital prosthesis-related complications following total shoulder arthroplasty

BACKGROUND

The occurrence of prosthesis-related complications after total shoulder arthroplasty is devastating and costly. The purpose was to determine the incidence and risk of in-hospital prosthesis-related complications after total shoulder arthroplasty utilizing a large-scale sample database.

METHODS

A retrospective database analysis was performed based on Nationwide Inpatient Sample from 2010 to 2014. Patients who underwent total shoulder arthroplasty were included. Patient demographics, hospital characteristics, length of stay, economic indicators, in-hospital mortality, comorbidities, and peri-operative complications were evaluated.

RESULTS

A total of 34,198 cases were capture from the Nationwide Inpatient Sample database. There were 343 cases of in-hospital prosthesis-related complications after total shoulder arthroplasty and the overall incidence was 1%, with a more than 2.5-fold decrease from 2010 to 2014. Dislocation was the most common category among prosthesis-related complications (0.1%). The occurrence of in-hospital prosthesis-related complications was associated with significantly more total charges and slightly longer length of stay while less usage of Medicare. Risk factors of prosthesis-related complications were identified including younger age (<64 years), female, the native American, hospital in the South, alcohol abuse, depression, uncomplicated diabetes, diabetes with chronic complications, fluid and electrolyte disorders, metastatic cancer, neurological disorders, and renal failure. Interestingly, advanced age (≥65 years) and proprietary hospital were found as protective factors. Furthermore, prosthesis-related complications were associated with aseptic necrosis, rheumatoid arthritis, rotator cuff tear arthropathy, Parkinson's disease, prior shoulder arthroscopy, and blood transfusion.

CONCLUSIONS

It is of benefit to study risk factors of prosthesis-related complications following total shoulder arthroplasty to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.

Incidence of complications related to shoulder arthroplasties identified on computed tomography

PURPOSE

Determine incidence of shoulder arthroplasty complications identified on computed tomography (CT).

MATERIALS AND METHODS

Retrospective institutional database review of patients with shoulder arthroplasties who underwent CT between 01/2006-11/2021 at a tertiary academic referral center with subspecialized orthopedic shoulder surgeons. CT reports were reviewed for arthroplasty type and complication. Data were stratified and summarized. Associations between complications and arthroplasty types were determined with Chi-squared goodness of fit test.

RESULTS

Eight hundred twelve CTs in 797 unique patients were included (438 (53.9%) females and 374 (46.1%) males; mean age 67 ± 11 years). There were 403 total shoulder arthroplasties (TSA), 317 reverse total shoulder arthroplasties (rTSA), and 92 hemiarthroplasties (HA). Complications were present in 527/812 (64.9%) and incidences were: loosening/aseptic osteolysis 36.9%, periprosthetic failure 21.6%, periprosthetic fracture 12.3%, periprosthetic dislocation 6.8%, joint/pseudocapsule effusion 5.9%, prosthetic failure 4.8%, infection 3.8%, and periprosthetic collection 2.1%. Complications per arthroplasty were: 305/403 (75.7%) TSAs, 176/317 (55.5%) rTSAs, and 46/92 (50%) HAs (p < 0.001). Periprosthetic fracture (20.8%), prosthetic dislocation (9.8%), and prosthetic failure (7.9%) were highest in rTSAs (p < 0.001, p < 0.013, p < 0.001, respectively). Loosening/aseptic osteolysis most frequent in TSAs (54.1%) (p < 0.001). Periprosthetic failure most frequent in HA (32.6%) (p < 0.001). Significant associations were identified with joint/pseudocapsule effusion and loosening/aseptic osteolysis (p = 0.04) and prosthetic dislocation (p < .001).

CONCLUSION

In this single tertiary academic referral center cohort, the incidence of shoulder arthroplasty complication identified on CT was 64.9% and the most commonly occurring complication was loosening/aseptic osteolysis (36.9%). TSA had the highest incidence of complication (75.7%).

Update on Shoulder Arthroplasties with Emphasis on Imaging

Shoulder pain and dysfunction may significantly impact quality of life. If conservative measures fail, advanced disease is frequently treated with shoulder arthroplasty, which is currently the third most common joint replacement surgery following the hip and knee. The main indications for shoulder arthroplasty include primary osteoarthritis, post-traumatic arthritis, inflammatory arthritis, osteonecrosis, proximal humeral fracture sequelae, severely dislocated proximal humeral fractures, and advanced rotator cuff disease. Several types of anatomic arthroplasties are available, such as humeral head resurfacing and hemiarthroplasties, as well as total anatomic arthroplasties. Reverse total shoulder arthroplasties, which reverse the normal ball-and-socket geometry of the shoulder, are also available. Each of these arthroplasty types has specific indications and unique complications in addition to general hardware-related or surgery-related complications. Imaging-including radiography, ultrasonography, computed tomography, magnetic resonance imaging, and, occasionally, nuclear medicine imaging-has a key role in the initial pre-operative evaluation for shoulder arthroplasty, as well as in post-surgical follow-up. This review paper aims to discuss important pre-operative imaging considerations, including rotator cuff evaluation, glenoid morphology, and glenoid version, as well as to review post-operative imaging of the various types of shoulder arthroplasties, to include normal post-operative appearances as well as imaging findings of complications.

Total shoulder arthroplasty vs. hemiarthroplasty in patients with primary glenohumeral arthritis with intact rotator cuff: meta-analysis using the ratio of means

BACKGROUND

Glenohumeral arthritis is a degenerative disease of the shoulder joint. There is limited evidence in the literature in superiority of outcomes between total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) for patients when the rotator cuff is intact. The purpose of this systematic review was to compare patient-reported outcome measures (PROMs) and rate of complication between these 2 interventions in patients with primary glenohumeral arthritis and an intact rotator cuff. Previous systematic reviews have focused only on results from randomized controlled trials, demonstrating mixed outcomes in PROMs and no difference in postoperative complications or rate of revision. Our study is the first, to our knowledge, to assess all comparative studies including prospective and retrospective observational studies, assessing a combined 1317 patients. Using the ratio of means, data from different PROMs were pooled to analyze and compare the total combined relative effect change following intervention.

METHODS

We undertook literature review of the reference databases until March 2021. We included randomized controlled trials in addition to comparative observational studies and case series (more than 10 patients). Study participants were adults who had primary glenohumeral arthritis with an intact rotator cuff. Meta-analysis was performed by the ratio of means for PROMs and risk ratio for revision and complication data.

RESULTS

Comparing clinical outcome of TSA against HA from 10 studies, meta-analyses using ratio of means demonstrated an 8% significantly improved relative increase in the postoperative PROMs in the TSA cohort (ratio of means 1.08, 95% confidence interval [CI] 0.04-1.12, P < .01). The TSA cohort additionally demonstrated a significantly lower revision rate (relative risk 1.84, 95% CI 1.05-3.24, P = .03). Although the risk of complication was nonsignificant, pooling revision and complications data revealed a 2-fold increased risk in the HA group compared with TSA (relative risk 2.09, 95% CI 1.17-3.74, P = .01).

CONCLUSIONS

In patients with primary glenohumeral osteoarthritis with an intact rotator cuff, TSA is favored to HA in terms of clinical outcome, risk of revision surgery, and postoperative complications.