Anatomic versus reverse shoulder arthroplasty: a mid-term follow-up comparison

Thresholds for diminishing returns in postoperative range of motion after total shoulder arthroplasty

BACKGROUND

Satisfaction following total shoulder arthroplasty (TSA), which is commonly reported using patient-reported outcome measures (PROMs), is partially dependent upon restoring shoulder range of motion (ROM). We hypothesized there exists a minimum amount of ROM necessary to perform functional tasks queried in PROM questionnaires, beyond which further ROM may provide no further improvement in PROMs.

METHODS

A retrospective review of a multicenter international shoulder arthroplasty database was performed between 2004 and 2020 for patients undergoing anatomic or reverse TSA (aTSA, rTSA), with minimum 2-year follow-up. Our primary outcome was to determine the threshold in postoperative active ROM (abduction, forward elevation [FE], external rotation [ER], and internal rotation [IR] score), whereby additional improvement was not associated with additional improvement in PROMs (Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and the Shoulder Pain and Disability Index). For comparison, we also evaluated the Shoulder Arthroplasty Smart (SAS) score, which is not subject to the ceiling effect.

RESULTS

We included 4459 TSAs (1802 aTSAs, 2657 rTSAs) with minimum 2-year follow-up (mean, 56 ± 32 months). The threshold in postoperative ROM that were associated with no further improvement were active abduction, 107-113° for PROMs vs. 163° for the SAS score; active FE, 149-162° for PROMs vs. 176° for the SAS score; active ER, 50-52° for PROMs vs. 72° for the SAS score; IR score, 4-5 points for all PROMs vs. 6 points for the SAS score. Out of 3508 TSAs with complete postoperative ROM data, 8.5% achieved or exceeded all ROM thresholds (14.5% aTSAs, 4.8% rTSAs).

CONCLUSIONS

Our findings demonstrate that postoperative ROM exceeding 113° of abduction, 162° of FE, 52° of ER, and IR to L1 is associated with minimal additional improvement in PROMs. While individual patient needs vary, the thresholds may provide helpful targets for patients undergoing postoperative rehabilitation.

Curtailing infection risks in hepatitis C patients: the effect of antiviral treatment in revision shoulder arthroplasty

BACKGROUND

Revision shoulder arthroplasty (RevSA) is a complex procedure that can result in various postoperative complications. However, the impact of hepatitis C virus (HCV) on postoperative complications after RevSA remains unclear because of limited and inconsistent evidence. This study aims (1) to investigate the incidence of postoperative complications in patients with HCV undergoing RevSA and (2) to evaluate the impact of HCV treatment on complication rates at different time points after the revision procedure, specifically at 90 days, 1 year, and 2 years.

METHODS

We queried a national, all-payer database to investigate recent trends in the use of RevSA among HCV patients to assess postoperative complication rates, including venous thromboembolism (VTE), wound complication, transfusion, and periprosthetic joint infection (PJI). Statistical analyses involved propensity score matching to create balanced cohorts and logistic regression to determine the relative risk of postoperative complications. Data were analyzed with SPSS software (version 24.0 for Windows). The study included patients who underwent partial or total RevSA procedures between January 1, 2010, and December 31, 2020. Patients were identified based on medical claims that included procedural codes for RevSA and associated diagnosis codes for PJI or insertion/removal of an antibiotic spacer. A Bonferroni correction was used because many tests were performed and statistical significance was set at P = .0125.

RESULTS

The HCV cohort demonstrated higher PJI rates at 1-year (5.5% vs. 3.9%, P = .006) and 2-year follow-ups (6.7% vs. 4.6%, P = .006). However, no significant differences emerged in VTE and wound complication rates between the HCV and non-HCV cohorts. Comparing untreated and treated HCV patients, the former showed significantly higher PJI rates at 2 years (P = .010), whereas the treated group had significantly lower odds ratios for PJI. When comparing treated HCV patients with the non-HCV cohort, minimal differences were found in postoperative outcomes, indicating no significant difference in the risk of complications between the groups.

CONCLUSION

Our study observed an association between HCV patients who received antiviral treatment prior to RevSA and a reduced incidence of PJI compared to untreated HCV patients. When comparing this group to the non-HCV controls, there was no significant difference in the incidence of PJI, suggesting a potential association between antiviral treatment and the observed risk patterns in HCV patients. Proper management of HCV-positive patients during RevSA is crucial for improving outcomes and reducing complications.

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.

Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum 2-year follow-up

BACKGROUND

Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up.

METHODS

A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, range of motion (ROM), strength, complications, readmissions, and reoperations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up.

RESULTS

A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < .0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different.

CONCLUSION

This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up.

Predictors of poor and excellent outcomes following reverse shoulder arthroplasty for glenohumeral osteoarthritis with an intact rotator cuff

BACKGROUND

As the indications for reverse total shoulder arthroplasty (RSA) continue to evolve, it has been more commonly utilized for the treatment of glenohumeral osteoarthritis with an intact rotator cuff (GHOA). Given the increased use of RSA for GHOA, it is important to identify factors influential of clinical outcomes. In this study, we sought to identify variables predictive of clinical outcomes following RSA for GHOA.

METHODS

Patients undergoing primary RSA for GHOA between 2015 and 2020 were retrospectively identified through a prospectively maintained, single surgeon registry. Eligible patients had complete patient-reported outcome measures and range of motion measurements with a minimum 2-year follow-up. Univariate analysis was utilized to compare characteristics and outcome measures of patients with poor and excellent outcomes, which was defined as postoperative American Shoulder and Elbow Surgeons (ASES) scores in the bottom and top quartiles, respectively. Multivariate linear regression was performed to determine factors independently predictive of postoperative ASES score.

RESULTS

A total of 230 patients were included with a mean follow-up of 33.4 months (SD 13.2). The mean age of the study population was 71.9 (SD 6.1). Two hundred twenty-four patients (97.4%) surpassed the minimal clinically important difference and 209 patients (90.1%) achieved substantial clinical benefit for ASES score. Preoperative factors differing between the poor and excellent outcome groups were sex (male: poor 37.9%, excellent 58.6%; P = .041), opioid use (poor 24.1%, excellent 5.2%; P = .009), ASES score (poor 32.9, excellent 41.0; P = .011), and forward elevation (poor 92°, excellent 101°; P = .030). Linear regression demonstrated that Walch B3 glenoids (β 7.08; P = .010) and higher preoperative ASES scores (β 0.14; P = .025) were predictors of higher postoperative ASES score, while postoperative complications (β -18.66; P < .001) and preoperative opioid use (β -11.88; P < .001) were predictive of lower postoperative ASES scores.

CONCLUSION

Over 90% of patients who underwent RSA for GHOA with an intact rotator cuff experienced substantial clinical benefit. An unsurprising handful of factors were associated with postoperative clinical outcomes; higher preoperative ASES scores were slightly associated with higher postoperative ASES, whereas preoperative opioid use and postoperative complications were associated with lower postoperative ASES. Additionally, Walch glenoid type B3 was associated with higher postoperative ASES, indicating that patients with posterior glenoid defects are not predisposed to poor clinical outcomes following RSA. These results serve as a resource to improve preoperative patient counseling and manage postoperative expectations.

Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty (RSA) has been increasingly utilized for a variety of shoulder pathologies that are difficult to treat with anatomical total shoulder arthroplasty (TSA). Few studies have compared the outcomes of TSA vs. RSA in patients with cuff intact glenohumeral osteoarthritis and poor preoperative forward elevation. This study aimed to determine whether there is a difference in functional outcomes and postoperative range of motion (ROM) between TSA and RSA in these patients.

METHODS

This retrospective cohort study included 116 patients who underwent RSA or TSA between 2013 and 2022 for the treatment of rotator cuff intact primary osteoarthritis with restricted preoperative forward flexion (FF) and a minimum 1-year follow-up. Each arthroplasty group was divided into 2 subgroups: patients with preoperative FF between 91° and 120° or FF lower than or equal to 90°. Patients' clinical outcomes, including active ROM, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective shoulder value were collected. Clinical and radiographic complications were evaluated.

RESULTS

There was no significant difference between RSA and TSA in terms of sex (58.3% male vs. 62.2% male, P = .692), or follow-up duration (20.1 months vs. 17.7 months, P = .230). However, the RSA cohort was significantly older (72.0 ± 8.2 vs. 65.4 ± 10.6, P = .012) and weaker in FF and (ER) before surgery (P < .001). There was no difference between RSA (57 patients) and TSA (59 patients) in visual analog scale pain score (1.2 ± 2.3 vs. 1.3 ± 2.3, P = .925), subjective shoulder value score (90 ± 15 vs. 90 ± 15, P = .859), or American Shoulder and Elbow Surgeons score (78.4 ± 20.5 vs. 82.1 ± 23.2, P = .476). Postoperative active ROM was statistically similar between RSA and TSA cohorts in FF (145 ± 26 vs. 146 ± 23, P = .728) and ER (39 ± 15 vs. 41 ± 15, P = .584). However, internal rotation was lower in the RSA cohort (P < .001). This was also true in each subgroup. RSA led to faster postoperative FF and ER achievement at 3 months (P < .001). There was no statistically significant difference in complication rates between cohorts.

CONCLUSION

This study demonstrates that patients with glenohumeral osteoarthritis who have a structurally intact rotator cuff but limited preoperative forward elevation can achieve predictable clinical improvement in pain, ROM, and function after either TSA or RSA. Reverse arthroplasty may be a reliable treatment option in patients at risk for developing rotator cuff failure.

Defining patient satisfaction after reverse total shoulder arthroplasty: a systematic review

BACKGROUND

The prevalence of reverse total shoulder arthroplasty (rTSA) has grown rapidly. As indications for the procedure expand, the proportion of patients who have satisfactory outcomes after rTSA has not been well defined. This systematic literature review explores overall patient satisfaction after rTSA and defines patient satisfaction based on indication for surgery.

METHODS

A literature search was performed for studies describing patient satisfaction after rTSA in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Papers were included if they investigated patient satisfaction after rTSA at a minimum of 2-year follow-up. Data were collected on patient demographics, including age, gender, and body mass index. Follow-up duration, indication for surgery, and patient reported outcome measures relating to patient satisfaction were also recorded.

RESULTS

There were a total of 5234 patients and 5288 shoulders from the 45 included studies. The overall study population was 61.2% female and the average age was 71.1 years (range 23-99). Satisfaction results were recorded at final follow-up, with average follow-up of 49.1 months (range 24-228). Overall patient satisfaction ranged from 77.7% to 87.8%, depending on patient satisfaction patient reported outcome measures. When stratified by diagnosis, patients with a diagnosis of glenohumeral osteoarthritis (GHOA) rated better satisfaction on all metrics when compared to patients with a diagnosis of cuff tear arthropathy or massive rotator cuff tear.

CONCLUSION

This systematic review demonstrated that patients who undergo rTSA for either GHOA, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. Focusing on patient satisfaction may provide the best overall assessment of health care quality in a very understandable and tangible form. Overall satisfaction rate is valuable information for patient education and can be utilized as part of effective surgical counseling.

Computer-Assisted Navigation in Reverse Shoulder Arthroplasty: Surgical Experience and Clinical Outcomes

Background: The primary cause of medium- to long-term complications in reverse shoulder arthroplasty (RSA) is the failure of the glenoid component. The purpose of this study was to evaluate both the achievement of planning through computer-assisted navigation and the clinical outcomes at a minimum follow-up (FU) of 12 months. Methods: From December 2019 to December 2022, 57 Equinoxe RSAs with computer-assisted navigation were performed. The average age was 72.8 ± 6.6 years. Using the Orthoblue software, the version and inclination of the glenoid were evaluated from a preoperative CT scan, and planning was performed. Intraoperative navigation data were evaluated, and the clinical outcomes were assessed at a minimum follow-up of 12 months. Results: The average follow-up was 30.7 ± 13.5 months. The planning was reproduced in all implants. No errors in the computer-assisted navigation system were detected. No intraoperative or postoperative complications were recorded. At the final FU, the average active anterior elevation was 143° ± 36°, external rotation was 34° ± 5°, QuickDASH score was 19 ± 16 points, and constant score was 77 ± 18. Conclusions: Computer-assisted navigation is a reliable system for positioning prosthetic implants on challenging glenoids. A longer follow-up period is necessary to confirm the reduction in postoperative complications and the increase in survival compared to traditional RSA.

Two-year minimum survivorship and radiographic analysis of a pressfit short humeral stem for total shoulder arthroplasty

Background

Newer generation humeral stem designs in total shoulder arthroplasty (TSA) are trending towards shorter lengths and uncemented fixation. The goal of this study is to report a 2-yr minimum clinical and radiographic outcomes of an uncemented short-stem press-fit humeral stem in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA).

Methods

A retrospective multicenter database review was performed of all patients who received an uncemented short-length press-fit humeral stem (Equinoxe Preserve humeral stem, Exactech, Inc., Gainesville, FL, USA) in ATSA and RTSA with a minimum two-year follow-up. The primary outcome was the prevalence of humeral stems at risk of radiographic loosening. Secondary outcomes included evaluation of functional outcome scores and prevalence of revision TSA for humeral stem loosening. Two blinded observers performed radiographic analyses, which included humeral stem alignment, canal filling ratio, radiolucent lines, stress shielding (calcar and greater tuberosity), and changes in component position (subsidence and stem shift). At risk stems were defined by the presence of one or more of the following: humeral stem with shifting or subsidence, scalloping of the humeral cortex, or radiolucent lines measuring 2 mm or greater in 3 or more zones.

Results

287 patients (97 ATSA and 190 RTSA) were included in this study. The mean follow-up was 35.9 (±6.1) months. There were significant improvements for all functional outcome scores (P < .05), range of motion (P < .05), and visual analogue pain scale pain (P < .05). The prevalence of humeral stem at risk of radiographic loosening was 1% in the ATSA group (1/97) and 18.4% in the RTSA group (35/190). Calcar resorption was seen in 34% of ATSA and 19% of RTSA, with severe resorption in 12.4% of ATSA and only 3.2% of RTSA. Greater tuberosity resorption was present in 3.1% of ATSA and 7.9% of RTSA. The mean canal filling ratio was 50.2% (standard deviation 11.2%). Using logistic regression, a significant positive correlation between canal filling ratio and stress shielding (P < .01) was seen for both calcar and tuberosity stress shielding. The revision surgery rate was 0% in ATSA compared to 1.6% in RTSA.

Conclusion

This retrospective study demonstrates a low revision rate and low prevalence of humeral stems at risk of radiographic loosening at two years with a press-fit short-stem humeral design in ATSA. Physiologic subsidence of humeral stems can account for higher prevalence of humeral stems at radiographic risk of loosening in RTSA compared to ATSA.

Revision reverse shoulder arthroplasty has similar outcomes to primary reverse shoulder arthroplasty at 5 Year average follow-up

Background

Shoulder arthroplasty is a successful procedure that provides pain relief and improvements in function and range of motion. Anatomic and reverse shoulder arthroplasty are both effective procedures, and their indications continue to expand. We look at the outcomes of revision reverse total shoulder arthroplasty and compare it to the outcomes of primary reverse and anatomic total shoulder arthroplasty.

Methods

We identified patients undergoing total shoulder arthroplasty at our institution between the years of 2010 and 2020. Data was prospectively collected and retrospectively reviewed for post-operative range of motion and strength in patients with revision surgery and compared to controls. Measurements were collected preoperatively and postoperatively including range of motion and strength in the affected and unaffected shoulder. We collected patient reported outcome measures in person and via phone to identify subjective outcomes of total shoulder arthroplasty. Average final follow-up was 5.27 years.

Results

Our total patient sample was split between three groups: those with primary anatomic arthroplasty those who underwent primary reverse arthroplasty, and those who were revised to a reverse shoulder arthroplasty. All three groups had significant improvements in abduction and forward elevation from their pre-operative baseline to two years follow-up. Primary reverse had a significant improvement over revision reverse in abduction at one year follow-up. For all other range of motion measurements, there was no statistically significant difference at 2 years between primary and revision reverse shoulder arthroplasty. Patient reported outcomes had a significant increase from pre-op to most recent follow-up in all three groups.

Conclusion

Overall, our data suggest there is an improvement in outcomes with both primary and revision surgeries, and that results after revision reverse total shoulder arthroplasty may be comparable to primary reverse total shoulder arthroplasty.

Anatomic Total Shoulder Arthroplasty Versus Reverse Total Shoulder Arthroplasty in Patients Aged Over 70 Without a Full-Thickness Rotator Cuff Tear: A Systematic Review and Meta-Analysis

Introduction

This systematic review and meta-analysis compared the revision rates, complications, and outcomes in anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA) performed for primary glenohumeral osteoarthritis in patients aged over 70 years without a full-thickness rotator cuff tear.

Materials and Methods

We performed a systematic literature search identifying comparative studies meeting the above patient criteria and published from January 2010 to May 2022 from 3 databases: MEDLINE, EMBASE, and Cochrane Library. We performed the systematic review in accordance with PRISMA guidelines and the study was prospectively registered on PROSPERO.

Results

From the 1798 studies identified from the initial literature search, 4 met our inclusion criteria. Two thousand seven hundred thirty-one shoulder arthroplasties (1472 aTSA and 1259 rTSA) were evaluated with a minimum follow up of 2 years. A statistically significant lower revision rate was observed in rTSA compared to aTSA (odds ratio [OR] 0.50, 95% confidence interval [CI]: 0.30, 0.84, p < .05). No significant difference was noted between aTSA and rTSA in overall complication rate (OR 0.98, 95% CI 0.34, 2.86, p = .97) while aTSA displayed a statistically significant improved postoperative Constant-Murley score [aTSA: 80(75; 82), rTSA: 68(66; 76.5), p < .001].

Conclusion

Higher revision rates were identified following aTSA in our study population, although admittedly this is within retrospective studies. aTSA displayed equal functional results and postoperative complications compared to rTSA in patients over 70 without a full-thickness rotator cuff tear. Given these similar results a shoulder surgeon must carefully consider each patient individually prior to deciding the optimal form of arthroplasty to offer.

Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients

BACKGROUND

Reverse total shoulder arthroplasty (RTSA), initially indicated for cuff tear arthropathy, is increasingly used to treat elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff. This is often done to avoid revision surgery in elderly patients for rotator cuff failure with anatomic total shoulder arthroplasty (TSA) despite traditionally good outcomes of TSA. We sought to determine whether there was a difference in outcomes in patients aged ≥70 years who received RTSA vs. TSA for GHOA.

METHODS

A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged ≥70 years who underwent primary shoulder arthroplasty for GHOA with an intact rotator cuff were included (2012-2021). RTSA was compared with TSA. Multivariable Cox proportional hazard regression was used to evaluate all-cause revision risk during follow-up, whereas multivariable logistic regression was used to evaluate 90-day emergency department (ED) visits and 90-day readmissions.

RESULTS

The final study sample comprised 685 RTSA patients and 3106 TSA patients. The mean age was 75.8 years (standard deviation, 4.6 years), and 43.4% of patients were men. After accounting for confounders, we observed no significant difference in all-cause revision risk for RTSA vs. TSA (hazard ratio, 0.79; 95% confidence interval [CI], 0.39-1.58). The most common reason for revision following RTSA was glenoid component loosening (40.0%). Over half of revisions following TSA were for rotator cuff tear (54.0%). No difference based on procedure type was observed in the likelihood of 90-day ED visits (odds ratio, 0.94; 95% CI, 0.71-1.26) and 90-day readmissions (odds ratio, 1.32; 95% CI, 0.83-2.09).

CONCLUSION

RTSA and TSA for GHOA with an intact rotator cuff in patients aged ≥70 years had a similar revision risk, as well as a similar likelihood of 90-day ED visits and readmissions. Although revision risk was similar, the most common causes of revision were different, with rotator cuff tears in TSA patients and glenoid component loosening in RTSA patients.

Impact of tobacco usage on readmission and complication rates following shoulder replacement surgery: A study of 164,527 patients

Background

Tobacco carcinogens have adverse effects on bone health and are associated with inferior outcomes following orthopedic procedures. The purpose of this study was to assess the impact tobacco use has on readmission and complication rates following shoulder arthroplasty.

Methods

The 2016-2018 National Readmissions Database was queried to identify patients who underwent anatomical, reverse, and hemi-shoulder arthroplasty. ICD-10 codes Z72.0 ×  (tobacco use disorder) and F17.2 ×  (nicotine dependence) were used to define "tobacco-users." Demographic, 30-/90-day readmission, surgical complication, and medical complication data were collected. Inferential statistics were used to analyze complications for both the cohort as a whole and for each procedure separately (i.e. anatomical, reverse, and hemiarthroplasty).

Results

164,527 patients were identified (92% nontobacco users). Tobacco users necessitated replacement seven years sooner than nonusers (p < 0.01) and were more likely to be male (52% vs. 43%; p < 0.01). Univariate analysis showed that tobacco users had higher rates of readmission, revisions, shoulder complications, and medical complications overall. In the multivariate analysis for the entire cohort, readmission, revision, and complication rates did not differ based on tobacco usage; however, smokers who underwent reverse shoulder arthroplasty in particular were found to have higher 90-day readmission, dislocation, and prosthetic complication rates compared to nonsmokers.

Conclusion

Comparatively, tobacco users required surgical correction earlier in life and had higher rates of readmission, revision, and complications in the short term following their shoulder replacement. However, when controlling for tobacco usage as an independent predictor of adverse outcomes, these aforementioned findings were lost for the cohort as a whole. Overall, these findings indicate that shoulder replacement in general is a viable treatment option regardless of patient tobacco usage at short-term follow-up, but this conclusion may vary depending on the replacement type used.

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.

Early clinical outcomes following navigation-assisted baseplate fixation in reverse total shoulder arthroplasty: a matched cohort study

BACKGROUND

Accurate placement of the glenoid baseplate is an important technical goal of reverse total shoulder arthroplasty (RSA). The use of computer navigated instrumentation has been shown to improve the accuracy and precision of intraoperative execution of preoperative planning. The purpose of this study was to compare early clinical outcomes of patients undergoing navigated RSA vs. a non-navigated matched cohort.

METHODS

A retrospective review of a prospectively collected shoulder arthroplasty database was used to identify 113 patients from a single institution who underwent navigated primary RSA with a minimum 2-year follow-up. A matched cohort of 113 non-navigated RSAs was created based on sex, age, follow-up, and preoperative diagnosis. Preoperative and postoperative range of motion, functional outcome scores, and complications were reported.

RESULTS

A total of 226 shoulders with a mean age of 71 years were evaluated after navigated (113) or non-navigated (113) RSAs. The mean follow-up was 32.8 months (range: 21-54 months). At the final postoperative follow-up, the navigated group had better active forward elevation (135° vs. 129°, P = .023), active external rotation (39° vs. 32°, P = .003), and Constant scores (71.1 vs. 65.5, P = .003). However, when comparing improvements from the preoperative state, there was no statistically significant difference in range of motion or functional outcome scores between the groups. Complications occurred in 1.8% (2) of patients undergoing navigated RSA compared with 5.3% (6) in the non-navigated group (P = .28). Scapular notching (3.1% vs. 8.0%, P = .21) and revision surgery (0.9% vs. 3.5%, P = .37) were more common in non-navigated shoulders.

CONCLUSION

At early follow-up, navigated and non-navigated RSAs yielded similar rates of improvement in range of motion and functional outcome scores. Notching and reoperation was more common in non-navigated shoulders, but did not reach statistical significance. Longer follow-up and larger cohort size are needed to determine if intraoperative navigation lengthens the durability of RSA results and reduces the incidence of postoperative complications.

Return to driving following anatomic and reverse shoulder arthroplasty: a comparative analysis

BACKGROUND

The currently recommended time to return to driving following shoulder arthroplasty is controversial. The purpose of this study was to determine patient-specific factors associated with early return to driving after anatomic (aTSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

All patients aged >18 years undergoing primary aTSA or RTSA at a single institution over a 3-year period were retrospectively identified. Patients were emailed a questionnaire to determine time to postoperative return to driving and frequency of driving prior to and following surgery. Patients who did not drive prior to surgery or did not complete the questionnaire were excluded from analysis. Multivariate analysis was used to determine patient-specific factors associated with early return to driving (within 2 weeks following surgery) and delayed return (>6 weeks following surgery).

RESULTS

Four hundred six patients were included for analysis (aTSA = 214, RTSA = 192). Patients undergoing aTSA were significantly younger (68 vs. 74 years) and drove more frequently both pre- and postoperatively than the RTSA cohort. One hundred percent of patients returned to driving postoperatively. Patients undergoing aTSA more commonly demonstrated earlier return to driving than RTSA patients (34% vs. 20%). Factors associated with increased odds of early return to driving included male sex (aTSA) and compliance with surgeon instruction (aTSA). Decreased odds of early return was associated with waiting to drive until cessation of sling use (RTSA), older age (RTSA), and increased body mass index (RTSA). The presence of surgical complications (aTSA) and prolonged use of narcotics (RTSA) were associated with return to driving >6 weeks following surgery. No difference in the rate of motor vehicle accidents was found between patients returning to driving <2 vs. >2 weeks postoperatively.

CONCLUSION

Patients undergoing aTSA return to driving sooner than those undergoing RTSA. Early return to driving appears to be influenced by patient sex, age, BMI, narcotic and sling use, and compliance with surgeon instruction, but does not appear to result in a high incidence of postoperative MVA.

Safety and short-term outcomes of anatomic vs. reverse total shoulder arthroplasty in an ambulatory surgery center

BACKGROUND

A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone.

METHODS

Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone.

RESULTS

Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001).

CONCLUSION

Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.

Characteristics of anatomic and reverse total shoulder arthroplasty patients who achieve ceiling scores with 3 common patient-reported outcome measures

BACKGROUND

Legacy shoulder outcome scores have postoperative ceiling scores effects when quantifying clinical outcomes for anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty patients. This study uses data from an international database of a single shoulder prosthesis using data from 30 different clinical sites to quantify and compare the percentage of aTSA and rTSA patients achieving postoperative ceiling scores with multiple outcome measures and defines the patient demographics, comorbidities, implant, and operative parameters associated with ceiling scores for each outcome measure.

METHODS

Clinical outcomes for 1817 aTSA and 2635 rTSA patients between 2007 and 2019 were quantified with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), the University of California, Los Angeles (UCLA), Constant, and Shoulder Arthroplasty Smart (SAS) scores. The number of aTSA and rTSA patients with ceiling scores were calculated and sorted into those that achieved ceiling scores with the SST, ASES, and UCLA measures and compared to patients without ceiling scores. A univariate and multivariate analysis then identified the patient demographics, comorbidities, and implant and operative parameters associated with ceiling scores for each outcome measure.

RESULTS

aTSA patients achieved ceiling scores at a significantly greater rate than rTSA patients for all outcome measures, except SAS. The SST score was the most susceptible to ceiling scores (aTSA = 43.4%, rTSA = 34.1%, P < .0001), followed by the ASES (aTSA = 23.7%, rTSA = 13.3%, P < .0001) and UCLA (aTSA = 22.2%, rTSA = 10.6%, P < .0001) scores. Ceiling scores were least likely with the Constant (aTSA = 0.4%, rTSA = 0%, P = .0060) and SAS (aTSA = 0.1%, rTSA = 0%, P = .0750) scores. Male patients had a significantly higher ceiling score rate than female patients using the SST and ASES scores, and no differences in ceiling score rates were observed with the UCLA, Constant, or SAS scores. Finally, we identified numerous patient demographic, comorbidity, implant, and operative parameters associated with SST, ASES, and UCLA ceiling scores for aTSA and rTSA patients.

DISCUSSION

Postoperative ceiling scores occur at a high rate for aTSA and rTSA patients with the SST, ASES, and UCLA scores. Those most susceptible to ceiling scores are aTSA patients treated with cage glenoids, aTSA patients of lower body mass index, rTSA patients of male gender, rTSA patients with osteoarthritis diagnosis, and rTSA patients with subscapularis repair. Clinical researchers should consider using alternative scores, such as the SAS score, to ensure a more normalized distribution of data and more accurately quantify aTSA and rTSA outcomes.

Does Pre-Arthroplasty Antiviral Treatment for Hepatitis C Reduce Complication Rates After Total Shoulder Arthroplasty? A Matched Cohort Study

Background

Hepatitis C virus (HCV) is associated with increased complications of risk after arthroplasty. The purpose of this study was to examine the impact of HCV and a pre-arthroplasty antiviral treatment on complications following total shoulder arthroplasty (TSA).

Methods

A retrospective matched cohort study was conducted using an administrative claims database. Patients who underwent TSA were identified with Current Procedural Terminology -23472 and International Classification of Diseases procedural codes. A total of 1244 HCV patients were matched 1:3 with 3732 noninfected controls across age, sex, diabetes mellitus, tobacco use, and obesity. The HCV patients with treatment before TSA were identified by claims containing antiviral drug codes. Multivariable logistic regression was used to compare rates of 90-day medical complications and prosthesis-related complications within 2 years postoperatively for (1) HCV patients vs. controls, (2) antiviral-treated HCV patients vs. controls, and (3) antiviral-treated HCV patients vs. untreated HCV patients.

Results

Patients with HCV exhibited significantly higher rates of blood transfusion (OR 2.12), acute kidney injuries (OR 1.86), inpatient readmission (OR 2.06), revision TSA (OR 1.48), dislocation (OR 1.92), mechanical complications (OR 1.39), and prosthetic joint infection (OR 1.53) compared to controls. Antiviral-treated HCV patients exhibited a significantly lower rate of myocardial infarction (OR 0.27) and comparable rates of all other complications relative to controls (all P > .05). Compared to untreated HCV patients, antiviral-treated HCV patients exhibited significantly lower rates of 90-day medical complications (OR 0.57) and prosthetic joint infection (OR 0.36).

Conclusions

HCV is associated with significantly increased complication rates after TSA. Antiviral treatment before TSA may reduce the risk of postoperative complications.

Deltoid fatigue part 2: a longitudinal assessment of anatomic total shoulder arthroplasty over time

BACKGROUND

Gradual loss of overhead range of motion (ROM) has been observed after reverse shoulder arthroplasty (RSA). It remains unclear if this is caused by the effect of RSA design on muscle fiber lengthening or is part of the natural aging process of the shoulder musculature. Although studies have attempted to evaluate deltoid fatigue after RSA, there is a paucity of literature evaluating this effect after anatomic shoulder arthroplasty (aTSA), which would be expected to occur due to aging alone. The purpose of this study is to evaluate the effect of time on overhead ROM after aTSA and compare this with previous data on a similar cohort of RSAs. We hypothesized that overhead ROM would decrease gradually over time in both groups without differences between prosthesis types.

METHODS

A retrospective review of 384 aTSAs without complications was performed over a 10-year period. All shoulders were treated for primary osteoarthritis using a single implant system. Patients were evaluated longitudinally at multiple postoperative time points. At least 1 follow-up visit was between 1 and 2 years postoperatively and another at least 5 years after surgery. ROM and patient reported outcome measures (PROMs) were evaluated using linear-mixed models for repeated measures. These results were compared with a previously evaluated cohort of 165 well-functioning RSAs analyzed using the same methodology.

RESULTS

Primary aTSA shoulders were observed to lose 0.7° of abduction per year starting 1 year postoperatively (P = .001). Smaller losses were observed in external rotation (-0.3°/yr, P = .06) and internal rotation (-0.04/yr, P < .001). However, no significant losses were observed in forward elevation (P = .8). All PROMs diminished slowly over time, but these changes did not exceed the minimally clinically important difference when modeled over 10 years (Simple Shoulder Test -0.08/yr, P < .001; American Shoulder Elbow Surgeons -0.5/yr, P < .001; University of California Los Angeles Shoulder Score -0.2/yr, P < .001). When compared with a similarly analyzed cohort of RSAs, overhead ROM decreased at a slower rate in the aTSA cohort (abduction -0.7° vs. -0.8°/yr, P = .9; FE -0.06° vs. -0.8°/yr, P = .05).

DISCUSSION

In the well-functioning aTSA, gradual loss of ROM occurs in all planes of motion except forward elevation. However, these losses are small and have little meaningful impact relative to minimally clinically important difference thresholds on PROMs. Progressive loss of abduction seen in both aTSA and RSA is likely secondary to aging of the periscapular and rotator cuff musculature. When compared with RSA, loss of motion after aTSA was statistically similar, calling into question the belief that RSA-induced deltoid fatigue leads to loss of overhead motion over time.

Shoulder arthroplasty is a viable option in patients with Ehlers-Danlos syndrome

BACKGROUND

Patients with Ehlers-Danlos syndrome (EDS) have high rates of shoulder instability, which place them at increased risk for instability-related arthropathy. Many studies have assessed outcomes for both primary and revision shoulder instability procedures in this patient population, but there is a paucity of data regarding the outcome of shoulder arthroplasty in EDS patients. The purpose of this study is to evaluate the results and complications of shoulder arthroplasty (SA) performed in a cohort of patients with EDS and compare them to a matched cohort of patients with no EDS.

METHODS

Over an 11-year period, 10 patients with EDS were identified at a single institution who underwent primary SA (6 anatomic total shoulder arthroplasties [aTSAs], 4 reverse shoulder arthroplasties [RTSAs]). Shoulders were evaluated at a mean follow-up of 60 months (range 25-97 months). This cohort was matched 1:2 based on age, sex, and year of surgery, with patients who underwent SA for either primary osteoarthritis (OA) for aTSA or cuff tear arthropathy for RTSA. EDS patients had a mean age of 55 years, mean body mass index of 26.1, and were all female. The primary outcome measures were postoperative pain, range of motion, complications, and reoperations.

RESULTS

SA produced similar postoperative pain, range of motion, complications, and reoperations in patients with EDS vs. controls. EDS patients improved pre- to postoperative visual analog scale (VAS) pain score (6.5 to 1.7, P < .001), elevation (96° to 138°, P = .04), and external rotation (36° to 57°, P = .16). Three EDS patients sustained postoperative complications (2 instability and 1 acromial fracture); however, no shoulder was reoperated.

CONCLUSIONS

EDS patients undergoing SA can expect outcomes comparable to patients with primary OA or cuff tear arthropathy, with clinically meaningful improvements in pain and range of motion. Although EDS patients had no statistically significant increase in complications when compared to controls, their absolute rate of overall complications (3/10 patients; 30%) and postoperative instability (2/10 patients; 20%) in this small case series was relatively high and should be considered when performing SA.