Complications and further surgery after reverse total shoulder arthroplasty : report of 854 primary cases

SECEC Grammont Award 2024: The critical role of posture adjustment for range of motion simulation in reverse total shoulder arthroplasty preoperative planning

Aims

The objective of this study was to compare simulated range of motion (ROM) for reverse total shoulder arthroplasty (rTSA) with and without adjustment for scapulothoracic orientation in a global reference system. We hypothesized that values for simulated ROM in preoperative planning software with and without adjustment for scapulothoracic orientation would be significantly different.

Methods

A statistical shape model of the entire humerus and scapula was fitted into ten shoulder CT scans randomly selected from 162 patients who underwent rTSA. Six shoulder surgeons independently planned a rTSA in each model using prototype development software with the ability to adjust for scapulothoracic orientation, the starting position of the humerus, as well as kinematic planes in a global reference system simulating previously described posture types A, B, and C. ROM with and without posture adjustment was calculated and compared in all movement planes.

Results

All movement planes showed significant differences when comparing protocols with and without adjustment for posture. The largest mean difference was seen in external rotation, being 62° (SD 16°) without adjustment compared to 25° (SD 9°) with posture adjustment (p < 0.001), with the highest mean difference being 49° (SD 15°) in type C. Mean extension was 57° (SD 18°) without adjustment versus 24° (SD 11°) with adjustment (p < 0.001) and the highest mean difference of 47° (SD 18°) in type C. Mean abducted internal rotation was 69° (SD 11°) without adjustment versus 31° (SD 6°) with posture adjustment (p < 0.001), showing the highest mean difference of 51° (SD 11°) in type C.

Conclusion

The present study demonstrates that accounting for scapulothoracic orientation has a significant impact on simulated ROM for rTSA in all motion planes, specifically rendering vastly lower values for external rotation, extension, and high internal rotation. The substantial differences observed in this study warrant a critical re-evaluation of all previously published studies that examined component choice and placement for optimized ROM in rTSA using conventional preoperative planning software.

Outcomes following revision of a failed primary reverse shoulder arthroplasty

Aims

Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA.

Methods

MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews were searched. Studies involving adult patients who underwent revision of a primary RSA for any indication were included. Those who underwent a RSA for failure of a total shoulder arthroplasty or hemiarthroplasty were excluded. Pre- and postoperative shoulder scores were evaluated in a random effects meta-analysis to determine the mean difference. The rates of re-revision and complications were also calculated.

Results

The initial search elicited 3,166 results and, following removal of duplicates and screening, 13 studies with a total of 1,042 RSAs were identified. An increase in shoulder scores pre- to postoperatively was reported in all the studies. Following revision of a RSA to a further RSA, there was a significant increase in the American Shoulder and Elbow Surgeons Score (mean difference 20.78 (95% CI 8.16 to 33.40); p = 0.001). A re-revision rate at final follow-up ranging from 9% to 32%, a one-year re-revision rate of 14%, and a five-year re-revision rate of 23% were reported. The complication rate in all the studies was between 18.5% and 36%, with a total incidence of 29%.

Conclusion

This is the largest systematic review of the outcomes following revision of a RSA. We found an improvement in functional outcomes after revision surgery, but the rates of re-revision and complications are high and warrant consideration when planning a revision procedure.

Reverse total shoulder arthroplasty with proximal bone loss: a biomechanical comparison of partially vs. fully cemented humeral stems

BACKGROUND

The appropriate amount of cementation at the time of reverse total shoulder arthroplasty with significant proximal bone loss or resection is unknown. Extensive cementation of a humeral prosthesis makes eventual revision arthroplasty more challenging, increasing the risk of periprosthetic fracture. We analyzed the degree of subsidence and torque tolerance of humeral components undergoing standard cementation technique vs. our reduced polymethyl methacrylate (PMMA) protocol. Reduced cementation may provide sufficient biomechanical stability to resist physiologically relevant loads, while still permitting a clinically attainable torque for debonding the prosthesis.

METHODS

A total of 12 cadaveric humeri (6 matched pairs) underwent resection of 5 cm of bone distal to the greater tuberosity. Each pair of humeri underwent standard humeral arthroplasty preparation followed by either cementation using a 1.5-cm PMMA sphere at a location 3 cm inferior to the porous coating or standard full stem cementation. A 6-degree-of-freedom robot was used to perform all testing. Each humeral sample underwent 200 cycles of abduction, adduction, and forward elevation while being subjected to a physiologic compression force. Next, the samples were fixed in place and subjected to an increasing torque until implant-cement separation or failure occurred. Paired t tests were used to compare mean implant subsidence vs. a predetermined 5-mm threshold, as well as removal torque in matched samples.

RESULTS

Fully and partially cemented implants subsided 0.49 mm (95% CI 0.23-0.76 mm) and 1.85 mm (95% CI 0.41-3.29 mm), respectively, which were significantly less than the predetermined 5-mm threshold (P < .001 and P < .01, respectively). Removal torque between fully cemented stems was 45.22 Nm (95% CI 21.86-68.57 Nm), vs. 9.26 Nm (95% CI 2.59-15.93 Nm) for partially cemented samples (P = .021). Every fully cemented humerus fractured during implant removal vs. only 1 in the reduced-cementation group. The mean donor age in our study was 76 years (range, 65-80 years). Only 1 matched pair of humeri belonged to a female donor with comorbid osteoporosis. The fractured humerus in the partially cemented group belonged to that donor.

CONCLUSION

Partially and fully cemented humeral prostheses had subsidence that was significantly less than 5 mm. Partially cemented stems required less removal torque for debonding of the component from the cement mantle. In all cases, removal of fully cemented stems resulted in humeral fracture. Reduced cementation of humeral prostheses may provide both sufficient biomechanical stability and ease of future component removal.

Cost-effectiveness of shoulder arthroplasty for osteoarthritis and rotator cuff tear arthropathy. An economic analysis using real-world data

INTRODUCTION

This study aimed to assess cost-effectiveness of shoulder arthroplasty for osteoarthritis (OA) and rotator cuff tear arthropathy (CTA) from the perspective of a publicly funded health care system using patient data, health utilities and costs from a real-world situation.

HYPOTHESIS

Our hypothesis was that arthroplasty for OA is more cost-effective than for CTA.

MATERIAL AND METHODS

We gathered a cohort of patients with 153 anatomic total shoulder arthroplasty (TSA) for OA and 107 reverse shoulder arthroplasty (RSA) for CTA between years 2016-2020 at a university hospital. Short-term (mean 2.8years) shoulder function, health utilities and costs were obtained from prospectively collected data, and a Markov cohort simulation was carried out to assess lifetime cost-utility. The primary outcome measures were change in 15D score to calculate gain in quality-adjusted life years (QALYs) and change in Western Ontario osteoarthritis score of the shoulder (WOOS).

RESULTS

Both TSA and RSA restored shoulder function well, WOOS improvement was 59.7 (95% CI: 56.2-63.2) and 55.8 (95% CI: 50.4-61.2), respectively. The cost/QALY gained was 20,846.82 € for TSA and 38,711.90 € for RSA. The cost-utility was not remarkable sensitive to costs, discounting of future costs or estimated revision rates. However, the cost-effectiveness was very sensitive to change in 15D health utility scores and thus QALY gain, especially for RSA patients.

DISCUSSION

Shoulder arthroplasty restores shoulder function well in both OA and CTA. In health economic terms, RSA is less cost-effective than TSA in an everyday setting, mainly due to inferior improvement of health-related quality-of-life and reduced life expectancy of CTA patients.

LEVEL OF EVIDENCE

III; case series.

Clinical Outcomes Do Not Deteriorate Over Time Following Primary Reverse Total Shoulder Arthroplasty: Minimum 10-Year Follow-up of 135 Shoulders

Background

Reverse total shoulder arthroplasty (RTSA) offers satisfactory mid-term outcomes for a variety of pathologies, but long-term follow-up data are limited. This study demonstrates the long-term clinical and radiographic outcomes as well as the predictive factors for an inferior outcome following RTSA.

Methods

Using the prospective database of a single, tertiary referral center, we included all primary RTSAs that were performed during the study period and had a minimum 10-year follow-up. Clinical outcomes included the absolute Constant-Murley score (CS), relative CS, Subjective Shoulder Value (SSV), range of motion, pain, complication rate, and reintervention rate. Radiographic measurements included the critical shoulder angle (CSA), lateralization shoulder angle (LSA), distalization shoulder angle (DSA), reverse shoulder angle (RSA), acromiohumeral distance (ACHD), center of rotation, glenoid component height, notching, radiolucent lines, heterotopic ossification, and tuberosity resorption.

Results

A total of 135 shoulders (133 patients) were available for analysis at a mean follow-up of 10.9 ± 1.6 years. The mean age was 69 ± 8 years, and 76 shoulders (76 patients; 56%) were female. For most of the clinical outcomes, initial improvements were observed in the short term and were sustained in the long term without notable deterioration, with >10-year follow-up values of 64 ± 16 for the absolute CS, 79% ± 18% for the relative CS, 79% ± 21% for the SSV, and 14 ± 3 for the CS for pain. However, after initial improvement, deterioration was seen for flexion and external rotation, with values of 117° ± 26° and 25° ± 18°, respectively, at the final follow-up. Scapular notching, heterotopic ossification, and radiolucent lines of <2 mm progressed during the study period. Younger age (p = 0.040), grade-II notching (p = 0.048), tuberosity resorption (p = 0.015), and radiolucent lines of <2 mm around the glenoid (p = 0.015) were predictive of an inferior outcome. The complication rate was 28%, with a reintervention rate of 11%.

Conclusions

RTSA provided improved long-term results that did not significantly deteriorate over time for most of the clinical parameters. Negative clinical outcome predictors were younger age, grade-II notching, tuberosity resorption, and radiolucent lines of <2 mm around the glenoid.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Validation of mixed-reality surgical navigation for glenoid axis pin placement in shoulder arthroplasty using a cadaveric model

BACKGROUND

Mixed reality may offer an alternative for computer-assisted navigation in shoulder arthroplasty. The purpose of this study was to determine the accuracy and precision of mixed-reality guidance for the placement of the glenoid axis pin in cadaver specimens. This step is essential for accurate glenoid placement in total shoulder arthroplasty.

METHODS

Fourteen cadaveric shoulders underwent simulated shoulder replacement surgery by 7 experienced shoulder surgeons. The surgeons exposed the cadavers through a deltopectoral approach and then used mixed-reality surgical navigation to insert a guide pin in a preplanned position and trajectory in the glenoid. The mixed-reality system used the Microsoft Hololens 2 headset, navigation software, dedicated instruments with fiducial marker cubes, and a securing pin. Computed tomography scans obtained before and after the procedure were used to plan the surgeries and determine the difference between the planned and executed values for the entry point, version, and inclination. One specimen had to be discarded from the analysis because the guide pin was removed accidentally before obtaining the postprocedure computed tomography scan.

RESULTS

Regarding the navigated entry point on the glenoid, the mean difference between planned and executed values was 1.7 ± 0.8 mm; this difference was 1.2 ± 0.6 mm in the superior-inferior direction and 0.9 ± 0.8 mm in the anterior-posterior direction. The maximum deviation from the entry point for all 13 specimens analyzed was 3.1 mm. Regarding version, the mean difference between planned and executed version values was 1.6° ± 1.2°, with a maximum deviation in version for all 13 specimens of 4.1°. Regarding inclination, the mean angular difference was 1.7° ± 1.5°, with a maximum deviation in inclination of 5°.

CONCLUSIONS

The mixed-reality navigation system used in this study allowed surgeons to insert the glenoid guide pin on average within 2 mm from the planned entry point and within 2° of version and inclination. The navigated values did not exceed 3 mm or 5°, respectively, for any of the specimens analyzed. This approach may help surgeons more accurately place the definitive glenoid component.

Total shoulder arthroplasty in patients with factor V Leiden

BACKGROUND

Anatomic and reverse total shoulder arthroplasty (TSA) are effective treatment options for end-stage glenohumeral osteoarthritis. However, consideration for pre-existing conditions must be taken into account. Factor V Leiden (FVL), the most common inherited thrombophilia, is one such condition that predisposes to a prothrombotic state and may affect perioperative and longer-term outcomes following TSA.

METHODS

Adult patients undergoing primary TSA for osteoarthritis indication were identified in the 2010 through October 2021 PearlDiver M157 database. Patients with or without FVL were matched at a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and 5-year revision rates were assessed and compared with multivariable logistic regression and rank-log tests, respectively. Finally, the relative use and bleeding/clotting outcomes were assessed based on venous thromboembolic (VTE) prophylactic agents used, with categories defined as (1) warfarin, heparin, or direct oral anticoagulant (DOAC) or (2) aspirin/no prescription found.

RESULTS

Of 104,258 TSA patients, FVL was identified for 283 (0.27%). Based on matching, 1081 patients without FVL and 272 patients with FVL were selected. Multivariable analyses demonstrated that those with FVL displayed independently greater odds ratios (ORs) of deep vein thrombosis (DVT, OR = 9.50, P < .0001), pulmonary embolism (PE, OR = 10.10, P < .0001), and pneumonia (OR = 2.43, P = .0019). Further, these events contributed to the increased odds of aggregated minor (OR = 1.95, P = .0001), serious (OR = 6.38, P < .0001), and all (OR = 3.51, P < .0001) adverse events. All other individual 90-day adverse events, as well as 5-year revision rates, were not different between the study groups. When compared to matched patients without FVL on the same anticoagulant agents, FVL patients on warfarin, heparin, or DOAC agents demonstrated lesser odds of 90-day DVT and PE (OR = 4.25, P < .0001, and OR = 2.54, P = .0065) than those on aspirin/no prescription found (OR = 7.64 and OR = 21.95, P < .0001 for both). Interestingly, those on VTE prophylactic agents were not at greater odds of bleeding complications (hematoma or transfusion).

DISCUSSION AND CONCLUSIONS

TSA patients with FVL present a difficult challenge to shoulder reconstruction surgeons. The current study highlights the strong risk of VTE that was reduced but still significantly elevated for those with stronger classes of VTE chemoprophylaxis. Acknowledging this risk is important for surgical planning and patient counseling, but also noted was the reassurance of similar 5-year revision rates for those with vs. without FVL.

Predictors of dislocations after reverse shoulder arthroplasty: a study by the ASES complications of RSA multicenter research group

BACKGROUND

Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants.

METHODS

A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA.

RESULTS

We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001).

CONCLUSION

The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA.

Reversed total shoulder arthroplasty after acromioclavicular joint resection yields equivalent clinical results compared to a matched control group

INTRODUCTION

Reverse total shoulder arthroplasty (RTSA) is a well-establish procedure with increasing incidence. Depending on the medical history, many patients undergo multiple soft-tissue procedures before RTSA. The role of acromioclavicular pathology as well as the consequences of a distal clavicle resection (DCR) before RTSA has not been evaluated yet.

MATERIAL AND METHODS

A retrospective single-center review was performed on all patients undergoing primary RTSA with or without DCR with a minimum follow-up of 2 years. We compared patient-reported outcome measures (Constant score (CS), subjective shoulder values (SSV), and range of motion (ROM)) with a matched control group. The control group consisted of patients treated with a RTSA without DCR and matching was performed for age, sex, operating side, American Society of Anesthesiologists (ASA), body mass index (BMI), and indication. Surgical time and complication rate were recorded.

RESULTS

Thirty-nine patients with a mean follow-up of 63 months (SD 33) were enrolled in the study group. Mean age was 67 years (SD 7) with 44% male patients for both groups. The mean relative CS improved from 43% (SD 17) to 73% (SD 20) in the study group, and from 43% (18) to 73% (22) in the control group. The SSV improved from 29% (SD 17) to 63% (SD 29) in the study group, and from 28% (SD 16) to 69% (SD 26) in the control group (both n.s.). The postoperative ROM did not significantly differ between the two groups. Five patients in the study group and six in the control group had reoperations.

CONCLUSION

Patients who received a DCR before RTSA showed equivalent clinical outcomes compared to a match-control group with RTSA only. Surgical time was not different, and no complication related to the open DCR was observed in the study group. Therefore, we conclude that a prior DCR does not influence the postoperative outcome after RTSA.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.

Understanding risk for early dislocation resulting in reoperation within 90 days of reverse total shoulder arthroplasty: extreme rare event detection through cost-sensitive machine learning

BACKGROUND

Reliable prediction of postoperative dislocation after reverse total shoulder arthroplasty (RSA) would inform patient counseling as well as surgical and postoperative decision making. Understanding interactions between multiple risk factors is important to identify those patients most at risk of this rare but costly complication. To better understand these interactions, a game theory-based approach was undertaken to develop machine learning models capable of predicting dislocation-related 90-day readmission following RSA.

MATERIAL & METHODS

A retrospective review of the Nationwide Readmissions Database was performed to identify patients who underwent RSA between 2016 and 2018 with a subsequent readmission for prosthetic dislocation. Of the 74,697 index procedures included in the data set, 740 (1%) experienced a dislocation resulting in hospital readmission within 90 days. Five machine learning algorithms were evaluated for their ability to predict dislocation leading to hospital readmission within 90 days of RSA. Shapley additive explanation (SHAP) values were calculated for the top-performing models to quantify the importance of features and understand variable interaction effects, with hierarchical clustering used to identify cohorts of patients with similar risk factor combinations.

RESULTS

Of the 5 models evaluated, the extreme gradient boosting algorithm was the most reliable in predicting dislocation (C statistic = 0.71, F2 score = 0.07, recall = 0.84, Brier score = 0.21). SHAP value analysis revealed multifactorial explanations for dislocation risk, with presence of a preoperative humerus fracture; disposition involving discharge or transfer to a skilled nursing facility, intermediate care facility, or other nonroutine facility; and Medicaid as the expected primary payer resulting in strong, positive, and unidirectional effects on increasing dislocation risk. In contrast, factors such as comorbidity burden, index procedure complexity and duration, age, sex, and presence or absence of preoperative glenohumeral osteoarthritis displayed bidirectional influences on risk, indicating potential protective effects for these variables and opportunities for risk mitigation. Hierarchical clustering using SHAP values identified patients with similar risk factor combinations.

CONCLUSION

Machine learning can reliably predict patients at risk for postoperative dislocation resulting in hospital readmission within 90 days of RSA. Although individual risk for dislocation varies significantly based on unique combinations of patient characteristics, SHAP analysis revealed a particularly at-risk cohort consisting of young, male patients with high comorbidity burdens who are indicated for RSA after a humerus fracture. These patients may require additional modifications in postoperative activity, physical therapy, and counseling on risk-reducing measures to prevent early dislocation after RSA.

Predictive factors of acromial fractures following reverse total shoulder arthroplasty: a subgroup analysis of 860 shoulders

Background

Acromion stress fractures (ASF) or scapular spine fractures (SSF) following reverse total shoulder arthroplasty (RTSA) are common complications with impaired clinical outcome. The underlying biomechanical factors remain unclear. The aim of this study was to evaluate basic demographic and radiographic parameters predicting occurrence of different types of ASF/SSF in a large single-center study cohort.

Methods

A total of 860 RTSA (805 patients) with available minimum follow-up of 2 years were implanted between 2005 and 2018 at a tertiary academic center. All RTSA with subsequent ASF/SSF (n = 45 in 43 shoulders [42 patients, 5%]) were identified and classified as Levy I to III. Predictive demographic, surgical, and radiographic factors were evaluated for each subtype and compared to the control group (817 RTSA, 763 patients). The radiographic analysis included critical shoulder angle, lateralization shoulder angle (LSA), distalization shoulder angle (DSA), acromio-humeral distance (ACHD), acromial thickness, deltoid tuberosity index, deltoid length, and center of rotation.

Results

Of the 45 ASF/SSF in 42 patients, 8 were classified as Levy I, 21 as Levy II, and 16 as Levy III. Demographic analysis revealed indication as risk factor for Levy I fractures, higher American Society of Anesthesiologists score as risk for Levy type II fractures and higher age as risk factor for Levy type III fractures. None of the measured radiographic parameters were predictive for occurrence of Levy type I and Levy type II ASF. However, analysis of Levy III SSF revealed a higher postoperative LSA (89° ± 10° vs. 83° ± 9°, P = .015), a lower postoperative DSA (45° ± 8° vs. 53° ± 12°, P = .002), less distalization (ACHD of 33 ± 8 mm vs. 38 ± 10 mm, P = .049), and a more medial center of rotation preoperatively (COR-LA 16 ± 8 mm vs. 12 ± 7 mm, P = .048) as predictive radiographic factors.

Conclusion

The present analysis showed a significant association of higher postoperative LSA, lower DSA, a lower ACHD, and higher age as predictive factor only for Levy type III fractures. Some of these factors can be surgically influenced and this knowledge can be of value for preoperative planning and surgical execution to avoid these complications.

Anterosuperior versus deltopectoral approach for primary reverse total shoulder arthroplasty

Aims

The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years.

Methods

All patients in the registry who underwent a primary rTSA between January 2014 and December 2016 using an anterosuperior or deltopectoral approach were included, with a minimum follow-up of five years. Cox and logistic regression models were used to assess the association between the approach and the implant survival, instability, and glenoid loosening, independent of confounders.

Results

In total, 3,902 rTSAs were included. A deltopectoral approach was used in 54% (2,099/3,902) and an anterosuperior approach in 46% (1,803/3,902). Overall, the mean age in the cohort was 75 years (50 to 96) and the most common indication for rTSA was cuff tear arthropathy (35%; n = 1,375), followed by osteoarthritis (29%; n = 1,126), acute fracture (13%; n = 517), post-traumatic sequelae (10%; n = 398), and an irreparable cuff rupture (5%; n = 199). The two high-volume centres performed the anterosuperior approach more often compared to the medium- and low-volume centres (p < 0.001). Of the 3,902 rTSAs, 187 were revised (5%), resulting in a five-year survival of 95.4% (95% confidence interval 94.7 to 96.0; 3,137 at risk). The most common reason for revision was a periprosthetic joint infection (35%; n = 65), followed by instability (25%; n = 46) and loosening (25%; n = 46). After correcting for relevant confounders, the revision rate for glenoid loosening, instability, and the overall implant survival did not differ significantly between the two approaches (p = 0.494, p = 0.826, and p = 0.101, respectively).

Conclusion

The surgical approach used for rTSA did not influence the overall implant survival or the revision rate for instability or glenoid loosening.

Optimizing Outcomes After Reverse Total Shoulder Arthroplasty: Rehabilitation, Expected Outcomes, and Maximizing Return to Activities

PURPOSE OF REVIEW

Given the touted clinical and patient-reported outcomes of reverse shoulder arthroplasty (RTSA) in improving pain and restoring function, shoulder surgeons are rapidly expanding the indications and utilization of RTSA. Despite its increasing use, the ideal post-operative management ensuring the best patient outcomes is still debated. This review synthesizes the current literature regarding the impact of post-operative immobilization and rehabilitation on clinical outcomes following RTSA including return to sport.

RECENT FINDINGS

Literature regarding the various facets of post-operative rehabilitation is heterogeneous in both methodology and quality. While most surgeons recommend 4-6 weeks of immobilization post-operatively, two recent prospective studies have shown that early motion following RTSA is both safe and effective with low complication rates and significant improvements in patient-reported outcome scores. Furthermore, no studies currently exist assessing the use of home-based therapy following RTSA. However, there is an ongoing prospective, randomized control trial assessing patient-reported and clinical outcomes which will help shed light on the clinical and economic value of home therapy. Finally, surgeons have varying opinions regarding return to higher level activities following RTSA. Despite no clear consensus, there is growing evidence that elderly patients are able to return to sport (e.g., golf, tennis) safely, though caution must be taken with younger or more high-functioning patients. While post-operative rehabilitation is believed to be essential to maximize outcomes following RTSA, there is a paucity of high-quality evidence that guides current rehabilitation protocols. There is no consensus regarding type of immobilization, timing of rehabilitation, or need for formal therapist-directed rehabilitation versus physician-guided home exercise. Additionally, surgeons have varied opinions regarding return to higher level activities and sports following RTSA. There is burgeoning evidence that elderly patients can return to sport safely, though caution must be taken with younger patients. Further research is needed to clarify the optimal rehabilitation protocols and return to sport guidelines.

Greater Tuberosity Fractures after RTSA: A Matched Group Analysis

Periprosthetic fractures, such as acromial and spine fractures, are known complications following implantation of reverse shoulder arthroplasty (RTSA). The entity of greater tuberosity fractures (GTF) has rarely been studied in the literature. The purpose of this study was to analyze the outcome of postoperative greater tuberosity fractures after RTSA compared to a matched control group. The main findings of this study are that a GTF after RTSA is associated with worse clinical outcome scores (mean absolute CS 50 ± 19 (p = 0.032); SSV 63% ± 26 (p = 0.022); mean force 1 kg ± 2 kg (p = 0.044)) compared with the control group (mean absolute CS 62 ± 21; SSV 77% ± 29; mean force 2 kg ± 2 kg). In terms of postoperative range of motion, the fracture group was significantly worse in terms of external rotation (17° ± 19° vs. 30° ± 19° (p = 0.029)). Internal rotation, flexion, as well as abduction of the shoulder appear to be unaffected (internal rotation GTF 4 ± 2, control group 5 ± 3 (p = 0.138); flexion GTF 102° ± 28°, control group 114° ± 27° (p = 0.160); abduction GTF 109° ± 42°, control group 120° ± 39° (p = 0.317)).

Management of glenoid bone loss in primary reverse shoulder arthroplasty

Aims

Rates of reverse total shoulder arthroplasty (rTSA) continue to grow. Glenoid bone loss and deformity remains a technical challenge to the surgeon and may reduce improvements in patients’ outcomes. However, there is no consensus as to the optimal surgical technique to best reconstruct these patients’ anatomy. This review aims to compare the outcomes of glenoid bone grafting versus augmented glenoid prostheses in the management of glenoid bone loss in primary reverse total shoulder arthroplasty.

Methods

This systematic review and meta-analysis evaluated study-level data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We performed searches of Medline (Ovid), Embase (Ovid), and PubMed from their dates of inception to January 2022. From included studies, we analyzed data for preoperative and postoperative range of motion (ROM), patient-reported functional outcomes, and complication rates.

Results

A total of 13 studies (919 shoulders) were included in the analysis. The mean age of patients at initial evaluation was 72.2 years (42 to 87), with a mean follow-up time of 40.7 months (24 to 120). Nine studies with 292 rTSAs evaluated the use of bone graft and five studies with 627 rTSAs evaluated the use of augmented glenoid baseplates. One study was analyzed in both groups. Both techniques demonstrated improvement in patient-reported outcome measures and ROM assessment, with augmented prostheses outperforming bone grafting on improvements in the American Shoulder and Elbow Surgeons Score. There was a higher complication rate (8.9% vs 3.5%; p < 0.001) and revision rate among the bone grafting group compared with the patients who were treated with augmented prostheses (2.4% vs 0.6%; p = 0.022).

Conclusion

This review provides strong evidence that both bone graft and augmented glenoid baseplate techniques to address glenoid bone loss give excellent ROM and functional outcomes in primary rTSA. The use of augmented base plates may confer fewer complications and revisions. Cite this article: Bone Joint J 2022;104-B(12):1334–1342.