Complications in reverse shoulder arthroplasty

Outcomes of lateralized reverse total shoulder arthroplasty versus latissimus dorsi transfer for external rotation deficit: a systematic review and meta-analysis

BACKGROUND

To compare clinical outcomes following lateralized reverse shoulder arthroplasty (RSA) versus RSA with latissimus dorsi transfer (LDT) in patients with poor preoperative active external rotation (ER).

METHODS

We performed a systematic review per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We queried PubMed/Medline, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of RSA with LDT or lateralized RSA alone performed in patients with preoperative ER ≤0°. Our primary outcomes were active ER, active forward elevation (FE), Constant score, and the incidence of complications.

RESULTS

We included 12 RSA with LDT studies with 188 shoulders and 4 lateralized RSA without transfer studies with 250 shoulders. Mean preoperative ER in RSA with LDT was -14°, while mean preoperative ER in lateralized RSA alone was -11°. Lateralized RSA alone was associated with superior postoperative ER (28° vs. 22°, P=0.010) and Constant score (69 vs. 65, P=0.014), but similar postoperative FE (P=0.590). Pre- to postoperative improvement in ER and FE was similar between cohorts. RSA with LDT had a higher incidence of nerve-related complications (2.1% vs. 0%) and dislocation (2.8% vs. 0.8%) compared to lateralized RSA alone.

CONCLUSIONS

Both RSA with LDT and lateralized RSA are reliable options to restore ER in patients with significantly limited preoperative ER. Our analysis suggests that lateralized RSA alone is superior to RSA with LDT in patients with either a medialized or lateralized implant design and confers a lower risk of complications, particularly nerve injury and dislocation. However, the addition of an LDT may still be indicated in certain patient populations with very severe ER loss. Level of evidence: IV.

Can ChatGPT answer patient questions regarding reverse shoulder arthroplasty?

INTRODUCTION

In recent years, artificial intelligence (AI) has seen substantial progress in its utilization, with Chat Generated Pre-Trained Transformer (ChatGPT) is emerging as a popular language model. The purpose of this study was to test the accuracy and reliability of ChatGPT's responses to frequently asked questions (FAQ) pertaining to reverse shoulder arthroplasty (RSA).

METHODS

The ten most common FAQs were queried from institution patient education websites. These ten questions were then input into the chatbot during a single session without additional contextual information. The responses were then critically analyzed by two orthopedic surgeons for clarity, accuracy, and the quality of evidence-based information using The Journal of the American Medical Association (JAMA) Benchmark criteria and the DISCERN score. The readability of the responses was analyzed using the Flesch-Kincaid Grade Level.

RESULTS

In response to the ten questions, the average DISCERN score was 44 (range 38-51). Seven responses were classified as fair and three were poor. The JAMA Benchmark criteria score was 0 for all responses. Furthermore, the average Flesch-Kincaid Grade Level was 14.35, which correlates to a college graduate reading level.

CONCLUSION

Overall, ChatGPT was able to provide fair responses to common patient questions. However, the responses were all written at a college graduate reading level and lacked reliable citations. The readability greatly limits its utility. Thus, adequate patient education should be done by orthopedic surgeons. This study underscores the need for patient education resources that are reliable, accessible, and comprehensible.

LEVEL OF EVIDENCE

IV.

The effect of lateralization and distalization after Grammont-style reverse total shoulder arthroplasty

BACKGROUND

The purpose of this study was to evaluate the relationship between multiple radiographic measures of lateralization and distalization and clinical outcome scores after a reverse total shoulder arthroplasty (RTSA).

METHODS

We retrospectively evaluated all RTSAs performed by the senior author between January 1, 2007, and November 1, 2017. We then evaluated the visual analog scale for pain (VAS pain), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) scores and complication and reoperation rates at a minimum of 2-year follow-up. We measured preoperative and postoperative (2-week) radiographs for the lateralization shoulder angle (LSA), the distalization shoulder angle (DSA), lateral humeral offset, and the distance from the glenoid to the lateral aspect of the greater tuberosity. A multivariable analysis was performed to evaluate the effect of the postoperative radiographic measurements on final patient-reported outcomes (ASES scores, SST, and VAS pain).

RESULTS

The cohort included 216 shoulders from unique patients who had patient-reported outcome scores available at a minimum of 2-year follow-up (average, 4.0 ± 1.9 years) for a total follow-up rate of 70%. In the multivariable models, more lateralization (LSA) was associated with worse final ASES scores -0.52 (95% confidence interval [CI]: -0.88, -0.17; P = .004), and more distalization (DSA) was associated with better final ASES scores 0.40 (95% CI: 0.11, 0.69; P = .007). More lateralization (LSA) was associated with worse final SST scores -0.06 (95% CI: -0.11, -0.003; P = .039). Finally, greater distalization (DSA) was associated with lower final VAS pain scores, ratio = 0.98 (95% CI: 0.96, 1.00; P = .021).

CONCLUSIONS

Greater distalization and less lateralization are associated with better function and less pain after a Grammont-style RTSA. When using a Grammont-style implant, remaining consistent with Grammont's principles of implant placement will afford better final clinical outcomes.

Outcomes following revision reverse shoulder arthroplasty for infection

BACKGROUND

In comparison to primary reverse shoulder arthroplasty (RSA) procedures, revision arthroplasty can be a longer and more complex procedure leading to an increased risk of complications. The reported rates of infection in primary RSA range from 1% to 19% and the cost impact on patients and health care systems is significant, leading to multiple revision surgeries. The purpose of this study was to evaluate the postoperative outcomes, complications, and revision rates for revision reverse shoulder arthroplasty (rRSA) due to infection compared with rRSA for noninfectious causes.

METHODS

Patients who underwent rRSA between 2009 and 2020 by a single fellowship-trained orthopedic surgeon at a single institution were retrospectively identified through a prospectively collected database. Patients were separated into 2 cohorts based on revision diagnosis: (1) rRSA due to infection (rRSAi) and (2) rRSA due to noninfectious causes (rRSAn). Patient-reported outcome scores (PROs), including the Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, University of California-Los Angeles shoulder score, Shoulder Arthroplasty Smart score, and active range of motion (ROM) were collected preoperatively and at a minimum 1-year follow-up. Postoperative complications and revision rates were also collected.

RESULTS

A total of 93 patients (n = 19 rRSAi group, n = 74 rRSAn group) with a mean age of 68 years were included in this analysis. All baseline demographics were comparable between groups. No significant differences were found in preoperative or postoperative PROs and ROM between the 2 groups. Postoperative complication rates and revision rates were comparable between the groups.

CONCLUSION

RSA due to infection results in similar patient-reported outcome scores, range of motion, and revision rates when compared to rRSA for noninfectious causes. Our results suggest that despite the unique challenges associated with rRSA for infection, patient outcomes do not differ from cases attributed to noninfectious causes. More efforts are warranted to further validate and contextualize these findings, considering the protentional influence of patient-specific and implant-specific factors.

Do constrained liners (in a 145° onlay implant) provide any benefit? A matched retrospective study

BACKGROUND

The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using constrained liners (in a 145° onlay implant, Equinoxe [Exactech]) with primary rTSA using standard liners with a minimum 1-year follow-up.

METHODS

A total of 836 primary rTSA patients were analyzed in this study. Patients treated with constrained liners (n = 209) were cross-matched 1:3 for age, gender, glenosphere diameter, and follow-up duration and compared with 627 patients who underwent primary rTSA with standard liners. Study endpoint was at 1 year. Outcomes were analyzed preoperatively and at the latest follow-up. Patient characteristics, postoperative range of motion (ROM), patient-reported outcomes (PROs), complications and revisions were recorded.

RESULTS

There was no statistically significant changes in improvement in pain (-4.9 vs. -5.1; P = .356), ROM (abduction, 45.7° vs. 47.9°, P = .522; forward elevation, 44.0° vs. 50.8°, P = .057; internal rotation score 1.0 vs. 1.1, P = .709; and external rotation, 17.9° vs. 16.7°, P = .543), or PROs (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] score, 44.5 vs. 43.7, P = .107; and Shoulder Arthroplasty Smart [SAS] score, 27.5 vs. 30.0, P = .052) between the constrained and standard liner cohorts at minimum 1-year follow-up. However, the constrained liner rTSA cohort had a significantly higher rate of adverse events (6.2% vs. 2.7%, P = .012), including a higher rate of scapular notching (15.6% vs. 8.8%, P = .015).

CONCLUSION

The use of constrained liners in primary rTSA demonstrated no significant difference in the change in pain, abduction, forward elevation, external and internal rotation scores, ASES scores, and SAS scores at minimum 1-year follow-up. There was no significant difference in forward elevation or abduction compared with standard liners. However, we observed that the overall rate of adverse events, including scapular notching, were significantly higher in the constrained liner cohort. Long-term clinical and radiographic follow-up is necessary to fully elucidate the durability of these results. At this time, it is unclear if constrained liners have any benefit in rTSA.

Complications after reverse total shoulder arthroplasty in the Korean population: a single center study of 299 cases

BACKGROUND

Knowledge regarding differences in the order of frequency of complications after reverse total shoulder arthroplasty (rTSA) between Asian and Western populations is limited. We therefore asked for (1) what is the order of frequency of complications after primary rTSA in the Korean population? (2) What are the rates of complication, reoperation, and revision, and clinical outcomes after index surgery?

METHODS

We retrospectively reviewed the 299 consecutive cases who underwent primary rTSA with more than 1 year of follow-up over a period of 12 years. The mean age of the patients was 73.4 years (range, 58-88 years) and the mean follow-up period was 3.8 years (range, 1-11.5 years). Evaluation of the clinical outcomes, complications, and reinterventions was performed at the final follow-up.

RESULTS

The mean visual analog scale pain score, University of California at Los Angeles score, American Shoulder and Elbow Surgeons score, and subjective shoulder value improved from 6.7, 10.2, 30.7, and 27.7% before rTSA to 1.4, 26.4, 80.5, 77.2% after rTSA, respectively (P < .001). Overall, 45 complications (15.1%) were observed in 44 patients. The order of frequency of complications was as follows: 16 cases of scapular stress fracture (5.4%), 9 intraoperative or postoperative periprosthetic fracture (3.0%), 6 brachial plexus injury (2.0%), 4 instability (1.3%), 2 glenoid loosening (0.7%), 2 glenoid disassembly (0.7%), 2 periprosthetic joint infection (0.7%), 1 glenoid fixation failure (0.3%), 1 humeral stem fixation failure (0.3%), 1 hematoma (0.3%), and 1 complex regional pain syndrome (0.3%). Reintervention was performed in 15 cases (5.0%) including reoperation (8 cases; 2.7%) and revision surgery (7 cases; 2.3%).

CONCLUSION

At a mean follow-up period of 3.8 years, primary rTSA showed satisfactory clinical outcomes with a complication rate of 15.1%, a reoperation rate of 2.7%, and a revision rate of 2.3%. Scapular stress fracture appears to be the most common complication after rTSA in the Korean population.

Conjoint tendon lengthening improves internal rotation following reverse total shoulder arthroplasty: a cadaveric study

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a common procedure for treating a variety of shoulder pathologies. However, many patients struggle with postoperative internal rotation (IR) deficits, which often hinder their activities of daily living. The conjoint tendon provides an anatomic barrier that can impede the postoperative IR of the shoulder, and this study aims to evaluate the effect of a conjoint tendon lengthening on the glenohumeral range of motion (ROM) following RSA.

METHODS

This study used ten fresh-frozen cadaver specimens of the upper extremity. An RSA was implanted using a standard deltopectoral approach, and the ROM was assessed postimplantation. Following this, the conjoint tendon was identified and lengthened using a tendon sheath z-plasty, and the ROM was rerecorded. Statistical significance for the ROM gains after conjoint tendon lengthening was determined with a significance level of P < .05.

RESULTS

Following the lengthening of the conjoint tendon, there were statistically significant improvements in all ROMs (P < .05). Subjects demonstrated a notable gain in IR to the back by 10.3 cm (P < .01), and all ROMs increased by at least 10°, except for forward flexion, which increased by 6° (P < .001).

CONCLUSIONS

This study suggests that lengthening the conjoint tendon improves postoperative ROM of the glenohumeral joint after RSA, offering a potential solution to considerable IR deficits that are commonly encountered post-RSA. Subsequent clinical and biomechanical studies should assess the stability of the shoulder joint following conjoint tendon lengthening.

Primary Arthroscopic Repair for Massive Rotator Cuff Tears Results in Good Shoulder Function, Low Pain, and Satisfactory Outcomes at 2-Year Minimum Follow-Up

PURPOSE

To evaluate outcomes of patients who underwent primary arthroscopic repair for massive rotator cuff tears (MRCTs).

METHODS

Patients with MRCTs (full-thickness tear of 2 or more tendons or full-thickness tear ≥5 cm) who underwent arthroscopic repair with a minimum follow-up of 2 years were retrospectively reviewed (n = 51). All patients had preoperative magnetic resonance imaging used to characterize pattern of tear, degree of fatty degeneration (Goutallier classification), and degree of rotator cuff arthropathy (Hamada classification). Outcomes were determined by American Shoulder and Elbow Surgeons (ASES) scores and Penn Shoulder Scores (PSS).

RESULTS

A total of 51 patients with a minimum 2.3-year follow-up (mean, 5.4 years; range, 2.3-9.7 years) were included in this study. Mean ASES score was 46.1 ± 7.8 (95% CI, 43.9-48.3) for pain and 39.4 ± 12.1 (95% CI, 36.0-42.8) for function. Total ASES score averaged 85.5 ± 18.4 (95% CI, 80.4-90.7). PSS had a mean pain score of 26.8 ± 4.4 (95% CI, 25.4-28.1), a mean satisfaction score of 7.9 ± 2.9 (95% CI, 7.0-8.2), and a mean function score of 48.5 ± 13.5 (95% CI, 44.7-52.3). Total PSS averaged 83.2 ± 19.6 (95% CI, 77.7-87.7). No correlation was found between Goutallier grade and ASES/PSS scores or between Hamada grade and ASES/PSS scores. Three patients underwent reoperation after primary arthroscopic repair of an MRCT (5.9%).

CONCLUSIONS

Patients with MRCTs who undergo primary arthroscopic repair have postoperative outcome scores indicative of good shoulder function, low pain, and high satisfaction. The rate of reoperation for individuals who underwent primary arthroscopic repair with MRCTs was low at 6%.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Functional outcomes and survivorship following aseptic revision shoulder arthroplasty

Background

Revision shoulder arthroplasty (SA) is a surgical procedure performed to address complications or failures of primary total SA. However, limited evidence exists regarding the functional outcomes and longevity of implants following revision.

Methods

A retrospective analysis was conducted on patients who underwent revision SA for failed primary arthroplasty at a single institution between 2009 and 2021 with a minimum of 2-years follow-up. Data was collected from medical records, including type of arthroplasty (anatomic total SA [TSA], reverse total SA [RSA], or hemi-SA [HSA]), demographics and patient-specific information, functional measurements, and implant survival. Patient reported outcomes were obtained during follow-up by phone.

Results

The mean age at index and revision surgeries was 60.5 ± 12.1 years and 64.8 ± 11.1 years, respectively, and average total follow-up was 5.5 ± 3.5 years. The average time to revision was 4.5 ± 5.2 years (range 0.01-24.5 years). Among 99 revision shoulder arthroplasty procedures, 28 were TSA/HA to TSA/HA, 51 were TSA/HA to RSA, 18 were RSA to RSA, and 2 were RSA to HA. Revision surgery significantly improved functional outcomes in forward elevation (preoperative: 79.8 ± 41.0 vs postoperative: 118.5 ± 38.3; p < 0.001), external rotation (preoperative: 27.8 ± 19.3 vs postoperative: 34.3 ± 16.2; p = 0.028), internal rotation (preoperative: glute vs postoperative: S1; p = 0.002), and forward elevation strength (preoperative: 4+/5 vs postoperative: 5/5; p = 0.002). Postoperative patient reported outcomes included: VAS pain (2.2 ± 2.9), SANE (72.6 ± 21.5), ASES (73.3 ± 20.4), and SST (7.7 ± 2.8) scores. The overall 2-, 5-, and 10-year post-revision implant survival rate was 85.48%, 83.06%, and 79.84%, respectively. Patients who had an initial RSA and were revised to RSA were at higher risk of implant failure and subsequent re-revision (RSA to RSA: 1.5 ± 2.5 years vs. TSA/HA to RSA: 2.5 ± 2.1 years vs. TSA/HA to TSA/HA: 4.0 ± 3.5 years; p = 0.0046).

Conclusion

Revision shoulder arthroplasty improved patient outcomes post-index arthroplasty failure. Revisions were more likely to be successful when revising from TSA/HA to RSA.

Level of evidence

Level III - retrospective comparative study.

Three-dimensional planning, navigation, patient-specific instrumentation and mixed reality in shoulder arthroplasty: a digital orthopedic renaissance

Accurate component placement in shoulder arthroplasty is crucial for avoiding complications, achieving superior biomechanical performance and optimizing functional outcomes. Shoulder and elbow surgeons have explored various methods to improve surgical understanding and precise execution including preoperative planning with 3D computed tomography (CT), patient-specific instrumentation (PSI), intraoperative navigation, and mixed reality (MR). 3D preoperative planning facilitated by CT scans and advanced software, enhances surgical precision, influences decision-making for implant types and approaches, reduces errors in guide pin placement, and contributes to cost-effectiveness. Navigation demonstrates benefits in reducing malpositioning, optimizing baseplate stability, improving humeral cut, and potentially conserving bone stock, although challenges such as varied operating times and costs warrant further investigation. The personalized patient care and enhanced operational efficiency associated with PSI are not only attractive for achieving desired component positions but also hold promise for improved outcomes in complex cases involving glenoid bone loss. Augmented reality (AR) and virtual reality (VR) technologies play a pivotal role in reshaping shoulder arthroplasty. They offer benefits in preoperative planning, intraoperative guidance, and interactive surgery. Studies demonstrate their effectiveness in AR-guided guidewire placement, providing real-time surgical advice during reverse total shoulder arthroplasty (RTSA). Additionally, these technologies show promise in orthopedic training, delivering superior realism and accelerating learning compared to conventional methods.

Imaging in shoulder arthroplasty: Current applications and future perspectives

Shoulder arthroplasty has become a standard surgical procedure for treating a variety of complex shoulder disorders, including those with degenerative and traumatic aetiologies. The ever-improving success rates of shoulder arthroplasty could be attributed to advancements in endoprosthesis design, improvements in the biomechanics of endoprosthetic components, and improvements in surgical techniques. It improves patient outcomes and helps restore shoulder joint function and mobility. Imaging plays a vital role by enabling surgeons to plan arthroplasty procedures, help guide endoprosthesis placement, and monitor postoperative outcomes. In addition, imaging plays a role in assessing the residual bone stock and status of rotator cuff integrity and in correcting the placement of prosthetic components to restore shoulder mobility. CT-guided navigation aids surgeons by helping them choose appropriate components for implants and ensuring that implants are placed optimally during surgery. It can lead to better surgical results with reduced patient morbidity and a longer duration of prosthetic stability. After surgery, it is crucial to use imaging techniques to detect issues such as periprosthetic loosening, infections, or fractures to start effective management strategies to enhance patient recovery. This article aims to provide orthopaedic surgeons and radiologists with knowledge on the imaging methods used in shoulder arthroplasty and their role in presurgical planning, intraoperative guidance and postoperative assessment. In this study, we aimed to investigate the rationale behind utilising various types of shoulder replacements: total shoulder replacement (TSA), reverse total shoulder arthroplasty (RTSA), and hemiarthroplasty; methods, their respective advantages and limitations; and outcomes. Our objective is to comprehensively analyse the procedures mentioned above and highlight their unique features and benefits to facilitate a better understanding of these approaches. Additionally, we will discuss how these imaging techniques help identify issues such as loose components, fractures around the implant site, joint instability and infections.

Shoulder arthroplasty in the management of native shoulder joint infections has a high complication rate and poor functional outcome - a systematic review

Background

Shoulder arthroplasty is a treatment option of the sequelae of native shoulder joint infections. However, the functional outcomes and re-infection rates are unknown. The aim of this review was to analyse the outcome of shoulder arthroplasty in patients with native shoulder infections.

Methods

A review of the online databases MEDLINE and Embase was conducted according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Studies reporting either primary or secondary infections of native shoulder joints treated with any form of arthroplasty were included and appraised using the methodological index for non-randomised studies (MINORS) tool.

Results

Fourteen studies were eligible for inclusion. Mean age ranged from 56 to 72 years and the mean follow-up from 20.5 months to 8.2 years. Primary shoulder infections were present in 50 patients and secondary infections in 86. 76 patients underwent a two stage: 46 patients a single-stage procedure whilst 14 refused second-stage surgery. Mean post-operative Constant score ranged from 38 to 56.2. The overall reported re-infection rate was 2.3% and complication rate was 26%.

Conclusion

Shoulder arthroplasty in the management of either primary or secondary native shoulder infections has a high complication rate and low functional outcome but low re-infection rates at short-term follow-up.

How to avoid baseplate failure: the effect of compression and reverse shoulder arthroplasty baseplate design on implant stability

BACKGROUND

Failure to achieve fixation of the glenoid baseplate will lead to clinical failure. The fixation of the baseplate to the scapula must be able to withstand sufficient shear forces to allow bony ingrowth. The importance of compression to neutralize the forces at the baseplate-bone interface has been assumed to be critical in limiting excessive micromotion. The purpose of this study is to determine the effect of compression on implant stability with different baseplate designs.

METHODS

Various baseplate designs (1-piece monolithic central screw [1P], 2-piece locking central screw [2PL], and 2-piece nonlocking center screw [2PNL]) were investigated at 3 different compressive forces (high [810 N], medium [640 N], and low [530 N]). Synthetic bone cylinders were instrumented, and peripheral screws were used in all models. The combination of 1 locking and 3 nonlocking peripheral screw fixation was selected as worst-case scenario. Dynamic testing protocol followed the ASTM F2028-17 standard. The baseplate micromotion at high compression was compared to low compression. Additionally, the baseplate micromotion for each design was compared at baseline (first 50 cycles) and at 10,000 cycles for the 3 different compressive forces where motion above 150 μm was defined as failure.

RESULTS

Baseplate micromotion was found to negatively correlate with compression (rpb = -0.83, P < .0001). At baseline, all baseplate designs were considered stable, regardless of compression. With high compression, average micromotion at the glenoid baseplate-bone interface remained below the 150-μm threshold for all baseplate designs at 10,000 cycles (1P: 50 ± 10 μm; 2PL: 78 ± 32 μm; 2PNL: 79 ± 8 μm; P = .060). With medium compression, average micromotion at 10,000 cycles for all 3 designs remained below the 150-μm threshold (1P: 88 ± 22 μm; 2PL: 132 ± 26 μm; 2PNL: 107 ± 39 μm). The 2PL design had the highest amount of micromotion (P = .013). With low compression, both 2-piece designs had an average micromotion above the 150-μm threshold whereas the 1-piece design did not (1P: 133 ± 35 μm; 2PL: 183 ± 21 μm; 2PNL: 166 ± 39 μm). The 2PL design had significantly higher micromotion when compared to 1P design (P = .041).

DISCUSSION

The stability of a central screw baseplate correlates with the amount of compression obtained and is affected by implant design. For the same amount of compression, more micromotion is observed in a 2-piece design than a 1-piece design.

The effect of subscapularis repair in reverse total shoulder arthroplasty depends on the design of the implant: a comparative study with a minimum 2-year follow-up

INTRODUCTION

The role of the subscapularis (Ssc) tendon does not yet have a well-defined role in RSA. The purpose of the present study was to evaluate if the repair of the Ssc in RSA improves overall clinical and radiographic results and if it has the same results using a medialized design humeral stem compared to a lateralized design.

METHODS

Eighty-four consecutive patients undergoing RSA were retrospectively analyzed. Nine patients were lost at FU. Two implants with similar glenosphere design and different stem design (medialized and lateralized) were used. The Ssc was repaired in case of good quality of the fibers and reducibility without tension intraoperatively. Patients were divided into four groups for data analysis depending on whether they had received a medialized or lateralized design and Ssc repair or not. Patients were reviewed at an average follow-up of 40.8 ± 13.1 months. Clinical outcome measures included Active range of motion (ROM), strength, visual analog scale (VAS), Constant-Murley score (CMS), and the American Shoulder and Elbow Surgeons score (ASES). Radiographic evaluation at final follow-up was performed to assess scapular notching, stress shielding, and radiolucent lines.

RESULTS

No statistically significant clinical differences (p > 0.05) emerged between Lat/Ssc+ and Lat/Ssc-. Conversely, the patients belonging to the Med/Ssc- group reported statistically worse (p < 0.05) results than the Med/Ssc + group in terms of VAS, ASES and CMS. Statistically worse (p < .05) results in the Med/Ssc- group than in the Med/Ssc + were found also in active ROM achieved in FE, ABD, ER1 and ER2, and in the strength obtained in FE, ABD and ER2. Scapular notching was reported in 3 shoulders (15.7%) in Lat/Ssc+ group and in 7 shoulders (50%) in Lat/Ssc- group, while it was reported in 4 shoulders (14.2%) in Med/Ssc + group and in 6 shoulders (42.8%) in Med/Ssc- group. Stress shielding was observed in 6 cases in Lat/Ssc+ group (31.6%), in 8 cases in Lat/Ssc- group (57.1%), in 3 cases (10.7%) in Med/Ssc + group and 4 cases in Med/Ssc- group (28.6%).

CONCLUSIONS

Patients undergoing RSA show clinical improvements at mid-term follow-up with a low rate of complications, regardless of the use of a medialized or a lateralized humeral stem design. Ssc repair is associated with better functional outcomes in the cohort of medialized stem, while it did not yield significant differences in the cohort of lateralized stem.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Comparison; Treatment Study.

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.

Outcomes of conservative treatment of acromial and scapular spine stress fracture post reverse shoulder arthroplasty: a systematic review with meta-analysis

INTRODUCTION

Acromial and scapular spine stress fractures are common complications post reverse shoulder arthroplasty. A systematic review with meta-analysis was conducted to evaluate the clinical outcomes of conservatively treated acromial and scapular spine stress fractures post reverse shoulder arthroplasty in comparison to nonfracture control.

METHODS

Embase, MEDLINE, and Web of Science were searched on September 9, 2022, using various terms related to fracture, acromion, scapula, and reverse shoulder arthroplasty. Meta-analysis using a random effects model was performed on common outcome scores. Risk of bias was assessed using the Joanna Briggs Institute tools for case-controlled studies. Sensitivity analysis was performed for imputed standard deviations and studies with <20 participants.

RESULTS

Thirteen studies with a total of 339 fracture and 3142 control patients were included in the systematic review. Meta-analysis was performed on 12 studies assessing active forward flexion, abduction, external rotation, Constant-Murley score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, pain score, Simple Shoulder Test, and Single Assessment Numeric Evaluation. Fracture patients experienced significantly poorer functional outcome compared with control patients when the fractures were managed conservatively. Levy III fractures tend to experience worse outcomes. Pain score did not demonstrate a statistically significant difference between the fracture and nonfracture cohort.

DISCUSSION

Currently, literature regarding surgical management is lacking, partially because of a dearth of high-quality literature but also hindered by a lack of standardized techniques. This review was limited by inclusion of studies of low evidence, small sample sizes, and inconsistency in outcome measurement and follow-up period. Overall, patients with acromial and scapular spine stress fractures treated conservatively are expected to have reduced shoulder function compared to nonfracture patients, with the spine of scapula fracture patients suffering the poorest outcomes. Future studies should aim to use the same sets of outcomes parameters to assess the patients at fixed time intervals and report outcomes stratified by Levy classification. This will enable interinstitutional collaboration and pooling of results.

Influence of subscapularis tendon reattachment after reverse shoulder arthroplasty: clinical findings and ultrasonographic evaluation of the subscapularis at 89 months mean follow-up

BACKGROUND

Reverse shoulder arthroplasty (RSA) is commonly used to treat rotator cuff arthropathy. In the deltopectoral approach for RSA, the subscapularis tendon is (partly) detached. The clinical effects of subscapularis reattachment are still under debate. An observational study was performed to evaluate the clinical effects of subscapularis tendon reattachment on the mid- to long-term following RSA.

METHODS

In this study, 40 patients for a total of 46 shoulders with a reverse shoulder prosthesis participated. Constant Murley Score (CMS), Oxford Shoulder Score (OSS), Range of Motion (ROM) and abduction and internal rotation strength were measured. The integrity of the subscapularis tendon at follow-up was assessed using ultrasound. Outcomes were compared between three groups: repair and intact at follow-up, repair and not intact, and no repair.

RESULTS

Mean follow-up was 89 months with a minimum of three years. CMS, OSS, ROM and strength did not differ between groups. One-third of the initially reattached subscapularis tendons were still present at follow-up. No dislocations were reported.

CONCLUSION

This study showed no clinical effects of subscapularis reattachment after reverse shoulder arthroplasty on the mid- to long-term.

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.

An Unusual Case of Onlay Reverse Shoulder Arthroplasty Disassembly Due to Cement Interposition. A Case Report

Introduction

Reverse shoulder arthroplasty (RSA) complication rates range between 1.4% and 28% depending on the nature of the indication. Even though glenosphere dissociation is the third most frequent complication after RSA, with an incidence that can rise to just over 12%, there is no evidence in the literature describing the disassembly between the humeral stem and its metaphysics.

Case Report

It is reported a novel early failure type in a reversed shoulder arthroplasty of a healthy 72-year-old female patient, involving the disassembly of the metaphysis from an onlay tray system due to cement interposition in a reversed shoulder prosthesis.

Conclusion

This case highlights a rare form of early failure after RSA as a result of a disassembly between the humeral stem and its metaphysis due to the presence of interposed cement. To prevent this complication, a two-step implantation procedure is recommended, which consists of cementing the stem before inserting the metaphyseal tray.

Improved functional, radiographic and patient-reported outcomes at midterm follow-up for shoulder arthroplasty patients 75 years and older

Background

Current discussion centers around the appropriateness of shoulder arthroplasty in elderly patients, and whether anatomic and reverse total shoulder arthroplasty yield acceptable results in this population. The purpose of this study was to examine midterm outcomes in patients 75 years and older who underwent either procedure.

Methods

A retrospective review was performed on patients who underwent anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) between 2000 and 2018. Inclusion criteria was patient age ≥75 years at time of surgery and ≥1 years postoperative follow-up. Primary outcomes were differences in Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, and range of motion. A secondary outcome was revision surgery.

Results

22 patients who underwent aTSA and 17 patients who underwent rTSA were included. Mean age at surgery was 79 and 80 in the aTSA and rTSA groups, respectively. Mean postoperative follow-up was 6.6 years across both cohorts. Anatomic TSA patients experienced improvements in VAS (7 preop vs. 1 postop; p < 0.001), ASES (16 vs. 75; p < 0.001), and SST (2 vs. 8; p < 0.001) scores. Reverse TSA patients also experienced improvements in VAS (7 vs. 1; p < 0.001), ASES (29 vs. 74; p < 0.001), and SST (1 vs. 7; p < 0.001) scores. Anatomic TSA patients experienced improved external rotation (17° vs. 53°; p < 0.001), forward elevation (108° vs. 155°; p < 0.001), and internal rotation (L5 vs. T10; p < 0.001). Reverse TSA patients experienced improved forward elevation (52° vs. 126°; p < 0.001). 21 aTSA patients (100%) and 16 rTSA patients (94%) experienced survival free from revision. 100% of aTSA and rTSA patients experienced survival free from loosening.

Conclusion

Both aTSA and rTSA can be performed in the elderly population with acceptable midterm outcomes, suggesting that implant survival and patient satisfaction have the potential to endure through the end of life.

Level of evidence

IV.

Preoperative planning in reverse shoulder arthroplasty: plain radiographs vs. computed tomography scan vs. navigation vs. augmented reality

Reverse shoulder arthroplasty (RSA) has become a highly successful treatment option for various shoulder conditions, leading to a significant increase in its utilization since its approval in 2003. However, postoperative complications, including scapular notching, prosthetic instability, and component loosening, remain a concern. These complications can often be attributed to technical errors during component implantation, emphasizing the importance of proper preoperative planning and accurate positioning of prosthetic components. Improper baseplate and glenosphere positioning in RSA have been linked to impingement, reduced range of motion, and increased scapular notching. Additionally, the relationship between component positioning and intrinsic stability of RSA has been established, with glenoid component retroversion exceeding 10° posing a risk to implant stability. Adequate initial glenoid baseplate fixation, achieved through optimal seating and the use of appropriate screws, is crucial for long-term success and prevention of early failure. Factors such as lateralization and distalization also influence outcomes and complications in RSA, yet standardized guidelines for preoperative planning in these parameters are still lacking. Despite the impact of component position on outcomes, glenoid component implantation remains challenging, with position errors being common even among experienced surgeons. Challenges arise due to factors such as deformity, bone defects, limited exposure, and the absence of reliable bony landmarks intraoperatively. With the evolving understanding of RSA biomechanics and the significance of implant configuration and positioning, advancements in preoperative planning and surgical aids have emerged. This review article explores the current evidence on preoperative planning techniques in RSA, including plain radiographs, three-dimensional imaging, computer planning software, intraoperative navigation, and augmented reality (AR), highlighting their potential benefits and advancements in improving implant position accuracy.

Multiplanar analysis of proximal humerus anatomy of patients with rotator cuff arthropathy and relevance to reverse shoulder press-fit stems

Background

Short stems have become increasingly popular in reverse shoulder arthroplasty (RSA) due to their ability to preserve bone stock for revision surgery. However, short stems may be more at risk for malalignment or loosening, and commercially available stems have varied designs. The purpose of this study was to perform a multiplanar analysis of proximal humerus anatomy in patients with rotator cuff arthropathy to better define canal geometry and identify differences based on sex.

Methods

A retrospective review was performed of a consecutive series of patients undergoing RSA for rotator cuff arthropathy. A total of 117 patients were identified with preoperative computed tomography scans. Measurements were undertaken following multiplanar reconstruction of the computed tomography scans. Measured parameters included the following: transition point (TP), anteroposterior (AP) and mediolateral (ML) distances, intramedullary (IM) and bone diameter, and cortical thickness. The TP was defined as the distance from the periosteal border of the greater tuberosity to the level of the IM canal where the endosteal borders became parallel. Measurements started at the metaphysis, and then proceeded 25 and 50 mm distal to the metaphysis followed by 10 mm increments thereafter. Each level was compared to the level above with t tests in the overall cohort and separately by sex. Height was correlated to ML-AP difference and IM diameter with Pearson correlation coefficient. Potential stem sizes that extended 50, 60, 70, and 80 mm from the metaphysis were analyzed to record the percentage of patients in whom the stem would reach past the TP.

Results

The mean TP for all patients was 55.6 ± 7.4 mm (37.5-78.4) from the greater tuberosity, 53.3 ± 6.6 mm (37.5-67.0) in females and 58.1 ± 7.5 mm (41.9-78.4) in males. ML and AP distances and IM diameter became consistent at level 3 (mean, 83 mm distal to the greater tuberosity) in the overall cohort and in both sexes. Height positively correlated with IM diameter. Males had significantly larger IM diameters compared to females at all levels. Cortical thickness remained relatively consistent throughout the proximal humerus. A stem length of 70 mm would extend past the TP in 98% of patients.

Conclusion

Humeral implants in RSA with a stem of at least 70 mm in length would extend distally past the TP in the majority of cases regardless of sex. At this point, the canal's area remains consistent which would facilitate diaphyseal fixation if required.

Reverse Total Shoulder Arthroplasty for Younger Patients: A Comparable Analysis of Patients Older and Younger Than 65 Years

INTRODUCTION

Reverse total shoulder arthroplasty (rTSA) has become a popular option for the surgical management of rotator cuff arthropathy and complex fractures of the proximal humerus. However, there is a paucity of studies evaluating outcomes, especially between patients of different age groups. The purpose of this study was to compare functional outcomes and survivorship between patients older than 65 years (o65) and those 65 years and younger (y65).

METHODS

A retrospective review was conducted at a single academic medical center identifying a consecutive cohort of patients undergoing rTSA between 2018 and 2020. The minimum follow-up time was 2 years. Patients were stratified into two groups for comparative analyses (y65 and o65). Patient demographics, perioperative and postoperative data, and functional outcomes were collected. A Kaplan-Meier survival analysis was conducted to determine survivorship, defined as revision surgery or implant failure.

RESULTS

Forty-eight patients were included for final analysis. Nineteen patients comprised the y65 group while 29 patients comprised the o65 group. No difference was observed in Quick Disabilities of the Arm, Shoulder, and Hand scores at baseline nor at the latest follow-up between the two groups. Patients in the y65 group had significantly greater internal and external rotation (IR/ER) from 3 months to 2 years compared with patients in the o65 group (P ≤ 0.05). Finally, there were no differences in revision surgery rates between the y65 group and the o65 group (11% vs. 14%, P = 1.0). A KM survival analysis revealed no difference in implant failure, necessitating revision surgery between the two groups at the latest follow-up (P = 0.69).

DISCUSSION

Despite a notable difference in the number of baseline comorbidities, there were no notable differences in functional outcomes, survivorship, and revision surgery rates between each cohort. Although both groups had a similar function initially, by 3 months postoperatively, the y65 group had markedly greater range of motion in IR and ER. Longer term survivorship is needed; however, rTSA may offer a reliable option for shoulder reconstruction even in the y65 patient group.

Outcomes of Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit: A Systematic Review and Meta-Analysis

BACKGROUND

Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed.

RESULTS

Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was -12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9).

CONCLUSIONS

RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes.

LEVEL OF EVIDENCE

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

Iatrogenic Ulnar Nerve Neuropathy Following Reverse Total Shoulder Arthroplasty: Electrodiagnostic Findings in 18 Patients

Background A reverse total shoulder arthroplasty (RTSA) is often recommended for rotator cuff pathology and may be associated with a myriad of complications, including prosthetic instability, infection, humeral problems, and glenoid loosening. Neurological injuries following an RTSA are infrequent and are usually related to brachial plexus or proximal nerve injury in the affected arm. Iatrogenic ulnar nerve neuropathy is exceedingly rare. Aims This study describes the clinical and electrodiagnostic (EDX) features of 18 patients with ulnar nerve neuropathy complicating RTSA. Materials and methods All patients underwent EDX studies, and 14 had an ultrasound (US) study. Results All patients complained of numbness, tingling, hyperalgesia, and/or allodynia in the distribution of the ulnar nerve. Eight (44%) patients reported hand weakness, and one (6%) noted wasting of the intrinsic hand muscles. Decreased pinprick sensation in the ulnar nerve distribution was detected in all patients. Seventeen (94%) patients had weakness of the ulnar nerve-innervated intrinsic hand muscles. All patients had focal slowing of the motor conduction of the ulnar nerve across the elbow. Sensory potentials were either absent or of a low amplitude over the digital and/or dorsal cutaneous branch of the ulnar nerve in all patients. Twelve (86%) patients showed an increase in the cross-sectional area (CSA) of the ulnar nerve at the elbow; six (43%) had a hypoechoic ulnar nerve. Ulnar nerve neuropathy was confirmed at the elbow in all 18 patients. Of the 14 (78%) patients who underwent surgical intervention for ulnar nerve neuropathy following an RTSA, only four had complete symptom resolution. Conclusions Surgeons should be cognizant of ulnar nerve neuropathy as a potential complication of an RTSA and take precautions to avoid damage to the ulnar nerve intraoperatively. EDX and US studies should be performed to confirm and assess the site and severity of the injury.

The learning curve for anatomic and reverse total shoulder arthroplasty: a systematic review

Background

Despite the rising incidence of anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) among surgeons, little is known about the learning curve associated with these procedures. The purpose of this systematic review was to (1) identify the learning curves associated with ATSA and RTSA, (2) evaluate the effect of the learning curves on clinical outcomes, and (3) determine the number of cases needed to achieve proficiency.

Methods

Four online databases [PubMed (NLM), MEDLINE (OVID), Cochrane Library (Wiley), and Scopus (Elsevier)] were systematically searched and screened according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The search included results from the inception of each database to May 18, 2022. Data regarding study characteristics, patient demographics, learning curve analyses, patient reported outcome measures, range of motion, complication rates, and reoperation rates were collected. A quality assessment for each article was performed according to the Methodological Index for Nonrandomized Studies criteria.

Results

A total of 13 studies of fair to good quality were included for analysis (one of level II evidence, five of level III, and seven of level IV) with the majority originating from the United States [n = 8, 61.5%]. Overall, there were a total of 3381 cases (1861 RTSA and 1520 ATSA), with a mean patient age of 72.6 years [range: 45-92 years]. From the studies analyzed in this systematic review, for RTSA, the approximate average number of cases surgeons need to perform to move to an acceptable position on the RTSA learning curve is 25 cases. For ATSA, a wider range of 16-86 cases was derived as only two studies reported on ATSA.

Conclusion

Progression along the learning curve for RTSA and ATSA results in decreased operative times, improved patient-reported outcomes, and fewer complications. However, a true learning curve is difficult to quantify given the heterogeneity of reported outcome measures, individual surgeon experience at the time of data collection, and statistical analyses used across studies.

Direct active rehabilitation after reverse total shoulder arthroplasty: an international multicentre prospective cohort safety study with 1-year follow up

OBJECTIVES

To gain insight in the safety of direct active rehabilitation without immobilisation in patients undergoing reverse total shoulder arthroplasty without subscapularis reattachment, measured by the occurrence of complications until 1-year follow up. Next, to explore improvement in shoulder function and in patient-reported outcome measures.

DESIGN

An international multicentre prospective cohort safety study.

SETTING

Patients indicated for reverse total shoulder arthroplasty, visiting the orthopaedics outpatient clinic at two hospitals in the Netherlands and one hospital in Curaçao between January 2019 and July 2021, were selected.

PARTICIPANTS

100 patients (68% female, mean age 74±7.0 years) undergoing unilateral primary shoulder replacement were included if: ≥50 years, diagnosed with shoulder osteoarthritis, rotator cuff arthropathy or avascular necrosis, and selected for reverse total shoulder arthroplasty. A sling was used for only 1 day, followed by a progressive active rehabilitation for ≥12 weeks with no precautions.

MAIN OUTCOME MEASURES

Complications, range of motion and patient-reported outcome measures (Oxford Shoulder Score, Pain Numeric Rating Scale and EuroQol-5D for quality of life). Patients were evaluated preoperatively and 6 weeks, 3 months and 1 year postoperatively.

RESULTS

In total, 17 complications were registered (17.0%) including five (5.0%) categorised as potentially related to the rehabilitation strategy: one dislocation, one acromion fracture and three cases with persistent pain. Anteflexion, abduction and external rotation, pain scores and the Oxford Shoulder Score all improved significantly (p<0.05) at all time points compared with preoperative. Quality of life improved significantly from 3 months onwards. These secondary outcomes improved further until 1 year postoperatively.

CONCLUSION

Direct active rehabilitation after reverse total shoulder arthroplasty seems to be safe and effective. Potentially, this approach will lead to less dependent patients and faster recovery. Larger studies, preferably including a control group, should corroborate our results.

TRIAL REGISTRATION NUMBER

NL7656.

How common is nerve injury after reverse shoulder arthroplasty? A systematic review

BACKGROUND

Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature.

METHODS

A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms "reverse shoulder," "reverse total shoulder," "inverted shoulder," and "inverted total shoulder" with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected.

RESULTS

After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases.

CONCLUSION

Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.

Reverse shoulder arthroplasty in upper extremity ambulators: a matched-cohort analysis

BACKGROUND

Upper extremity ambulators (UEAs) who require prolonged use of assistive devices for mobility have a high incidence of shoulder pathology secondary to increased stress across the shoulder joint with upper extremity weight-bearing. Reverse shoulder arthroplasty (RSA) for rotator cuff arthropathy has historically been associated with increased complications in UEA, but more recent studies have shown more promising outcomes. The objective of this study is to evaluate clinical outcomes and complication rates between these 2 groups to define the relative risk of RSA in the UEA population and identify opportunities to improve treatment outcomes.

METHODS

An institutional review board-approved retrospective chart review was performed in patients who underwent RSA at our institution by the senior author from 2004 to 2019. UEAs were defined as patients who used regular upper extremity assistive devices for community ambulation before initial consultation for the surgical extremity. Pre- and postoperative range of motion, visual analog scale scores, American Shoulder and Elbow Surgeons scores, Constant-Murley scores, and Simple Shoulder Test scores were measured at defined intervals. Complications including infection, instability, and need for revision surgery were also compared. All patients were followed for a minimum of 2 years postoperatively.

RESULTS

A total of 159 RSA procedures (70 UEAs, 89 controls) were performed during the study period. On average, UEA patients had more preoperative pain and less shoulder function than controls, with statistically significant differences in visual analog scores (6.897 vs. 5.532, P = .0010) and American Shoulder and Elbow Surgeons scores (33.50 vs. 40.20, P = .0290), respectively. Despite the lower baseline values, UEA patients experienced excellent postoperative improvement, leading to similar postoperative pain and shoulder function except for a lower average forward flexion in the UEA group (127° vs. 135°, P = .0354). Notching and complication rates were also similar between the 2 groups, with notching rates of 59% and 50% and complication rates of 14.3% and 13.5% in the UEA and control groups, respectively.

CONCLUSIONS

RSA in the UEA population can achieve similar pain and functional outcomes as compared with age-matched controls without a significant increase in complication rates; however, further studies are required to assess long-term comparative outcomes in this challenging patient population.

The association between reverse total shoulder arthroplasty neck-shaft angle on postoperative patient experienced shoulder disability: a retrospective cohort study

Background

The neck-shaft angle (NSA) of the glenoid component used in reverse total shoulder arthroplasty (RTSA) was reduced to improve functional outcomes. This led to a decreased abduction but increased external rotation ability of patients who underwent RTSA. The impact of the decreased NSA on patient-reported shoulder disability is unknown but may have important implications for functional ability. Therefore, the aim of this study was to assess the difference in patient experienced shoulder disability between an NSA of 135° and 155° 12 months after RTSA.

Methods

In this retrospective cohort study, 109 patients undergoing RTSA were included. In 68 patients, a glenoid component with an NSA of 135° was used and 41 patients received a glenoid component with an NSA of 155°. The primary outcome was Disabilities of the Arm, Shoulder, and Hand (DASH) scores at 12 months and change scores between baseline and 12-month follow-up. Secondary outcomes were complications, Constant Murley Score, Numeric Rating Scale, active forward elevation and external rotation ability. Differences between groups were tested with t-tests or Mann-Whitney U-tests.

Results

A mean difference of 10.0 in 12 months postoperative DASH scores between NSA groups was observed in favor of the 135° NSA (P = .004), which did not exceed the Minimal Clinically Important Difference. DASH changes scores did not differ between NSA groups (P = .652). Mean postoperative Constant Murley Score at 12 months was 11.1 higher in the 135° NSA group (P = .013). No differences were observed in complications (P = .721) and postoperative pain (P = .710) between groups. Difference in postoperative external rotation and forward elevation at 12 months was 10° (P = .022) and 20° (P = .046), respectively, in favor of the 135° NSA group, exceeding Minimal Clinically Important Differences.

Conclusions

No clinically important difference in patient-reported shoulder disability (DASH) was found between both groups, despite a larger range of motion in the 135° NSA group. This study is the first to show the impact of NSA on patient-reported shoulder disability using the DASH.

Complications and revisions in anatomic and reverse short stem shoulder arthroplasty

INTRODUCTION

One current trend in the field of shoulder arthroplasty is a design shift to shorter and metaphyseal fixed humeral stem components. The aim of this investigation is to analyze complications resulting in revision surgery after anatomic (ASA) and reverse (RSA) short stem arthroplasty. We hypothesize that complications are influenced by the type of prosthesis and indication for arthroplasty.

MATERIALS AND METHODS

A total of 279 short stem shoulder prostheses were implanted by the same surgeon (162 ASA; 117 RSA), and 223 of these prostheses were implanted as primary procedures; in 54 cases, arthroplasty was performed secondary to prior open surgery. Main indications were osteoarthritis (OA) (n = 134), cuff tear arthropathy (CTA) (n = 74) and posttraumatic deformities (PTr) (n = 59). Patients were evaluated at 6 weeks (follow-up 1; FU1), 2 years (FU2) and the time span of the last follow-up defined as FU3 with a minimum FU of 2 years. Complications were categorized into early complications (within FU1), intermediate complications (within FU2) and late complications (> 2 years; FU3).

RESULTS

In total, 268 prostheses (96.1%) were available for FU1; 267 prostheses (95.7%) were available for FU2 and 218 prostheses (77.8%) were available for FU3. The average time for FU3 was 53.0 months (range 24-95). A complication leading to revision occurred in 21 prostheses (7.8%), 6 (3.7%) in the ASA group and 15 (12.7%) in the RSA group (p < 0.005). The most frequent cause for revision was infection (n = 9; 42.9%). After primary implantation, 3 complications (2.2%) occurred in the ASA and 10 complications (11.0%) in the RSA group (p < 0.005). The complication rate was 2.2% in patients with OA, 13.5% in CTA and 11.9% in PTr.

CONCLUSIONS

Primary reverse shoulder arthroplasty had a significantly higher rate of complications and revisions than primary and secondary anatomic shoulder arthroplasty, respectively. Therefore, indications for reverse shoulder arthroplasty should be critically questioned in each individual case.

[Revision surgery in reverse shoulder arthroplasty : Management of the most common complications]

BACKGROUND

In recent years, the number of reverse shoulder arthroplasty implantations has increased continuously and a higher number of revision surgeries due to complications can be expected in the future. Current data show a mean complication rate for RSA of around 4%. The most common complications are instability, infection, component loosening, and periprosthetic fracture.

TREATMENT OPTIONS

Revision surgery for RSA is challenging, and an individual treatment plan is necessary. For prosthetic instability, different operative or non-operative treatment options are available. Revision surgery for periprosthetic infection with replacement of the prosthesis is usually necessary for infection management. The treatment of periprosthetic fractures is based on techniques of general fracture treatment and depends on the fracture type. Knowledge of complications and risk factors may decrease complication rates in primary reverse shoulder arthroplasty in the future.

Clinical and Radiological Outcomes after Total Shoulder Arthroplasty Using Custom-Made Glenoid Components: A Systematic Review

Reverse total shoulder arthroplasty presents itself sometimes as challenging when it comes to addressing massive bone loss, either in primary or revision settings. Custom components recently have made their way into shoulder prosthetics and are meant to help in the case of extensive glenoid bone destruction. Because of strict indication and the fairly recent introduction of these implants, the usage of custom-made glenoid implants is not very common yet. However, the early results are promising. The purpose of this review was to summarize and analyze the available literature. Therefore, a systematic review was performed according to PRISMA guidelines. A comprehensive search of the databases PubMed, Cochrane, and Livivo was performed to screen for studies reporting on clinical and radiological outcomes of custom glenoid implants. Four studies with a total of 46 shoulders were included in this review. The mean patient age was 68.8 years and the mean time of follow-up was 24.3 months. The weighted means showed an increase in CMS (32.7 points), in ASES (39.8 points), in anteversion (67.4 degrees), and in abduction (51.9 degrees) and a decrease in VAS (5.4 points). Custom-made glenoid implants are therefore a viable option in cases of large combined glenoid bone loss, both in primary and revision shoulder arthroplasty.

Factors affecting internal rotation following total shoulder arthroplasty

Background

Reverse shoulder arthroplasty (RSA) was developed in the late twentieth century to provide a stable arthroplasty option for patients with rotator cuff deficiency arthropathy. Since its inception, there have been changes in materials, design, and positioning. One of the persistent clinical issues has been difficulty with internal rotation (IR) and the associated difficulty with behind the back activities. Implant design, positioning, and the available soft tissues may influence IR after RSA. The purpose of this systematic review is to assess factors that impact IR following RSA.

Methods

The literature search, based on PRISMA guidelines, used 4 databases: Pubmed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials. We included clinical trials that compared different implantation and design modifications and assessed IR.

Results

Of the 617 articles identified in the initial search, 46 satisfied the inclusion criteria. The articles explored multiple factors of RSA and their effects on IR, including humeral and glenoid components and muscle function and integrity. Among humeral factors affecting rotation, there was a broad consensus that: IR decreases as retroversion increases, humeral neck-shaft angle less than 155° improves IR, lateralized humeral offset does not improve IR, and shallow cups improve IR. Insert thickness was not associated with a reproducible effect. Of the studies evaluating the effect of glenoid components, there was majority agreement that glenosphere lateralization improved IR, and there were mixed results regarding the effects of glenosphere size and tilt. Others included one study in each: glenoid overhang, retroversion, and baseplate. One study found an association between teres minor insufficiency and improved IR, with mixed results in the presence of fatty infiltration in both teres minor and subscapularis. Most studies noted subscapularis repair had no effect on IR.

Conclusion

Prosthetic variables affecting IR are not widely studied. Based on the existing literature, evidence is conflicting. More research needs to be undertaken to gain a greater understanding regarding which factors can be modified to improve IR in RSA patients.

Clinical outcomes of reverse shoulder arthroplasty and rotator cuff repair in patients with massive rotator cuff tears without osteoarthritis: comparison using propensity score matching

BACKGROUND

The optimal management for massive rotator cuff tears (MRCTs) without osteoarthritis (OA) remains controversial. The purpose of this study was to evaluate and compare the clinical outcomes of reverse shoulder arthroplasty (RSA) vs. rotator cuff repair (RCR) in patients with MRCTs without OA.

METHODS

We conducted a retrospective data analysis of 68 patients treated for MRCTs via RSA and 215 patients treated for MRCTs via arthroscopic RCR between January 2014 and April 2019. Through propensity score matching, patients were matched for sex, age, tear size, and global fatty degeneration index. Thirty-nine patients in each group were included, and all patients had completed minimal 2-year follow-up. Postoperative radiologic evaluations of healing failure were performed. The visual analog scale score for pain, range of motion, and functional outcome measures including the American Shoulder and Elbow Surgeons score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, Simple Shoulder Test score, and Constant score were assessed and compared between the 2 groups.

RESULTS

Healing failure was observed in 10 patients in the RCR group (32.3%). No statistically significant differences in preoperative range of motion and functional scores were found between the RCR and RSA groups. Both groups showed significant pain relief and functional improvement at final follow-up. Patients in the RCR group showed significantly greater forward elevation (156.4° ± 23.8° vs. 139.7° ± 22.4°, P < .001) and internal rotation (thoracic vertebra, T8.2 ± 1.2 vs. T9.7 ± 2.6, P = .001). The average American Shoulder and Elbow Surgeons score was 88.3 ± 12.2 in the RCR group and 81.8 ± 16.1 in the RSA group (P = .045). The QuickDASH score was significantly higher in the RCR group (P = .019). A significantly higher Simple Shoulder Test score (9.7 ± 2.8 vs. 8.1 ± 3.0, P = .01) and a significantly higher Constant score (67.2 ± 6.5 vs. 63.2 ± 7.1, P = .011) were seen in the RCR group.

CONCLUSION

Both RSA and RCR are effective and reliable treatment options for MRCTs without OA. However, the RCR group showed better shoulder function improvement than the RSA group. Considering the possible implications of RSA, RCR should be referred to as a first-line treatment option for patients with MRCTs without OA with proper indications.

Clinical perspectives for repairing rotator cuff injuries with multi-tissue regenerative approaches

Background

In the musculoskeletal system, bone, tendon, and muscle form highly integrated multi-tissue units such as the rotator cuff complex, which facilitates functional and dynamic movement of the shoulder joint. Understanding the intricate interplay among these tissues within clinical, biological, and engineering contexts is vital for addressing challenging issues in treatment of musculoskeletal disorders and injuries.

Methods

A wide-ranging literature search was performed, and findings related to the socioeconomic impact of rotator cuff tears, the structure-function relationship of rotator cuff bone-tendon-muscle units, pathophysiology of injury, current clinical treatments, recent state-of-the-art advances (stem cells, growth factors, and exosomes) as well as their regulatory approval, and future strategies aimed at engineering bone-tendon-muscle musculoskeletal units are outlined.

Results

Rotator cuff injuries are a significant socioeconomic burden on numerous healthcare systems that may be addressed by treating the rotator cuff as a single complex, given its highly integrated structure-function relationship as well as degenerative pathophysiology and limited healing in bone-tendon-muscle musculoskeletal tissues. Current clinical practices for treating rotator cuff injuries, including the use of commercially available devices and evolving trends in surgical management have benefited patients while advances in application of stem/progenitor cells, growth factors, and exosomes hold clinical potential. However, such efforts do not emphasize targeted regeneration of bone-tendon-muscle units. Strategies aimed at regenerating bone-tendon-muscle units are thus expected to address challenging issues in rotator cuff repair.

Conclusions

The rotator cuff is a highly integrated complex of bone-tendon-muscle units that when injured, has severe consequences for patients and healthcare systems. State-of-the-art clinical treatment as well as recent advances have resulted in improved patient outcome and may be further enhanced by engineering bone-tendon-muscle multi-tissue grafts as a potential strategy for rotator cuff injuries.

Translational Potential of this Article

This review aims to bridge clinical, tissue engineering, and biological aspects of rotator cuff repair and propose a novel therapeutic strategy by targeted regeneration of multi-tissue units. The presentation of these wide-ranging and multi-disciplinary concepts are broadly applicable to regenerative medicine applications for musculoskeletal and non-musculoskeletal tissues.

Short-term comparative outcomes between reverse shoulder arthroplasty for shoulder trauma and shoulder arthritis: a Southeast Asian experience

Background

Reverse shoulder arthroplasty (RSA), first introduced as a management option for cuff tear arthropathy, is now an accepted treatment for complex proximal humeral fractures. Few studies have identified whether the outcomes of RSA for shoulder trauma are comparable to those of RSA for shoulder arthritis.

Methods

This is a retrospective, single-institution cohort study of all patients who underwent RSA at our institution between January 2013 and December 2019. In total, 49 patients met the inclusion criteria. As outcomes, we evaluated the 1-year American Shoulder and Elbow Surgeons (ASES) and Constant shoulder scores, postoperative shoulder range of motion, intra- and postoperative complications, and cumulative revision rate. The patients were grouped based on preoperative diagnosis to compare postoperative outcomes across two broad groups.

Results

The median follow-up period was 32.8 months (interquartile range, 12.6–66.6 months). The 1-year visual analog scale, range of motion, and Constant and ASES functional scores were comparable between RSAs performed to treat shoulder trauma and that performed for arthritis. The overall complication rate was 20.4%, with patients with a preoperative diagnosis of arthritis having significantly more complications than those with a preoperative diagnosis of trauma (34.8% vs. 7.7%).

Conclusions

Patients who underwent RSA due to a proximal humeral fracture or dislocation did not fare worse than those who underwent RSA for arthritis at 1 year, in terms of both functional and radiological outcomes.

Reverse shoulder replacement versus hemiarthroplasty for proximal humeral fracture in elderly patients: a systematic review

This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.

Total shoulder arthroplasty versus reverse total shoulder arthroplasty: Outcome comparison in osteoarthritis patients with or without concurrent rotator cuff deficiency

Osteoarthritis (OA) is a common shoulder disorder that impacts shoulder functions. Shoulder arthroplasty is often required to restore function and quality of life. Reverse total shoulder arthroplasty (RSA), which was originally designed mainly for irreparable rotator cuff damage, has gained popularity in recent years for the treatment of advanced shoulder OA instead of the clinically standard total shoulder arthroplasty (TSA). However, this RSA has some nonnegligible flaws such as higher complications rate and economic cost, not mention the following problems caused by irreversible physical structural damage. Therefore, the employment of RSA needs to be carefully considered. This study aimed to compare TSA and RSA in OA patients with or without rotator cuff damage to better guide clinical decision making. We believe the radical use of RSA in patients without rotator cuff deficiency may cause more harm than good. We queried the Nationwide Inpatient Sample (NIS) database from 2011 to 2014 to collect information on OA patients who received TSA and RSA. Patients were divided into 2 groups of comparison according to the presence of rotator cuff deficiency and matched with propensity score analysis. A total of 57,156 shoulder arthroplasties were identified. RSA patients in the rotator cuff deficiency group had significant higher transfusion rates and longer hospital stays. RSA patients without rotator cuff deficiency had a statistically significantly higher number of implant-related mechanical complications, acute upper respiratory infections and postoperative pain. Overall, RSA incurred higher costs in both groups. For OA patients with rotator cuff deficiencies, RSA has its benefits as complication rates were comparable to TSA. For those patients without rotator cuff deficiencies, the use of RSA should be reconsidered as there were more complications with higher severity.

The painful shoulder arthroplasty: appropriate work-up and review of interventional pain treatments

Shoulder arthroplasty is a successful surgical procedure for several conditions when patients become refractory to conservative management modalities. Unfortunately, some patients experience persistent chronic pain after shoulder arthroplasty. These individuals should undergo a comprehensive evaluation by an orthopedic surgeon to determine whether structural pathology is responsible for the pain and to decide whether reoperation is indicated. At times, a surgical solution does not exist. In these circumstances, a thorough and specific plan for the management of persistent chronic pain should be developed and instituted. In this article, we review common reasons for persistent pain after shoulder arthroplasty and outline the evaluation of the painful shoulder arthroplasty. We then provide a thorough review of interventional pain management strategies. Finally, we hypothesize developments in our field that might provide better outcomes in the future for patients suffering with chronic intractable pain after shoulder arthroplasty.

Use of a locking stem for reverse shoulder arthroplasty is a rare but reliable option

INTRODUCTION

RSA is widely used in the treatment of complex trauma or degenerative changes of the shoulder. Strong primary fixation of the stem is necessary to prevent any loosening of the stem and subsequent revision. Presently, cement fixation or press-fit fixation are two options for humeral fixation, though each has its own limitations and risks. The aim of the current study is to evaluate the effectiveness of an alternative option involving a distal screw interlocking system for fixation of the humeral stem from initial implantation.

METHODS

We performed a retrospective multicenter study of patients implanted with the Humelock Reversed® stem RSA that can be locked with distal humeral screws in cases of operative poor press fit or to modulate the lengthening of the arm via prosthetic humeral height. Seventy-two patients with a minimum two year follow-up were included, 13 for acute trauma, 42 for degenerative changes, and 17 for revision surgery.

RESULTS

No difference was seen in radiological or clinical results for patients with or without interlocking screw primary stabilization. For non-trauma patients, the mean raw Constant score improved significantly from 31 (± 12) to 71 (± 12). For trauma patients, the mean raw Constant score for trauma (63.4) was significantly lower than for non-trauma cases (72.1) (p < 0.001). Analysis of the filling ratio demonstrated that interlocking screws were not used for lower filling ratios and that midterm fixation of the stem is not negatively impacted by distal interlocking screw fixation.

DISCUSSION

Even if use of a distal interlocking screw fixation system is rare, it can be useful for patients with poor quality fixation of stemmed RSA.

CONCLUSION

Use of an interlocking screw system to stabilize the stem in RSA provides good immediate and midterm stability of the implant allowing for clinical and radiological outcomes comparable to those obtained with press-fit fixation alone.

Incidence, radiographic predictors, and clinical outcome of acromial stress reaction and acromial fractures in reverse total shoulder arthroplasty

BACKGROUND

Acromial and scapular spine fractures (ASFs) are known complications following implantation of reverse total shoulder arthroplasty (RTSA). The entity of acromial stress reaction (ASR) without fracture has recently been described. The purpose of this study was to analyze the incidence, radiographic predictors, treatment options, healing rates, and clinical outcomes of ASF and ASR compared with a control group.

METHODS

A total of 854 primary RTSAs were implanted between 2005 and 2018 in a single shoulder unit of a tertiary referral hospital and retrospectively reviewed for the incidence of ASF and ASR. ASR was defined as pain at the acromion or scapular spine after fracture exclusion on computed tomography scans. The ASF group was matched to a control group. Preoperative and postoperative radiographs were analyzed for radiographic predictors of ASF or ASR. The impact of ASF and ASR, operative vs. nonoperative treatment, and fracture union on clinical outcomes (Constant-Murley score [CS], Subjective Shoulder Value [SSV], and range of motion) with a minimum follow-up period of 2 years was analyzed.

RESULTS

A total of 46 ASFs (5.4%) in 44 patients and 44 ASRs (5.2%) in 43 patients were detected at a mean of 16 ± 24 months and 20 ± 23 months postoperatively, respectively. Predictive radiographic factors were an increased critical shoulder angle and lateralization shoulder angle. The overall union rate was 55% (22 of 40) but was significantly higher following operative treatment (9 of 11, 82%) compared with nonoperative treatment (13 of 29, 45%). Patients with ASF or ASR demonstrated inferior clinical outcomes (CS, 44 ± 21 and 48 ± 18; SSV, 52% ± 25% and 57% ± 27%) compared with the control group (CS, 66 ± 14; SSV, 82% ± 22%) independent of bony union or treatment at a mean of 59 ± 33 months (ASF) and 61 ± 38 months (ASR).

CONCLUSION

ASF and ASR are frequent complications following RTSA implantation with similar poor clinical outcome measures. The healing rate was shown to be much higher with a surgical approach. Nevertheless, fracture consolidation does not result in better clinical outcomes compared with nonunion.

Improved Clinical Outcomes After Lateralized Reverse Shoulder Arthroplasty: A Systematic Review

BACKGROUND

Lateralized reverse shoulder arthroplasty (RSA) has emerged as an attempt to improve on some of the drawbacks of conventional RSA, such as glenoid notching and decrease in ROM. Although this new design is being used in clinical practice, the evidence is mostly limited to case series and has not been systematically reviewed.

QUESTIONS/PURPOSES

(1) How much did patient-reported outcome measures (PROMs) and ROM improve among patients who receive a lateralized RSA implant? (2) What proportion of shoulders experience complications, revision surgery, or scapular notching?

METHODS

The PubMed and EMBASE databases were searched from database inception to January 31, 2020. We included clinical studies that reported the PROMs and/or ROM of patients with insufficient rotator cuffs undergoing RSA with a lateralized implant. All other types of studies and those including patients with fractures, instability or escape, infection, rheumatologic disease, neurologic disease, or revision surgeries as an indication for RSA were excluded. PROMs and ROM were collected and are reported as mean values and ranges. Complications, revision surgery, and scapular notching are presented as proportions. The percentage of the mean change relative to the minimum clinically important difference (MCID) was calculated using the anchor-based value for each outcome. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. The initial search yielded 678 studies; 61 full-text articles were analyzed according to our eligibility criteria. After a detailed analysis, we included nine studies that evaluated 1670 patients (68% of whom [1130] were women) with a mean age of 71.8 ± 0.6 years. The mean follow-up period was 41.1 ± 5.6 months. The mean MINORS score was 12 ± 4.

RESULTS

Active ROM improved for forward flexion (mean change 47° to 82°; MCID 12°), abduction (mean change 43° to 80°; MCID 7°), external rotation (mean change 8° to 39°; MCID 3°), and internal rotation (mean change -2 to 1 points). PROM scores also improved, including the American Shoulder and Elbow Surgeons score (mean change 20 to 50; MCID 20.9 points), Constant score (mean change 28 to 40; MCID 5.7 points), Simple Shoulder Test score (mean change 3 to 7; MCID 2.4 points), and VAS score (mean change -1.8 to -4.9; MCID -1.6 points). The proportion of shoulders with complications ranged from 0% (0 of 44) to 21% (30 of 140), and the proportion of shoulders with scapular notching ranged from 0% (0 of 76) to 29% (41 of 140). The proportion of patients undergoing revision ranged from 0% (0 of 44) to 13% (10 of 76) at short-term follow-up.

CONCLUSION

Lateralized RSA is a reasonable alternative to medialized implants for patients with rotator cuff insufficiency because it might reduce the likelihood of scapular notching without apparently compromising PROMs or ROM. More studies are required to determine whether there is a direct correlation between the amount of lateralization and PROMs or ROM.

Stemless reverse total shoulder arthroplasty: a systematic review

BACKGROUND

The use of reverse total shoulder arthroplasty and stemless anatomic total shoulder replacement has been increasing in the United States every year. Stemless humeral components in reverse total shoulder arthroplasty are only approved for clinical trials in the United States with an investigational device exception with limited data.

METHODS

A systematic review on stemless reverse total shoulder arthroplasty was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search was conducted on November 25, 2020, using the MEDLINE/PubMed, Cochrane, and Embase databases. All articles were reviewed by 2 independent evaluators, with any conflicts or issues resolved by consensus or a final decision by the senior author. The primary outcomes extracted were complications, radiographic results, and outcome scores.

RESULTS

We evaluated 10 studies that used either the Total Evolutive Shoulder System (TESS) or Verso implant. There were 430 total patients and 437 total procedures; 266 patients in the TESS group underwent a total of 272 procedures, and 164 patients in the Verso group underwent a total of 165 procedures. The mean age at the time of surgery was 73.8 years (range, 38-93 years). The mean follow-up period ranged from 6.4 to 101.6 months per study. There was an overall trend of improved clinical outcome scores, a 0.2% humeral component loosening rate, and an 11.2% complication rate.

CONCLUSIONS

This review shows that the clinical and functional outcomes following stemless or metaphyseal reverse total shoulder arthroplasty are quite promising, especially with the low rate of humeral-sided complications. There continues to be a need for additional long-term studies and randomized clinical trials.

Patient satisfaction and clinical outcomes of reverse shoulder arthroplasty: a minimum of 10 years' follow-up

BACKGROUND

Reverse shoulder arthroplasty (RSA) has been shown to reliably improve pain and functional outcomes for multiple pathologies. Despite its increasing use in the United States since its introduction in 2004, few studies have investigated long-term outcomes of this procedure. This information is vital in many ways, including durability of functional outcomes, complication profiles, and implant survivorship.

METHODS

Our prospectively collected shoulder arthroplasty registry included 471 patients who had undergone RSA prior to December 31, 2010, by a single surgeon at a high-volume shoulder arthroplasty center. The study sample included 94 patients with a minimum of 10 years' follow-up, and we evaluated the indications for RSA, complications, pain, Single Assessment Numeric Evaluation (SANE), and patient satisfaction on these patients at baseline, 2-5 years, and 10 or more years of follow-up. Prosthesis survivorship was determined by Kaplan-Meier survival analysis performed with revision for any reason as the end point for all 471 patients in the study period regardless of follow-up interval.

RESULTS

The 93 patients with at least 10 years of follow-up were 63% female (60) and 37% male (34), with an average age of 66±10 years at the time of RSA. There were 70 (75%) primary RSAs and 23 (25%) revision RSAs. Patient-reported outcome measures at 10 years or more included a current pain rating averaging 2±3 on a 0-10 scale and Single Assessment Numeric Evaluation (SANE) of 73±28. There was no deterioration in function or pain from midterm to long-term follow-up, as the SANE and pain score changed by less than the minimal clinically important difference or improved in 87% and 90% of patients, respectively. Overall, patients were satisfied with the RSA procedure, with 52 (56%) very satisfied, 24 (26%) satisfied, 13 (14%) dissatisfied, and 4 (4%) very dissatisfied. For the subset of 68 patients who were contacted for follow-up, 64 (94%) would have the procedure again and 4 (6%) would not. Kaplan-Meier prosthesis survival rate for all 471 RSA patients was 88% (95% confidence interval [CI] 84%-92%) at 5 years and 81% (95% CI 74%-86%) at 10 years.

CONCLUSIONS

This study presents the largest American cohort of Grammont design RSA at a minimum 10-year follow-up. Although RSA provided clinically significant and durable improvements in pain and function, the complication and revision rates were higher than prior reports. Despite this, the vast majority of patients were satisfied and would have the procedure again.

Incidence, Risk Factors, Prevention, and Management of Peripheral Nerve Injuries Following Shoulder Arthroplasty

In this article, the authors review the incidence and causes of iatrogenic peripheral nerve injuries following shoulder arthroplasty and provide preventative measures to decrease nerve injury rate and management options. They describe common direct and indirect causes of injury such as laceration and retractor use versus arm positioning and lengthening, respectively. Preventative measures include an understanding of anatomy and high-risk locations in the shoulder, minimizing extreme ranges of arm motion and utilization of intraoperative nerve monitoring. Lastly, the authors review diagnosis and management of neurologic symptoms including how and when to use electrodiagnostic studies, nerve grafts, transfers, or muscle/tendon transfers.