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de Geofroy B, Micicoi G, Olmos M, Boileau P, Bronsard N, Gonzalez JF, Gauci MO. Early morbidity and mortality after one-stage bilateral shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2024; 48:505-511. [PMID: 37853140 DOI: 10.1007/s00264-023-06003-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high. METHODS A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders. RESULTS There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction. CONCLUSIONS One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation.
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Affiliation(s)
- Bernard de Geofroy
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Grégoire Micicoi
- Department of Orthopaedic Surgery and Sport Surgery, University Institute of Locomotion and Sport, University Hospital of Nice, 30 Av Voie Romaine, 06000 Cedex 1, Nice, CS, France
| | - Manuel Olmos
- Department of Orthopaedic Surgery and Sport Surgery, University Institute of Locomotion and Sport, University Hospital of Nice, 30 Av Voie Romaine, 06000 Cedex 1, Nice, CS, France
| | - Pascal Boileau
- Institut de Chirurgie Réparatrice, Groupe Kantys, Locomoteur & Sport, Clinique St Antoine7 Av Durante, 06000, Nice, France
| | - Nicolas Bronsard
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Jean-François Gonzalez
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Marc Olivier Gauci
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France.
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Girdler SJ, Maza N, Lieber AM, Vervaecke A, Kodali H, Zubizarreta N, Poeran J, Cagle PJ, Galatz LM. Impact of Surgeon Case Volume on Outcomes After Reverse Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2023; 31:1228-1235. [PMID: 37831947 DOI: 10.5435/jaaos-d-23-00181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/01/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Despite a rapid increase in utilization of reverse total shoulder arthroplasty (rTSA), volume-outcome studies focusing on surgeon volume are lacking. Surgeon-specific volume-outcome studies may inform policymakers and provide insight into learning curves and measures of efficiency with greater case volume. METHODS This retrospective cohort study with longitudinal data included all rTSA cases as recorded in the Centers for Medicare & Medicaid Services Limited Data Set (2016 to 2018). The main effect was surgeon volume; this was categorized using two measures of surgeon volume: (1) rTSA case volume and (2) rTSA + TSA case volume. Volume cutoff values were calculated by applying a stratum-specific likelihood ratio analysis. RESULTS Among 90,318 rTSA cases performed by 7,097 surgeons, we found a mean annual rTSA surgeon volume of 6 ± 10 and a mean rTSA + TSA volume of 9 ± 14. Regression models using surgeon-specific rTSA volume revealed that surgery from low (<29 cases) compared with medium (29 to 96 cases) rTSA-volume surgeons was associated with a significantly higher 90-day all-cause readmission (odds ratio [OR], 1.17; confidence interval [CI], 1.10 to 1.25; P < 0.0001), higher 90-day readmission rates because of an infection (OR, 1.46; CI, 1.16 to 1.83; P = 0.0013) or dislocation (OR, 1.43; CI, 1.19 to 1.72; P = 0.0001), increased 90-day postoperative cost (+11.3% CI, 4.2% to 19.0%; P = 0.0016), and a higher transfusion rate (OR, 2.06; CI, 1.70 to 2.50; P < 0.0001). Similar patterns existed when using categorizations based on rTSA + TSA case volume. CONCLUSION Surgeon-specific volume-outcome relationships exist in this rTSA cohort, and we were able to identify thresholds that may identify low and medium/high volume surgeons. Observed volume-outcome relationships were independent of the definition of surgeon volume applied: either by focusing on the number of rTSAs performed per surgeon or anatomic TSAs performed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Steven J Girdler
- From the Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY
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Avendano JP, Sudah SY, Gencarelli P, Imam N, Manzi JE, Ghajar M, Menendez ME, Nicholson AD. The learning curve for anatomic and reverse total shoulder arthroplasty: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:150-159. [PMID: 37588447 PMCID: PMC10426533 DOI: 10.1016/j.xrrt.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- John P. Avendano
- Department of Orthopedics, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Suleiman Y. Sudah
- Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ, USA
| | - Pasquale Gencarelli
- Department of Orthopedics, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Nareena Imam
- Department of Orthopedics, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Mina Ghajar
- Rutgers University Libraries, New Brunswick, NJ, USA
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How common is nerve injury after reverse shoulder arthroplasty? A systematic review. J Shoulder Elbow Surg 2023; 32:872-884. [PMID: 36427756 DOI: 10.1016/j.jse.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 11/25/2022]
Abstract
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.
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Swindell HW, deMeireles AJ, Zhong JR, Bixby EC, Saltzman BM, Jobin CM, Levine WN, Trofa DP. Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopedic Shoulder Arthroplasty: A Matched - Pair Analysis. Shoulder Elbow 2023; 15:151-158. [PMID: 37035610 PMCID: PMC10078817 DOI: 10.1177/17585732211065444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022]
Abstract
Background There is minimal work defining the economic impact of resident participation in shoulder arthroplasty. Thus, this study quantified the opportunity cost of resident participation in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) by determining differences in operative time, relative value units (RVUs)/hour, and RVUs/case. Methods A retrospective analysis of shoulder arthroplasty procedures were identified from the ACS-NSQIP database from 2006 to 2014 using CPT codes. Demographic, comorbidity, preoperative laboratory data and surgical procedure were used to develop matched cohorts. Mean differences in operative time, RVUs/case and RVUs/hour between attending-only (AO) cases and cases with resident involvement (RI) were examined. Cost analysis was performed to identify differences in RVUs generated per hour in dollars/case. Results A total of 1786 AO and 1102 RI cases were identified. With the exception of PGY-3 and PGY-4 cases, RI cases had lower mean operative times compared to AO cases. The cost of RI was highest for PGY-3 ($199.87 per case) and PGY-4 ($9 .2 9) residents with all other postgraduate years providing a cost reduction. Discussion Involvement of residents was associated with shorter operative times leading to a savings of $29.64 per case. Involvement of intermediate-level (PGY-3) residents were associated with increased costs that ultimately decreased as residents became more senior.
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Affiliation(s)
- Hasani W Swindell
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alirio J deMeireles
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - Jack R Zhong
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - Elise C Bixby
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - Bryan M Saltzman
- Department of Orthopedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Charles M Jobin
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
| | - David P Trofa
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, NY, USA
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Zhou Y, Frampton C, Hirner M. Medium-term results of stemless, short, and conventional stem humeral components in anatomic total shoulder arthroplasty: a New Zealand Joint Registry study. J Shoulder Elbow Surg 2022; 32:1001-1008. [PMID: 36473693 DOI: 10.1016/j.jse.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of this study was to compare the medium-term results for anatomic total shoulder arthroplasty by humeral component stem length. We hypothesize that the newer stemless implants may have comparable results to short-stem and conventional stemmed implants. METHODS The 12 most used anatomic total shoulder arthroplasty implants on the New Zealand Joint Registry were included in the study. Implants were categorized by stem length-conventional, short, and stemless. The primary outcome was revision up to 7 years postsurgery. Secondary outcomes included revision cause, implant survival, and early functional outcomes as evaluated by the Oxford Shoulder Score. Analysis was stratified by age and surgeon volume to control for potential confounding. RESULTS A total of 3952 patients (conventional, 3114; short, 360; stemless, 478) were included in the study. No significant difference in revision rate per 100 component-years was found between stemless, short-stem, and conventional stemmed implants (revision rate per 100 component-years: conventional, 1.01 [95% confidence interval (CI) 0.89-1.14]; short, 0.54 [95% CI 0.25-1.03]; stemless, 0.99 [95% CI 0.51-1.74]). This finding was irrespective of patient age or surgeon volume. There were no cases of humeral loosening up to 7 years' follow-up and no cases of intraoperative humeral fracture in the stemless group. Functional outcomes at 6 months postsurgery suggested better outcomes in the stemless group compared with the conventional stem group (mean Oxford Shoulder Score: conventional, 39.4; stemless, 40.7; P value = .023). CONCLUSION The medium-term survival of stemless implants for anatomic total shoulder arthroplasty appears comparable to short-stem and conventional stemmed implants. Further follow-up is required to understand the long-term survivorship and functional outcomes between these groups.
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Affiliation(s)
- Yushy Zhou
- Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia; Department of Orthopaedic Surgery, Whangarei Hospital, Whangarei, New Zealand.
| | - Chris Frampton
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Marc Hirner
- Department of Orthopaedic Surgery, Whangarei Hospital, Whangarei, New Zealand
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Calkins TE, Baessler AM, Throckmorton TW, Black C, Bernholt DL, Azar FM, Brolin TJ. Safety and short-term outcomes of anatomic vs. reverse total shoulder arthroplasty in an ambulatory surgery center. J Shoulder Elbow Surg 2022; 31:2497-2505. [PMID: 35718256 DOI: 10.1016/j.jse.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/26/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone. METHODS Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone. RESULTS Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001). CONCLUSION Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.
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Affiliation(s)
- Tyler E Calkins
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Aaron M Baessler
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Carson Black
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Dolci A, Melis B, Verona M, Capone A, Marongiu G. Complications and Intraoperative Fractures in Reverse Shoulder Arthroplasty: A Systematic Review. Geriatr Orthop Surg Rehabil 2021; 12:21514593211059865. [PMID: 34900387 PMCID: PMC8664304 DOI: 10.1177/21514593211059865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/14/2021] [Accepted: 10/21/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction The reverse shoulder arthroplasty is nowadays a treatment option for a variety of shoulder problems. As its incidence rose, also the number of complications increased, including intraoperative fractures. Significance We performed a systematic review and critical analysis of the current literature following the PRISMA guidelines. Our purpose was to: 1) determine incidence, causes, and characteristics of intraoperative fractures; 2) evaluate their current treatment options, possible related complications, reoperation rates, and the patients’ outcome; and 3) determine the overall incidence of each complication related to reverse shoulder arthroplasty. The articles were selected from PubMed medical database in April 2020 using a comprehensive search strategy. Rayyan software was used to support the selection process of the records. A descriptive and critical analysis of the results was performed. Results The study group included a total of 13,513 reverse shoulder arthroplasty procedures. The total number of complications was 1647 (rate 12.1%). The most common complication was dislocation (340 cases, rate 2.5%). Forty-six studies reported a total of 188 intraoperative fractures among the complications (rate 1.4%). The intraoperative fracture rate was 2.9% and 13.6% in primary and revision settings, respectively. There were 136 humeral fractures, 60% of them occurred in revision RSAs, during the removal of the previous implant, and involved the shaft in the majority of cases (39%). Glenoid fractures were 51 and occurred mostly during the reaming of the glenoid. We observed 7 further related complications (rate of 4%) and 3 reoperations (rate of 1.5%). The outcome was satisfactory in the majority of cases. Conclusions A comprehensive review on intraoperative fractures in reverse shoulder arthroplasties is presented. Results suggest favorable outcomes for all treatment methods, with a modest further complication rate. This investigation may aid in the treatment decision-making for these complications.
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Affiliation(s)
- Andrea Dolci
- Department of Surgical Sciences, Orthopaedic and Trauma Clinic, Policlinico Universitario D. Casula, University of Cagliari, Monserrato, Cagliari, Italy
| | - Barbara Melis
- Orthopaedic and Sport Trauma Unit, Casa di Cura Policlinico Città di Quartu, Quartu Sant'Elena, Italy
| | - Marco Verona
- Department of Surgical Sciences, Orthopaedic and Trauma Clinic, Policlinico Universitario D. Casula, University of Cagliari, Monserrato, Cagliari, Italy
| | - Antonio Capone
- Department of Surgical Sciences, Orthopaedic and Trauma Clinic, Policlinico Universitario D. Casula, University of Cagliari, Monserrato, Cagliari, Italy
| | - Giuseppe Marongiu
- Department of Surgical Sciences, Orthopaedic and Trauma Clinic, Policlinico Universitario D. Casula, University of Cagliari, Monserrato, Cagliari, Italy
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Gill DRJ, Page BMedSci RS, Graves SE, Rainbird S, Hatton A. A Comparison of Revision Rates for Osteoarthritis of Primary Reverse Total Shoulder Arthroplasty to Primary Anatomic Shoulder Arthroplasty with a Cemented All-polyethylene Glenoid: Analysis from the Australian Orthopaedic Association National Joint Replacement Registry. Clin Orthop Relat Res 2021; 479:2216-2224. [PMID: 34180871 PMCID: PMC8445579 DOI: 10.1097/corr.0000000000001869] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/03/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been decreased use of anatomic total shoulder arthroplasty (aTSA) because reverse TSA (rTSA) is increasingly being used for the same indications. Although short-term studies generally have not found survivorship differences between these implant designs, these studies are often small and their follow-up is limited to the short term. Likewise, the degree to which patient characteristics (such as gender, age, and American Society of Anesthesiologists [ASA] score) may or may not be associated with survivorship differences calls for larger and longer-term studies than is often possible in single-center designs. Large national registry studies may be able to help answer these questions. QUESTIONS/PURPOSES By analyzing a large Australian registry series of primary aTSAs with cemented all-polyethylene glenoids and rTSA for osteoarthritis (OA), we asked: (1) Is the revision risk for OA higher for aTSA with all-polyethylene glenoids or for rTSA, adjusting for patient characteristics such as age, gender, ASA score, and BMI? (2) Is the patient's gender associated with differences in the revision risk after controlling for the potentially confounding factors of age, ASA score, and BMI? METHODS In this comparative, observational registry study performed between January 1, 2015, and December 31, 2019, all primary aTSAs with all-polyethylene glenoids and rTSA for OA as determined by the treating surgeon and reported to our national registry formed two groups for analysis. The study period was set to time-match for the collection of ASA score and BMI in 2012 and 2015, respectively. Our registry enrolls more than 97% of all shoulder arthroplasties undertaken in Australia. There were 29,294 primary shoulder arthroplasties; 1592 hemiarthroplasties, 1876 resurfacing and stemless shoulders, 269 stemmed, and 11,674 reverse shoulder arthroplasties were excluded for other diagnoses. A total of 1210 metal-backed glenoids in stemmed aTSA for OA were excluded. A total of 3795 primary aTSAs with all-polyethylene glenoids and 8878 primary rTSAs for OA were compared. An aTSA with an all-polyethylene glenoid and rTSA were more likely to be performed in women (56% and 61% of patients, respectively). The mean age was 69 ± 8 years for aTSA with all-polyethylene glenoids and 74 ± 8 years for rTSA. One aTSA for OA was performed in a patient with an unknown glenoid type. The ASA score (n = 12,438) and BMI (n = 11,233) were also recorded. The maximum follow-up was 5 years for both groups, and the mean follow-up was 2.6 ± 1.4 years for aTSA with all-polyethylene glenoids and 2.1 ± 1.4 years for rTSA. The endpoint was time to revision (all causes), and the cumulative percent revision was determined using Kaplan-Meier estimates of survivorship (time to revision) and HRs from Cox proportional hazard models that were adjusted for age, gender, ASA score, and BMI category. RESULTS Overall, there were no differences in the 4-year cumulative percent revision between the groups; the 4-year cumulative percent revision was 3.5% for aTSA with all-polyethylene glenoids (95% CI 2.9%-4.2%) and 3.0% for rTSA (95% CI 2.6%-3.5%). There was an increased risk of revision of rTSA compared with aTSA using all-polyethylene glenoids in the first 3 months (HR 2.17 [95% CI 1.25-3.70]; p = 0.006, adjusted for age, gender, ASA score, and BMI). After that time, there was no difference in the rate of revision, with the same adjustments. In the first 3 months, men undergoing rTSA had a higher rate of revision than men with aTSA using all-polyethylene glenoids (HR 4.0 [95% CI 1.72-9.09]; p = 0.001, adjusted for age, BMI, and ASA). There was no difference between men in the two groups after that time. Women with aTSA using all-polyethylene glenoids were at a greater risk of revision than women with rTSA from 3 months onward (HR 2.77 [95% CI 1.55-4.92]; p < 0.001, adjusted for age, BMI, and ASA), with no difference before that time. CONCLUSION Given the absence of survivorship differences at 4 years between rTSA and aTSA, but in light of the differences in the revision risk between men and women, surgeons might select an aTSA with an all-polyethylene glenoid to treat OA, despite the current popularity of rTSA. However, there are survivorship differences between genders. Future studies should evaluate whether our comparative findings are replicated in men and women undergoing aTSA with all-polyethylene glenoids and rTSA for primary diagnoses such as rheumatoid arthritis or post-traumatic arthritis, and whether there are functional differences between the two implant designs when used for OA. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | - Richard S. Page BMedSci
- Barwon Centre of Orthopaedic Research and Education, Deakin University, Geelong, Australia
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Stephen E. Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Sophia Rainbird
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Alesha Hatton
- South Australia Health and Medical Research Institute, Adelaide, Australia
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Godlewski M, Knudsen ML, Braman JP, Harrison AK. Perioperative Management in Reverse Total Shoulder Arthroplasty. Curr Rev Musculoskelet Med 2021; 14:282-290. [PMID: 34414560 PMCID: PMC8390714 DOI: 10.1007/s12178-021-09709-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW A successful reverse total shoulder arthroplasty requires careful preoperative planning and perioperative management. Preoperative comorbidity risks, perioperative pain management, and postoperative rehabilitation are all critical components of this arthroplasty. The current review examines available literature to guide the perioperative care of the reverse total shoulder arthroplasty patient. RECENT FINDINGS One of the most important advances for shoulder arthroplasty in recent years has been heightened awareness of various modalities for perioperative pain management. A number of recent studies have focused on the options for regional blockade as a critical tool for postoperative pain relief and the use of either continuous interscalene blocks or single shot blocks are supported. Additional studies are necessary to define the best local anesthetic agent and delivery mechanism to provide appropriate pain relief with a low side effect profile. Management of the patient throughout the perioperative course is a critical component in achieving better patient outcomes delivering high quality patient care. An orthopedic surgery team focused on perioperative management is better positioned to decrease adverse events and improve patient outcomes after reverse total shoulder arthroplasty.
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Affiliation(s)
- Matthew Godlewski
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MIN USA
| | - Michael L Knudsen
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MIN USA
| | - Jonathan P Braman
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MIN USA
| | - Alicia K Harrison
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MIN USA
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11
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Lohre R, Bois AJ, Pollock JW, Lapner P, McIlquham K, Athwal GS, Goel DP. Effectiveness of Immersive Virtual Reality on Orthopedic Surgical Skills and Knowledge Acquisition Among Senior Surgical Residents: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2031217. [PMID: 33369660 PMCID: PMC7770558 DOI: 10.1001/jamanetworkopen.2020.31217] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Video learning prior to surgery is common practice for trainees and surgeons, and immersive virtual reality (IVR) simulators are of increasing interest for surgical training. The training effectiveness of IVR compared with video training in complex skill acquisition should be studied. OBJECTIVES To evaluate whether IVR improves learning effectiveness for surgical trainees and to validate a VR rating scale through correlation to real-world performance. DESIGN, SETTING, AND PARTICIPANTS This block randomized, intervention-controlled clinical trial included senior (ie, postgraduate year 4 and 5) orthopedic surgery residents from multiple institutions in Canada during a single training course. An intention-to-treat analysis was performed. Data were collected from January 30 to February 1, 2020. INTERVENTION An IVR training platform providing a case-based module for reverse shoulder arthroplasty (RSA) for advanced rotator cuff tear arthropathy. Participants were permitted to repeat the module indefinitely. MAIN OUTCOMES AND MEASURES The primary outcome measure was a validated performance metric for both the intervention and control groups (Objective Structured Assessment of Technical Skills [OSATS]). Secondary measures included transfer of training (ToT), transfer effectiveness ratio (TER), and cost-effectiveness (CER) ratios of IVR training compared with control. Additional secondary measures included IVR performance metrics measured on a novel rating scale compared with real-world performance. RESULTS A total of 18 senior surgical residents participated; 9 (50%) were randomized to the IVR group and 9 (50%) to the control group. Participant demographic characteristics were not different for age (mean [SD] age: IVR group, 31.1 [2.8] years; control group, 31.0 [2.7] years), gender (IVR group, 8 [89%] men; control group, 6 [67%] men), surgical experience (mean [SD] experience with RSA: IVR group, 3.3 [0.9]; control group, 3.2 [0.4]), or prior simulator use (had experience: IVR group 6 [67%]; control group, 4 [44%]). The IVR group completed training 387% faster considering a single repetition (mean [SD] time for IVR group: 4.1 [2.5] minutes; mean [SD] time for control group: 16.1 [2.6] minutes; difference, 12.0 minutes; 95% CI, 8.8-14.0 minutes; P < .001). The IVR group had significantly better mean (SD) OSATS scores than the control group (15.9 [2.5] vs 9.4 [3.2]; difference, 6.9; 95% CI, 3.3-9.7; P < .001). The IVR group also demonstrated higher mean (SD) verbal questioning scores (4.1 [1.0] vs 2.2 [1.7]; difference, 1.9; 95% CI, 0.1-3.3; P = .03). The IVR score (ie, Precision Score) had a strong correlation to real-world OSATS scores (r = 0.74) and final implant position (r = 0.73). The ToT was 59.4%, based on the OSATS score. The TER was 0.79, and the system was 34 times more cost-effective than control, based on CER. CONCLUSIONS AND RELEVANCE In this study, surgical training with IVR demonstrated superior learning efficiency, knowledge, and skill transfer. The TER of 0.79 substituted for 47.4 minutes of operating room time when IVR was used for 60 minutes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04404010.
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Affiliation(s)
- Ryan Lohre
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Aaron J. Bois
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - J. W. Pollock
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Lapner
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Katie McIlquham
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - George S. Athwal
- Roth McFarlane Hand and Upper Limb Center, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Canadian Shoulder Elbow Society, Canadian Orthopaedic Association, Westmount, Quebec, Canada
| | - Danny P. Goel
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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12
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Shah SS, Roche AM, Sullivan SW, Gaal BT, Dalton S, Sharma A, King JJ, Grawe BM, Namdari S, Lawler M, Helmkamp J, Garrigues GE, Wright TW, Schoch BS, Flik K, Otto RJ, Jones R, Jawa A, McCann P, Abboud J, Horneff G, Ross G, Friedman R, Ricchetti ET, Boardman D, Tashjian RZ, Gulotta LV. The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II. JSES Int 2020; 5:121-137. [PMID: 33554177 PMCID: PMC7846704 DOI: 10.1016/j.jseint.2020.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous. Methods Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests. Results The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%. Conclusions Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.
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Affiliation(s)
- Sarav S. Shah
- American Shoulder and Elbow Surgeons (ASES) Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
- Corresponding author: Sarav S. Shah, MD, 125 Parker Hill Ave, Boston, MA 02120, USA.
| | | | | | - Benjamin T. Gaal
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Stewart Dalton
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Arjun Sharma
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Joseph J. King
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Brian M. Grawe
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Surena Namdari
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Macy Lawler
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Joshua Helmkamp
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | | | - Thomas W. Wright
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | | | - Kyle Flik
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Randall J. Otto
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Richard Jones
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Andrew Jawa
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Peter McCann
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Joseph Abboud
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Gabe Horneff
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Glen Ross
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Richard Friedman
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | | | - Douglas Boardman
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
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13
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Farley KX, Schwartz AM, Boden SH, Daly CA, Gottschalk MB, Wagner ER. Defining the Volume-Outcome Relationship in Reverse Shoulder Arthroplasty: A Nationwide Analysis. J Bone Joint Surg Am 2020; 102:388-396. [PMID: 31977820 DOI: 10.2106/jbjs.19.01012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As the utilization of reverse total shoulder arthroplasty (RSA) grows, it is increasingly important to examine the relationship between hospital volume and RSA outcomes. We hypothesized that hospitals that perform a higher volume of RSAs would have improved outcomes. We also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA. METHODS The Nationwide Readmissions Database was queried for patients who had undergone elective RSA from 2011 to 2015. Annual hospital volume and 90-day outcome data were collected, including readmission, revision, complications, hospital length of stay (LOS), supramedian cost, and discharge disposition. SSLR analysis was performed to determine hospital volume cutoffs associated with increased risks for adverse events. Cutoffs generated through SSLR analysis were confirmed via binomial logistic regression. RESULTS The proportion of patients receiving care at high-volume centers increased from 2011 to 2015. SSLR analysis produced hospital volume cutoffs for each outcome, with higher-volume centers showing improved outcomes. The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year, whereas cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year. SSLR analysis of 90-day readmission produced 3 hospital volume categories (1 to 16, 17 to 69, and ≥70 RSAs/year), each significantly different from each other. These were similar to the strata for 90-day revision (1 to 16, 17 to 53, and ≥54 RSAs/year) and 90-day complications (1 to 9, 10 to 68, and ≥69 RSAs/year). SSLR analysis produced 6 hospital volume categories for cost of care over the median value (1 to 5, 6 to 25, 26 to 47, 48 to 71, 72 to 105, and ≥106 RSAs/year), 5 categories for an extended LOS (1 to 10, 11 to 25, 26 to 59, 60 to 105, and ≥106 RSAs/year), and 4 categories for non-home discharge (1 to 31, 32 to 71, 72 to 105, and ≥106 RSAs/year). CONCLUSIONS We have defined hospital surgical volumes that maximize outcomes after RSA, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways. This information may be used in future policy decisions to consolidate complex procedures, such as RSA, at high-volume destinations, or to encourage lower-volume institutions to strategize an approach to function as a higher-volume center. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kevin X Farley
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
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Whitham RDJ, Clifford ZJ, Tasker AJB, Woods DA. Rib fracture as a complication of erroneous baseplate and inferior screw placement in reverse total shoulder replacement: a case report. J Shoulder Elbow Surg 2020; 29:e87-e92. [PMID: 32067713 DOI: 10.1016/j.jse.2019.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 11/07/2019] [Accepted: 11/16/2019] [Indexed: 02/01/2023]
Affiliation(s)
- Robert D J Whitham
- Department of Trauma and Orthopaedics, Great Western Hospital, Swindon, UK.
| | - Zoë J Clifford
- Department of Trauma and Orthopaedics, Great Western Hospital, Swindon, UK
| | - Andrew J B Tasker
- Department of Trauma and Orthopaedics, Great Western Hospital, Swindon, UK
| | - David A Woods
- Department of Trauma and Orthopaedics, Great Western Hospital, Swindon, UK
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