Outcomes and Costs of Reverse Shoulder Arthroplasty in the Morbidly Obese: A Case Control Study

Preventing Infections in Reverse Shoulder Arthroplasty

PURPOSE OF REVIEW

Reverse shoulder arthroplasty (rTSA) is a commonly performed procedure to treat degenerative conditions of the shoulder. With its growing utilization, techniques to reliably diagnose and treat prosthetic joint infection (PJI) have become increasingly important. In this review we outline the current research and prevention methods of prosthetic joint infection in rTSA. This includes preoperative considerations, intraoperative, and postoperative treatment algorithms.

RECENT FINDINGS

There is currently no established standardized protocol for preoperative infection prevention or post operative management. However, recent studies have identified risk factors for infection, as well as successful prevention techniques that can be implemented to minimize infection risk. Although there is no standardized protocol currently utilized to diagnose and treat shoulder PJI, we outline a potential set of preventative measures and postoperative management strategies that clinicians can use to properly diagnose and treat patients with this difficult condition.

Association between radiographic soft-tissue thickness and increased length of stay, operative time, and infection rate after reverse shoulder arthroplasty

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a widely performed surgical procedure to address various shoulder pathologies. Several studies have suggested that radiographic soft-tissue thickness may play a role in predicting complications after orthopedic surgery, but there have been limited studies determining the use of radiographic soft-tissue thickness in RSA. The purpose of this study was to evaluate whether radiographic soft-tissue thickness could predict clinical outcomes after RSA and compare the predictive capabilities against body mass index (BMI). We hypothesized that increased radiographic shoulder soft-tissue thickness would be a strong predictor of operative time, length of stay (LOS), and infection in elective RSA.

MATERIAL AND METHODS

A retrospective review of patients undergoing RSA at an academic institution was conducted. Preoperative radiographic images were evaluated including measurements of the radius from the humeral head center to the skin (HS), deltoid radius-to-humeral head radius ratio (DHR), deltoid size, and subcutaneous tissue size. Different correlation coefficients were used to analyze various types of relationships, and the strength of these associations was classified based on predefined boundaries. Subsequently, multivariable linear and logistic regressions were performed to determine whether HS, DHR, deltoid size, and subcutaneous tissue size could predict LOS, operative time, or infection while controlling for patient factors.

RESULTS

HS was the most influential factor in predicting both operative time and LOS after RSA, with strong associations indicated by standardized β coefficients of 0.234 for operative time and 0.432 for LOS. Subcutaneous tissue size, deltoid size, and DHR also showed stronger predictive values than BMI for both outcomes. In terms of prosthetic joint infection, HS, deltoid size, and DHR were significant predictors, with HS demonstrating the highest predictive power (Nagelkerke R2 = 0.44), whereas BMI did not show a statistically significant association with infection. Low event counts resulted in wide confidence intervals for odds ratios in the infection analysis.

CONCLUSION

Greater shoulder soft-tissue thickness as measured with concentric circles on radiographs is a strong predictor of operative time, LOS, and postoperative infection in elective primary RSA patients.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Effects of increased body mass index on one year outcomes following soft tissue arthroscopic shoulder instability repair

Background

The purpose of this study was to investigate the impact of high body mass index on the 1-year minimal outcome following arthroscopic shoulder stabilization.

Methods

Patients who underwent arthroscopic Bankart repair (ABR) between 2017 and 2021 were identified and assigned to 1 of 3 cohorts based on their preoperative body mass index: normal (18-25), overweight (25-30), and obese (>30). The primary outcomes assessed were postoperative shoulder instability and revision rates. The 3 groups were compared using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, pain intensity, Clinical Global Impression scores, visual analog scale pain scores, and shoulder range of motion at 1 year postoperatively.

Results

During the study period, 142 patients underwent ABR and had an average age of 35 ± 10 years. Obese patients had a higher percentage of partial rotator cuff tears (60% vs. 27%, odds ratio: 3.2 [1.1, 9.2]; P = .009), longer mean operative time (99.8 ± 40.0 vs. 75.7 ± 28.5 minutes; P < .001), and shorter time to complication (0.5 ± 0 vs. 7.0 ± 0 months; P = .038). After controlling for confounding factors, obesity was associated with a lesser improvement in upper extremity function scores (obese vs. normal: -4.9 [-9.4, -0.5]; P = .029); although this difference exists, found future studies are needed to determine the clinical significance. There were no differences in patient reported outcome measures, recurrence rate, or revision surgery rates between cohorts at any time point (P > .05).

Conclusion

Obesity is an independent risk factor for longer operative times but does not confer a higher risk of recurrent instability, revision surgery, or lower outcome scores 1 year following ABR.

Introducing A Day-Case Shoulder Arthroplasty Pathway In The UK - How We Did It

Background

As the demand for elective orthopaedics grows, day-case arthroplasty is gaining popularity. The aim of this study was to create a safe and reproducible pathway for day-case shoulder arthroplasty (DCSA) based upon a literature review and discussion with the local multidisciplinary team (MDT).

Methods

A literature review was performed using OVID MEDLINE and Embase databases reporting 90-day complication and admission rates following DCSA. Minimum follow-up was 30 days. Day-case was defined as discharge on the same day of surgery.

Results

The literature review revealed a mean 90-day complication rate of 7.7% [range, 0-15.9%] and mean 90-day readmission rate of 2.5% [range 0-9.3%]. A pilot protocol was devised based upon the literature review and consisted of 5 phases: (1) pre-operative assessment, (2) intra-operative phase, (3) post-operative phase, (4) follow-up, and (5) readmission protocol. This was presented, discussed, amended, and ultimately ratified by the local MDT. In May 2021 the unit successfully completed its first day-case shoulder arthroplasty.

Discussion

This study proposes a safe and reproducible pathway for DCSA. Patient selection, well-defined protocols and communication within the MDT are important factors to achieve this. Further studies with extended follow-up will be needed to gauge long-term success within our unit.

Similar Value Demonstrated in the Short-Term Outcomes of Superior Capsular Reconstruction and Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears

Purpose

The purposes of this study were to investigate the difference in value (benefit to cost ratio) of dermal allograft superior capsular reconstruction (SCR) versus reverse total shoulder arthroplasty (rTSA) for the treatment of massive rotator cuff tears (MRCTs) without arthritis; to compare the patient populations selected for the operations and report pre- and postoperative functional data; and to understand other characteristics of the 2 operations, including operating time, use of institutional resources, and complications.

Methods

A retrospective, single-institution analysis during the study period 2014-2019 with MRCT treated with SCR or rTSA by 2 surgeons with complete institutional cost data and minimum 1-year clinical follow-up with American Shoulder and Elbow Surgeons (ASES) score. Value was defined as ΔASES/(total direct costs/$10,000).

Results

Thirty patients underwent rTSA and 126 patients SCR during the study period with significant differences noted in patient demographics and tear characteristics between the groups (patients who underwent rTSA were older, less male, had more pseudoparalysis, had greater Hamada and Goutallier scores, and had more proximal humeral migration). Value was 25 and 29 (ΔASES/$10,000) for rTSA and SCR, respectively (P = .7). The total costs of rTSA and SCR were $16,337 and $12,763, respectively (P = .7). Both groups experienced substantial improvements in ASES scores: 42 for rTSA vs 37 for SCR (P = .6). The operative time for SCR was much longer (204 vs 108 minutes, P < .001) but complication rate lower (3% vs 13%, P = .02) versus rTSA.

Conclusions

In a single institutional analysis of the treatment of MRCT without arthritis, rTSA and SCR demonstrated similar value; however, the value calculation is highly dependent on institution specific variables and duration of follow-up. The operating surgeons demonstrated different indications in selecting patients for each operation. rTSA had an advantage over SCR in shorter operative time, whereas SCR demonstrated a lower complication rate. Both SCR and rTSA are demonstrated to be effective treatments for MRCT at short-term follow-up.

Level of Evidence

III, retrospective comparative study.

Outcomes and complications of primary reverse shoulder arthroplasty with minimum of 2 years' follow-up: a systematic review and meta-analysis

BACKGROUND

Primary reverse shoulder arthroplasty (rTSA) is an effective treatment option for reducing pain and improving function for patients with rotator cuff tear arthropathy, irreparable rotator cuff tears, glenoid deformity, and other challenging clinical scenarios, including fracture sequelae and revision shoulder arthroplasty. There has been a wide range of reported outcomes and postoperative complication rates reported in the literature. The purpose of this systematic review and meta-analysis is to provide an updated review of the clinical outcomes and complication rates following primary rTSA.

METHODS

A systematic review and meta-analysis was performed to evaluate outcomes and complications following primary rTSA according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Demographics, range of motion, patient-reported outcome measures (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant scores), number of complications, and revisions were extracted, recorded, and analyzed from the included articles.

RESULTS

Of the 1415 studies screened, 52 studies met the inclusion criteria comprising a total of 5824 shoulders. The mean age at the time of surgery was 72 years (range: 34-93), and the mean follow-up was 3.9 years (range: 2-16). Patients demonstrated a mean improvement of 56° in active flexion, 50° in active abduction, and 14° in active external rotation. Regarding functional outcome scores, rTSA patients demonstrated a mean clinically significant improvement of 37 in Constant score (minimal clinically important difference [MCID] = 5.7) and ASES score (42.0; MCID = 13.6). The overall complication rate for rTSA was 9.4% and revision rate of 2.6%. Complications were further subdivided into major medical complications (0.07%), shoulder- or surgical-related complications (5.3%), and infections (1.2%). The most frequently reported shoulder- or surgical-related complications were scapular notching (14.4%), periprosthetic fracture (0.8%), glenoid loosening (0.7%), and prosthetic dislocation (0.7%).

DISCUSSION

Primary rTSA is a safe and reliable procedure with low complication, revision, infection, and scapular notching rates. Additionally, patients demonstrated clinically significant improvements in both range of motion and clinical outcome scores.

Influence of medical comorbidity and surgical indication on total elbow arthroplasty cost of care

BACKGROUND

Movement toward providing value-based musculoskeletal care requires understanding the cost associated with surgical care as well as the drivers of these costs. The aim of this study was to investigate the effect of common medical comorbidities and specific total elbow arthroplasty (TEA) indications on reimbursement costs throughout the 90-day TEA episode of care. The secondary aim was to identify the drivers of these costs.

METHODS

Administrative health claims for patients who underwent orthopedic intervention between 2010 and 2020 were queried using specific disease classification and procedural terminology codes from a commercially available national database of 53 million patients. Patients with commercial insurance were divided into various cohorts determined by different surgical indications and medical comorbidities. The reimbursement costs of the surgical encounter, 89-day postoperative period, and total 90-day period in each cohort were evaluated. The cost drivers for the 89-day postoperative period were also determined. Analyses were performed using descriptive statistics and the Kruskal-Wallis test for comparison.

RESULTS

A total of 378 patients who underwent TEA were identified. The mean reimbursement cost of the surgical encounter ($13,393 ± $8314) did not differ significantly based on patient factors. The mean reimbursement cost of the 89-day postoperative period ($4232 ± $2343) differed significantly when stratified by surgical indication (P < .0001) or by medical comorbidity (P < .0001). The indication of rheumatoid arthritis ($4864 ± $1136) and the comorbidity of chronic kidney disease ($5873 ± $1165) had the most expensive postoperative period. In addition, the total 90-day reimbursement cost ($16,982 ± $4132) differed significantly when stratified by surgical indication (P = .00083) or by medical comorbidity (P < .0001), with the indication of acute fracture ($18,870 ± $3971) and the comorbidity of chronic pulmonary disease ($19,194 ± $3829) showing the highest total 90-day cost. Inpatient costs related to readmissions represented 38% of the total reimbursement cost. The overall readmission rate was 5.0%, and the mean readmission cost was $16,296.

CONCLUSION

TEA reimbursements are significantly influenced by surgical indications and medical comorbidities during the postoperative period and the total 90-day episode of care. As the United States transitions to delivering value-based health care, the need for surgeons and policy makers to understand treatment costs associated with different patient-level factors will expand.

Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction

BACKGROUND

Superior capsular reconstruction (SCR) can be used for massive irreparable rotator cuff tears in the absence of significant degenerative changes; however, those who fail an SCR may require reverse shoulder arthroplasty (RSA). The effect of a previously performed SCR on outcomes following RSA remains unknown.

METHODS

Subjects who underwent RSA from May 2015 to January 2021 at 2 separate institutions were retrospectively identified through prospectively collected databases. Patients who underwent RSA after failed SCR were matched to those who underwent RSA after failed rotator cuff repair (RCR) based on the number of previous ipsilateral shoulder procedures (n = 1, 2, ≥3) and secondarily by age within 5 years. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Western Ontario Osteoarthritis of the Shoulder index (WOOS) scores were compared between groups. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were calculated to determine clinically relevant differences between groups.

RESULTS

Forty-five patients were included (32 RSA following RCR, 13 following SCR). There were more smokers (P = .001) and worker's compensation cases (P = .034) in the SCR group. The RCR cohort was older (P = .007) and had a greater incidence of mental health (P > .999) and somatic disorders (P = .698), although these did not reach statistical significance. The mean follow-up for the RCR and SCR groups were 24.2 ± 23.3 and 20.4 ± 14.9 months following RSA, respectively (P = .913). The time from index RCR or SCR to RSA were 94.4 ± 22.2 and 89.2 ± 5.3 months, respectively (P = .003). Pre- and postoperative range of motion were similar between groups, as was the overall change in forward flexion (P = .879), abduction (P = .971), and external rotation (P = .968) following RSA. The RCR group had lower postoperative VAS pain (P = .009), higher SANE (P = .015), higher ASES (P = .008), and higher WOOS (P = .018) scores. The percentage achieving the MCID (P = .676) and SCB (P > .999) were similar; however, 56.7% of the RCR group met the SANE PASS threshold compared with 0.0% in the SCR group (P = .005). There were no differences in postoperative complications (P = .698) or revision rates (P = .308) following RSA between cohorts.

CONCLUSION

When matched for number of previous procedures to the ipsilateral extremity and age, patients who underwent RSA following failed SCR had worse clinical outcome scores than their RSA following failed RCR counterparts. No patient in the SCR group met the SANE PASS threshold, whereas more than half of the RCR group did.

Substantial Inconsistency and Variability Exists Among Minimum Clinically Important Differences for Shoulder Arthroplasty Outcomes: A Systematic Review

BACKGROUND

As the value of patient-reported outcomes becomes increasingly recognized, minimum clinically important difference (MCID) thresholds have seen greater use in shoulder arthroplasty. However, MCIDs are unique to certain populations, and variation in the modes of calculation in this field may be of concern. With the growing utilization of MCIDs within the field and value-based care models, a detailed appraisal of the appropriateness of MCID use in the literature is necessary and has not been systematically reviewed.

QUESTIONS/PURPOSES

We performed a systematic review of MCID quantification in existing studies on shoulder arthroplasty to answer the following questions: (1) What is the range of values reported for the MCID in commonly used shoulder arthroplasty patient-reported outcome measures (PROMs)? (2) What percentage of studies use previously existing MCIDs versus calculating a new MCID? (3) What techniques for calculating the MCID were used in studies where a new MCID was calculated?

METHODS

The Embase, PubMed, and Ovid/MEDLINE databases were queried from December 2008 through December 2020 for total shoulder arthroplasty and reverse total shoulder arthroplasty articles reporting an MCID value for various PROMs. Two reviewers (DAK, MAM) independently screened articles for eligibility, specifically identifying articles that reported MCID values for PROMs after shoulder arthroplasty, and extracted data for analysis. Each study was classified into two categories: those referencing a previously defined MCID and those using a newly calculated MCID. Methods for determining the MCID for each study and the variability of reported MCIDs for each PROM were recorded. The number of patients, age, gender, BMI, length of follow-up, surgical indications, and surgical type were extracted for each article. Forty-three articles (16,408 patients) with a mean (range) follow-up of 20 months (0.75 to 68) met the inclusion criteria. The median (range) BMI of patients was 29.3 kg/m2 (28.0 to 32.2 kg/m2), and the median (range) age was 68 years (53 to 84). There were 17 unique PROMs with MCID values. Of the 112 MCIDs reported, the most common PROMs with MCIDs were the American Shoulder and Elbow Surgeons (ASES) (23% [26 of 112]), the Simple Shoulder Test (SST) (17% [19 of 112]), and the Constant (15% [17 of 112]).

RESULTS

The ranges of MCID values for each PROM varied widely (ASES: 6.3 to 29.5; SST: 1.4 to 4.0; Constant: -0.3 to 12.8). Fifty-six percent (24 of 43) of studies used previously established MCIDs, with 46% (11 of 24) citing one study. Forty-four percent (19 of 43) of studies established new MCIDs, and the most common technique was anchor-based (37% [7 of 19]), followed by distribution (21% [4 of 19]).

CONCLUSION

There is substantial inconsistency and variability in the quantification and reporting of MCID values in shoulder arthroplasty studies. Many shoulder arthroplasty studies apply previously published MCID values with variable ranges of follow-up rather than calculating population-specific thresholds. The use of previously calculated MCIDs may be acceptable in specific situations; however, investigators should select an anchor-based MCID calculated from a patient population as similar as possible to their own. This practice is preferable to the use of distribution-approach MCID methods. Alternatively, authors may consider using substantial clinical benefit or patient-acceptable symptom state to assess outcomes after shoulder arthroplasty.

CLINICAL RELEVANCE

Although MCIDs may provide a useful effect-size based alternative to the traditional p value, care must be taken to use an MCID that is appropriate for the particular patient population being studied.

Obesity and Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Rates of obesity and reverse total shoulder arthroplasty (rTSA) in the USA have both escalated with time. Obese patients experience arthritis at higher rates than normal weight patients; therefore, these numbers go hand in hand. Obesity has been correlated with health comorbidities such as anxiety, cardiovascular disease, diabetes, and metabolic syndrome as well as poorer outcomes and higher complication rates following lower extremity arthroplasty. The current review investigates these comorbidities as they relate to obese patients undergoing rTSA.

RECENT FINDINGS

Functional outcomes are similar to normal weight counterparts. Although longer operative times and a large soft tissue envelope would intuitively predispose these patients to higher risk for infection or other complications, this has not been reliably demonstrated. Technical considerations and awareness of potential risks in the obese patient demographic may aid the surgeon in preoperative planning and counseling of their patient. Obese patients undergoing rTSA have been shown to have higher risks specifically for infection, revision, and medical complications; however, this has not been consistently demonstrated in the single surgeon series where, more often, no difference in these metrics has been found. Outcomes measures and satisfaction are reliably improved, even when considering superobese patients, and majority of studies find their improvements and absolute values to be in line with their normal weight counterparts. Thus, rTSA does not seem to carry the same level of adverse risk associated with lower joint arthroplasty but potential for higher risk still bears consideration when counseling obese patients. Attention to factors that may negatively affect prosthesis positioning may optimize retention rates and limit early failure.

Do TKAs in Patients with Higher BMI Take Longer, and is the Difference Associated with Surgeon Volume? A Large-database Study from a National Arthroplasty Registry

BACKGROUND

Increased surgical time in TKA may impact economic costs and clinical outcomes. Prior work has found that TKAs in patients with high BMI take longer, and these patients may be at greater risk for postoperative complications like infection. However, these studies included small numbers of patients and surgeons from single institutions and they did not consider surgeon volume.

QUESTIONS/PURPOSES

Using the New Zealand Joint Registry (NZJR), we asked: (1) Is there a relationship between increasing patient BMI and TKA operative time? (2) Is the effect of BMI on surgical time less pronounced among surgeons who perform more TKAs per year than those who perform fewer?

METHODS

Data were collected from the NZJR between January 2010 and December 2018 as it is the only national registry that records both BMI and surgical time. Primary TKA performed for osteoarthritis by surgeons with more than 50 TKAs over the period of the study were identified. BMI and operative time (skin incision to closure in minutes) were recorded. Patients with the following were excluded: lateral parapatellar or minimally invasive approaches; navigated, patient-specific instrumentation, or robot-assisted TKA; uncemented or hybrid fixation; those with procedures performed by a trainee (all or part); or a nonosteoarthritic indication. Of 64,108 TKAs performed during the study period, a total of 42% (27,057) met our inclusion criteria. The primary outcome was the effect of BMI on operative time. Operative time is expressed in minutes as a mean for each single-unit BMI increase across all surgeons, controlled for other variables that might influence operative time such as patella resurfacing and cruciate-retaining versus posterior-stabilized designs. Overall, the mean operative time (skin incision to closure) was 79 ± 22 minutes. Surgical experience was assessed by subdividing surgeons into six groups according to the number of TKAs performed annually (< 10, 10 to 24, 25 to 49, 50 to 74, 75 to 99, and > 100). Statistical analyses were performed including a general linear model to assess the independent association between BMI and operative time, allowing for the effects of other patient and surgical features. In addition, linear regression analyses explored the associations between BMI and operative time in the whole group and within surgical volume groups.

RESULTS

There was an association between increasing BMI and increasing surgical duration. The mean operative time increased from 75 ± 22 minutes in patients with a normal BMI of 25 kg/m2 to 87 ± 24 minutes in patients with a BMI of 40 kg/m2 to 94 ± 28 minutes in patients with a BMI > 50 kg/m2 (p < 0.001). Surgeons performing fewer than 25 TKAs per year took 14% longer to perform a TKA on a patient with a BMI of 40 kg/m2 than on a patient with a normal BMI of 25 kg/m2. However, surgeons performing greater than 25 TKAs per year took 10% longer.

CONCLUSION

In this study, an increase BMI was associated with increased surgical time in TKA. Surgical duration for high-volume surgeons appears less influenced by increases in BMI than lower volume surgeons. Although the absolute increase in duration was small, prolonged surgical time may reduce theater productivity. Even though the issues around managing patients with high BMI are multifactorial and complex, considerations from these findings include ensuring appropriate theater scheduling and possibly referring patients with high BMI to specialist centers. Further studies should focus on assessing the effectiveness of such measures in reducing complications and improving outcomes in patients with elevated BMI.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Investigating a Potential Limit to Access to Care: Preoperative Cutoff Values for Body Mass Index for Shoulder Arthroplasty

INTRODUCTION

The primary purpose of this study was to determine the number of patients who would be denied a complication-free total shoulder arthroplasty (TSA) based on implementation of body mass index (BMI) eligibility cutoffs.

METHODS

The National Surgical Quality Improvement Program database was queried to identify all patients who underwent primary TSA. Patient demographics and 30-day postoperative complications were compared according to BMI stratification using the Pearson chi-square test and binary logistic regression analysis adjusted for age and modified Charlson comorbidity index. A BMI eligibility criterion of ≥40 kg/m2 was used to calculate the positive predictive value (PPV) to assess the number of complication-free TSAs that would be denied to avoid a complication in a single patient.

RESULTS

A total of 23,284 patients who underwent TSA met inclusion criteria. The overall complication rate was 7.2%. Using a BMI cutoff of ≥40 kg/m2 would yield a PPV of 7% for all Major Complications. This means that 14 complication-free procedures would be denied to avoid a Major Complication. In addition, BMI ≥40 kg/m2 served as an independent risk factor for acute renal failure, pulmonary embolism, ventilator use >48 hours, and readmission. The PPV for these clinically significant complications using BMI ≥40 kg/m2 as a cutoff was 4.9%. This translates into 20 patients being denied a complication-free procedure to avoid a single clinically significant medical complication. If this policy was enforced on the 2,426 patients who exceeded BMI ≥40 kg/m2 in this study, nearly 2,307 patients would be denied the potential benefit of surgery to prevent 119 complications.

CONCLUSION

The use of eligibility criteria for primary TSA or RSA based solely on BMI threshold values presents a potential limitation in access to care to these patients who otherwise would have a complication-free procedure.

LEVEL OF EVIDENCE

Level III, prognostic, retrospective cohort study.

Effects of obesity on clinical and functional outcomes following anatomic and reverse total shoulder arthroplasty

BACKGROUND

Limited data exist regarding the clinical and functional outcomes following primary total shoulder arthroplasty in obese patients. The purpose of this study is to determine the effects of obesity on the clinical and functional outcomes following primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) in a large patient population with mid-term follow-up.

METHODS

Patients in a multi-institutional shoulder registry receiving either primary aTSA (n = 1520) or rTSA (n = 2054) from 2004 to 2018 with a minimum follow-up period of 2 years were studied. All patients received the same single-platform shoulder prosthesis. Study groups were assigned based on implant type (anatomic or reverse), and further stratification was based on patient body mass index (BMI), with obese patients having a BMI ≥ 30 and non-obese patients having a BMI < 30. Patients were evaluated and scored preoperatively and at latest follow-up by use of 5 scoring metrics and range of motion (ROM).

RESULTS

The mean follow-up period was 5 years (range, 2-14 years). Obese patients comprised 41% of the aTSA group and 35% of the rTSA group. Significant postoperative improvements in visual analog scale pain scores, ROM, and all 5 scoring metrics occurred in both obese and non-obese patients (P < .05). Obese patients in both groups reported higher preoperative and postoperative visual analog scale pain scores and less preoperative and postoperative ROM compared with non-obese patients. Compared with non-obese patients, obese patients receiving aTSA reported significantly worse postoperative Simple Shoulder Test, Constant-Murley, American Shoulder and Elbow Surgeons, University of California, Los Angeles, and Shoulder Pain and Disability Index scores compared with non-obese patients, and those receiving rTSA reported significantly worse American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index scores (all P < .05). However, these differences did not exceed the minimal clinically important difference or substantial clinical benefit criteria. Radiographic analysis showed that in the rTSA group, obese patients had significantly less postoperative scapular notching and a lower scapular notching grade compared with non-obese patients (P < .05).

DISCUSSION

Both non-obese and obese patients can expect clinically significant improvements in pain, motion, and functional outcome scores following both aTSA and rTSA. Obese patients reported significantly more postoperative pain, lower outcome scores, and less ROM compared with non-obese patients after both aTSA and rTSA at a mean follow-up of 5 years. However, statistically significant differences were not found to be clinically significant with respect to established minimal clinically important difference and substantial clinical benefit criteria. Therefore, obese and non-obese patients experience similar clinical outcomes following total shoulder arthroplasty, regardless of BMI. However, obese patients have more comorbidities, greater intraoperative blood loss, and less scapular notching compared with non-obese patients.

Complications and Intraoperative Fractures in Reverse Shoulder Arthroplasty: A Systematic Review

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.

Does preoperative disease severity influence outcomes in reverse shoulder arthroplasty for cuff tear arthropathy?

BACKGROUND

The degree of symptomatic disease and functional burden has been demonstrated to influence patient results and satisfaction in total hip and knee arthroplasty. Although the relationship between preoperative diagnosis and patient outcomes has been an area of study for reverse total shoulder arthroplasty (RTSA), the influence of the progression of cuff tear arthropathy (CTA) has not yet been examined. The purpose of this study was to evaluate whether preoperative radiographic disease burden and scapular geometry impact patient outcomes and satisfaction in a cohort of patients with CTA treated with RTSA.

METHODS

Eighty-six patients were treated for CTA with RTSA performed by the senior author (B.G.) between September 2016 and September 2018 and were enrolled in an institutional registry. At the time of initial evaluation, the baseline American Shoulder and Elbow Surgeons (ASES) score, patient demographic characteristics, history of shoulder surgery, and presence of pseudoparalysis were collected. Radiographs were obtained to evaluate the critical shoulder angle, acromial index, and progression of CTA as assessed by Hamada grading and the Seebauer classification. Patients were contacted to reassess the ASES score and their satisfaction with the improvement in their shoulder function.

RESULTS

A total of 79 patients (91.6%) were available for evaluation at a minimum of 24 months of follow-up. Multivariate logistic regression modeling revealed that scapular geometry measurements (critical shoulder angle and acromial index) and the degree of CTA (Seebauer and Hamada classifications) were not associated with worse outcomes as assessed by the ASES score. However, degenerative changes as assessed by the Hamada grade (odds ratio, 0.13 [95% confidence interval, 0.02-0.86]; P = .03) and preoperative ASES score (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .008) were independently associated with higher satisfaction at 24 months of follow-up.

CONCLUSION

The results indicate that patients with greater CTA disease progression did not show differing outcomes after RTSA compared with patients with milder disease. In contrast, both poorer preoperative function and degenerative changes as assessed by the Hamada classification were associated with greater satisfaction after RTSA for CTA. Given the broad spectrum of disease in CTA, there is likely a corresponding range in patient expectations that requires further study to maximize patient satisfaction.

The Association of Body Mass Index with Surgical Time Is Mediated by Comorbidity in Patients Undergoing Total Hip Arthroplasty

Overweight represents a major issue in contemporary orthopaedic practice. A higher body mass index (BMI) is associated with an increase of perioperative complications following several orthopaedic procedures, in particular total hip arthroplasty (THA). However, the influence of overweight on THA surgical time is controversial. In this study, we investigated the association between BMI and surgical time analyzing the role of patients’ comorbidities. We conducted a retrospective study on 748 patients undergoing THA at our institutions between 2017 and 2018. Information regarding medical diseases was investigated and the burden of comorbidity was quantified using the Charlson score (CCI). Surgical time and blood loss were also recorded. Median surgical time was 76.5 min. Patients with surgical time above the median had both a higher BMI (28.3 vs. 27.1 kg/m²; p = 0.002); and CCI (1 vs. 0; p = 0.016). According to linear regression, surgical time was associated with BMI in the unadjusted model (p < 0.0001), after adjusting for age and sex (p < 0.0001), and in the multivariable model (p = 0.005). Furthermore, BMI was associated with increased surgical time only in patients with a Charlson score above the median, but not in others. Obesity is associated with increased surgical time during THA, especially in pluricomorbid patients, with a higher risk of perioperative complications.

Teres minor muscle hypertrophy is a negative predictor of outcomes after reverse total shoulder arthroplasty: an evaluation of preoperative magnetic resonance imaging and postoperative implant position

BACKGROUND

Predictors of outcomes after reverse total shoulder arthroplasty (rTSA) remain unclear. The purpose of this study was to analyze the impact of preoperative muscle quality and postoperative implant positioning on patient-reported outcomes following rTSA.

METHODS

We evaluated 88 shoulders treated with rTSA in which preoperative magnetic resonance imaging was available. Preoperative muscle quality was evaluated, including fatty infiltration, rotator cuff muscle volume, and total tear size. Postoperative implant position was determined radiographically. The correlation between imaging parameters and the 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score was examined. Multivariate analyses were performed to adjust for confounding factors including patient demographic characteristics and implant position.

RESULTS

Univariate analysis showed that the ASES score was significantly lower in patients with teres minor muscle hypertrophy relative to those with normal muscle (73.3 ± 22.8 vs. 84.2 ± 16.9, P = .02). The functional subscore was significantly lower in patients with grade 2 fatty infiltration of the deltoid muscle relative to those with grade 0 fatty infiltration (26.1 ± 14.6 vs. 34.8 ± 11.6, P = .03). Older age was associated with a higher pain subscore (ρ = 0.32, P = .002). Multivariate analysis demonstrated that teres minor muscle hypertrophy remained a significant independent predictor of the ASES score (β coefficient = 91.3, P = .03).

CONCLUSION

Teres minor muscle hypertrophy is an independent negative predictor of patient-reported outcomes after rTSA.

Drivers of lower inpatient hospital costs and greater improvements in health-related quality of life for patients undergoing total shoulder and ream-and-run arthroplasty

BACKGROUND

With increasing emphasis on value-based care and the heavy demands on the US health care budget, surgeons must be cognizant of factors that drive cost and quality of patient care. Our objective was to determine patient-level drivers of lower costs and improved health-related quality of life (HRQoL) in 2 anatomic shoulder arthroplasty procedures: total shoulder arthroplasty (TSA) and ream-and-run arthroplasty.

METHODS

This study included 222 TSAs and 211 ream-and-run arthroplasties. Simple Shoulder Test, Single Assessment Numeric Evaluation, and Short Form 36 scores were collected preoperatively and 2 years postoperatively. Quality-adjusted life-years (QALYs) were calculated as a measure of HRQoL. Univariate and multivariate analyses determined factors significantly associated with decreased hospitalization costs and improved HRQoL.

RESULTS

In the TSA group, female sex, lower American Society of Anesthesiologists class, diagnosis other than capsulorrhaphy arthropathy, lower pain score, and higher Single Assessment Numeric Evaluation score were associated with decreased total hospitalization costs; in addition, female sex was an independent predictor of lower total costs. Insurance other than workers' compensation, a diagnosis of chondrolysis, and higher optimism led to greater QALY gains, but a diagnosis of capsulorrhaphy arthropathy was the only independent predictor of greater QALY gains. In the ream-and-run arthroplasty group, older age, lower body mass index (BMI), lower American Society of Anesthesiologists class, insurance other than Medicaid, diagnosis other than capsulorrhaphy arthropathy, no history of surgery, higher preoperative Simple Shoulder Test score, and higher preoperative Short Form 36 Physical Component Summary score were associated with lower total costs; moreover, lower BMI was an independent predictor of lower costs. Higher preoperative optimism was an independent predictor of greater QALY gains.

CONCLUSIONS

Identifying factors associated with decreased costs and increased quality is becoming increasingly important in value-based care. This study identified fixed (sex and diagnosis) and modifiable (BMI) factors that drive decreased hospitalization costs and increased HRQoL improvements in shoulder arthroplasty patients. Higher preoperative patient optimism is a consistent predictor of improved HRQoL for both TSA patients and ream-and-run arthroplasty patients, and further study on optimizing the influence of patient expectations and optimism may be warranted.

An analysis of body weight changes after shoulder arthroplasty

Background

To determine if there are postoperative weight changes for patients undergoing primary shoulder arthroplasty (SA). In addition, we aimed to determine if glycemic control (hemoglobin A1C levels) change postoperatively for patients undergoing SA.

Methods

All patients 18 years of age or older who had undergone primary SA over a 12-year period were analyzed. Patients were excluded if they did not have a preoperative body mass index or if they had less than 1-year follow-up. Baseline demographics were recorded for all patients and comparisons were made between the obese and nonobese groups. Clinically meaningful weight loss was defined as a ≥ 5% reduction in body weight postoperatively.

Results

A total of 469 patients met inclusion criteria. Of them, 65% of patients were obese, and the mean preoperative body mass index for all patients was 33. With a mean follow-up of 40 months, 70% of patients demonstrated clinically significant weight loss. Compared with patients without obesity, patients with obesity lost significantly more weight (10 vs. 6 kg) and demonstrated significantly greater postoperative body mass index reductions (4 vs. 2). Overall, 72% of patients with obesity demonstrated clinically meaningful postoperative weight loss of ≥5% body weight. Patients with obesity who lost weight also saw a decrease in their postoperative hemoglobin A1C: for every 10 pounds of weight loss, A1C decreased by 0.08 units.

Conclusions

In our series, 72% of patients with obesity undergoing primary SA achieved clinically meaningful weight loss, with a mean follow-up of more than 3 years. Patients who lose weight after SA additionally demonstrate improved glycemic control. Surgeons and patients should balance the association between postoperative weight loss after SA with the potential increased risks of operative complications, particularly for severely obese patients.

Value Analysis of Anatomic and Reverse Shoulder Arthroplasty for Glenohumeral Osteoarthritis with an Intact Rotator Cuff

BACKGROUND

While anatomic total shoulder arthroplasty (TSA) has historically been considered the ideal treatment for end-stage glenohumeral osteoarthritis, reverse shoulder arthroplasty (RSA) has recently gained popularity. With substantial differences in implant design and cost between TSA and RSA, further investigation of outcomes and value is needed to support recent trends. The purpose of this study was to use the average and incremental cost-effectiveness ratio (ACER and ICER) and the procedure value index (PVI) to examine differences in outcomes and value between TSA and RSA for treatment of glenohumeral osteoarthritis with an intact rotator cuff.

METHODS

We performed a retrospective matched-cohort study of patients treated with primary shoulder arthroplasty for osteoarthritis with an intact rotator cuff who had a minimum 2-year follow-up. Outcome measures analyzed included the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) questionnaire, visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE), and overall satisfaction. Patients treated with TSA were matched 4:1 to those treated with RSA based on sex, age, and preoperative SST score. Value differences between TSA and RSA were calculated. Radiographs were analyzed for preoperative glenoid classification and postoperative radiolucent lines and gross loosening.

RESULTS

Two hundred and fifty-two TSA-treated patients were matched to 63 RSA-treated patients with no significant differences in sex, age, or preoperative SST score. Total hospitalization costs, charges, and reimbursements along with outcome improvements in units of minimal clinically important differences (MCIDs) and patient satisfaction did not differ between the groups. For RSA, the implant cost was significantly higher than that for TSA, but the operating room, anesthesia, and cement costs were lower. The TSA group had a 3.2% rate of gross glenoid loosening and a 2.4% revision rate. There was no loosening or revision in the RSA group. None of the value analytics differed between groups even after inclusion of the outcomes and costs of early TSA revisions.

CONCLUSIONS

TSA and RSA demonstrated similar outcomes and value when used to manage glenohumeral osteoarthritis with an intact rotator cuff.

LEVEL OF EVIDENCE

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

The impact of Charlson and Elixhauser comorbidities on patient outcomes following shoulder arthroplasty

AIMS

To investigate the impact of the Charlson and Elixhauser comorbidity indices on patient-reported outcomes measures (PROMs) following shoulder arthroplasty.

METHODS

Patients undergoing total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or hemiarthroplasty (HA) from 2016 to 2018 were identified, along with the Charlson and Elixhauser comorbidities listed as their secondary diagnoses in the electronic medical records. Patients were matched to our institution's registry to obtain their PROMs, including shoulder-specific (American Shoulder and Elbow Society (ASES) and Shoulder Activity Scale (SAS)) and general health scales (12-Item Short Form Survey (SF-12) and Patient-Reported Outcomes Measurement Information System-Pain Interference). Linear regression models adjusting for age and sex were used to evaluate the association between increasing number of comorbidities and PROM scores. A total of 1,817 shoulder arthroplasties were performed: 1,017 (56%) TSA, 726 (40%) RSA, and 74 (4%) HA. The mean age was 67 years (SD 10), and 936 (52%) of the patients were female.

RESULTS

The most common comorbidities were obesity (1,256, 69%) and hypertension (990, 55%). Patients with more comorbidities had lower ASES and SAS scores at baseline (p < 0.001). Elixhauser comorbidities continued to negatively impact ASES and SAS scores at one year (p = 0.002) and two-year follow-up (p = 0.002). Patients with more comorbidities reported greater pain interference on PROMIS at baseline (p = 0.007), but not at two years. Higher number of Charlson comorbidities were associated with lower scores on the SF-12 mental component at baseline (p < 0.001) and two years (p = 0.020). Higher number of Elixhauser comorbidities were associated with lower SF-12 physical component scores at baseline (p < 0.001) and two years (p = 0.004).

CONCLUSION

Higher number of comorbidities was associated with lower baseline scores and worse outcomes on both shoulder-specific and general health PROMs. The presence of specific comorbidities may be used during shared decision-making to manage expectations for patients undergoing shoulder arthroplasty. Cite this article: Bone Joint J 2021;103-B(5):964-970.

The effect of body mass index on one-year functional outcome, quality of life and postoperative complications in total shoulder arthroplasty

The aim of this retrospective cohort study was to investigate the effect of BMI on 1-year functional outcome, quality of life (QoL) and rate of postoperative complications after shoulder arthroplasty. We included 121 patients (59 men and 62 women) with primary osteoarthritis (OA) who underwent anatomical or reverse total shoulder arthroplasty (TSA or rTSA) between 2011 and 2016. Age, sex, preoperative BMI, preoperative medical status using American score of anesthesiologists (ASA) class, type of prosthesis, preoperative and 1-year postoperative functional outcome using the Constant score and quality of life (QoL) using the EQ-5D as well as postoperative complication rate were documented. Patients were divided into three groups based on their BMI, group 1 (normal weight, BMI <25), group 2 (overweight, BMI 25-30) and group 3 (obese, >BMI 30). All three groups were comparable regarding age, sex and ASA class, preoperative Constant score EQ-5D. We found significant improvement of the Constant score and EQ- 5D at 1-year postoperative follow-up, regardless of BMI (p<0.05). Comparing the three groups, we found no significant differences among them in 1-year Constant score, EQ-5D or postoperative rate of complications. This study showed that BMI did not affect functional outcome, QoL and postoperative complication rate in TSA. These results can help physicians and patients to make reasonable perioperative expectations and planning.

Bundled Payment Plans Are Associated With Notable Cost Savings for Ambulatory Outpatient Total Shoulder Arthroplasty

INTRODUCTION

Bundling of services, typically into a 90-day episode of care, is intended to facilitate cost reduction. The purpose of this study was to determine the impact of a private insurance bundling program on the costs of outpatient total shoulder arthroplasty (TSA) at a freestanding ambulatory surgery center.

METHODS

A cost minimization analysis was done of patients who had anatomic TSA by a single surgeon at a single freestanding ambulatory surgery center, including line-by-line comparisons of demographic and comorbidity factors for all patients treated within the 90-day episode of care.

RESULTS

Seventy-six primary anatomic TSAs were included, 39 in the bundled group and 37 outside of the program. The bundled group was on average older (58 years) than the unbundled group (54 years, P = 0.021), but the groups were otherwise similar in demographics. The average total implant charges were significantly less for the bundled group ($24,822.43 versus $28,405.51, P = 0.014). Average total surgery supply charges and anesthesia supply charges were similar (P > 0.05). Mean total outpatient surgical day charges (implants, surgical, and anesthesia equipment) were significantly less for the bundled group ($29,782.43 versus $33,238.68, P = 0.022), as were average operating room staffing costs ($135.37 versus $162.55, P = 0.015). During the 90-day postoperative period, charges were similar.

CONCLUSIONS

Primary anatomic TSA using a bundled care program in an outpatient setting coincides with markedly lower charges. The primary driver of this reduction is implant pricing, which is negotiated as part of the bundle. Surgeons must carefully analyze their unique practices in the changing economic health care environment when creating an outpatient TSA and/or bundling program.

LEVEL OF EVIDENCE

Level III economic analysis.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part I

Background

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this 2-part study was to systematically review each of the most common complications of RSA, limiting each search to publications in 2010 or later. In this part (part I), we examined (1) scapular notching (SN), (2) periprosthetic infection (PJI), (3) mechanical failure (glenoid or humeral component), and (4) neurologic injury (NI).

Methods

Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Overall, 113 studies on SN, 62 on PJI, 34 on mechanical failure, and 48 on NI were included in our reviews. Univariate analysis was performed with the χ² or Fisher exact test.

Results

The Grammont design had a higher SN rate vs. all other designs combined (42.5% vs. 12.3%, P < .001). The onlay humeral design had a lower rate than the lateralized glenoid design (10.5% vs. 14.8%, P < .001). The PJI rate was 2.4% for primary RSA and 2.6% for revision RSA. The incidence of glenoid and humeral component loosening was 2.3% and 1.4%, respectively. The Grammont design had an increased NI rate vs. all other designs combined (0.9% vs. 0.1%, P = .04).

Conclusions

Focused systematic reviews of the recent literature with a large volume of RSAs demonstrate that with the use of non-Grammont modern prosthesis designs, complications including SN, PJI, glenoid component loosening, and NI are significantly reduced compared with previous studies. As the indications for RSA continue to expand, it is imperative to accurately track the rates and types of complications to justify its cost and increased indications.

Early outcomes and complications of obese patients undergoing shoulder arthroplasty: A meta-analysis

OBJECTIVE

The prevalence of obesity and shoulder arthroplasty have both been increasing in the United States. Although lower extremity arthroplasty literature suggests higher complication rates in these patients, there is a paucity of studies evaluating the outcome of shoulder arthroplasty in obese patients. Our purpose was to perform a meta-analysis to determine clinical outcomes and complications of these patients.

METHODS

Following the PRISMA guidelines, the MEDLINE (PubMed), Embase, and Ovid libraries were used to perform a comprehensive literature review to compare complications and outcomes following shoulder arthroplasty between obese and non-obese patients. Our initial search returned 143 publications. Our inclusion criteria included full-text reports, minimum follow-up of 1 year, minimum of 10 patients, no cadaveric or biomechanical studies, only studies published in English, studies involving obese patients undergoing either anatomic or reverse shoulder arthroplasty. A total of 13 studies met the inclusion criteria. These studies were then evaluating using a methodological index for non-randomized studies (MINORS) score. Ultimately, 6 studies met our criteria and were included in the final analysis.

RESULTS

A total of 978 patients were identified from the 6 studies. Patients with a BMI <30 kg/m² had a complication rate of 9.7% and American Shoulder and Elbow Surgeons score (ASES) increased from 37.4 to 76.7. Patients with a BMI >30 kg/m² had a complications rate of 6.5% and ASES increased from 34.4 to 76.2. Patients with a BMI >40 kg/m² ASES increased from 29.5 to 68.6. The postoperative ASES score of 68.6 for patients with a BMI >40 kg/m² was significantly lower than the ASES score of 76.8 in patients with a BMI <40 kg/m² (p = 0.007). There were an insufficient number of patients and an insufficient number of complications to perform any meaningful statistical test on complication rates in patients with a BMI >40 kg/m².

CONCLUSION

No significant difference was observed in number of complications and follow-up ASES scores following shoulder arthroplasty between obese and non-obese patients. Morbidly obese patients (BMI > 40 kg/m²) have a significantly lower ASES follow-up score than non-morbidly obese patients; however, this difference may not be clinically significant. Future studies are needed to investigate outcomes and complications associated with morbidly obese patients undergoing shoulder arthroplasty.

Minimum Clinically Important Difference: Current Trends in the Orthopaedic Literature, Part I: Upper Extremity: A Systematic Review

BACKGROUND

The minimum clinically important difference (MCID) attempts to define the patient's experience of treatment outcomes. Efforts at calculating the MCID have yielded multiple and inconsistent MCID values. The purposes of this review were to describe the usage of the MCID in the most recent orthopaedic literature, to explain the limitations of its current uses, and to clarify the underpinnings of MCID calculation. Subsequently, we hope that the information presented here will help practitioners to better understand the MCID and to serve as a guide for future efforts to calculate the MCID. The first part of this review focuses on the upper-extremity orthopaedic literature. Part II will focus on the lower-extremity orthopaedic literature.

METHODS

A review was conducted of the 2014 to 2016 publications in The Journal of Arthroplasty, The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, Foot & Ankle International, Journal of Orthopaedic Trauma, Journal of Pediatric Orthopaedics, and Journal of Shoulder and Elbow Surgery. Only clinical science articles utilizing patient-reported outcome measure (PROM) scores were included in the analysis. A keyword search was then performed to identify articles that calculated or referenced the MCID. Articles were then further categorized into upper-extremity and lower-extremity publications. MCID utilization in the selected articles was subsequently characterized and recorded.

RESULTS

The MCID was referenced in 129 (7.5%) of 1,709 clinical science articles that utilized PROMs: 52 (40.3%) of 129 were related to the upper extremity, 5 (9.6%) of 52 independently calculated MCID values, and 47 (90.4%) of 52 used previously published MCID values as a gauge of their own results. MCID values were considered or calculated for 16 PROMs; 12 of these were specific to the upper extremity. Six different methods were used to calculate the MCID. Calculated MCIDs had a wide range of values for the same PROM (e.g., 8 to 36 points for Constant-Murley scores and 6.4 to 17 points for American Shoulder and Elbow Surgeons [ASES] scores).

CONCLUSIONS

Determining useful MCID values remains elusive and is compounded by the proliferation of PROMs in the field of orthopaedics. The fundamentals of MCID calculation methods should be critically evaluated. If necessary, these methods should be corrected or abandoned. Furthermore, the type of change intended to be measured should be clarified: beneficial, detrimental, or small or large changes. There should also be assurance that the calculation method actually measures the intended change. Finally, the measurement error should consistently be reported.

CLINICAL RELEVANCE

The MCID is increasingly used as a measure of patients' improvement. However, the MCID does not yet adequately capture the clinical importance of patients' improvement.

Risk of poor outcomes in patients who are obese following total shoulder arthroplasty and reverse total shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

A systematic review was performed to investigate the impact of obesity on outcomes following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

Electronic databases and the grey literature were searched for studies that evaluated the influence of obesity (body mass index ≥ 30 kg/m²) on TSA and RTSA outcomes. A total of 15 studies were identified, with 10 studies reporting on predetermined outcomes considered in the TSA and RTSA population. Unadjusted data were pooled in a statistical meta-analysis where appropriate (Review Manager [RevMan], version 5.3) or summarized in narrative form. Effect sizes were expressed as odds ratios (ORs) for categorical data and weighted mean differences (WMDs) for continuous data.

RESULTS

The findings suggested that patients who were obese were at increased odds of a dislocation (OR, 2.49; 95% confidence interval [CI], 2.32-2.66), fracture (OR, 1.92; 95% CI, 1.77-2.08), and revision (OR, 1.49; 95% CI, 1.40-1.58) following TSA or RTSA. Conversely, obesity had no influence on the odds of an unscheduled return to the operating theater (OR, 0.83; 95% CI, 0.43-1.61). Postoperative forward flexion in patients who were obese differed from that in patients who were not obese (WMD, -9.8°; 95% CI, -17.53° to -2.07°); however, no differences in other functional measures including abduction (WMD, -0.78; 95% CI, -7.27 to 5.71) and external rotation (WMD, -1.41; 95% CI, -5.11 to 2.29) were found. Although patients who were obese reported significantly higher levels of pain (WMD, 1.13; 95% CI, 0.21 to 2.06), the difference was not clinically relevant.

CONCLUSIONS

Surgeons should consider advising patients who are obese of the greater risk of dislocation, fracture, and revision when considering elective TSA or RTSA. Findings are limited by confounding variables but further our understanding of additional risks associated with pre-existing obesity, which will promote better-informed decisions prior to proceeding with surgery.

Predictors of unsatisfactory patient outcomes in primary reverse total shoulder arthroplasty

BACKGROUND

Despite favorable clinical and functional results for reverse total shoulder arthroplasty (RSA), there remains a group of patients without postoperative complications who demonstrate poor improvement and overall outcome.

METHODS

Using a single surgeon shoulder arthroplasty registry, we identified patients who underwent RSA from 2013 to 2016 with minimum of 2-year postoperative follow-up. Patients with intra- and postoperative complications were excluded. Poor postoperative clinical outcome was defined as those patients within the bottom 30th percentile for American Shoulder and Elbow Surgeons (ASES) score. Poor postoperative improvement was defined as the bottom 30th percentile of ASES improvement, measured preoperatively to the 2-year postoperative mark. Multivariate logistic regression modeling was used to determine preoperative characteristics (e.g., demographics, comorbidities, preoperative ASES score) associated with poor outcome.

RESULTS

A total of 137 patients met the inclusion and exclusion criteria. Multivariable logistic regression modeling found that prior shoulder surgery, the majority (75%) of which were arthroscopic, was the only independent factor associated with both poor improvement (adjusted odds ratio, 2.46 [1.03-5.83]) and outcome (adjusted odds ratio, 4.92 [1.74-14.96]). Preoperative opioid use was associated with poor outcomes only, whereas the high preoperative ASES score was associated with poor postoperative improvement.

CONCLUSIONS

Prior ipsilateral shoulder surgery was strongly associated with poor clinical improvement and outcome after RSA. No other factors correlated with both poor improvement and outcome. This association is important to decision making for any shoulder surgery, given the long-term implications.

Patient-reported outcomes of reverse total shoulder arthroplasty: a comparative risk factor analysis of improved versus unimproved cases

Background

The purpose of this study was to compare characteristics of patients who reported to be subjectively unimproved vs. improved after reverse total shoulder arthroplasty.

Methods

Data were derived from a prospective registry of patients who underwent reverse total shoulder arthroplasty with a minimum 2-year follow-up. Patients were asked to rate their subjective satisfaction and then divided into those who were unchanged or worse (unimproved group [UG]) vs. better or much better (improved group [IG]). The groups were compared for differences in demographic characteristics, preoperative factors, functional outcomes, and complications.

Results

There were 1425 patients in the IG and 134 patients in the UG. Patients in the IG were more likely to have a diagnosis of osteoarthritis. Patients in the UG were more likely to have coronary artery disease and diabetes and to have undergone prior surgery. No differences in implant configuration were found between groups. Preoperative measures for patients in the UG were worse for pain and function but not for range of motion. The outcomes in patients in the UG were worse for all postoperative measures, as well as for preoperative-to-postoperative improvement. Of the patients in the UG, 48% continued to have moderate to severe pain postoperatively. The complication rate was significantly higher in the UG.

Discussion

Up to 8.5% of patients rate themselves as unimproved after surgery. These patients are more likely to have certain comorbidities and to have undergone prior surgery. Although outcomes were significantly worse for all measures in the UG, improvement occurred in all measures despite patients subjectively being worse or unchanged. Residual pain and difficulty sleeping play a substantial role in subjective assessment of overall outcome.

Body mass index as a risk factor for dislocation of total shoulder arthroplasty in the first 30 days

Background

Dislocation of total shoulder arthroplasty has an incidence as high as 31%. Obesity is one of many proposed risk factors, but no consensus exists on this relationship. The purpose of this study was to determine whether there is a relationship between body mass index (BMI) and dislocation of total shoulder arthroplasty.

Methods

The National Surgical Quality Improvement Program database was used to identify patients older than 50 years who underwent anatomic or reverse total shoulder arthroplasty between the years 2012 and 2016 for primary or secondary osteoarthritis, post-traumatic arthritis, or cuff tear arthropathy. Patients requiring reoperation or readmission for dislocation were identified by Current Procedural Terminology code. The relationship between World Health Organization BMI classification and dislocation was assessed.

Results

A total of 9382 patients were identified; 46% were male and 54% female, with an average age of 68.7 years (range 50-90) and average BMI of 31.2 (range 15.1-79.3). There were only 24 dislocation events within the first 30 days after the procedure (0.26%). Ten of 24 (42%) occurred after discharge. Seventy percent of cases (17 of 24) required an open procedure. Underweight patients (BMI < 18.5) experienced the highest dislocation rate (1/50, 2.00%), whereas overweight patients (BMI 25-29.9) experienced the lowest dislocation rate (3/3069, 0.1%).

Conclusion

The rate of dislocation of total shoulder arthroplasty in the acute postoperative period differs across categories of BMI. However, there does not appear to be a linear association between BMI and risk of dislocation of total shoulder arthroplasty. Further studies are required to elucidate the risk factors for total shoulder dislocation.

Predictors of Length of Stay and Discharge Disposition After Shoulder Arthroplasty: A Systematic Review

INTRODUCTION

Identifying patient factors that affect length of stay (LOS) and discharge disposition after shoulder arthroplasty is key in managing patient expectations. In this systematic review, we identify patient-specific covariates that correlate with increased LOS and need for discharge to a facility.

METHODS

We searched biomedical databases to identify associations between patient-specific factors and LOS and discharge disposition after shoulder arthroplasty. We included all studies involving hemiarthroplasty, anatomic shoulder arthroplasty, and reverse shoulder arthroplasty. Reported patient and provider factors were evaluated for their association with increased LOS and discharge to a facility.

RESULTS

Twenty-two studies were identified. Age >65 years, female sex, obesity, and reverse shoulder arthroplasty were associated with extended LOS and correlated with discharge to a facility. Greater hospital and surgeon volume were associated with decreased LOS and decreased risk of discharge to a facility. Local injection of liposomal bupivacaine combined with intravenous dexamethasone was associated with reduced LOS.

DISCUSSION

Patient factors affecting LOS and likelihood of discharge to a facility include age >65 years, female sex, diabetes, obesity, and reverse shoulder arthroplasty. These factors can be used to develop studies to preoperatively predict outcomes after shoulder arthroplasty and to help identify patients who may be at risk of prolonged postoperative admission.

LEVEL OF EVIDENCE

Prognostic level IV.

An analysis of costs associated with shoulder arthroplasty

BACKGROUND

The purpose of this study was to identify factors associated with variation in direct costs with shoulder arthroplasty.

METHODS

This was a retrospective study of all shoulder arthroplasties performed at a single facility between July 1, 2011, and November 30, 2016. We collected patient factors, indications, procedure (including implant details), implant brand (A, B, and other), and complications. We collected direct costs over a 90-day period using a validated internal tool. We identified patient and procedure characteristics associated with costs using multivariable generalized linear models.

RESULTS

A total of 361 patients were included, 19% with revision arthroplasty procedures, 32% with anatomic total shoulder arthroplasties, and 66% with reverse total shoulder arthroplasties (RTSAs). Of total costs, 13% were operative facility utilization costs and 58% were operative supply costs. Factors associated with increased total cost included younger age (P = .002) and an indication for surgery of other, that is, not osteoarthritis, a failed arthroplasty, or the sequelae of a rotator cuff tear (P = .030). Factors associated with increased operative costs included younger age (P = .002), use of an RTSA (P < .001), use of a bone graft (P < .001), implant brand B (P = .098), implant brands other than A and B (P = .04), the sequelae of a rotator cuff tear as an indication for surgery (P = .041), or an indication for surgery of other (P = .007).

CONCLUSION

Most short-term (90-day) costs with shoulder arthroplasty are operative costs. Nonmodified factors associated with increased cost included younger age and less common indications for surgery, whereas potentially modifiable factors included the intraoperative use of a bone graft, implant brand, and RTSA use.

Reducing Lateral Femoral Cutaneous Nerve Palsy in Obese Patients in the Beach Chair Position: Effect of a Standardized Positioning and Padding Protocol

INTRODUCTION

To report on the effectiveness of a standardized patient positioning and padding protocol in reducing lateral femoral cutaneous nerve (LFCN) palsy in obese patients who have undergone shoulder surgery in the beach chair position.

METHODS

We retrospectively reviewed the medical records of 400 consecutive patients with a body mass index (BMI) of ≥30 kg/m who underwent either open or arthroscopic shoulder surgery in the beach chair position by a single surgeon. Before June 2013, all patients were placed in standard beach chair positioning with no extra padding. After June 2013, patients had foam padding placed over their thighs underneath a wide safety strap and underneath the abdominal pannus. Flexion at the waist was minimized, and reverse Trendelenburg was used to position the shoulder appropriately. Patient demographic and surgical data, including age, sex, weight, BMI, presence of diabetes, procedure duration, American Society of Anesthesiologists (ASA) grade, and anesthesia type (general, regional, regional/general) were recorded. Symptoms of LFCN palsy were specifically elicited postoperatively in a prospective fashion and identified clinically by focal pain, numbness, and/or tingling over the anterolateral thigh.

RESULTS

The median age was 58.0 years, and the study consisted of 142 male (36%) and 258 female (64%) subjects. Five cases (3.6%) of LFCN palsy occurred with conventional beach chair positioning, and a single case (0.4%) occurred with the standardized positioning and padding technique (P = 0.02). Median age, sex, presence of diabetes, median BMI, surgery type, and surgical time were not significantly different between the patients who did and did not develop LFCN palsy. All cases resolved completely within 6 months.

DISCUSSION

The occurrence of LFCN palsy following shoulder surgery in the beach chair position remains uncommon, even among obese patients. Use of a standardized positioning and padding protocol for obese patients in the beach chair position reduced the prevalence of LFCN palsy.

LEVEL OF EVIDENCE

Level III (prognostic).

Shoulder arthroplasty. Comorbidity as prognostic factor

Introduction

Preoperative comorbidity seems to be an important factor for the functional recovery of patients after shoulder replacement, but few studies support this correlation.The purpose of this study was to clinically evaluate the influence of comorbidity in restoring function after shoulder replacement.

Methods

We performed a retrospective analysis of shoulder replacement accomplished at our institution from 2005 to 2016 (n = 70). Demographic data, number of comorbidities, preoperative drugs, type of arthroplasty, and postoperative complications were collected. Functional results were evaluated according to the QuickDASH questionnaire.

Results

QuickDASH as continuous data was directly correlated with number of drugs prior to the surgical intervention (R = 0.270, p = 0.024) and number of comorbidities (R = 0.280, p = 0,016); especially neurological disorders (R = 0.338, p = 0.004) and osteoporosis (R = 0.0242, p = 0.043). The QuickDASH score is inversely correlated with patient satisfaction (R = -0.621, p < 0.01) and with gender (male) (R = -0.469, p < 0.001).When the patients were divided into 2 equally sized groups according to the QuickDASH score, statistical significance was found between the group with the worst outcome and female sex (91.2%) (p < 0.001), neurological disorders (p = 0.004), alcohol consumption (p = 0.028) and when shoulder arthroplasty is due to proximal humeral fracture (p = 0.002).

Conclusion

Better functional results are obtained in patients with less comorbidities.Worse functional results are obtained in patients taking more drugs, in women, alcohol consumers and those after proximal humeral fractures. Preoperative clinical status must be optimized and the patients' comorbidities should be carefully taken into accounting order to ascertain the correct shoulder arthroplasty.

The Effect of Obesity in Shoulder Arthroplasty Outcomes and Complications

The effect of obesity in shoulder arthroplasty has been recently reported in the literature with different and conflicting results. This review analyzes the role of obesity on outcomes and complications in shoulder arthroplasty. Morbid obesity (body mass index >40 kg/m²), more than standard obesity, is associated with a longer operative time, higher complication rate, reoperation rate and superficial infection. Obesity does not have a detrimental effect on functional outcomes. The magnitude of functional improvement in obese patients, however, can be inferior to that in nonobese patients. Obesity and morbid obesity do not increase hospital charges.

The Influence of Obesity on Total Elbow Arthroplasty

Total elbow arthroplasty (TEA) has undergone a significant evolution in indications and outcomes in the past decade. Although rheumatoid patients once had the overwhelming number of TEAs, now TEAs for the sequelae of trauma predominate. Furthermore, as obesity has mirrored the increase in the posttraumatic population, TEA complications have increased whereas the durability of implants under these loads has decreased. Solutions are urgently needed to address the complications and revision burden related to posttraumatic deformity and obesity.

Good functional outcomes expected after shoulder arthroplasty irrespective of body mass index

BACKGROUND

This study evaluated how body mass index (BMI) factors into functional outcomes and complications after shoulder arthroplasty.

METHODS

A retrospective analysis was performed of age-matched patients with a minimum 2-year follow-up after total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), or hemiarthroplasty (HA). Patient-reported outcome (PRO) scores, range of motion (ROM), and complications were assessed. Forty-nine patients were classified into the following groups: normal (BMI <24.9 kg/m²), overweight (BMI 25-29.9 kg/m²), class I obese (BMI 30-34.9 kg/m2), class II obese (BMI 35-39.9 kg/m²), and class III morbid obese (BMI ≥40 kg/m²).

RESULTS

A total of 245 patients (134 women, 111 men; average age, 64 ± 8 years) were evaluated at an average follow-up of 48 ± 18 months. TSA was performed in 122 patients (50%), RTSA was performed in 103 (42%), and HA was performed in 20 (8%). No significant difference was found among the 5 BMI groups in arthroplasty type (P = .108) or in complications, including reoperations (P = .27). All groups had significant postoperative improvements in PROs and ROM (P < .001 for both). There were no significant differences among the BMI groups in postoperative ROM or PROs.

DISCUSSION

This study demonstrates that patients undergoing TSA, RTSA, and HA can expect good functional outcomes, with improvements in pain, function and outcome scores, irrespective of BMI.

Reverse shoulder arthroplasty in obese patients: analysis of functionality in the medium-term

INTRODUCTION

Obesity is an epidemic nowadays and this fact conditions results in orthopaedic surgery. Very few studies evaluates if obesity is a risk factor for reverse shoulder arthroplasty. The aim of this study is to confirm if there are differences with regard to the outcomes in patients undergoing reverse shoulder arthroplasty according to their body mass index (BMI).

MATERIALS AND METHODS

A total of 35 patients were enrolled in the study. Then divided into subpopulations according to their BMI and analyzed twice. First analysis set a division 30 of BMI and second set it in 35. ASES score, major complications, length of the hospital stay, radiolucent lines in components as well as scapular notching were assessed.

RESULTS

No major complications were described in our patients. No differences were found related to hospital stay, radiolucent lines or scapular notching. However, in the second analysis (BMI < 35 and ≥ 35) statistical differences were found regarding ASES score. Poorer functional outcomes were described in the type-II obese and morbidly obese population.

CONCLUSION

Functional outcomes of reverse shoulder arthroplasty are worse in patients with a BMI over 35.

Periprosthetic humeral fractures after reverse shoulder arthroplasty. Case report

Periprosthetic fractures is a severe complication after joint replacement. The rapidly increase of reverse shoulder arthroplasty surgeries, periprosthetic humeral fractures, which are described as rare, may increase in the near future. We report the case of displaced humeral fracture bellow the stem of reverse shoulder prosthesis. The patient was an 85-year-old woman who had a total shoulder replacement 6 years previously. The surgical solution consisted of plate osteossynthesis and cerclage. This report describes an unprecedented case in Brazilian literature; and gives an overview of the existing literature including this injury classification.

Shoulder arthroplasty following gastric bypass, do complications follow?

INTRODUCTION

Previous reports have shown an increased risk of complications after arthroplasty in the obese population. It remains unclear if gastric bypass surgery prior to shoulder arthroplasty modifies the complication and failure rate. The purpose of this study is to assess the complication and re-operation rates following shoulder arthroplasty in this population.

METHODS

Between 2002 and 2012, 39 shoulders with prior gastric bypass underwent shoulder arthroplasty (3 HA, 16 TSA, 20 RSA). The mean time from the gastric bypass to arthroplasty was 13 years (range, 0.7-32). Shoulders were followed for a minimum of two years (mean, 3.8 years) or until re-operation. Outcome measures included pain, range of motion, satisfaction, modified Neer ratings, and ASES scores.

RESULTS

Complications occurred in seven shoulders (18%), with five requiring re-operation. There was no common failure mechanism. Re-operations occurred for aseptic glenoid loosening, periprosthetic fracture, and unexplained pain. Those shoulders with complications were similar to those without in regard to age, sex, and BMI. Complications were more common following anatomic arthroplasty compared to reverse arthroplasty (5 vs 1, p = 0.06); however, complications were not improved compared to historical controls with morbid obesity. Overall, pain improved significantly from 4.8 pre-operatively to 2.3 postoperatively (p < 0.001). All groups, regardless of arthroplasty type, demonstrated significant improvements in forward elevation and external rotation.

CONCLUSION

Gastric bypass surgery prior to shoulder arthroplasty leads to clinical improvement in both pain and range of motion. Prior gastric bypass surgery does not result in a lower surgical complication rate compared to previously published reports in the morbidly obese population.

LEVEL OF EVIDENCE

Level 4, case series.

Complications in total shoulder and reverse total shoulder arthroplasty by body mass index

INTRODUCTION

The purpose of this study was to identify the effects of body mass index (BMI) on long-term outcomes (revision rate, 1-year mortality rate, 3-year surgical site infection rate, and 90-day inpatient all-cause readmission rate) after total shoulder arthroplasty (TSA) and reverse TSA (RTSA).

METHODS

A large shoulder arthroplasty registry was used to review outcomes after TSA and RTSA. The registry monitors patient's revision, mortality, infection, and readmission rates. The exposure of interest was the patient's BMI at the time of the surgery, which was stratified by 5 kg/m² increments.

RESULTS

Selected for this study were 4630 patients who underwent TSA and RTSA between 2007 and 2013, of which 3483 (75.2%) were TSA and 1147 (24.8%) were RTSA. The overall combined (TSA and RTSA) revision rate was 1.7%. After adjusting for confounders in the overall models (TSA and RTSA combined), higher BMI was not associated with higher risk of aseptic revision, 1-year mortality, or 3-year deep infection. In TSA-specific models, every 5 kg/m² increase in BMI was marginally associated with a 16% increase in the likelihood of 90-day readmission. This association was not observed in the RTSA model. In RTSA-specific models, every 5 kg/m² increase in BMI was marginally associated with higher risk of 3-year deep infection. This association was not observed in the TSA model.

CONCLUSION

Shoulder arthroplasty in obese patients is not associated with higher risk of aseptic revision. The BMI has different effects on TSA and RSA. The surgeon should anticipate increased risk of readmission after TSA and infection after RSA.

Comorbidity effects on shoulder arthroplasty costs analysis of a nationwide private payer insurance data set

BACKGROUND

The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures.

METHODS

We conducted a retrospective query of a single private payer insurance claims database using PearlDiver (Warsaw, IN, USA) from 2010 to 2014. Our search included the Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for total shoulder arthroplasty (TSA), hemiarthroplasty, and reverse shoulder arthroplasty (RSA). Medical comorbidities were also searched for through International Classification of Diseases codes. The comorbidities selected for analysis were obesity, morbid obesity, hypertension, smoking, diabetes mellitus, hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease, cirrhosis, depression, and chronic kidney disease (excluding end-stage renal disease). The reimbursement charges of the day of surgery, 90-day global period, and 90-day period excluding the initial surgical day of each comorbidity were analyzed and compared. Statistical analysis was conducted through analyses of variance or Kruskal-Wallis test.

RESULTS

Comorbidities did not have a significant effect on same-day reimbursements but instead caused a significant effect on the subsequent 89-day (interval) and 90-day reimbursements in the TSA and RSA cohorts. For TSA and RSA, the highest reimbursement costs during the 90-day period after surgery were seen with the diagnosis of hepatitis C, followed by atrial fibrillation and later chronic obstructive pulmonary disease. For hemiarthroplasty, the same was true in the following order: hepatitis C, cirrhosis, and atrial fibrillation.

CONCLUSION

Shoulder arthroplasty reimbursements are significantly affected by comorbidities at time intervals following the initial surgical day.

Increasing Body Mass Index Is Associated with Worse Outcomes After Shoulder Arthroplasty

BACKGROUND

Although obesity is associated with increased complication rates after lower-extremity arthroplasty, there is a relative paucity of studies examining the effect of body mass index (BMI) on shoulder arthroplasty. The purpose of this investigation was to evaluate the effect of BMI on implant survival and the rate of complications after shoulder arthroplasty.

METHODS

Using an institutional total joint registry, 4,567 consecutive shoulder arthroplasty cases from 1970 to 2013 were studied. The mean BMI was 29.7 kg/m (range, 14 to 66 kg/m), with 1,622 patients (36%) with a BMI of 30 to 40 kg/m and 297 patients (7%) with a BMI of >40 kg/m. There were 2,493 female patients (55%). BMI was dichotomized after examination of the smoothing spline curve. The associations of factors and complications were assessed using Cox proportional hazard regression analysis.

RESULTS

Increasing BMI was associated with an increased risk of a revision surgical procedure, reoperation, revision for mechanical failure, and superficial infection, and it was negatively associated with risk of a periprosthetic fracture. The risk of a revision surgical procedure increased in a linear fashion with increasing BMI (hazard ratio [HR], 1.05, or a 5% increased risk per 1 unit of BMI; p = 0.03). Increased BMI was also associated with an increased risk of revision for mechanical failure (HR, 1.05; p = 0.004). In a multivariate model, the association of BMI and risk of a revision for any reason, revision for mechanical failure, and reoperation maintained significance (p ≤ 0.02). The most marked association between increasing BMI and any complication in shoulder arthroplasty was its association with superficial wound infection (HR, 1.09; p = 0.03).

CONCLUSIONS

Increasing BMI is strongly associated with increased rates of revision surgical procedures and postoperative complications after shoulder arthroplasty. It is important to consider these findings when counseling patients, estimating risks, and estimating complication risks in policy decisions.

LEVEL OF EVIDENCE

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

Generic targeting guides place revision glenoid components in more anatomic version than traditional techniques

BACKGROUND

Glenoid component positioning in revision shoulder arthroplasty is difficult because of distorted anatomic landmarks and scarring in and around the glenoid vault. This study compared glenoid component version in revision total shoulder arthroplasty (TSA) and reverse TSA (RTSA) using traditional instrumentation vs. a generic glenoid targeting guide.

METHODS

Radiographs of 50 shoulders undergoing revision arthroplasty were reviewed by an independent reviewer. Twenty-one components were placed using traditional instrumentation and 29 with a generic targeting guide. Glenoid component version was measured on axillary lateral radiographs, and absolute deviation from anatomic version was calculated.

RESULTS

The average deviation in version from anatomic was 8° (range, 0°-21°) with the traditional technique and 5° (range, 0°-18°) with the targeting guide (P = .03). In revision to TSA, the average deviation was 10° with the traditional technique and 3° with the targeting guide (P = .01). There was no significant difference in revision to RTSA (average deviation was 8° with traditional technique and 6° with the targeting guide). Glenoid components in obese patients (body mass index  >30 kg/m²) had less deviation (5°) with the targeting guide technique than with the traditional technique (9°, P = .04). No significant differences were found between techniques in glenoids with more than 15° of preoperative retroversion, TSA conversion to RSTA, or arthroplasty after proximal humeral fixation.

CONCLUSIONS

For revision arthroplasty, glenoid components placed with the generic targeting guide were significantly more accurate in version than with traditional instrumentation, particularly with revision to anatomic TSA. The targeting guide was useful in obese patients.

Resilience correlates with outcomes after total shoulder arthroplasty

BACKGROUND

Resilience, characterized by an ability to bounce back or recover from stress, is increasingly recognized as a psychometric property affecting many outcomes' domains including quality of life, suicide risk in active-duty military personnel, and recovery in cancer patients. This study examines the correlation between resilience, as measured by the Brief Resilience Scale (BRS), and traditional outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn scores in patients undergoing total shoulder arthroplasty (TSA).

METHODS

Seventy patients undergoing primary anatomic TSA were followed up for a minimum of 2 years (mean, 30 ± 3 months). Patients were stratified into groups a priori, based on deviation from the mean of the BRS score, into low-resilience (LR), normal-resilience (NR), and high-resilience (HR) patients, and outcome scores were calculated for each group.

RESULTS

Postoperative BRS scores significantly correlated with ASES, Penn, and SANE scores (r = 0.41-0.44, P < .004 for all scores). When we evaluated patients based on resilience group, the LR group had a Penn score that was 34 points lower than that in the HR group. Likewise, the LR group had a SANE score that averaged 40 points lower than that in the HR group (SANE score of 53 points in LR group and 92 points in HR group, P = .05). When we evaluated ASES subscores, it appeared that the pain subscale was responsible for most of the difference between the LR and HR groups (29 points and 48 points [out of 50 points], respectively; P = .03).

CONCLUSIONS

Resilience is a major predictor of postoperative outcomes after TSA. Patients who are classified as having LR have outcome scores that are 30 to 40 points lower on traditional outcome scales than patients with HR.

The influence of diabetes mellitus and obesity on upper limb arthroplasty outcomes: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to locate and synthesize the best available evidence investigating the impact of selected comorbidities on upper limb arthroplasty outcomes.The review question is: Are patients with diabetes mellitus or obesity at an increased risk of complications and/or poorer postoperative outcomes following total shoulder, reverse total shoulder and total elbow arthroplasty?