Difference in clinical outcome between total shoulder arthroplasty and reverse shoulder arthroplasty used in hemiarthroplasty revision surgery

Does Reverse Shoulder Arthroplasty Improve Function and Quality of Life in Patients With Rotator Cuff Tear Arthropathy?

Background This study aims to determine the change in functional capacity and quality of life in patients who underwent reverse shoulder arthroplasty (RSA) due to rotator cuff tear arthropathy (RCTA). Methodology A total of 89 patients who underwent RSA due to RCTA between 2016 and 2022 were included in the study, as examined by the senior author. The Constant-Murley Score (CMS) was used for functional assessment, whereas the Short Form-36 (SF-36) was used for quality-of-life evaluation. The assessment scores before and after the surgery were compared to the reference values of CMS and SF-36 scores, as determined by reference studies, based on age groups. The change in functional capacity and quality of life with RSA was calculated. In addition, the impact of age and body mass index (BMI) on the results was examined. Results No differences were found in demographic data except for BMI (p = 0.026). CMS did not reach the reference values of a normal shoulder during the 12-month postoperative period. However, a significant increase of 156% in comparison to the preoperative values was detected (p < 0.001). In the postoperative period, there was a statistically significant improvement in SF-36 scores compared to preoperative scores, except for social functioning (p = 0.099) and vitality (p = 0.255) (for all other parameters, p < 0.001). In patients under the age of 65 years, all parameters except for physical functioning, physical role, and social functioning statistically reached the reference values. A decrease in CMS scores was noted with an increase in BMI, and the negative correlation further increased in the postoperative period (preoperative: r = -0.274, 12-month postoperative: r = -0.476). Conclusions RSA performed for RCTA leads to an improvement in functional outcomes and quality of life. Although there was a considerable improvement after surgery for CMS compared to preoperatively, it was observed that normal shoulder reference values ​​could not be reached. For SF-36, it was observed that it reached normal shoulder reference values, especially in patients over 65 years of age.

Outcome and complications following revision shoulder arthroplasty : a systematic review and meta-analysis

AIMS

It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis.

RESULTS

A total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores.

CONCLUSION

Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA. Cite this article: Bone Jt Open 2021;2(8):618-630.

Unexpected positive cultures after revision shoulder arthroplasty: does it affect outcome?

BACKGROUND

Several studies have confirmed a high rate of unexpected positive cultures (UPCs) after presumably aseptic revisions of shoulder arthroplasties; however, the impact on the outcome is still unclear. The purpose of this prospective study is to compare the patient-reported outcomes of standard revisions with and without the emergence of UPCs.

METHODS

During a 3-year period, we included all patients who were revised for reasons other than suspicion of infection from 2 orthopedic centers. Five biopsies were obtained from every revision, and only cultures with the same bacteria in at least 3 biopsy specimens were classified as UPCs. All patients were assessed using the Oxford Shoulder Score (OSS) and range of motion preoperatively and after at least a 2-year follow-up.

RESULTS

In this study, 124 patients were included, with a median follow-up of 29 months (range 29-32), and UPCs emerged after 27 revisions (22%), with Cutibacterium acnes accounting for 67% (18/27). At baseline, the OSS was 22 in both the culture-negative and UPC groups (P = .46). Then, at follow-up, the OSS was 37 in the culture-negative group and 35 in the UPC group (P = .91). The forward elevation increased significantly by 44° and 41°, respectively, in the 2 groups, but no statistically significant difference between the culture-negative group and the UPC group was found (P = .66). In contrast, the external rotation was unchanged after the revision, and again, no difference in the change between the culture-negative and UPC groups (P = .54) was observed. Subgroup analyses stratified by different implant designs revealed equal patterns with no statistical differences in outcome.

CONCLUSION

We did not find a difference in outcome after a presumed aseptic revision regardless of the emergence of UPCs. Similarly, we could not demonstrate that patients with UPCs presented with poorer function at baseline compared with culture-negative patients. The clinical relevance of UPCs thus requires further evaluation, especially in the case of C acnes as a potential pathogenic versus a merely colonizing microbe.

Reversed shoulder arthroplasty leads to significant histological changes of the deltoid muscle: a prospective intervention trial

INTRODUCTION

Reverse shoulder arthroplasty (RSA) shows promising short- and mid-term results in cuff tear arthropathy. However, functional impairments are described in long-term findings. Micromorphological changes in the periarticular musculature could be in part responsible for this, but have not yet been analysed. Thus, histological changes of the deltoid muscle and their association to the functional outcome were evaluated in this study.

MATERIAL AND METHODS

A total of 15 patients treated with RSA were included in this prospective study. Functional outcome was assessed using the Constant Score (CS) and the DASH (disabilities of the arm, shoulder and hand) Score before RSA and after a mean follow-up of 12 months. Deltoid muscle biopsies were harvested intraoperatively and 12 months postoperatively. Mean deltoid muscle fibre area (MMFA) was calculated histologically after haematoxylin-eosin staining.

RESULTS

Postoperative shoulder function significantly improved within 12 months (CS: Δ 37.4 ± 22.6, p = 0.001; DASH: Δ 27.1 ± 29.1, p = 0.006). The MMFA significantly decreased (p = 0.02), comparing the results from the intraoperative biopsy (MMFA: 8435.8 µm², SD ± 5995.9 µm²) to the 12 months biopsy (MMFA: 5792. µm², SD ± 3223.6 µm²). No correlation could be found between the functional score results and MMFA.

CONCLUSION

Signs of deltoid muscle changes in terms of a reduced MMFA can be detected 1 year after RSA and thus already a long time before long-term functional impairments become apparent. Further studies with larger patient series and longer follow-up periods as well as extended histological assessments and simultaneous radiological examinations are required.

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

Background

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous.

Methods

Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests.

Results

The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%.

Conclusions

Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.

Revision shoulder arthroplasty: a systematic review and comparison of North American vs. European outcomes and complications

BACKGROUND

Joint registries provide invaluable data on primary arthroplasties with revision as the endpoint; however, the revision outcomes are often excluded. Therefore, a PROSPERO registered review (CRD42015032531) of all revision studies in North America and Europe was conducted to evaluate demographics, etiologies and indications, implant manufacturer, and complications by geographic region.

METHODS

The MEDLINE, EMBASE, and CENTRAL databases were searched for revision arthroplasty clinical studies with a minimum mean 24-month follow-up. There were no language exclusions. Articles published in German, French, and Italian were reviewed by research personnel proficient in each language.

RESULTS

The mean age at revision was 66 ± 5 years (male = 759, female = 1123). The male-female ratio in North American and Europeans studies was 43:57 and 34:66, respectively. The most common etiology for primary surgery in both regions was osteoarthritis or glenoid arthrosis (38%). The most common revision indication overall was rotator cuff tear, deficiency, or arthropathy (26%). The most common implant type used in revisions was a reverse shoulder arthroplasty (54%). The complication rate for all revisions was 17%. There were a total of 465 complications, and of those, 74% lead to a reoperation.

CONCLUSION

Generally, shoulder arthroplasties are designed to last 10-15 years; however, revisions are being performed at a mean 3.9 years from the primary procedure, based on the published studies included in this systematic review. Additionally, of the complications, a large number (74%) went on to a reoperation. Further insight into the reasons for early revisions and standardized reporting metrics and data collection on revisions is needed.

Reverse total shoulder arthroplasty in the younger patient (≤65 years): a systematic review

The purpose of this study was to evaluate outcomes of reverse total shoulder arthroplasty (RTSA) in patients aged ≤65 years. MEDLINE, Embase, and PubMed were searched for relevant studies from database inception to September 18, 2018. All studies that evaluated RTSA in patients aged ≤65 years were included. Two independent reviewers screened all studies and performed a quality assessment. In the total of 6 studies reviewed, 245 participants underwent RTSA, with the most common indications being failed rotator cuff repair and rotator cuff tear arthropathy. Postoperative functional outcomes indicated a significant level of improvement across all reported outcomes at a mean follow-up of 49 months (range, 19-140 months) (P < .05). The pooled mean complication rate was 18% (n = 44/245), and this higher rate may be due to 36% of patients undergoing an RTSA for a failed arthroplasty procedure and the inclusion of older studies that lacked modern implants and techniques. Although there is a significant improvement in functional outcomes at midterm follow-up for RTSA in the patients aged ≤65 years, the pooled complication rates are high. However, the results of this systematic review are limited because of the heterogenous patient population undergoing surgery for various indications, including revision arthroplasty. Long-term studies and registry data are required using current modern techniques and implants to provide an accurate assessment of outcomes following RTSA in a young patient population.

[Shoulder prosthesis replacement options : New implants, treatment algorithms and clinical results]

BACKGROUND

Bony defect situations are a common problem in revision arthroplasty of the shoulder and are the cause of the complexity of the procedure. Aseptic and septic loosening as well as difficult implant removal can result in humeral and/or glenoid bone loss.

PLANNING

A careful preoperative imaging is needed to estimate the extent of the bony defect and to enable precise planning of the bone reconstruction and the required implants. However, the size of the defect needs to be re-evaluated intraoperatively after removal of the implant components and any larger defects have to be addressed appropriately.

PROSTHESIS DESIGN

While in the glenoid autologous bone grafts and, to a lesser extent, allogenic bone grafts are preferred, metallic augmented implants have recently become available to fill the glenoid bone defect. However, humeral defects are normally addressed with longer revision stems, possibly with allograft augmentation. The soft tissue loss in proximal humeral defects can be addressed with fixation techniques to improve function and reduce the risk of dislocation. Modern modular prosthesis designs allow prosthesis conversion while leaving bony, tightly integrated component parts on the glenoid or shaft. This review describes the preoperative diagnostic steps as well as techniques for revision surgery of the shoulder in the case of bone loss.

How common are acromial and scapular spine fractures after reverse shoulder arthroplasty?: A systematic review

AIMS

Acromial fractures following reverse shoulder arthroplasty (RSA) have a wide range of incidences in reported case series. This study evaluates their incidence following RSA by systematically reviewing the current literature.

MATERIALS AND METHODS

A systematic review using the search terms "reverse shoulder", "reverse total shoulder", or "inverted shoulder" was performed using PubMed, Web of Science, and Cochrane databases between 1 January 2010 and 31 March 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Studies were included if they reported on RSA outcomes and the incidence rate of acromial and/or scapular spine fractures. The rate of these fractures was evaluated for primary RSA, revision RSA, RSA indications, and RSA implant design.

RESULTS

The review included 90 articles out of 686 identified after exclusions. The incidence rate of acromial and/or scapular spine fractures was 2.8% (253/9048 RSAs). The fracture rate was similar for primary and revision RSA (2.8% vs 2.1%; p = 0.4). Acromial fractures were most common after RSA for inflammatory arthritis (10.9%) and massive rotator cuff tears (3.8%). The incidence was lowest in RSA for post-traumatic arthritis (2.1%) and acute proximal humerus fractures (0%). Lateralized glenosphere design had a significantly higher rate of acromial fractures compared with medial glenosphere designs.

CONCLUSION

Based on current English literature, acromial and/or scapular spine fractures occur at a rate of 2.8% after RSA. The incidence is slightly more common after primary compared with revision arthroplasty. Also, higher rates of acromial fractures are reported in RSA performed for inflammatory arthritis and in the lateralized glenoid design. Cite this article: Bone Joint J 2019;101-B:627-634.

Revision of Failed Resurfacing Hemiarthroplasty: Midterm Results, Survival, and Group Comparison

Shoulder arthroplasty is a valuable option for treating glenohumeral osteoarthritis. Revision surgery for a failed shoulder arthroplasty is associated with difficult procedures, complications, and worse outcomes. Compared with a total joint arthroplasty, a resurfacing prosthesis has the supposed advantages of limited perioperative complications and little bone loss during revision. The aim of this study was to describe patient-reported outcome measures of revision surgery from failed uncemented Global CAP (DePuy, Warsaw, Indiana) resurfacing hemiarthroplasty to total shoulder or reverse shoulder arthroplasty. Eleven patients from 2 collaborating institutes had a failed resurfacing prosthesis. Revision surgery was performed to total shoulder prosthesis in 7 patients and to reverse shoulder prosthesis in 3 patients. Data were missing for 1 patient. Outcomes were monitored using the Constant-Murley score, Dutch Simple Shoulder Test, Short Form-12, visual analog scale for pain, and physical examination. Mean time to revision was 54 months (SD, 15.6 months). No perioperative complications occurred. At 42 months of follow-up (SD, 15.9 months), clinical and patient-reported outcomes were excellent. The Constant-Murley score improved a significant 29 points (P<.01). The visual analog scale pain score decreased from 55 to 5 points (P<.01), and the Dutch Simple Shoulder Test and Short Form-12 scores improved significantly (P≤.02). Five-year survival was 82.6% (95% confidence interval, 71.6%-93.6%). At 3.5-year follow-up, clinical and patient-reported outcome measures had satisfying results. [Orthopedics. 2019; 42(1):e111-e117.].

Revision of failed hemiarthroplasty for painful glenoid arthrosis to anatomic total shoulder arthroplasty

BACKGROUND

The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Painful glenoid arthrosis following hemiarthroplasty is a common cause of reoperation, and conversion to anatomic total shoulder arthroplasty is one option.

METHODS

We identified patients who underwent revision of painful hemiarthroplasty to total shoulder arthroplasty over a 15-year period in a single tertiary-care health system. Presurgical and operative data were analyzed for 28 patients who met the inclusion and exclusion criteria. Patients were contacted at a minimum of 2 years' follow-up after revision surgery for functional outcome scores, reoperations, and implant survival.

RESULTS

The 2- and 5-year implant survival rates were 93% and 86%, respectively. Functional outcomes were obtained from 21 patients with surviving implants. The mean American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Single Assessment Numerical Evaluation score were 78 ± 20, 2.3 ± 2.6, and 71 ± 24, respectively. The mean Short Form 12 mental and physical scores were 49 ± 10 and 43 ± 9, respectively. Of the patients, 17 (81%) were either satisfied or very satisfied with their outcome. Complications were seen in 10 patients (36%), and 6 patients (21%) required reoperation.

CONCLUSIONS

Anatomic total shoulder arthroplasty following hemiarthroplasty can achieve successful outcomes and implant survival rates. Given our poor understanding of reverse shoulder arthroplasty longevity, this procedure should remain an option for patients with glenoid arthrosis and an intact rotator cuff.

Clinical and radiological results 7 years after Copeland shoulder resurfacing arthroplasty in patients with primary glenohumeral osteoarthritis: an independent multicentre retrospective study

PURPOSE

The aim of this multicentre cohort study was to evaluate the midterm outcomes and survival after cementless stemless resurfacing arthroplasty (CSRA) in a series of 33 shoulders in 27 patients with primary osteoarthritis.

METHODS

Clinical outcome assessment included: Constant-Murley score (CMS); Simple Shoulder Test (SST); Disability of Arm, Shoulder, Hand (DASH); EuroQol-5D (EQ-5D) utility scores; Numerous Rating Scale (NRS) for pain. Radiographs were assessed by two independent observers for oversizing, radiolucency, glenohumeral subluxation, glenoid erosion and subsidence. Correlations between the clinical and radiological outcomes were calculated. Complications were registered, and revision and survival rates were calculated.

RESULTS

Mean age at time of surgery and mean follow-up time were, respectively, 67.7 (range 50.2-85.1) and 7.2 years (range 5.7-9.3 years). Means (SD) for CMS, age- and gender-adjusted CMS, SST, DASH and EQ-5D utility scores were: 56.4 (20.2), 76.5 (25.0), 54.0 (29.8), 37.6 (23.3) and 0.8 (0.1), respectively. NRS for pain was 2.0 and 3.8, respectively, in rest and during activities. Radiographic assessment of the CSRAs showed oversizing in 54.5%; radiolucency in 18.2%; superior glenohumeral subluxation in 33.3%; glenoid erosion in 45.5%; and subsidence in 3.0%. Perioperative complications did not occur. Revision surgery was performed in one patient (3.0%).

CONCLUSION

For primary osteoarthritis, the CSRA showed good clinical but poor radiological outcomes at midterm follow-up.

Use of a shorter humeral stem in revision reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to examine the outcomes of revision reverse arthroplasty using short bone-preserving humeral components in revising a long-stemmed component.

METHODS

During a 7-year period, 39 patients who underwent revision reverse shoulder arthroplasty using the long to short humeral component technique were included. The mean age was 72 years. Prior implants used in the primary setting included anatomic (n = 26), hemiarthroplasty (n = 11), and reverse (n = 2).

RESULTS

At a follow-up of 3 years (2-5), 5 shoulders (13%) required revision surgery, including 1 for a periprosthetic humerus fracture and 4 for glenoid component loosening. The survival free of revision for any reason and revision for humeral disease was 84% and 94%, respectively. One patient experienced a nondisplaced greater tuberosity fracture at 18 months postoperatively that healed without operative intervention. There were no dislocations or infections. Overall, patients experienced excellent overall improvements in their pain levels and shoulder motion (P < .001), with a postoperative 91% satisfaction rate as well as postoperative American Shoulder and Elbow Surgeons score of 68 and Simple Shoulder Test score of 6.7. At most recent radiographic follow-up, 1 (5%) patient had grade 3 humeral lucency.

CONCLUSIONS

Preserving bone stock through conversion to a shorter reverse humeral stem in the revision setting is a reasonable option with good short- to intermediate-term results and low rates of humeral complications. Using the shorter stem components provides adequate stability and high rates of humeral component ingrowth.