Return to sports after shoulder arthroplasty

Total Shoulder Arthroplasty is associated With Less Pain and Better Functional Outcomes, but Humeral Head Resurfacing may be Preferred in Younger, Higher Demand Patients: A Short-Term Outcomes Study in Patients with Glenohumeral Osteoarthritis

Objectives

This study aimed to compare short-term outcomes following Total Shoulder Arthroplasty (TSA) and Humeral Head Resurfacing (HHR) in patients with glenohumeral osteoarthritis (GHOA).

Methods

A retrospective analysis included patients who had undergone either TSA or HHR for GHOA at a single institution. Baseline demographics, complications, range of motion (active forward flexion, FF and active external rotation, ER), visual analog scores (VAS), and Subjective Shoulder Values (SSV) were collected.

Results

A total of 69 TSA and 56 HHR patients were analyzed. More HHR patients were laborers (44% versus 21%, P=0.01). There were more smokers in the TSA group (25% versus 11%, P=0.04) and more cardiovascular disease in the HHR cohort (64% versus. 6%, p<0.0001). Postoperative FF was similar, but ER was greater in the HHR (47° ± 15°) vs. TSA group (40° ± 12°, P = 0.01). VAS was lower after TSA vs. HHR (median 0, IQR 1 versus median 3.7, IQR 6.9, p<0.0001), and SSV was higher after TSA (89% ± 13% vs. 75% ± 20% after HHR; p<0.0001). Post-operative impingement was more common after HHR (32% vs. 3% for TSA, p<0.0001). All other complications were equivalent.

Conclusion

While younger patients and heavy laborers had improved ER following HHR, their pain relief was greater after TSA. Decisions on surgical technique should be based on patient-specific demographic and anatomic factors.

Comparison of Treatment Options of Three- and Four-Part Humerus Proximal Fractures in Patients Over 50 Years of Age

Introduction

Our aim was to evaluate different treatment methods including conservative treatment (CT), locking-plate osteosynthesis (OS) and hemiarthroplasty (HA) in three- and four-part humeral fractures in patients older than 50 years.

Methods

Forty-seven patients that have at least one year of follow-up were divided into three groups: 18 patients treated with OS, 14 patients treated conservatively and 15 patients treated with HA. For further evaluation, constant shoulder score, disabilities of the arm, shoulder and hand score (DASH), American Shoulder and Elbow Society (ASES) score had been used. Shoulder range of motion was also assessed.

Results

OS and CT groups had better scores than HA group. In OS group, average Constant score was 71.6 ± 16.2, DASH score was 12.1 (5.2-24.2) and ASES score was 77.5 (50.8-96.6). In CT group, average Constant score was 69.6 ± 19.2, DASH score was 16.4 (12.5-36.7) and ASES score was 76.6 (45.4-87.9). DASH scores (p = 0.032), Constant scores (p = 0.001), forward elevation (p < 0.001), abduction (p < 0.001), internal (p = 0.022) and external rotation (p = 0.048) were significantly improved in OS and CT groups than HA group.

Conclusions

HA should not be considered a priority in surgical planning in Neer three-part and four-part proximal humerus fractures. CT is superior for patients with additional morbidity and advanced age. But in patients who are younger and can tolerate the surgical procedure, the priority should be OS.

Clinical and Radiographic Outcomes of Total Shoulder Arthroplasty With a Nonspherical Humeral Head and Inlay Glenoid in Elite Weight Lifters: A Prospective Case Series

Background:

Weight lifting after total shoulder arthroplasty (TSA) can place significant stresses on implants that could lead to instability, loosening, and increased wear. A TSA system with nonspherical humeral head resurfacing and inlay glenoid—which improves the biomechanics and thus reduces instability, wear, and potential loosening—may be able to tolerate repetitive loads from weight lifting.

Purpose:

To determine clinical and radiographic outcomes after TSA in weight lifters.

Study Design:

Case series; Level of evidence, 4.

Methods:

We prospectively enrolled 16 weight lifters (mean ± SD age, 57.2 ± 7.8 years; 15 male) undergoing primary anatomic TSA (n = 17 shoulders, 1 staged bilateral) with nonspherical humeral head resurfacing and inlay glenoid replacement for glenohumeral osteoarthritis between February 2015 and February 2019. Exclusion criteria were rotator cuff deficiency, revision TSA, post-traumatic arthritis, and inflammatory arthritis. Outcome measures included the rate of return to weight lifting, results of patient-reported outcome measures (Penn Shoulder Score, Kerlan-Jobe Orthopaedic Clinic, and 12-Item Veterans RAND Health Survey), radiographic outcomes, and complication rate.

Results:

Follow-up was obtained on all patients at a mean of 38 months (range, 14-63 months). All patients returned to competitive weight lifting at 15.6 ± 6.9 weeks. Compared to the preoperative weight lifting level, at last follow-up patients reported performance at the following level: lighter weight, 1 (6%); same weight, 8 (50%); heavier weight, 7 (44%). Preoperative eccentric posterior glenoid wear was common (71% Walch B2 classification; 12/17), but posterior humeral subluxation improved at follow-up according to the Walch index (mean, 55.5% preoperative vs 48.5% postoperative; P < .001) and contact point ratio (mean, 63.9% preoperative vs 50.1% postoperative; P < .001). Pre- to postoperative improvements were seen in Penn Shoulder Score (44.3 vs 82.6; P < .001), Kerlan-Jobe Orthopaedic Clinic (50.6 vs 91.1; P < .001), and 12-Item Veterans RAND Health Survey physical component score but not mental component score. No signs of radiographic loosening were detected in follow-up images, nor were there any postoperative instability episodes or revision surgeries.

Conclusion:

There were substantial improvements in shoulder function and a high rate of return to weight lifting after TSA with a nonspherical humeral head resurfacing and inlay glenoid component. Radiographically, the humeral head centralized on the glenoid after surgery, and there was no evidence of component loosening at a mean 38-month follow-up.

Return to Golf After Shoulder Arthroplasty: A Systematic Review

BACKGROUND

The number of golfers aged ≥65 years has increased in recent years, and shoulder arthritis is prevalent in this age group. Guidelines for return to golf (RTG) after shoulder arthroplasty have not been fully established.

PURPOSE

To review the data available in the current literature on RTG after shoulder arthroplasty.

STUDY DESIGN

Systematic review.

METHODS

A systematic review based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Two independent reviewers searched PubMed, Embase, and the Cochrane Library using the terms "shoulder,""arthroplasty,""replacement," and "golf." The authors sought to include all studies investigating RTG after total shoulder arthroplasty (TSA), shoulder hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA). Outcomes of interest included indications for shoulder arthroplasty, surgical technique, rehabilitation protocol, amount of time between surgery and resumption of golf activity, and patient-reported outcome measures.

RESULTS

A total of 10 studies were included, 2 of which reported on golf performance after shoulder arthroplasty. The other 8 studies described return to sports after shoulder arthroplasty with golf-specific data for our analysis. Three studies that included patients who underwent TSA reported RTG rates ranging from 89% to 100% after mean follow-up periods of 5.1 to 8.4 months. Two studies included patients who underwent TSA and HA and reported RTG rates of 77% and 100% after mean intervals of 5.8 and 4.5 months, respectively. Two studies included patients who underwent RSA, with RTG rates of 50% and 79% after mean postoperative intervals of 5.3 and 6 months, respectively. One study included only patients undergoing HA, with an RTG rate of 54% and a mean RTG time of 6.5 months. Varying surgical procedures and baseline patient characteristics precluded our ability to draw conclusions regarding surgical technique, rehabilitation protocol, or patient-reported outcome measures among studies reporting these data.

CONCLUSION

Most patients who undergo a shoulder arthroplasty procedure can expect to resume playing golf approximately 6 months after the index procedure. The rate of return may be lower after RSA and HA as compared with anatomic TSA. The data presented in our review can help physicians counsel patients who wish to continue golf participation after a shoulder arthroplasty procedure.

Return to sport following reverse shoulder arthroplasty: a systematic review

BACKGROUND

The purpose of this study is to systematically review the evidence in the literature to ascertain the rate and timing of return to sport following reverse shoulder arthroplasty (RSA).

METHODS

A systematic literature search based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, using the Embase, MEDLINE, and Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to sport following RSA. Statistical analysis was performed using SPSS.

RESULTS

Overall, 8 studies including 455 patients (464 shoulders) met our inclusion criteria. The majority of patients were female (77.7%), with an average age of 74.2 years. The overall rate of return to sport was 79.1%; with 66.7% of golfers, 74.3% of swimmers, 50.0%, of tennis players, 94.4% of joggers, and 69.7% of cyclists returning. In addition, 71.4% of patients returned to the same level of sporting activity. The average time to return to sport was 3.4 months with a mean follow-up of 34.0 months.

DISCUSSION AND CONCLUSION

The results from our systematic review show that the majority of patients are able to return to sport following RSA, with a large number returning to the same level of sport. However, results were modest in overhead athletes, with a concerning number unable to return to tennis post-RSA.

Advances and Update on Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Reverse total shoulder arthroplasty (RTSA) is a procedure that has been increasingly utilized since its inception over 20 years ago. The purpose of this review is to present the most up to date practice and advances to the RTSA literature from the last 5 years.

RECENT FINDINGS

Recent literature on RTSA has focused on identifying complications, maximizing outcomes, and determining its cost-effectiveness. RTSA has become a valuable tool in the treatment of various shoulder pathologies from fractures to massive-irreparable rotator cuff tears. Maximizing outcomes, proper patient counseling, and limiting complications are vital to a successful procedure. RTSA can be a difficult procedure; however, when utilized appropriately, it can be an invaluable tool in the orthopedic surgeon's armament. Recent evidence suggests, more and more, that RTSA not only provides value to the patient, but it is also cost-effective.

Functional workspace and patient-reported outcomes improve after reverse and total shoulder arthroplasty

BACKGROUND

Low-cost motion analysis systems (LCMASs) have emerged as easy and practical methods to measure the functional workspace (FWS). Thus, we ventured to apply an LCMAS, the Kinect2 gaming camera, to evaluate the FWS in patients with shoulder osteoarthritis (OA) and patients who underwent total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA).

METHODS

A cross-sectional study of participants with OA (n = 53), TSA (n = 70), and RTSA (n = 34) was performed. The FWS as measured by an LCMAS, the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, and the Patient-Reported Outcomes Measurement Information System (PROMIS) score were collected. For participants who underwent TSA or RTSA, the FWS was evaluated at 6, 12, and 24 months postoperatively. The correlation of the FWS with the ASES score and PROMIS score was determined. Significance was set at P < .05.

RESULTS

Patients who underwent TSA or RTSA had a significantly higher FWS than patients with shoulder OA at almost all time points. Patients who underwent TSA had a significantly higher FWS than patients who underwent RTSA at 24 months after surgery. PROMIS and ASES scores showed strong correlations with the FWS in patients who underwent TSA (R = 0.75 [P < .001] and R = 0.83 [P < .001], respectively) and RTSA (R = 0.84 [P < .001] and R = 0.73 [P < .001], respectively).

CONCLUSION

The FWS measured by an LCMAS is an easy and low-cost method to quantify the reachable space of the hand in patients and shows strong correlations with patient-reported outcome measures. This may be a useful tool to assess upper-extremity range of motion before and after shoulder arthroplasty.

Impact of Age and Subscapularis Tendon Reparability on Return to Recreational Sports Activities and 2-Year Outcomes After Reverse Total Shoulder Arthroplasty

Background:

As the indications for reverse total shoulder arthroplasty (RTSA) have continued to expand, the average age of patients undergoing RTSA has decreased.

Purpose/Hypothesis:

The purpose of this study was to report the minimum 2-year outcomes after RTSA and to evaluate the impact of surgical variables on outcomes. We hypothesized that younger patients, patients with larger glenosphere, and patients with irreparable subscapularis tendons would experience worse subjective patient-reported outcome scores (PROS) and that younger patients and those with a reparable subscapularis would demonstrate a higher rate of return to recreational sports activities.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent RTSA by a single surgeon between November 2005 and September 2014 were considered for this study. Patient characteristics, surgical details, PROS, and rates of return to recreational sports activity were prospectively collected and retrospectively reviewed. We assessed correlations between PROS and both patient age and subscapularis reparability. PROS collected included the American Shoulder and Elbow Surgeons (ASES) score, Short Form 12 (SF-12), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Single Assessment Numeric Evaluation (SANE), and postoperative patient satisfaction.

Results:

A total of 110 patients with an average age of 68.0 years (range, 45-87 years) were included. Minimum 2-year follow-up was obtained in 94 patients (85.4%), with a mean follow-up of 3.6 years (range, 2.0-9.3 years). The subscapularis was reparable in 58 patients (57.4%). All PROS significantly improved from pre- to postoperatively (P < .001). The median patient postoperative satisfaction was 9 out of 10 (range, 1-10). Increasing patient age was correlated with significant improvements in QuickDASH and ASES scores. Postoperatively, 76.1% (67/88) of patients were able to return to recreational sports activity. However, of those who did return, 68.2% indicated that they had to modify their activity in some way. Glenosphere size was not significantly associated with PROS or the rate of return to recreational sports activity, but patients with reparable subscapularis tendons demonstrated higher PROS and return to activity rates.

Conclusion:

Patients who had a reparable subscapularis tendon showed a significantly higher rate of return to recreational sports activity than patients who had a irreparable subscapularis tendon. Older age was correlated with greater improvement in several, although not all, patient-reported outcome measures. Glenosphere size was not significantly associated with higher PROS or rate of return to recreational sports activity.

Humeral head resurfacing is associated with less pain and clinically equivalent functional outcomes compared with stemmed hemiarthroplasty at mid-term follow-up

PURPOSE

Humeral head resurfacing (HHR) is a less invasive, anatomic alternative to the conventional stemmed hemiarthroplasty in patients in whom isolated humeral head replacement is preferred. It was hypothesized that, in a mid-term cross-sectional subjective outcome analysis, HHR would have equivalent patient-reported and functional outcomes to stemmed hemiarthroplasty (HA).

METHODS

A total of 213 HHR and 153 HA procedures were performed at a single academic institution from 2000 to 2014. Of these, 106 HHR and 47 HA patients corresponding with 120 HHR and 55 HA shoulders responded to a survey that collected patient demographics, surgical outcomes, patient satisfaction, and self-reported range of motion scores using both bespoke and validated metrics.

RESULTS

Follow-up was longer in the HA group (9.4 ± 3.4 vs. 5.2 ± 1.8 years, p < 0.0001). Self-reported range of motion was equivalent between groups. Surgery was perceived as helpful following 76.7% of HHRs and 78.2% of HAs (p > 0.99). The ASES pain subscore was significantly worse in the HA group (25.2 ± 29.5 vs. 38.5 ± 12.7 after HHR, p < 0.0001), which translated into worse ASES total scores (45.1 ± 14.8 HA vs. 52.2 ± 23.7 HHR, p < 0.05). These findings were equivocal in responses received 2-8 years vs. ≥ 8 years after surgery.

CONCLUSIONS

Indications should be equivocal; humeral head resurfacing is a viable alternative to hemiarthroplasty, with equivalent patient satisfaction and reduced pain in the mid-term post-operative period.

LEVEL OF EVIDENCE

III.

Establishing maximum medical improvement following reverse total shoulder arthroplasty for rotator cuff deficiency

BACKGROUND

Since US Food and Drug Administration approval of the reverse prosthesis in 2003, the incidence of shoulder arthroplasty in the United States has risen dramatically. With increasing demand, efforts have shifted from traditional volume-based health care models to more patient-centered care. The purpose of this systematic literature review is to establish the time point of maximum medical improvement (MMI) following reverse total shoulder arthroplasty (rTSA).

MATERIALS AND METHODS

We conducted a systematic review of studies reporting validated patient-reported outcome measures (PROMs) across multiple postoperative time points following rTSA. Established minimal clinically important difference values for PROMs specific to shoulder arthroplasty were used to determine significant clinical improvement. The time point beyond which significant improvement did not occur was established as MMI.

RESULTS

MMI occurred at 1 postoperative year following rTSA. When preoperative measures were compared with 1-year postoperative outcomes, all but 1 PROM demonstrated significant clinical improvement (P < .001). There were no significant improvements between any 2 subsequent time points beyond 1 year (P > .050). Range of motion significantly improved between preoperative and 1-year levels (P < .001). No PROMs or range-of-motion parameters significantly improved beyond 1 year (P > .999).

CONCLUSIONS

Patients achieved MMI at 1 postoperative year following rTSA. Patients showed rapid improvements in subjective symptoms within the first 3 months and continued to gradually improve until 1 year. Surgeons should counsel patients with these evidence-based expectations for clinical recovery, particularly the time frame of expected improvements in pain, function, and range of motion, as well as risks of and plans of action for postoperative complications.

Return to Recreational Sporting Activities Following Total Shoulder Arthroplasty

Background:

Patients are staying active longer and expect to return to sports or continue participating in recreational activities after total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis.

Purpose/Hypothesis:

The purpose of this study was to assess the ability of patients to return to recreational sports following TSA. We hypothesized that TSA would allow a high rate of return to recreational sports.

Study Design:

Case series; Level of evidence, 4.

Methods:

All patients who underwent primary TSA by a single surgeon and were at least 2 years out from surgery were included and were studied for their ability to return to recreational activity following surgery between December 2005 and January 2015. Patient-reported outcomes were obtained, including the 12-Item Short Form Health Survey–Physical Component Summary (SF-12 PCS); Single Assessment Numeric Evaluation (SANE); Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire; American Shoulder and Elbow Surgeons (ASES) score; and satisfaction scores (10-point scale), preoperatively and at a minimum of 2 years postoperatively. Return-to-sport rates were assessed using a standardized patient-reported outcome questionnaire.

Results:

A total of 165 patients (186 shoulders) that received TSA met the inclusion criteria for the study. Preoperatively, 139 patients (157 shoulders) were involved in recreational sports; 16 (8.6%) shoulders required additional surgical intervention after the index TSA procedure. A significant postoperative increase was noted in the mean ASES (from 48.3 to 87.0; P < .001), QuickDASH (from 41.0 to 15.8; P < .001), SANE (from 49.1 to 81.2; P < .001), and SF-12 PCS scores (from 38.6 to 48.9; P = .004). Of the 157 shoulders in the recreational sports cohort, responses to the survey examining recreational sporting activities after surgery were available for 112 shoulders. The overall rate of return to sport or recreational activity following TSA was 93.7% (105/112 shoulders). The rate of return to recreational sporting activity equal to or better than the preinjury level was 69.7% (78/112 shoulders), while 6.3% (7/112 shoulders) of our cohort reported that they were unable to compete in recreational sports following TSA. Of the patients who participated in predominantly upper extremity sporting activities after TSA, 49% had to modify their postoperative recreational sporting activity because of lifestyle change, pain, weakness, or decreased range of motion.

Conclusion:

Patients undergoing TSA showed excellent postoperative improvement in their outcome scores, satisfaction, and return to athletic activities. Despite the expected decrease in activity levels with the slow progression of osteoarthritis over time until TSA was performed, almost 94% of patients successfully returned to various recreational sporting activities postoperatively. This study showed that return to recreational sports can be achieved at participation levels that are comparable with preoperative levels, but athletes in some sports such as tennis or swimming, which require more intense levels of exercise, are less likely to return to the same participation levels.

Restoration of the joint geometry and outcome after stemless TESS shoulder arthroplasty

AIM

To evaluate the joint geometry and the clinical outcome of stemless, anatomical shoulder arthroplasty with the TESS system.

METHODS

Twenty-one shoulders with a mean follow-up 18 of months were included. On scaled digital radiographs the premorbid center of rotation (CoR) was assessed and compared to the CoR of the prosthesis by using the MediCAD^® software. Additionally, the pre- and post-operative geometry of the CoR was assessed in relation to the glenoid, the acromion as well as to the proximal humerus. Radiological changes, such as radiolucencies, were also assessed. Clinical outcome was assessed with the Constant and DASH score.

RESULTS

Both, the Constant and DASH scores improved significantly from 11% to 75% and from 70 to 30 points, P < 0.01 respectively. There were no significant differences regarding age, etiology, cemented or metal-backed glenoids, etc. (P > 0.05). The pre- and postoperative humeral offset, the lateral glenohumeral offset, the height of the CoR, the acromiohumeral distance as well as neck-shaft angle showed no significant changes (P > 0.05). The mean deviation of the CoR of the prosthesis from the anatomic center was 1.0 ± 2.8 mm. Three cases showed a medial deviation of more than 3 mm. These deviations of 5.1, 5.7 and 7.6 mm and were caused by an inaccurate humeral neck cut. These 3 patients showed a relatively poor outcome scoring.

CONCLUSION

TESS arthroplasty allows an anatomical joint reconstruction with a very good outcome. Outliers described in this study sensitize the surgeon for an accurate humeral neck cut.