Beyond the joint: Exploring the interplay between mental health and shoulder arthroplasty outcomes

Considering the fact that mental health illnesses increase with age, and that shoulder arthroplasty procedures are often indicated in the older population, exploring the relationship between mental health and shoulder arthroplasty outcomes can have pivotal implications for shoulder surgeons and patients worldwide. The literature has shown that patients with poor mental health report lower patient-reported outcomes, higher peri-operative complications (such as anemia, infection, delirium, and others), lengthier hospital stays, and higher readmission rates than the normal patient. Employing a holistic approach when managing shoulder arthroplasty patients is necessary for optimizing outcomes and setting up recovery expectations.

Does achieving clinically important thresholds after first shoulder arthroplasty predict similar outcomes of the contralateral shoulder?

BACKGROUND

Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA.

METHODS

We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA.

RESULTS

Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P < .001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P < .001); this difference persisted when stratified by type of prosthesis for first and second TSA.

CONCLUSIONS

Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type.

Insertion sites of latissimus dorsi tendon transfer performed during reverse shoulder arthroplasty: A systematic review and meta-analysis

BACKGROUND

Reverse shoulder arthroplasty (RSA) with concurrent latissimus dorsi transfer (LDT) is a potential treatment option for restoration of external rotation (ER). Biomechanical studies have emphasized the importance of the insertion site location for achieving optimal outcomes. In this systematic review and meta-analysis, we aimed to describe what insertion sites for LDT are utilized during concomitant RSA and their associated clinical outcomes.

METHODS

A systematic review and meta-analysis were performed per PRISMA guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on patients who received RSA with LDT to restore ER and specified the site of tendon transfer insertion on the humerus. We first describe reported insertion sites in the literature. Secondarily, we present preoperative and postoperative range of motion and Constant score for different insertion sites as well as reported complications.

RESULTS

Sixteen studies, analyzed as 19 separate cohorts (by insertion site and tendon-transfer), reporting on 264 RSAs with LDT (weighted mean age 66 years, follow-up 39 months, 61% female) were evaluated. Of these, 143 (54%) included a concomitant teres major transfer (LDT/TMT) and 121 (46%) were LDT-only. Fourteen cohorts (14/19, 74%) reported insertion at the posterolateral aspect of the greater tuberosity, four cohorts (4/19, 21%) reported insertion site at the lateral bicipital groove, and one cohort (1/19, 5%) reported separate LDT and TMT with insertion of the TMT to the posterolateral aspect of the greater tuberosity and LDT to the lateral bicipital groove. Meta-analysis revealed no differences in range of motion or Constant score based on humeral insertion site or whether the LDT was transferred alone or with TMT. Leading complications included dislocation, followed by infection and neuropraxia. No discernible correlation was observed between postoperative outcomes and the strategies employed for tendon transfer, prosthesis design, or subscapularis management.

CONCLUSION

The posterolateral aspect of the greater tuberosity was the most-utilized insertion site for LDT performed with RSA. However, in the current clinical literature, LDT with or without concomitant TMT result in similar postoperative ROM and Constant score regardless of insertion site. Analysis of various proposed transfer sites reinforce the ability of LDT with RSA to restore both FE and ER in patients with preoperative active elevation and external rotation loss. Meta-analysis revealed significant improvements in range of motion and Constant score regardless of humeral insertion site or whether the LDT was transferred alone or with TMT, although future studies are needed to determine whether an ideal tendon transfer technique exists.

LEVEL OF EVIDENCE

IV.

Anatomic versus reverse total shoulder arthroplasty outcomes after prior contralateral anatomic total shoulder arthroplasty in patients with bilateral primary osteoarthritis with an intact rotator cuff

PURPOSE

We aimed to compare outcomes in patients that underwent bilateral anatomic total shoulder arthroplasty (aTSA) vs. aTSA/ reverse total shoulder arthroplasty (rTSA) for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA) to further elucidate the role of rTSA in this patient population.

METHODS

A single-institution prospectively collected shoulder arthroplasty database was reviewed for patients undergoing bilateral total shoulder arthroplasty (TSA) for RCI-GHOA with a primary aTSA and subsequent contralateral aTSA or rTSA. Outcome scores (SPADI, SST, ASES, UCLA, Constant) and active range of motion (abduction, forward elevation [FE], external and internal rotation [ER and IR]) were evaluated. Clinically relevant benchmarks (minimal clinically important difference [MCID], substantial clinical benefit [SCB], and patient acceptable symptomatic state [PASS]) were evaluated against values in prior literature. Incidence of surgical complications and revision rates were examined in qualifying patients as well as those without 

RESULTS

Of the 55 bilateral TSA patients with an intact rotator cuff, 46 underwent aTSA/aTSA and 9 underwent aTSA/rTSA. At the time of the second TSA, patients undergoing aTSA/rTSA were older (71 ± 4 vs. 67 ± 7, P = .032) and more commonly had inflammatory arthritis (44% vs. 11%, P = .031). Mean time to the second TSA was shorter for aTSA/aTSA (2.3 ± 2.8 vs. 4.4 ± 3.6 years, P < .001). Postoperative outcomes were similar after the first aTSAs between groups with similar proportions achieving the MCID, SCB, and PASS (all P > .05). The 2nd TSAs between groups were similar preoperatively, but aTSA/rTSA had superior outcome scores, overhead motion, and active abduction compared to patients that underwent aTSA/aTSA. There were no differences in active ER and IR scores or complication rates between groups.

CONCLUSION

Patients with RCI-GHOA have excellent clinical outcomes after either aTSA/aTSA or aTSA/rTSA.

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Key Words

• Clinical outcome
• Inflammatory arthritis, Rotator cuff
• Reverse shoulder arthroplasty
• Shoulder replacement

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MESH Headings

• Humans
• Arthroplasty, Replacement, Shoulder/adverse effects
• Rotator Cuff/surgery
• Shoulder Joint/surgery
• Treatment Outcome
• Retrospective Studies
• Osteoarthritis/surgery
• Osteoarthritis/etiology
• Range of Motion, Articular

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Early morbidity and mortality after one-stage bilateral shoulder arthroplasty

PURPOSE

One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high.

METHODS

A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders.

RESULTS

There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction.

CONCLUSIONS

One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation.

Influence of acromioclavicular joint arthritis on outcomes after reverse total shoulder

Background

Although substantial motion at the acromioclavicular joint (ACJ) occurs during overhead shoulder motion, the influence of ACJ arthritis on postoperative outcomes of patients undergoing reverse total shoulder arthroplasty (rTSA) is unclear. We assessed the influence of ACJ arthritis, defined by degenerative radiographic changes, and its severity on clinical outcomes after primary rTSA.

Methods

We conducted a retrospective review of a prospectively collected shoulder arthroplasty database of patients that underwent primary rTSA with a minimum 2-year clinical follow-up. Imaging studies of included patients were evaluated to assess ACJ arthritis classified by radiographic degenerative changes of the ACJ; severity was based upon size and location of osteophytes. Both the Petersson classification and the King classification (a modified Petersson classification addressing superior osteophytes and size of the largest osteophyte) were used to evaluate the severity of degenerative ACJ radiographic changes. Severe ACJ arthritis was characterized by large osteophytes (≥2 mm). Active range of motion (ROM) in abduction, forward elevation, and external and internal rotation as well as clinical outcome scores (American Shoulder and Elbow Surgeons Shoulder, Constant, Shoulder Pain and Disability Index, simple shoulder test, University of California, Los Angeles scores) were assessed both preoperatively and at the latest follow-up; outcomes were compared based on severity of ACJ arthritis. Multivariable linear regression models were used to determine whether increasing severity of ACJ arthritis was associated with poorer outcomes.

Results

A total of 341 patients were included with a mean age of 71 ± 8 years and 55% were female. The mean follow-up was 5.1 ± 2.4 years. Preoperatively, there were no differences in outcomes based on the severity of ACJ pathology. Postoperatively, there were no differences in outcomes based upon the severity of ACJ arthritis except for greater preoperative to postoperative improvement in active internal rotation in patients with normal or grade 1 ACJ arthritis vs. grade 2 and 3 (3 ± 2 vs. 1 ± 2 and 1 ± 3, P = .029). Patients with ACJ arthritis and osteophytes ≥2 mm had less favorable Shoulder Pain and Disability Index scores, corresponding to greater pain (-49.3 ± 21.5 vs. -41.3 ± 26.8, P = .015). On multivariable linear regression, increased severity of ACJ arthritis was not independently associated with poorer postoperative ROM or outcome scores.

Conclusion

Overall, our results demonstrate that greater ACJ arthritis severity score is not associated with poorer outcome scores and has minimal effect on ROM. However, patients with the largest osteophytes (≥2 mm) did have slightly worse pain postoperatively. Radiographic presence of high-stage ACJ arthritis should not alter the decision to undergo rTSA.

Mid-term results of the use of structural humeral head autograft to correct glenoid bone loss in reverse total shoulder arthroplasty

Background

Native glenoid bone loss presents technical challenges in shoulder arthroplasty. The purpose of this study is to report the mid-term clinical and radiographic outcomes of patients treated with structural humeral head autograft reconstruction of glenoid bone loss in the setting of reverse total shoulder arthroplasty (rTSA).

Methods

Retrospective review of 30 shoulders in 28 patients undergoing rTSA with a structural humeral head autograft to correct glenoid bone loss. Demographics, comorbidities, anatomic details, and patient-reported outcome measures were collected for analysis.

Results

Range of motion and patient-reported outcome measures were all significantly improved postoperatively (P < .001). Bone grafts were found to incorporate into 100% of shoulders, with no protheses displaying signs of loosening or other structural concerns. No revision procedures were performed, and all patients were satisfied with their shoulder postoperatively. Two patients developed scapular notching on follow-up.

Discussion

The use of a humeral head autograft to reconstruct glenoid bone loss in patients undergoing rTSA is a safe and effective procedure. It allows for a local graft source to be utilized thus avoiding potential comorbidity and complications associated with the use of alternative site autografts or allografts and has the advantage of nearly congruent fit within the defect.

Intraoperative navigation system use increases accuracy of glenoid component inclination but not functional outcomes in reverse total shoulder arthroplasty: a prospective comparative study

BACKGROUND

While the use of computer-assisted navigation systems in prosthetic implantation is steadily increasing, its utility in reverse shoulder arthroplasty (RSA) remains unclear. The purpose of this study was to evaluate the clinical utility of an intraoperative navigation system in patients undergoing RSA.

MATERIALS AND METHODS

Patients undergoing navigated or standard RSA at a single institution between September 2020 and December 2021 were prospectively enrolled. Exclusion criteria included noncompliance with study procedures or humeral fracture. Outcome measures included postoperative version and inclination, range of motion (ROM), complications, and patient-reported outcome measurements (PROMs: American Shoulder and Elbow Surgeons score [ASES], Disabilities of the Arm, Shoulder, and Hand score [DASH], Simple Shoulder Test [SST], and Visual Analog Scale [VAS]) at final follow-up.

RESULTS

The final cohort contained 16 patients with navigation and 17 with standard RSA at a mean follow-up of 16 months (range 12-18 months). Average age was 72 years (range 66-80 years), 8 male (24%) and 25 female (76%). There were no differences in demographics between groups (p > 0.05). At baseline, the navigated group had a greater proportion of Walch B1 and B2 glenoids (p = 0.04). There were no differences between groups regarding baseplate type and native/planned/postoperative glenoid version and inclination. In both groups, planned and postoperative versions were not significantly different (p = 0.76). Patients who did not have navigation demonstrated significant differences between planned and postoperative inclination (p = 0.04), while those with navigation did not (p = 0.09). PROM scores did not differ between groups at final follow-up for SST (p = 0.64), DASH (p = 0.38), ASES (p = 0.77), or VAS (p = 0.1). No difference in final ROM was found between groups (p > 0.05). Over 50% of all screws in both groups were positioned outside the second cortex (p = 0.37), albeit with no complications.

CONCLUSIONS

There were no statistically significant differences in ROM, PROMs, and satisfaction between patients receiving computer-navigated and standard RSA at a short-term follow-up. Despite more severe preoperative glenoid erosion in the navigated group, all patients were able to achieve an appropriate neutral axis postoperatively. The cost effectiveness and appropriate use of computer-navigated RSA warrant specific investigation in future studies.

LEVEL OF EVIDENCE

II, prospective cohort study.

TRIAL REGISTRATION

9/1/2020 to 12/31/2021.

Quantifying success after reverse total shoulder arthroplasty: the substantial clinically important percentage of maximal possible improvement

BACKGROUND

Changes in preoperative to postoperative outcome scores are often used to quantify success after reverse total shoulder arthroplasty (rTSA). However, ceiling effects associated with many outcome scores limit the ability to differentiate success among high-functioning patients. The percentage of maximal possible improvement (%MPI) was introduced to simplify and better stratify patient success. The primary purpose of this study was to define the %MPI thresholds associated with substantial clinical improvement following primary rTSA and compare the rates of success as defined by those achieving the substantial clinical benefit (SCB) compared to the 30% MPI for different outcome scores.

METHODS

A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary rTSAs performed using a single implant system with a minimum 2-year follow-up were reviewed. Preoperative and postoperative outcome scores were evaluated for all patients to calculate improvement. Six outcome scores were assessed: the Simple Shoulder Test (SST), Constant, American Shoulder and Elbow Surgeons (ASES), University of California Los Angeles (UCLA), Shoulder Pain and Disability Index (SPADI), and Shoulder Arthroplasty Smart (SAS) scores. The proportion of patients achieving the SCB and 30% MPI was determined for each outcome score. Thresholds for the substantial clinically important %MPI (SCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex.

RESULTS

Of total, 2573 shoulders with a mean follow-up of 47 months were included. Outcome scores with known ceiling effects (SST, ASES, UCLA, SPADI) had higher rates of patients achieving the 30% MPI compared to scores without ceiling effects (Constant, SAS). However, scores without ceiling effects had higher rates of patients achieving the SCB. The SCI-%MPI differed among outcome scores, and mean values were 47% for the SST, 35% for the Constant score, 50% for the ASES score, 52% for the UCLA score, 47% for the SPADI score, and 45% for the SAS score. The SCI-%MPI increased in patients older than 60 years (P < .001) except for the SAS and Constant scores. SCI-%MPI was greater in females for all scores assessed except the Constant and SPADI scores (P < .001 for all). The higher SCI-%MPI thresholds in these populations mean that these patients required a greater fraction of the MPI to have substantial improvement.

CONCLUSION

The %MPI judged relative to patient-reported substantial clinical improvement offers an alternative method to quickly assess improvements across patient outcome scores. Given considerable variation in the %MPI corresponding to substantial clinical improvement, we recommend utilizing score-specific estimates of the SCI-%MPI to gauge success when evaluating patients undergoing primary rTSA.

Patients with poor early clinical outcomes after anatomic total shoulder arthroplasty have sustained poor performance at 2 years from surgery

PURPOSE

We sought to define the risk of persistent shoulder dysfunction after anatomic total shoulder arthroplasty (aTSA) beyond the early postoperative period and identify risk factors for persistent poor performance.

METHODS

We retrospectively identified 144 primary aTSAs performed for primary osteoarthritis with early poor performance and 2-year minimum follow-up. Early poor performance was defined as a postoperative ASES score below the 20th percentile at 3- or 6-months (62 and 72 points, respectively). Persistent poor performance at 2 years was defined as failing to achieve the patient acceptable symptomatic state (PASS) [ASES = 81.7 points].

RESULTS

At 2-year follow-up, 51% (n = 74) of patients with early poor performance at either 3- or 6-month follow-up had persistent poor performance. There was no difference in the rate of persistent poor performance if patients were poor performers at the 3-, 6-month follow-up, or both (50% vs. 49% vs. 56%, P = .795). Of aTSAs achieving the PASS at 2-year follow-up, a greater proportion exceeded the minimal clinically important differences (MCID) [Forward elevation, external rotation, and all outcome scores] and substantial clinical benefit (SCB) [external rotation and all outcome scores] compared to persistent poor performers. However, over half of persistent poor performers still exceeded the MCID for all outcome measures (56-85%). Independent predictors of persistent poor performance were hypertension (2.61 [1.01-6.72], P = .044) and diabetes (5.14 [1.00-26.4], P = .039).

CONCLUSION

Over half of aTSAs with an ASES score < 20th percentile at early follow-up had continued poor shoulder function at 2-years postoperatively. Persistent poor performance was best projected by preoperative hypertension and diabetes.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Comparison using Large Database; Treatment Study.

Forecasting the future burden of primary total shoulder replacement in Australia

OBJECTIVE

To forecast the number of primary total shoulder replacements (TSR) in Australia to the year 2035, and associated costs.

METHODS

De-identified TSR data for 2009-2019 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data, including population projections to 2035, were obtained from the Australian Bureau of Statistics. Three forecasting scenarios were used: constant TSR rates from 2019 onwards (Scenario 1, conservative); continued growth in TSR rates using negative binomial regression (Scenario 2, exponential); and continued growth using negative binomial regression with monotone B-splines (Scenario 3, moderate). Healthcare costs were estimated using TSR projections and average procedure costs, inflated to 2035 Australian dollars.

RESULTS

The use of TSR increased by 242% in Australia from 2009 to 2019 (from 1983 to 6789 procedures for people ≥40 years). Under Scenario 1, the incidence of TSR is conservatively projected to rise to 9676 procedures by 2035 (43% increase from 2019), at a cost of $AUD 312.6 million to the health system. Under Scenario 2, TSR incidence would increase to 45,295 procedures by 2035 (567% increase), costing $AUD 1.46 billion. Under Scenario 3, 28,257 TSR procedures are forecast in 2035 (316% increase) at a cost of $913 million.

CONCLUSIONS

Recent growth in TSR likely relates to prosthesis improvements, greater surgeon proficiency, and expanded clinical indications. Under moderate and exponential scenarios that consider rising TSR rates and population projections, Australia would face three- to five-fold growth in procedures by 2035. This would have profound implications for the healthcare budget, clinical workforce, and infrastructure.

Quantifying success after anatomic total shoulder arthroplasty: the substantial clinically important percentage of maximal possible improvement

BACKGROUND

Percentage maximal possible improvement (%MPI) has been described as a threshold by which to evaluate patient improvement after anatomic total shoulder arthroplasty (aTSA) that has favorable psychometric properties. The primary purpose of this study was to define the percentage maximal possible improvement (%MPI) thresholds associated with substantial clinical improvement following primary anatomic total shoulder arthroplasty (aTSA) and compare the rates of success as defined by those achieving the substantial clinical benefit (SCB) compared with the 30% MPI for different outcome scores.

METHODS

A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary aTSAs performed using a single implant system with minimum 2-year follow-up were reviewed. Pre- and postoperative outcome scores were evaluated for all patients to calculate improvement. Six outcome scores were assessed: the Simple Shoulder Test (SST), Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), University of California-Los Angeles shoulder score (UCLA), Shoulder Pain and Disability Index (SPADI), and Shoulder Arthroplasty Smart (SAS) scores. The proportion of patients achieving the SCB and 30% MPI were determined for each outcome score. Thresholds for the substantial clinically important %MPI (SCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex.

RESULTS

A total of 1593 shoulders with a mean follow-up of 59.3 months were included. Outcome scores with known ceiling effects (SST, ASES, UCLA) had higher rates of patients achieving the 30% MPI but not the previously reported SCB compared to scores without ceiling effects (Constant, SAS). The SCI-%MPI differed among outcome scores, and mean values were as follows: 48% for the SST, 39% for the Constant score, 53% for the ASES score, 55% for the UCLA score, 50% for the SPADI score, and 42% for the SAS score. The SCI-%MPI increased in patients older than 60 years (P ≤ .006 for all) and was greater in females for all scores assessed except the Constant score (P < .001 for all), meaning that patients with higher thresholds required a greater fraction of the maximum possible improvement for a given score to have substantial improvement.

CONCLUSION

The %MPI judged relative to patient-reported substantial clinical improvement offers a new method to assess improvements across patient outcome scores. Given considerable variation in the %MPI corresponding to substantial clinical improvement, we recommend utilizing score-specific estimates of the SCI-%MPI to gauge success when evaluating patients undergoing primary aTSA.

Quantifying success after reverse total shoulder arthroplasty: the minimal clinically important percentage of maximal possible improvement

BACKGROUND

In high functioning patients, the ceiling effect associated with many patient-reported outcome measures (PROMs) limits the ability to appropriately stratify success. The percentage maximal possible improvement (%MPI) was introduced as another evaluation tool, with a proposed threshold of success at 30%. It remains unclear if this threshold correlates with perceived patient success following shoulder arthroplasty. The purpose of this study was to compare the proportion of patients that achieved the minimal clinically important difference (MCID) and %MPI for different outcome scores and to define the %MPI thresholds associated with patient satisfaction following primary reverse total shoulder arthroplasty (rTSA).

METHODS

A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary rTSAs performed using a single implant system with minimum 2-year follow-up were reviewed. Pre- and postoperative outcome scores were evaluated for all patients to determine the raw improvement and %MPI. The proportion of patients achieving the MCID and 30% MPI were determined for each outcome score. Thresholds for the minimal clinically important %MPI (MCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex.

RESULTS

A total of 2573 shoulders with a mean follow-up of 47 months were included. Outcome scores with known ceiling effects (Simple Shoulder Test [SST], Shoulder Pain and Disability Index [SPADI], University of California-Los Angeles shoulder score [UCLA]) had higher rates of patients achieving the 30% MPI but not the previously reported MCID. Inversely, outcome scores without significant ceiling effects (Constant and Shoulder Arthroplasty Smart [SAS] scores) had higher rates of patients achieving the MCID, but not the 30% MPI. The MCI-%MPI differed among outcome scores and mean values were as follows: 33% for the SST, 27% for the Constant score, 35% for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, 43% for the UCLA score, 34% for the SPADI score, and 30% for the SAS score. The MCI-%MPI increased with greater age for SPADI (P < .04) and SAS (P < .01) scores, meaning that patients with higher thresholds required a greater fraction of the possible improvement for a given score to be satisfied but did not reach statistical significance for other scores. Females had a greater MCI-%MPI for the SAS and ASES scores and a lower MCI-MPI% for the SPADI score.

CONCLUSION

The %MPI offers a simple method to quickly assess improvements across patient outcome scores. However, the %MPI that represents patient improvement after surgery is not uniformly the previously established 30% threshold. Surgeons should use score-specific estimates of the MCI-%MPI to gauge success when evaluating patients undergoing primary rTSA.

Shoulder replacement surgery's rising demand, inequality of provision, and variation in outcomes: cohort study using Hospital Episode Statistics for England

BACKGROUND

The aim of this study was to forecast future patient demand for shoulder replacement surgery in England and investigate any geographic and socioeconomic inequalities in service provision and patient outcomes.

METHODS

For this cohort study, all elective shoulder replacements carried out by NHS hospitals and NHS-funded care in England from 1999 to 2020 were identified using Hospital Episode Statistics data. Eligible patients were aged 18 years and older. Shoulder replacements for malignancy or acute trauma were excluded. Population estimates and projections were obtained from the Office for National Statistics. Standardised incidence rates and the risks of serious adverse events (SAEs) and revision surgery were calculated and stratified by geographical region, socioeconomic deprivation, sex, and age band. Hospital costs for each admission were calculated using Healthcare Resource Group codes and NHS Reference Costs based on the National Reimbursement System. Projected rates and hospital costs were predicted until the year 2050 for two scenarios of future growth.

RESULTS

A total of 77,613 elective primary and 5847 revision shoulder replacements were available for analysis. Between 1999 and 2020, the standardised incidence of primary shoulder replacements in England quadrupled from 2.6 to 10.4 per 100,000 population, increasing predominantly in patients aged over 65 years. As many as 1 in 6 patients needed to travel to a different region for their surgery indicating inequality of service provision. A temporal increase in SAEs was observed: the 30-day risk increased from 1.3 to 4.8% and the 90-day risk increased from 2.4 to 6.0%. Patients from the more deprived socioeconomic groups appeared to have a higher risk of SAEs and revision surgery. Shoulder replacements are forecast to increase by up to 234% by 2050 in England, reaching 20,912 procedures per year with an associated annual cost to hospitals of £235 million.

CONCLUSIONS

This study reports a rising incidence of shoulder replacements, regional disparities in service provision, and an overall increasing risk of SAEs, especially in more deprived socioeconomic groups. These findings highlight the need for better healthcare planning to match local population demand, while more research is needed to understand and prevent the increase observed in SAEs.

Return to sport criteria following upper extremity surgery in athletes-part 4: shoulder arthroplasty procedures: a scoping review

PURPOSE

To describe the reported return to sports (RTS) criteria following all types of shoulder arthroplasty procedures in athletes.

METHODS

This scoping review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review (PRISMA-ScR) as a guide. A comprehensive search was conducted in four electronic databases (Scopus, Pubmed/MEDLINE, Web of Science, and Google Scholar Advanced Search) in the English Language that reported a minimum of 1 RTS criterion in athletes after shoulder arthroplasty. The data were aggregated and summarized as frequencies, means, and standard deviations.

RESULTS

Thirteen studies were included, with a total of 942 athletes with a mean age of 68.7 years. The most commonly used RTS criterion was time from surgery (range 3-6 months), reported by 7/13 (54%) of all studies, followed by restrictions on contact sports (36%). Other reported RTS criteria included no lifting/limited lifting (3/13, 23%), physician clearance based on assessment (3/13, 23%), return per patient tolerance (2/13, 15%), and upon return to full range of motion (ROM) and strength in the operated shoulder (1/13, 8%). Three studies (3/13, 23%) allowed for an unrestricted RTSpostoperatively.

CONCLUSION

Thirteen studies reported one or more RTS criteria following shoulder arthroplasty, with time after surgery being the most common RTS criterion used. These results emphasise the need for interprofessional discussions and communication amongst surgeons, physical therapists, and athletic trainers to establish evidence-based RTS criteria following arthroplasty and promote a safe and effective return to sport.

Glenoid component placement accuracy in total shoulder arthroplasty with preoperative planning and standard instrumentation is not influenced by supero-inferior glenoid erosion

PURPOSE

Accurate glenoid component placement in total shoulder arthroplasty (TSA) remains challenging even with preoperative planning, especially for variable glenoid erosion patterns in the coronal plane.

METHODS

We retrospectively reviewed 170 primary TSAs in which preoperative planning software was used. After registration of intraoperative bony landmarks, surgeons were blinded to the navigation screen and attempted to implement their plan by simulating placement of a central-axis guide pin: 230 screenshots of simulated guide pin placement were included (aTSA = 66, rTSA = 164). Displacement, error in version and inclination, and overall malposition from the preoperatively-planned target point were stratified by the Favard classification describing superior-inferior glenoid wear: E0 (n = 89); E1 (n = 81); E2 (n = 29); E3(n = 29); E4(n = 2). Malposition was considered > 10° for version/inclination errors or > 4 mm displacement from the starting point.

RESULTS

Mean displacement error was 3.5 ± 2.7 mm (aTSA = 2.7 ± 2.3 mm, rTSA = 3.8 ± 2.9 mm), version error was 5.7 ± 4.7° (aTSA = 5.8 ± 4.4°, rTSA = 5.7 ± 4.8°), inclination error was 7.1 ± 5.6 (aTSA = 4.8 ± 4.8°, rTSA = 8.1 ± 5.7°), and malposition rate was 53% (aTSA = 38%, rTSA = 59%). When compared by Favard classification, there were no differences in any measure; when stratified by TSA type, version error differed for rTSAs (P = .038), with E1 having the greatest version error (6.9 ± 5.2°) and E3 the least (4.2 ± 3.4°). When comparing glenoids without wear (E0) and glenoids with superior wear (E2 and E3), the only difference was greater version error in glenoids without wear (6.0 ± 4.9° vs. 4.6 ± 3.7°, P = .041).

CONCLUSIONS

Glenoid malposition did not differ based on coronal glenoid morphology. Although, malposition was relatively high, suggesting surgeons should consider alternate techniques beyond preoperative planning and standard instrumentation in TSA. LEVEL OF EVIDENCE III: Retrospective Cohort Study.

Does radiolucency really predict loose components in revision shoulder arthroplasty?

OBJECTIVE

The number of shoulder arthroplasties is increasing along with the need for revision surgeries. Determining the stability of the implant is crucial in preoperative planning. This study aims to investigate whether radiolucent lines (RLL) in preoperative radiographs predict component loosening.

MATERIALS AND METHODS

Preoperative radiographs of 93 cases in 88 patients who underwent shoulder arthroplasty revision were evaluated regarding the presence of RLL. Correlation analyses were performed for radiographic findings and demographic factors (age, gender, BMI, prior surgeries) compared to intraoperative findings.

RESULTS

The presence of RLL around the humeral component correlated with loosening (p < 0.001, Phi 0.511), and the distal zones 3 and 5 showed the strongest correlation (Phi 0.536). While RLL in only one zone did not predict loosening (p = 0.337), RLL present in two or more zones showed correlation with loosening (p < 0.001). Risk factors associated with loosening were a higher age at the time of revision surgery (p = 0.030) and the number of zones with RLL (p < 0.001). The glenoid component was loose in 39.0% of the cases; 5.5% of the glenoid components with RLL were stable. Nevertheless, the presence of RLL was highly associated with loosening (p < 0.001, Phi 0.603). A longer time between implantation and revision correlated with loosening of the glenoid component (p = 0.046).

CONCLUSION

While RLL do not predict loosening of the implant in general, occurrence in more than one zone correlates with loosening. If located in distal zones and with increasing number of zones with RLL, the correlation becomes even stronger and loosening is more likely.

Shoulder arthroplasty in the setting of previous stabilization surgery: a systematic review of matched case control studies at minimum 2 years follow-up

Background

Anterior shoulder instability causes considerable patient morbidity and the volume of shoulder stabilization surgery being performed annually is rising. Despite stabilization surgery, instability arthropathy in the long-term may arise requiring consideration of shoulder arthroplasty. This study evaluated the outcomes of shoulder arthroplasty following previous stabilization surgery with their associated changes in bony anatomy or soft tissue structure.

Methods

A systematic review was performed as per Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies reporting outcomes of shoulder arthroplasty in the setting of previous stabilization surgery. Studies of >10 patients with a minimum of 24 months follow-up were included.

Results

Overall, 377 shoulder arthroplasties composed of 247 anatomical total shoulder arthroplasties (aTSAs), 102 reverse total shoulder arthroplasties (RTSAs), and 28 hemiarthroplasties (HAs) were reported across 14 included studies at mean age 55.4 years, with 203 compared to 451 control shoulders in 7 matched case-control studies. The mean interval from arthroplasty to stabilization procedure was 19.7 years, with 27.2% of patients having undergone multiple procedures and 39.5% bone transfer procedures. Improvements in patient outcomes were observed both for patients who had underwent aTSA or RTSA, with the American Shoulder and Elbow Surgeons score the most commonly used scoring system. Across matched studies comparing to control, large improvements in American Shoulder and Elbow Surgeons were seen for both aTSA and RTSA implants, 38.1-80.5 and 34.9-82.3, which compared to control groups 38.0-85.5 and 35.5-82.3, respectively. There were differences observed in complication profiles between aTSA and RTSA procedures, with lower revision rates in the short-term to medium-term for RTSA implants in present literature. A significantly higher rate of aTSA revision was observed compared to matched control patients undergoing aTSA for primary osteoarthritis without previous stabilization surgery, 9.4% (13/139) vs. 4.1% (11/269) (P = .044). Aseptic loosening posed a particular challenge in the aTSA group, with significantly higher rates of 5.0% (7/139 f = 54.6 months) compared to control 0.74% (2/269 f = 49.1 months, P = .0088). No significant difference in infection rate was observed between matched study and control groups, 1.5% vs. 2.2% (P = .76).

Conclusion

Shoulder arthroplasty may improve functional outcomes for patients experiencing instability arthropathy with a history of stabilization surgery. Careful consideration of potential complications is warranted both in surgical planning and patient counselling given the altered anatomy and biomechanics, with significantly higher revision and loosening rates observed following aTSA compared to control.

Balancing clinician and patient priorities for total shoulder replacement preoperative education programs

OBJECTIVE

To investigate patient and clinician preferences regarding a preoperative educational program for patients undergoing shoulder replacement surgery.

METHODS

This study used a cross-sectional survey of patients awaiting shoulder replacement surgery and clinicians. The survey was comprised of 41 questions for patients and clinicians, regarding preferences for receiving information, content preferences and device preferences. Descriptive statistics were reported for survey questions.

RESULTS

180 patients and 175 clinicians completed the survey. Patients and clinicians' top choices for ways to receive information were: in-person, website and booklets, with use of CD/DVD being extremely unlikely. Patients and clinicians had different preferences regarding content choices. Patients rated the following content topics as important to include in a program: including other patient's previous experiences with this surgery (83 % patients; 40 % clinicians), information for caregivers (84 % patients; 65 % clinicians), expectations for hospital stay (89 % patients; 57 % clinicians), process of anesthesia (87 % patients; 51 % clinicians), and how the surgery is performed (94 % patients; 60 % clinicians).

CONCLUSIONS

Clinicians and patients have differing priorities and perspectives on the content and delivery of preoperative education programs, however, therapeutic goals and accessibility should be considered when designing programs.

PRACTICE IMPLICATIONS

Creating education programs should include the lens of both clinicians and patients.

Quantifying success after anatomic total shoulder arthroplasty: the minimal clinically important percentage of maximal possible improvement

INTRODUCTION

Changes in pre- to postoperative outcome scores are often used to quantify success after anatomic total shoulder arthroplasty (aTSA). However, ceiling effects associated with many outcome scores limit the ability to differentiate success among high-functioning patients. The percentage maximal possible improvement (%MPI) was introduced to better stratify patient success; however, it is unclear if the 30% threshold first proposed correlates with perceived patient success across all outcome scores. The purpose of this study was to compare the proportion of patients that achieved the minimal clinically important difference (MCID) and %MPI for different outcome scores and to define the %MPI thresholds associated with patient satisfaction following primary aTSA.

METHODS

A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary aTSAs performed using a single implant system with minimum 2-year follow-up were reviewed. Pre- and postoperative outcome scores were evaluated for all patients to calculate improvement. The proportion of patients achieving the MCID and 30% MPI were determined for each outcome score. Thresholds for the minimal clinically important %MPI (MCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex.

RESULTS

1593 shoulders with a mean follow-up of 59.3 months were included. Outcome scores with known ceiling effects (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], University of California-Los Angeles shoulder score [UCLA]) had higher rates of patients achieving the 30% MPI but not the previously reported MCID. Inversely, outcome scores without significant ceiling effects (Constant and Shoulder Arthroplasty Smart [SAS] scores) had higher rates of patients achieving the MCID but not the 30% MPI. The MCI-%MPI differed among outcome scores, and mean values were as follows: 33% for the SST, 24% for the Constant score, 32% for the ASES score, 38% for the UCLA score, 30% for the Shoulder Pain and Disability Index score, and 33% for the SAS score. The MCI-%MPI increased with greater age (P < .003) and females had thresholds greater than or equal to males for all scores assessed, meaning that patients with higher thresholds required a greater fraction of the possible improvement for a given score to be satisfied.

CONCLUSION

The %MPI offers a simple method to quickly assess improvements across patient outcome scores. However, the %MPI that represents patient improvement after surgery is not uniformly the previously established 30% threshold. Surgeons should use score-specific estimates of the MCI-%MPI to gauge success when evaluating patients undergoing primary aTSA.

Validation of the distal filling ratio in uncemented convertible short-stem shoulder arthroplasty

INTRODUCTION

Radiographic stress shielding is a common finding in uncemented convertible short-stem shoulder arthroplasty (UCSSSA). The distal filling ratio (DFR) has been described as a predictor for the occurrence of stress shielding. A DFR > 70% was mentioned as a risk factor for the occurrence of stress shielding for some UCSSSA. However, measurements were only performed on conventional radiographs and no validation exists for 3D automated planning tools.

METHODS

DFR was manually measured on postoperative true ap radiographs of 76 shoulder arthroplasties using a standardized protocol and were compared to preoperative CT scans with an automated calculation of the DFR after virtual implantation of the stem.

RESULTS

The mean DFR measured on X-rays was 75.9% (SD = 8.7; 95% CI = 74-78) vs. 78.9% (SD = 9.1; 95% CI = 76.8-83) automatically measured on CT scans. This difference was significant (p < 0.001). In 7 out of 76 cases (9%) the difference between manual measurement on radiographs and computerized measurement on CT scans was > 10%.

CONCLUSION

Manual measurement of the DFR is underestimated on conventional radiographs compared to automated calculation on CT scans be a mean of 3%. Therefore, automated measurement of the DFR on CT scans seems to be beneficial, especially in cases with osteopenic cortices. Manual measurement of the DFR on conventional ap radiographs in cases without CT scans, however, is still a viable alternative.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Optimizing Outcomes After Reverse Total Shoulder Arthroplasty: Rehabilitation, Expected Outcomes, and Maximizing Return to Activities

PURPOSE OF REVIEW

Given the touted clinical and patient-reported outcomes of reverse shoulder arthroplasty (RTSA) in improving pain and restoring function, shoulder surgeons are rapidly expanding the indications and utilization of RTSA. Despite its increasing use, the ideal post-operative management ensuring the best patient outcomes is still debated. This review synthesizes the current literature regarding the impact of post-operative immobilization and rehabilitation on clinical outcomes following RTSA including return to sport.

RECENT FINDINGS

Literature regarding the various facets of post-operative rehabilitation is heterogeneous in both methodology and quality. While most surgeons recommend 4-6 weeks of immobilization post-operatively, two recent prospective studies have shown that early motion following RTSA is both safe and effective with low complication rates and significant improvements in patient-reported outcome scores. Furthermore, no studies currently exist assessing the use of home-based therapy following RTSA. However, there is an ongoing prospective, randomized control trial assessing patient-reported and clinical outcomes which will help shed light on the clinical and economic value of home therapy. Finally, surgeons have varying opinions regarding return to higher level activities following RTSA. Despite no clear consensus, there is growing evidence that elderly patients are able to return to sport (e.g., golf, tennis) safely, though caution must be taken with younger or more high-functioning patients. While post-operative rehabilitation is believed to be essential to maximize outcomes following RTSA, there is a paucity of high-quality evidence that guides current rehabilitation protocols. There is no consensus regarding type of immobilization, timing of rehabilitation, or need for formal therapist-directed rehabilitation versus physician-guided home exercise. Additionally, surgeons have varied opinions regarding return to higher level activities and sports following RTSA. There is burgeoning evidence that elderly patients can return to sport safely, though caution must be taken with younger patients. Further research is needed to clarify the optimal rehabilitation protocols and return to sport guidelines.

Comparison of clinical outcomes of revision reverse total shoulder arthroplasty for failed primary anatomic vs. reverse shoulder arthroplasty

Background

Both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (RTSA) are being increasingly performed. In the event of a complication necessitating revision, RTSA is more commonly performed in both scenarios. The purpose of this study was to compare clinical outcomes between patients undergoing revision RTSA for failed primary anatomic versus reverse total shoulder arthroplasty.

Methods

We performed a retrospective review of a prospective single-institution shoulder arthroplasty database. All revision RTSAs performed between 2007 and 2019 with a minimum 2-year clinical follow-up were initially included. After excluding patients with a preoperative diagnosis of infection, an oncologic indication, or incomplete outcomes assessment, we included 45 revision RTSAs performed for failed primary aTSA and 15 for failed primary RTSA. Demographics, surgical characteristics, active range of motion (external rotation [ER], internal rotation, forward elevation [FE], abduction), outcome scores (American Shoulder and Elbow Surgeons score, Constant Score, Shoulder Pain and Disability Index, Simple Shoulder Test, and University of California, Los Angeles score), and the incidence of postoperative complications was compared between groups.

Results

Primary aTSA was most often indicated for degenerative joint disease (82%), whereas primary RTSA was more often indicated for rotator cuff arthropathy (60%). On bivariate analysis, no statistically significant differences in any range of motion or clinical outcome measure were found between revision RTSA performed for failed aTSA vs. RTSA. On multivariate linear regression analysis, revision RTSA performed for failed aTSA vs. RTSA was not found to significantly influence any outcome measure. Humeral loosening as an indication for revision surgery was associated with more favorable outcomes for all four range of motion measures and all five outcome scores assessed. In contrast, an indication for revision of peri-prosthetic fracture was associated with poorer outcomes for three of four range of motion measures (ER, FE, abduction) and four of five outcome scores (Constant, Shoulder Pain and Disability Index, Simple Shoulder Test, University of California, Los Angeles). A preoperative diagnosis of fracture was associated with a poorer postoperative range of motion in ER, FE, and abduction, but was not found to significantly influence any outcome score. However, only two patients in our cohort had this indication. Complication and re-revision rates after revision RTSA for failed primary aTSA and RTSA were 27% and 9% vs. 20% and 14% (P = .487 and P = .515), respectively.

Conclusion

Clinical outcomes of patients undergoing revision RTSA for failed primary shoulder arthroplasty did not significantly differ based on whether aTSA or RTSA was initially performed. However, larger studies are needed to definitively ascertain the influence of the primary construct on the outcomes of revision RTSA.

The impact of tobacco use on clinical outcomes and long-term survivorship after anatomic total shoulder arthroplasty

Introduction

Postoperative outcomes following total shoulder arthroplasty can be affected by preoperative health factors such as tobacco usage.

Methods

The charts of patients who underwent anatomic total shoulder arthroplasty were retrospectively analyzed and stratified based on smoking status. The primary data included range of motion and patient reported outcomes. Additionally, demographic, radiographic, and survivorship analyses were conducted. All data were analyzed using statistical inference.

Results

There were 78, 49, and 16 non-smoker, former smoker, and current smoker shoulders respectively with no significant differences in sex, American Society of Anesthesiologists status, body mass index, or mean follow-up time (average: 10.7 yrs). Smokers (51.5 ± 10.4 years) were younger than both non-smokers (64.9 ± 8.1 years; p < 0.01) and former smokers (65.1 ± 9.1years; p < 0.01) at the time of surgery. For non-smokers and former smokers, all range of motion and patient reported outcome scores significantly improved. Smokers reported significant improvements in all patient reported outcomes and external and internal rotation. Visual Analog Scale, American Shoulder and Elbow, and Simple Shoulder Test scores were lower for smokers comparatively, but these differences did not reach significance. Forward elevation was higher postoperatively for non-smokers (149.7o ± 17.2o) and former smokers (147.1o ± 26.0o) compared to current smokers (130.9o ± 41.2o; p = 0.017). No differences between the cohorts were found in the radiographic analysis. Revision rates were lower in the non-smoking cohort (7.7%) compared to both former (20.4%; p = 0.036) and current smokers (37.5%; p < 0.01). Survival curves showed that non-smoker implants lasted longer than those of current smokers.

Conclusion

After a decade, patients generally had improved shoulder range of motion, functionality, and pain regardless of smoking status. However, current smokers required shoulder replacements sooner and revision surgery more frequently.

Stemless shoulder arthroplasty

The concept of stemless shoulder arthroplasty was born in 2005. It is now a valid option in the context of either anatomical or reverse shoulder replacement. Several questions have come up over our 15 years of using this system: How was the stemless shoulder arthroplasty concept born? It was motivated by a desire to have epiphyso-metaphyseal fixation using a corolla-shaped impacted anchor design. What are the features of commercially available stemless shoulder arthroplasty implants? The stemless anatomical implants now available have either a cage or central peg that is impacted or a system that is screwed into the epiphysometaphyseal bone. Several companies have introduced stemless reverse implants, some of which have an onlay configuration. How do the results of stemless implants compare to those of traditional stemmed implants? At a mean follow-up of 10 years, the outcomes of stemless TSA can be superimposed with those of traditional stemmed TSA. What are the advantages of stemless shoulder implants? The advantages are their simple implantation, ability to adapt to patient morphology and any malunions, various orientation angles, no stress-shielding, reduced risk of infection and bleeding and less complex revision surgery (if needed). What are the limitations or drawbacks of using stemless implants? The two main limitations are insufficient metaphyseal bone stock and poor bone quality, especially for reverse configurations. What does the future hold for stemless shoulder arthroplasty? Like with traditional stemmed implants, the longevity of stemless shoulder arthroplasty depends on its tribology, which can still be improved. In the future, a stemless implant will need to be convertible like stemmed humeral implants, and if possible, provide an inlay reverse configuration.

[Humeral bone defects in revision shoulder arthroplasty]

BACKGROUND

Revision shoulder arthroplasty is mainly performed with reverse TSA and should consider proper adjustment of the length and the amount of bone loss in humeral reconstruction. Whilst epi-/metaphyseal bone loss can mostly be compensated easily by stemmed standard implants, advanced bone loss exceeding 2° requires the support of longer revision stems.

EXTENSIVE HUMERAL BONE LOSS

Cementless fixation in the intact diaphyseal humerus is recommended in bone loss exceeding 2°, preferably with modular revision systems, because cemented reverse revision stems have higher loosening rates in the mid to long-term follow-up. In cases of advanced bone loss 3°-4° (more than 6-7 cm), structural humeral allografts should be considered to prevent instability and early loosening. Unfortunately, the access to fresh frozen allografts is very limited due to regulation of the German government in contrast to the situation in the US or Switzerland. Reverse tumor arthroplasty is an option with a higher complication rate and inferior function even when polyester mesh is used for ingrowth of soft tissues.

DISTINCT DIAPHYSEAL DEFECTS

In bone loss 4°-5° the minimal anchorage length is mostly critical due to the curvature of the medullary canal. The fixation of a revision stem is only possible when at least 2-3 widths of the diaphyseal diameter are available. Custom-made implants with flanges or distal locking screws, or bipolar tumor arthroplasty may be required. Additionally, strut allografts can be useful to achieve stable fixation. Two-stage biological reconstruction in impaction-bone-graft or the Masquelet technique are rarely used as a salvage procedure.

Survivorship after reverse total shoulder arthroplasty and predictors of 1-year and overall mortality

BACKGROUND

Patient survivorship and risk factors of mortality after reverse total shoulder arthroplasty (RTSA) are seldom and inadequately studied. The purpose of this study was to evaluate the mortality rates and predictors of 1-year and overall mortality after RTSA.

METHODS

We retrospectively reviewed 1518 consecutive adult patients who underwent RTSA at our institution. The Social Security Death Index and institutional electronic medical records were queried to verify patient living status. Patients were censored at date of death if deceased, the date that living status was verified if alive, or latest follow-up if living status could not be verified. Mortality rates and risk factors of 1-year and overall mortality after RTSA were identified on univariate and multivariate analysis.

RESULTS

Mean follow-up was 5.1 ± 3.8 years. Thirty-day (0.1%), 90-day (0.7%), and 1-year (1.8%) mortality rates were low but increased to 11% at 5 years. Increased odds of 1-year mortality were independently associated with heart disease (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.07-6.50, P = .035) and use of a cemented stem (OR 2.64, 95% CI 1.04-6.69, P = .041). Independent risk factors of overall mortality included older age at surgery (hazard ratio [HR] 1.05, 95% CI 1.03-1.07, P < .001), minority ethnicity (protective risk factor, HR 0.37, 95% CI 0.15-0.91, P = .031), heart disease (HR 1.42, 95% CI 1.00-2.02, P = .048), diabetes mellitus (HR 1.47, 95% CI 1.04-2.08, P = .028), tobacco use (HR 1.79, 95% CI 1.08-2.98, P = .025), post renal transplant (HR 12.69, 95% CI 3.92-41.05, P < .001), chronic liver failure (HR 4.40, 95% CI 1.38-14.09, P = .013), and receiving a cemented stem (HR 1.60, 95% CI 1.13-2.26, P = .008).

CONCLUSIONS

RTSA carries a low risk of short-term mortality postoperatively. When counseling patients preoperatively, surgeons should consider the predictors of mortality after RTSA reported herein to ensure appropriate patient selection and counseling.

Surgeon confidence in planning total shoulder arthroplasty improves after consulting a clinical decision support tool

PURPOSE

Software algorithms are increasingly available as clinical decision support tools (CDSTs) to support shared decision-making. We sought to understand if patient-specific predictions from a CDST would impact orthopedic surgeons' preoperative planning decisions and corresponding confidence.

METHODS

We performed a survey study of orthopedic surgeons with at minimum of 2 years of independent shoulder arthroplasty experience. We generated patient profiles for 18 faux cases presenting with glenohumeral osteoarthritis and emailed 93 surgeons requesting their recommendation for anatomic or reverse total shoulder arthroplasty for each case and their certainty in their recommendation on a 4-point Likert scale. The thirty respondents were later sent a second survey with the same cases that now included predicted patient-specific outcomes and complication rates generated by a CDST.

RESULTS

Initial recommendations and changes in recommendation varied widely by surgeon and by case. After viewing the results of the CDST, surgeons switched from anatomic to reverse recommendations in 46 instances (12% of initial anatomic) and from reverse to anatomic in 22 instances (6% of initial reverse). Overall, surgeon change in confidence increased significantly across all responses (p = 0.0001), with certain cases and certain surgeons having significant changes. Change in confidence did not correlate with surgeon-specific factors, including years in practice.

CONCLUSION

The addition of CDST reports to preoperative planning for anatomic and reverse total shoulder arthroplasty informed decision-making but did not direct recommendations uniformly. However, the CDST information provided did increase surgeon confidence regardless of implant selection and irrespective of surgeon experience.

Factors affecting internal rotation following total shoulder arthroplasty

Background

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

Methods

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

Results

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

Conclusion

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

Shoulder replacement: an epidemiological nationwide study from 2009 to 2019

Background

Shoulder replacement (SR) constitutes the gold standard treatment for severe shoulder diseases, including osteoarthritis, rheumatoid arthritis, complex fractures, avascular necrosis and rotator cuff arthropathy. Although several countries have national registries, there is a lack of epidemiological data on SR. Sharing national statistics and correlating those to other countries could be helpful to compare outcomes and costs internationally. This paper aims to evaluate the trend of hospitalizations for SR (both first implants and revisions of anatomical and reverse prosthesis) in Italy from 2009 to 2019, based on the National Hospital Discharge Reports (S.D.O) provided by the Italian National Health Service (INHS). Moreover, the economic impact on the healthcare system of SR and SR revisions was assessed, providing a statistical prediction for the next ten years.

Methods

The data used in this paper were about patients who underwent Total Shoulder Replacement (TSR), Shoulder Hemiarthroplasty (SH) or Revision of shoulder joint replacement (RSR) from 2009 to 2019 in Italy. Information about patients was anonymous and included age, sex, days of hospitalization, procedures and diagnoses codes.

Results

From 2009 to 2019, 73,046 TSR and SH were performed in adult Italian residents, with a cumulative incidence of 13.6 cases per 100,000 adult Italian residents. While, 2,129 revisions of shoulder replacement were performed, with a cumulative incidence of 0.4 cases per 100,000 residents. Overall, females represented the majority of the cases (72.4% of patients who underwent TSR or SH and 59.1% of patients who underwent RSR). From 2009 to 2019, has been assessed an overall cost of 625,638,990€ for TSR or SH procedures in Italy. While, an overall cost of 9,855,141€ for RSR procedures in Italy was calculated.

Conclusions

The incidence of SR and RSR is expected to increase in the following years, constituting a burden for the healthcare systems. Overall, in Italy, the females represented the majority of patients. Further prospective studies on this topic in different countries can be con-ducted to make comparisons.

Return to work following shoulder arthroplasty: A systematic review

BACKGROUND

Many patients prioritize the ability to return to work (RTW) after shoulder replacement surgeries such as total shoulder arthroplasty (TSA), reverse TSA (rTSA), and shoulder hemiarthroplasty (HA). Due to satisfactory clinical and functional long-term outcomes, the number of shoulder replacements performed will continue to rise into this next decade. With younger individuals who compose a significant amount of the workforce receiving shoulder replacements, patients will begin to place a higher priority on their ability to RTW following shoulder arthroplasty.

AIM

To summarize RTW outcomes following TSA, rTSA, and HA, and analyze the effects of workers’ compensation status on RTW rates and ability.

METHODS

This systematic review and analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search regarding RTW following shoulder arthroplasty was performed using four databases (PubMed, Scopus, Embase, and Cochrane Library), and the Reference Citation Analysis (https://www.referencecitationanalysis.com/). All studies in English relevant to shoulder arthroplasty and RTW through January 2021 that had a level of evidence I to IV were included. Nonclinical studies, literature reviews, case reports, and those not reporting on RTW after shoulder arthroplasty were excluded.

RESULTS

The majority of patients undergoing TSA, rTSA, or HA were able to RTW between one to four months, depending on work demand stratification. While sedentary or light demand jobs generally have higher rates of RTW, moderate or heavy demand jobs tend to have poorer rates of return. The rates of RTW following TSA (71%-93%) were consistently higher than those reported for HA (69%-82%) and rTSA (56%-65%). Furthermore, workers’ compensation status negatively influenced clinical outcomes following shoulder arthroplasty. Through a pooled means analysis, we proposed guidelines for the average time to RTW after TSA, rTSA, and HA. For TSA, rTSA, and HA, the average time to RTW regardless of work demand stratification was 1.93 ± 3.74 mo, 2.3 ± 2.4 mo, and 2.29 ± 3.66 mo, respectively.

CONCLUSION

The majority of patients are able to RTW following shoulder arthroplasty. Understanding outcomes for rates of RTW following shoulder arthroplasty would assist in managing expectations in clinical practice.

Stem size prediction in shoulder arthroplasty with preoperative 3D planning

INTRODUCTION

Three-dimensional surgical planning software provides virtual reconstructions of the shoulder with automated joint indices for a preoperative case assessment. The aim of this single center study was to evaluate the concordance between the preoperatively selected humeral components and the final implants used in shoulder arthroplasty.

METHODS

129 cases who had undergone anatomic (n = 16) or reverse shoulder arthroplasty (n = 117) using the same type of uncemented short stem implant and were included for review in this study. The type of arthroplasty, stem size, stem inclination, tray-offset and liner-thickness were noted preoperatively and compared to the final implant specifications used in surgery.

RESULTS

The type of arthroplasty matched the surgical plan in 99.2% of cases, as one case was converted from RSA to TSA. The concordance of planned to implanted stem size was 44.2% and the planned size was in range of one adjacent size in 87.6% of cases. Stem inclination in TSA matched the surgical plan in 50% of cases. Tray offset in RSA was predicted correctly in 65% and liner-thickness matched the surgical plan in 98.3% of cases.

CONCLUSION

Despite a low degree of concordance of planned to implanted stem sizes of 44.2%, the choice of stem size was found to be in range of one adjacent size in 87.6% of cases. Further investigations of other contributing factors are necessary to increase the accuracy of the preoperative selection of humeral implants.

LEVEL OF EVIDENCE

level IV, retrospective case study.

Early reduction in postoperative pain is associated with improved long-term function after shoulder arthroplasty: a retrospective case series

PURPOSE

Mixed modalities are frequently utilized in total shoulder arthroplasty (TSA) to control pain, improve patient satisfaction, reduce narcotics use and facilitate earlier discharge. We investigate the relationship between early postoperative pain control and long-term functional outcomes after shoulder arthroplasty.

METHODS

A retrospective review identified 294 patients (314 shoulders) who underwent anatomic or reverse TSA and received a continuous cervical paravertebral nerve block perioperatively. Opioid and non-opioid analgesics were also available to the patients in an "as needed" capacity to augment perioperative pain control. In addition to demographic and surgical characteristics, the impact on functional outcomes of relative pain (i.e., a patient's subjective pain relative to the entire cohort), pain gradient (i.e., the slope of a patient's subjective pain), and opioid consumption during the first 24 h postoperatively were assessed. Shoulder function was assessed using validated outcome measures collected at 2 year follow-up. Outcomes were measured using American Shoulder and Elbow Surgeons questionnaire (ASES), Shoulder Pain and Disability Index (SPADI), SPADI-130, Raw and Normalized Constant Score, SST-12 and UCLA score.

RESULTS

Patients younger than 65, females, reverse TSA, revisions, and preoperative opioid users had worse functional outcomes. On univariate analysis, increased pain perioperatively (> 50% percentile relative pain) was associated with decreased function at 2 years when analyzed with all seven outcome scores (P < .001 for all), reaching minimal clinically important difference (MCID) using the Constant Score. On multivariate analysis, increased pain in the first 24 h postoperatively (assessed on a continuous scale) was independently associated with worse ASES, SPADI, and SPADI-130 scores. Intraoperative ketamine administration and opioid consumption in the 24 h postoperative period did not influence long-term shoulder function.

CONCLUSION

Patients reporting reduced pain after TSA demonstrated improved shoulder function with the Constant score at 2 years postoperatively in both univariate and multivariate analysis. Larger-scale investigation may be warranted to see if this is true for other functional outcome measures.

LEVEL OF EVIDENCE

III, treatment study.

Mid-term results of Eclipse total shoulder arthroplasty

AIMS

The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up.

METHODS

Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening.

RESULTS

Mean OSS at mean follow-up of 6.67 years (5.0 to 10.74) was 40.12 (9 to 48), with no statistically significant difference between those implanted for a non-OA indication and those for OA (p = 0.056) or time-dependent deterioration between two years and five years (p = 0.206). Ranges of motion significantly improved compared with preoperative findings and were maintained between two and five years with a mean external rotation of 38° (SD 18.1, 0 to 100) and forward elevation of 152° (SD 29.9, 90 to 180). Of those components with radiographs suitable for analysis (n = 83), 23 (28%) were found to have a least one humeral radiolucent line, which were predominantly incomplete, less than 2 mm, and in a single anatomical zone. No humeral components were loose. A radiolucent line was present around 22 (15%) of glenoid components, and 15 (10%) of components had failed. Rotator cuff failure was found in 21 (15%) components. The mean time to either glenoid or rotator cuff failure was greater than three years following implantation. Survivorship was 96.4% (95% CI 91.6 to 98.5, number at risk 128) at five years, and 94.3% (95% CI 88.2 to 97.3, number at risk 76) at seven years, both of which compare favourably with best results taken from available registries.

CONCLUSION

Functional and radiological outcomes of the Eclipse stemless TSA are excellent, with no loose humeral components at minimum five-year follow-up. The presence of radiolucent lines is of interest and requires long-term observation but does not impact on the clinical results. Of the eight revisions required, this was predominantly for glenoid and rotator cuff failure. Cite this article: Bone Joint J 2022;104-B(1):83-90.

Subscapularis management in stemmed and stemless total shoulder arthroplasty: a surgeon decision-making analysis study

Background

Stemless total shoulder arthroplasty (TSA) continues to grow in popularity as an evolution of stemmed humeral implants. Proposed advantages include bone preservation and ease of potential revision. However, absence of a stem may necessitate a change in subscapularis takedown approach. Specifically, there is theoretical concern about violation of supportive bone with lesser tuberosity osteotomy when using a stemless device. Therefore, the goal of this study was to identify if surgeons change their subscapularis takedown preference when performing stemless vs. stemmed TSA.

Methods and materials

Data from a consecutive series of patients who underwent stemmed and stemless TSA at an academic institution were collected. The subscapularis management technique was documented. Subscapularis takedown techniques were divided into 2 groups: soft-tissue approach (subscapularis tenotomy or peel) and bony approach (lesser tuberosity osteotomy). Historical preference for each surgeon was determined by evaluating techniques employed using stemmed TSA. A Cramers V analysis was run to determine the strength of association between this historical preference and subscapularis management technique used for stemless TSA.

Results

One hundred and fifty-four patients were included in this analysis. There were 72 and 82 stemmed and stemless arthroplasty cases performed, respectively. Of the 154 patients, 50.6% were women. The average age of patients was 64.2 years. Four surgeons were included in this study. In all, there were 79 and 75 bony and soft-tissue subscapularis techniques, respectively. The historical preference for 3 of the surgeons was a subscapularis bony approach, and the historical preference for one of the surgeons was a soft-tissue approach. A Cramer's V analysis was used to measure the relative strength of association between patient factors, historical subscapularis management preference, and subscapularis takedown approach in stemless TSA. Our analysis yielded a value of 0.65 (P < .01), indicating a redundant association between subscapularis management approach used between stemmed and stemless implant per surgeon.

Conclusion

In determining subscapularis tendon management strategy, in surgeons who performed stemmed TSA before stemless TSA, the subscapularis takedown approach used for stemless TSA is strongly associated with surgeon's historical preference for stemmed TSA. Future research will be needed to determine the clinical ramifications of this finding.

Survival of the Aequalis total shoulder replacement at a minimum 20-year follow-up: a clinical and radiographic study

AIMS

Shoulder replacement is increasingly performed for end-stage arthritis. Information on the long-term survival and patient outcomes is very limited. This study aimed to quantify the survival and clinical outcome at a minimum of 20-yr follow-up.

METHODS

A single-center, single-surgeon, consecutive cohort study was performed. Forty-four shoulder replacements in 40 patients (age at surgery 68.5 years, 82.5% female, preoperative visual analog scale [VAS] pain score 5.1/10, standard deviation [SD] 2.7) implanted between 1996 and 2000 were assessed. All-cause construct survival, radiographic glenoid and humeral stem loosening, radiographic humeral head migration, and patient-reported outcome measures were assessed.

RESULTS

Survival with all-cause revision as an endpoint was 84.1% (95% confidence interval [CI] 60.7, 94.1) at 20 years, glenoid loosening was seen in all patients who survived to the 20-year follow-up. Survival of rotator cuff integrity was 16.8% (95% CI 3.5, 38.5) at 20 years. VAS pain scores demonstrated improvement at 10 years (mean change -4/10) but not at 20 years (effect size -0.15, mean change 0.4/10, SD 2.7). At 20 years, 72% of patients had died with the prosthesis in situ.

CONCLUSION

Older patients undergoing total shoulder arthroplasty are unlikely to require revision in their lifetime. However, beyond 10 years, a large proportion of implants demonstrate glenoid loosening, humeral head migration, and declining patient outcomes. This information will be of use to patients and clinicians when discussing the potential outcomes of surgery.

Neurologic complications in primary anatomic and reverse total shoulder arthroplasty: A review

Neurologic injury during shoulder replacement is one of the less common complications of the procedure, however the clinical implications can be significant. The purpose of this paper is to review the current literature on neurologic complications in various types of shoulder replacement and provide recommendations regarding avoidance, evaluation, and management of these complications.

Treating cuff tear arthropathy by reverse total shoulder arthroplasty: do the inclination of the humeral component and the lateral offset of the glenosphere influence the clinical and the radiological outcome?

PURPOSE

Reverse total shoulder arthroplasty is widely used for the treatment of cuff tear arthropathy. Standard implants consist of a humeral component with an inclination angle of 155° and a glenosphere without lateral offset. Recently, lower inclination angles of the humeral component as well as lateralized glenospheres are implanted to provide better rotation of the arm and to decrease the rate of scapular notching. This study investigates the clinical and radiological results of a standard reverse total shoulder in comparison with an implant with an inclination angle of 135° in combination with a 4 mm lateralized glenosphere in context of cuff tear arthropathy.

MATERIAL AND METHODS

For this retrospective comparative analysis 42 patients treated by reverse total shoulder arthroplasty for cuff tear arthropathy were included. Twenty-one patients (m = 11, f = 10; mean age 76 years; mean follow-up 42 months) were treated with a standard 155° humeral component and a standard glenosphere with caudal eccentricity (group A), while twenty-one patients (m = 5, f = 16; mean age 72 years; mean follow-up 34 months) were treated with a 135° humeral component and 4 mm lateral offset of the glenosphere (group B). At follow-up patients of both groups were assessed with plain X-rays (a.p. and axial view), Constant Score, adjusted Constant Score, the subjective shoulder value and the range of motion.

RESULTS

The clinical results were similar in both groups concerning the Constant Score (group A = 56.3 vs. group B = 56.1; p = 0.733), the adjusted CS (group A = 70.4% vs. group B = 68.3%; p = 0.589) and the SSV (group A = 72.0% vs. group B = 75.2%; p = 0.947). The range of motion of the operated shoulders did not differ significantly between group A and group B: Abduction = 98° versus 97.9°, p = 0.655; external rotation with the arm at side = 17.9° versus 18.7°, p = 0.703; external rotation with the arm positioned in 90° of abduction = 22.3° versus 24.7°, p = 0.524; forward flexion = 116.1° versus 116.7°, p = 0.760. The rate of scapular notching was higher (p = 0.013) in group A (overall: 66%, grade 1: 29%, grade 2: 29%, grade 3: 10%, grade 4: 0%) in comparison to group B (overall: 33%, grade 1: 33%, grade 2: 0%, grade 3: 0%, grade 4: 0%). Radiolucency around the humeral component was detected in two patients of group B. Stress shielding at the proximal humerus was observed in six patients of Group A (29%; cortical thinning and osteopenia in zone M1 and L1) and two patients of group B (10%; cortical thinning and osteopenia in zone M1 and L1). Calcifications of the triceps origin were observed in both groups (group A = 48% vs. group B = 38%).

CONCLUSION

Theoretically, a lower inclination angle of the humeral component and an increased lateral offset of the glenosphere lead to improved impingement-free range of motion and a decreased rate of scapular notching, when compared to a standard reverse total shoulder implant. This study compared two different designs of numerous options concerning the humeral component and the glenosphere. In comparison to a standard-fashioned implant with a humeral inclination of 155° and a standard glenosphere, implants with a humeral inclination angle of 135° and a 4 mm lateralized glenosphere lead to comparable clinical results and rotatory function, while the rate of scapular notching is decreased by almost 50%. While the different implant designs did not affect the clinical outcome, our results indicate that a combination of a lower inclination angle of the humeral component and lateralized glenosphere should be favored to reduce scapular notching.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Acromial and glenoid morphology in glenohumeral osteoarthritis: a three-dimensional analysis

Background

The purpose of this study was to determine the association between glenohumeral osteoarthritis (GHOA) and three-dimensional acromial and glenoid morphology.

Methods

In this retrospective study, we compared computed tomographic studies of three groups of scapulae: normal healthy, mild GHOA (Samilson-Prieto grade 1), and severe GHOA (Samilson-Prieto grade 3). All scans were segmented to create three-dimensional reconstructions. From these models, critical shoulder angle and acromial offset were measured, as normalized to scapular height. The coronal plane inclination of the glenoid was measured using a glenoid sphere-fit method. Reliability was confirmed via intraclass correlation coefficients > 0.75.

Results

Eighty scapulae were included: 30 normal, 20 mild GHOA, and 30 severe GHOA. There were no differences in acromial offset between the normal group and either the mild-GHOA group or the severe-GHOA group. The severe-GHOA group had a smaller critical shoulder angle than either the normal (30 ± 5° vs. 34 ± 4°, P = .003) or mild-GHOA groups (34 ± 4°, P = .020), but the normal and mild-GHOA groups did not differ (P = .965). The severe-GHOA group had more inferiorly inclined glenoids than either the normal (7 ± 6° vs. 12 ± 5°, P = .002) or mild-GHOA groups (14 ± 5°, P ≤ .001), but the normal and mild-GHOA groups did not differ (P = .281).

Conclusion

Normal and severe-GHOA shoulders differ in critical shoulder angle and glenoid inclination but not acromial offset. The lack of a difference in critical shoulder angle or inferior inclination between mild-GHOA and normal groups calls into question whether inclination and critical shoulder angle differences predate severe GHOA.

Locked anterior glenohumeral dislocation: is it always recommendable a conservative treatment?

PURPOSE

Chronic anterior shoulder dislocation represents a rare condition, and there is still lack of consensus in its treatment. Purpose of this study is to evaluate the clinical and radiological outcome of painful locked dislocation underwent shoulder replacement, with a minimum follow-up of two years. Second endpoint is to assess the glenoid bone graft, harvested from the humeral head.

METHODS

Eight patients underwent shoulder replacement for locked anterior shoulder dislocation. Four patients with a mean age of 23 y.o. were treated with Pyrocarbon-hemiarthroplasty and four patients with a mean age of 76 y.o. were treated with reverse shoulder arthroplasty. Glenoid single stage reconstruction was performed with a bone autograft harvested from the resected humeral head. Patients were observed for a clinical and radiological follow-up for a minimum period of 2 years; ASES and Constant score were assessed.

RESULTS

Pain and ROM improvement was reported in all the patients. In one case, postoperative recurrent RSA instability was found. Glenoid reconstruction was performed in seven cases, showing a good integration and no reabsorption issues in all but one cases. ASES and Constant-Murley functional outcomes were rated as excellent by 1 patient with pyrocarbon HA and 1 patient with RSA, good by 3 patients with RSA and 2 patients with HA, fair by 1 patient with HA and poor by one patient with RSA.

CONCLUSION

The treatment of locked anterior glenohumeral dislocation still represents a challenge in symptomatic patients. Shoulder replacement showed good results in young and older patients, with HA and RSA, respectively. Autograft from the humeral head is reliable for glenoid defect, even in ream and run procedure. Locked dislocation lasting more than one year, surgery is debatable for higher risk of a poor outcome and recurrent instability.

Subscapularis-sparing approaches in shoulder arthroplasty: A systematic review

Background

Novel approaches for anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) that spare the subscapularis (SSC) have recently been described. Outcomes for the SSC-sparing approach were evaluated through this systematic review.

Methods

Medline, Embase, PubMed, and CENTRAL were searched.

Results

From 2051 citations, 8 studies were included (aTSA group, n = 241; rTSA group, n = 68). SSC-sparing aTSA and rTSA were associated with significant postoperative improvements in shoulder function and range of motion at 12- to 24-month follow-up.

Conclusion

The SSC-sparing approach may provide a safe alternative for up to two years post-surgery. Evidence for long-term use remains inconclusive.

Computer-Assisted Surgery in Reverse Shoulder Arthroplasty: Early Experience

BACKGROUND

In the last decade, new technologies have been applied to shoulder arthroplasty. The aim of this work was to show that navigated RSA allows the surgeon to reach the planned version/inclination in all cases. In this article are shown preliminary data, advantages, disadvantages and limits of the technique.

METHODS

Eighteen computer-assisted reverse shoulder arthroplasty were performed. Preoperative glenoid version and inclination were evaluated with preoperative CT scan using Orthoblue^® (Exactech, Gainesville, FL,USA) software, as well as baseplate type, planned glenoid component seating, planned postoperative version, planned postoperative inclination, intraoperative glenoid version/inclination, screw length and surgical time. A senior shoulder surgeon has analyzed the advantages, disadvantages and limitation of this kind of surgery.

RESULTS

Mean surgical time of the primary implants was 92 ± 12 min (min 75-max 110). Mean preoperative inclination was + 2.6° ± 6.4, mean preoperative version was - 7.6° ± 8.4. Mean planned postoperative inclination was - 2.7° ± 2.3, mean planned postoperative version was - 1.6° ± 2.9 and mean planned glenoid seating was 89% ± 8%. Planned settings were reached in all cases during surgery. Baseplate implanted were in nine cases 8° posterior augmented, in six cases standard and in three cases 10° superior augmented. Mean screw length was 33.5 mm ± 4.2 mm. No GPS system failure has been recorded. One coracoid fracture occurred during the first case.

DISCUSSION

Intraoperative navigation system is a reliable and user-friendly technology that allows the surgeon to reach planned glenoid positioning during surgery. Furthermore, this technology will allow the surgeon to compare clinical outcomes to component positioning data. The lack of humeral implant navigation is the main limit of this technique.

Clinical results and survivorship of the Mathys Affinis Short, Short Stem Total Shoulder Prosthesis

AIMS

The Mathys Affinis Short is the most frequently used stemless total shoulder prosthesis in the UK. The purpose of this prospective cohort study is to report the survivorship, clinical, and radiological outcomes of the first independent series of the Affinis Short prosthesis.

METHODS

From January 2011 to January 2019, a total of 141 Affinis Short prostheses were implanted in 127 patients by a single surgeon. Mean age at time of surgery was 68 (44 to 89). Minimum one year and maximum eight year follow-up (mean 3.7 years) was analyzed using the Oxford Shoulder Score (OSS) at latest follow-up. Kaplan-Meier survivorship analysis was performed with implant revision as the endpoint. Most recently performed radiographs were reviewed for component radiolucent lines (RLLs) and proximal humeral migration.

RESULTS

Five shoulders underwent revision surgery (3.5%); three for rotator cuff failure, one for infection, and one for component malposition. Survivorship of the implant was 95.4% (95% confidence interval 90.1% to 97.9%) at five and nine years. Mean OSS improved significantly compared to preoperative values from 19.0 (1 to 35) to 43.3 (7 to 48) (p < 0.001). Radiological analysis was undertaken for 99 shoulders. This revealed humeral RLLs in one case (1%), glenoid RLLs in 15 cases (15.2%), and radiological rotator cuff failure in 22 cases (22.2%).

CONCLUSION

This prospective cohort study shows encouraging short- to mid-term survivorship and clinical and radiological results for the Mathys Affinis Short, Short Stem Total Shoulder Prosthesis.Level of Evidence: IVCite this article: Bone Jt Open 2021;2(1):58-65.

Baseplate Options for Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Baseplate fixation has been known to be the weak link in reverse total shoulder arthroplasty (RTSA). A wide variety of different baseplates options are currently available. This review investigates the recent literature to present the reader with an overview of the currently available baseplate options and modes of fixation.

RECENT FINDINGS

The main elements that differentiate baseplates are the central fixation element, the size of the baseplate, the shape, the backside geometry, whether or not an offset central fixation exists, the number of peripheral screws, and the availability of peripheral augmentation. The wide array of baseplate options indicates that no particular design has proven superiority. As such, surgeons should be aware of their options and choose an implant that the surgeon is comfortable with and one that best suits the individual patient anatomy. With the growing number of RTSA procedures and registries with long-term follow-up, future investigations will hopefully delineate the ideal baseplate design to optimize survivorship.

Early migration of stemless and stemmed humeral components after total shoulder arthroplasty for osteoarthritis-study protocol for a randomized controlled trial

BACKGROUND

Glenohumeral osteoarthritis can, in the most severe cases, require surgery with insertion of a shoulder arthroplasty. A design with a stem in the humeral bone canal is currently regarded as the standard treatment option in patients who have an intact rotator cuff function, but complications related to the stem including humeral fractures can have devastating consequences. By using a stemless humeral component, stem-related complications can be reduced. The aim of this study is to compare the Comprehensive Nano stemless total shoulder arthroplasty (intervention group) with the Comprehensive stemmed total shoulder arthroplasty (control group).

MATERIALS AND METHODS

This is a randomized controlled trial comparing the stemless and the stemmed total shoulder arthroplasty. All Danish citizens with glenohumeral osteoarthritis indicating a total shoulder arthroplasty referred to the orthopedic department at Copenhagen University Hospital in Herlev/Gentofte will be offered participation. The following exclude from participation: below 18 years of age, cognitive or linguistic impairment, insufficient function of the rotator cuff, poor bone quality, and ASA groups 4-5. A total of 122 patients will be included of which 56 will be part of a radiostereometric analysis (RSA) study of humeral component migration. The primary outcomes are magnitude of migration of the humeral component assessed by RSA and patient-reported outcome by Western Ontario Osteoarthritis of the Shoulder index (WOOS). The secondary outcomes are additional patient-reported outcomes, functional outcome, readmission, complications, revisions, and changes in bone mineral density (BMD) of the proximal humerus assessed by duel energy x-ray absorptiometry (DXA) and economy (cost-utility analysis). The patients are examined before the operation and 3, 6, 12, and 24 months postoperative.

DISCUSSION

To our knowledge, RSA has never been used to access migration of a stemmed or a stemless humeral component nor has the stemmed and the stemless humeral component been compared with regard to pain relief and shoulder function in a randomized clinical trial. Today, the two designs are considered equal in the treatment of osteoarthritis. The study will provide surgeons and patients with information about shoulder arthroplasty for osteoarthritis and assist them in decision-making.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04105478 . Registered on 25 September 2019.

Constrained or unconstrained shoulder replacement for musculoskeletal tumor resections?

BACKGROUND

Many options exist for reconstructing the shoulder after large bony resections of the proximal humerus. One of the more widely used is endoprosthetic replacement. Proximal migration of unconstrained hemiarthroplasty articulations may cause difficulties particularly in the setting of loss of the rotator cuff and/or deltoid musculature. To attempt to overcome these issues, a fixed-fulcrum constrained reverse shoulder replacement option may be considered.

METHODS

A retrospective review of prospectively collected data from the Queensland Bone and Soft Tissue Sarcoma Service was undertaken to compare the function, implant survivorship, and reoperation rate of constrained reverse and unconstrained hemiarthroplasty-type endoprostheses in patients with tumors.

RESULTS

We retrospectively reviewed data on 41 consecutive proximal or total humeral endoprosthetic replacements undertaken between January 2003 and July 2018. One patient was excluded as lost to follow-up prior to 24 months. There were 21 unconstrained implants and 19 constrained shoulder replacements (Stanmore Modular Endoprosthesis Tumour System with Bayley-Walker articulation). Proximal migration of the unconstrained hemiarthroplasty articulation occurred in 8 patients (38%), and dislocation or failure of the constrained mechanism occurred in 5 (26%). Reoperation for implant-related issues was required in 5 patients in the constrained group and none in the unconstrained group. Of the 18 patients alive at the time of review, 12 provided functional scores. The mean follow-up period for surviving patients was 4.2 years (standard deviation, 2.7 years), with a minimum of 2 years' follow-up. Functional scores were similar between the 2 groups.

CONCLUSION

Constrained reverse prostheses were associated with a higher reoperation rate in this series without any functional benefit compared with unconstrained hemiarthroplasty-type articulations. We favor the use of unconstrained hemiarthroplasty-type endoprostheses for reconstruction after resection of destructive lesions of the proximal humerus.

Functional improvement is sustained following anatomical and reverse shoulder arthroplasty for fracture sequelae: a registry-based analysis

INTRODUCTION

Shoulder arthroplasty for proximal humerus fracture sequelae is known to provide significant patient improvement, yet this outcome varies with time, prosthesis type, and fracture sequelae. We outline the expected course of postoperative shoulder pain and function in patients with anatomical (ASA) or reverse (RSA) shoulder arthroplasty following different fracture sequelae.

MATERIALS AND METHODS

Of 111 consecutive patients from our local shoulder arthroplasty registry, 32 underwent ASA for Boileau type 1 sequelae and 77 RSA patients were identified with Boileau types I, III, and IV. By 5 year post-surgery, there were 72 patients available. All patients underwent standardised ASA or RSA procedures with anatomical (Promos Standard; Lima SMR™; Arthrex Eclipse™; Univers™ II) or reverse prostheses (Promos Reverse^®; Lima SMR™ Reverse; Univers Revers™; Aequalis^® Reversed). Range of motion, Constant-Murley, Disability of the Arm, Shoulder and Hand (DASH), and Shoulder Pain and Disability Index (SPADI) scores were compared at 6, 12, 24, and 60 months postoperatively. We used generalised linear mixed models or random-effects ordered logistic regression to investigate postoperative changes of outcome parameters from baseline to follow-up time points for each group as well as for group comparisons.

RESULTS

Range of motion and clinical scores improved until 24 months postoperatively and did not deteriorate thereafter, except for internal rotation of Boileau type III and IV patients and external rotation of RSA patients with type I and IV sequelae. At all follow-ups, ASA patients with Boileau type I sequelae had significantly better internal and external rotation versus patients with RSA and/or other Boileau types (p < 0.001), while Constant, DASH, and SPADI scores were not significantly different between groups.

CONCLUSION

In humeral fracture sequelae, ASA and RSA lead to sustained clinical improvements. Surgeons may primarily consider implantation of ASA in type I sequelae.

Patient-reported outcome after stemmed versus stemless total shoulder arthroplasty for glenohumeral osteoarthritis: a patient-blinded randomized clinical trial

BACKGROUND

Stemless shoulder arthroplasty systems with uncemented metaphyseal fixation have been used for glenohumeral osteoarthritis since 2004 (Hawi, et al. BMC Musculoskelet Disord 17:376, 2016). The stemless design has several theoretical advantages compared with the stemmed shoulder arthroplasty systems: restoring patients' anatomy; preserving humeral bone stock; and few complications in component removal if the need for a revision arthroplasty arises. The purpose of the study is to compare the short-term, patient-reported outcome of stemless and stemmed total shoulder arthroplasty (TSA).

MATERIALS AND METHODS

A randomized clinical trial will be conducted. Eighty patients with clinical and radiological signs of primary or post-traumatic glenohumeral osteoarthritis, computed tomography (CT) scan-verified adequate glenoid bone stock, and no total rupture of rotator cuff tendons verified by a magnetic resonance imaging (MRI) scan will be randomly allocated to a stemless or stemmed TSA. The primary outcome will be the Western Ontario Osteoarthritis Shoulder (WOOS) score at 12 months. Secondary outcomes are the WOOS score at three months and the Oxford Shoulder Score (OSS) and EQ-5D at 3 and 12 months. All complications, including glenoid and humeral component loosening, instability, rotator cuff tear, intraoperative and postoperative periprosthetic fracture, nerve injury, infection, deltoid injury, and symptomatic deep venous thrombosis, will be reported.

DISCUSSION

Findings will provide patients with better information about the potential benefits and harms of stemless and stemmed TSA and will assist shoulder surgeons and patients in decision-making.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03877315 . Registered on 13 March 2019.

Short-term results of a second generation anatomic short-stem shoulder prosthesis in primary osteoarthritis

INTRODUCTION

The aim of the study was to evaluate the short-term clinical results of anatomic total shoulder arthroplasty with a short-stem prosthesis in primary osteoarthritis.

MATERIALS AND METHODS

65 shoulders with a mean age of 70 years (range 47-85 years) were available for minimum follow-up of 24 months. Clinical outcome was determined by range of motion, Constant score (CS) age and sex-adjusted Constant score (CS%), and subjective shoulder value (SSV). The influence of six different factors (high bone adaptations, age > 65 years, female gender, dominant side, atrophy of the supraspinatus tendon ≥ grade 2, glenoid type B2/B3) on the clinical outcome was assessed.

RESULTS

At mean follow-up of 37 months (range 24-58 months), the CS improved from 36 ± 8 to 75 ± 12 (p < 0.001). The shoulder flexion (100° ± 21° to 159° ± 19°) as well as the external rotation (3° ± 11° to 43° ± 18°) improved significantly (p < 0.001). Three complications were noted (transient neuropraxia of the radial nerve, subjective instability, hematoma with superficial wound infection) leading to one revision surgery (wound debridement). No stem loosening was observed. High bone adaptation was present in 19 out of 65 shoulders (29%). The clinical outcome was not influenced by high bone adaptations (p ≥ 0.095). Age > 65 years (n = 44) and female gender (n = 38) were associated with worse clinical outcome (p ≤ 0.043).

CONCLUSIONS

In the short term, the clinical results of this anatomical short-stem shoulder prosthesis are encouraging. A low prevalence of high bone adaptations was found without any influence on the clinical outcome and stem loosening was not observed.