Outcomes of total shoulder arthroplasty in patients younger than 65 years: a systematic review

Anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis is associated with excellent outcomes and low revision rates in the elderly

BACKGROUND

The relative indications of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) continue to evolve. Some surgeons favor RSA over TSA for elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff due to fear of a postoperative (secondary) rotator cuff tear in this age group. However, RSA is associated with unique complications and a worse functional arc of motion compared with TSA. Therefore, it is important to understand the clinical outcomes and rates of revision surgery and secondary rotator cuff tears in elderly patients undergoing TSA.

METHODS

Between January 1, 2010, and December 31, 2017, 377 consecutive TSAs were performed for primary GHOA in 340 patients 70 years of age or older. The mean age at surgery was 76.2 years (standard deviation [SD], 4.9). Clinical evaluation included pain, motion, and American Shoulder and Elbow Surgeons score. Radiographs were reviewed for preoperative morphology and postoperative complications. All complications and reoperations were recorded. The average clinical follow-up time was 3.3 years (SD, 2.0). Statistical analyses were performed, and Kaplan-Meier implant survival estimates were calculated. For all analyses, a P value <.05 was considered statistically significant.

RESULTS

The mean pain visual analog scale and American Shoulder and Elbow Surgeons score at the final follow-up were 1.6 (SD, 2.2) and 78.0 (SD, 17.8), respectively. Forward elevation and external rotation increased from 96° (SD, 30°) and 26° (SD, 20°) preoperatively to 160° (SD, 32°) and 64° (SD, 26°) postoperatively (P < .001 for each). The percentage of patients who had internal rotation to L5 or greater increased from 24.8% preoperatively to 71.8% postoperatively (P < .001). Revision surgery was performed in 3 shoulders (0.8%), and the 5-year implant survival estimate was 98.9% (95% confidence interval: 97.3%-100%). There were 3 medical (0.8%), 10 minor surgical (2.7%), and 5 major surgical (1.3%) complications. No shoulder had radiographic evidence of humeral component loosening, whereas 7 (2%) had evidence of some degree of glenoid component loosening. In total, there were 5 secondary rotator cuff tears (1.3%), of which 2 (0.5%) required revision surgery.

CONCLUSION

Elderly patients with primary GHOA and an intact rotator cuff have excellent clinical and radiographic outcomes after anatomic TSA, with high implant survival rates and a low incidence of secondary rotator cuff tears in the first 5 postoperative years. Age greater than 70 by itself should not be considered an indication for RSA over TSA.

Preliminary outcomes of arthroscopic biceps rerouting for the treatment of large to massive rotator cuff tears

BACKGROUND

We aimed to evaluate the short-term outcomes of arthroscopic biceps rerouting (ABR) for the treatment of large to massive rotator cuff tears (LMRCTs).

METHODS

A prospective evaluation of patients treated with ABR for the repair of LMRCTs was performed, with a minimum follow-up period of 18 months. Range of motion and functional outcomes (visual analog scale pain score, American Shoulder and Elbow Surgeons score, and Korean Shoulder Scale score) were assessed preoperatively and at final follow-up. Radiographs were used to evaluate the acromiohumeral interval (AHI). Magnetic resonance imaging was performed at 2 and 12 months postoperatively to examine the integrity of the repaired rotator cuff tendons.

RESULTS

Eighty patients who met the study criteria underwent ABR from March 2017 to January 2019 in our hospital. Of these patients, 61 could be evaluated ≥18 months after surgery. The average age of the enrolled patients was 64.5 years. The visual analog scale pain score decreased from 3.7 preoperatively to 1.6 at final follow-up (P = .019), the American Shoulder and Elbow Surgeons score improved from 60.0 to 85.2 (P < .001), and the Korean Shoulder Scale score improved from 64.3 to 85.3 (P = .001). Assessment of range of motion showed significant improvement in forward flexion (from 138° to 146°, P < .001), external rotation at 90° of abduction (from 80° to 85°, P = .037), and internal rotation (from spinal level 9 to spinal level 10, P = .015) from preoperatively to last follow-up. The AHI was 7.1 mm at baseline and improved significantly to 9.7 mm at 3 months postoperatively (P < .001). The mean AHI at last follow-up was only 9 mm, but this was still significantly better than the mean preoperative AHI (P < .001). Of the patients, 16 (26%) exhibited a retear of the repaired rotator cuff on magnetic resonance imaging at 12 months postoperatively. Male sex was the only significant risk factor for retear (P = .037).

CONCLUSION

ABR improved the functional and radiologic outcomes of patients with LMRCTs. The ABR technique can be a useful treatment option for LMRCTs.

Development and ex-vivo assessment of a novel patient specific guide and instrumentation system for minimally invasive total shoulder arthroplasty

Objective

To develop and assess a novel guidance technique and instrumentation system for minimally invasive short-stemmed total shoulder arthroplasty that will help to reduce the complications associated with traditional open replacement such as poor muscle healing and neurovascular injury. We have answered key questions about the developed system including (1) can novel patient-specific guides be accurately registered and used within a minimally invasive environment?; (2) can accuracy similar to traditional techniques be achieved?

Methods

A novel intra-articular patient-specific guide was developed for use with a new minimally invasive posterior surgical approach that guides bone preparation without requiring muscle resection or joint dislocation. Additionally, a novel set of instruments were developed to enable bone preparation within the minimally invasive environment. The full procedure was evaluated in six cadaveric shoulders, using digitizations to assess accuracy of each step.

Results

Patient-specific guide registration accuracy in 3D translation was 2.2±1.2mm (RMSE±1 SD; p = 0.007) for the humeral component and 2.7±0.7mm (p<0.001) for the scapula component. Final implantation accuracy was 2.9±3.0mm (p = 0.066) in translation and 5.7–6.8±2.2–4.0° (0.001<p<0.009) across the humerus implants’ three rotations. Similarly, the glenoid component’s implantation accuracy was 3.0±1.7mm (p = 0.008) in translation and 2.3–4.3±2.2–4.4° (0.008<p<0.09) in rotation.

Conclusion

This system achieves minimally invasive shoulder replacement with accuracy similar to traditional open techniques while avoiding common causes of complications.

Significance

This novel technique could lead to a paradigm shift in shoulder arthroplasty for patients with moderate arthritis, which could significantly improve rehabilitation and functional outcomes.

Anatomic Total Shoulder Arthroplasty With a Stemless Humeral Component

Background

This technique video reviews anatomic total shoulder arthroplasty (TSA) with a stemless humeral component using a representative case example.

Indications

Stemless TSA is indicated for patients with symptomatic glenohumeral arthritis typically younger than 65 years of age. Stemless TSA may be used for other glenohumeral degenerative conditions such as avascular necrosis or posttraumatic arthropathy, provided acceptable humeral bone quality is confirmed intraoperatively using a thumb-press test. Poor bone quality is the primary contraindication.

Technique Description

Preoperatively, computed tomography is typically used for planning, and intraoperative navigation through magnetic resonance imaging is also useful. The procedure's critical elements include beach chair positioning, standard deltopectoral approach with lesser tuberosity osteotomy (LTO), freehand proximal humeral osteotomy, perpendicular proximal humeral exposure and subsequent preparation over a central guidewire, stemless implant and humeral head sizing, perpendicular glenoid exposure and implant placement, and final humeral implantation with LTO repair/fixation. A phased rehabilitation protocol includes 6-week sling immobilization to protect the subscapularis/LTO repair and return to normal activities between 3 and 6 months postoperatively.

Discussion/Conclusion

Stemless TSA shows promising early and mid-term outcomes with complication rates, including humeral loosening rates, similar to standard stemmed components. Potential complications include neurovascular injury, infection, glenoid or humeral component loosening, and rotator cuff failure.

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

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

Glenohumeral Osteoarthritis: The Role for Orthobiologic Therapies: Platelet-Rich Plasma and Cell Therapies

The glenohumeral (GH) joint ranks third on the list of the large joints that are most commonly affected by osteoarthritis, after the knee and the hip. General nonsurgical modalities, including changes in daily activities, physical therapy, pharmacotherapy, and corticosteroid injections, constitute the mainstay of treatment. Most of these options, however, have shown moderate and short-term effectiveness. Arthroplasty techniques have proven to be successful for elderly patients. Nevertheless, replacement options are not optimal for younger patients because their functional demands are higher and prostheses have a finite life span. This has led to the search for new nonoperative treatment options to target this subgroup of patients. It has been suggested that orthobiologic therapies, including platelet-rich plasma (PRP) and cell therapies, present great promise and opportunity for the treatment of GH osteoarthritis. Despite the promising results that have been shown by cell therapies and PRP for treating degenerative joint conditions, additional studies are needed to provide more definitive conclusions.

Comparison of "Bilboquet" device and locking plate for surgical treatment of proximal humerus complex fractures at two years follow-up

PURPOSE

Surgical treatment of three or four part fractures of the proximal humerus is complex. Different conservative techniques have been described. The main goal of this study was to compare the clinical and radiological outcomes of Bilboquet and locking plate at two year follow-up.

METHODS

This is a retrospective, comparative study, with a continuous series of 41 patients. Bony fixation was achieved with a Bilboquet device in 22 patients or a locking plate in 19 patients. Patient evaluation included clinical data: shoulder range of motion, Constant-Murley shoulder score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and imaging using standard shoulder X-rays.

RESULTS

Of the 41 patients included, 1 patient was lost to follow-up in the locking plate group. At a mean follow-up of 24 months patients in Bilboquet group showed a Constant score higher than in locking plate (p = 0.02). Range of motion and DASH score were not significantly different between the two groups. avascular necrosis occured in three patients of Bilboquet group (14%) versus in two patients in the locking plate group (11%) (p > 0.5). Complication and reintervention rate were non-significantly higher in the locking plate group than in the Bilboquet group (37 vs 14%).

CONCLUSION

Bilboquet and locking plate give good functional outcomes in complex proximal humerus fractures. However, the Bilboquet device appears to provide better functional results than locking plate at mid-term follow-up.

Impaired health-related quality of life, psychological distress, and productivity loss in younger people with persistent shoulder pain: a cross-sectional analysis

PURPOSE

To investigate wellbeing and work impacts in younger people with persistent shoulder pain.

MATERIALS AND METHODS

People aged 20-55 years with shoulder pain of >6 weeks' duration (excluding those with recent fracture or dislocation) were recruited from orthopaedic clinics at three major public hospitals. Health-related quality of life (HRQoL) and psychological distress were evaluated using the Assessment of Quality of Life (AQoL) and K10 instruments and compared to population norms. Shoulder-related absenteeism and presenteeism were quantified using the Work Productivity and Activity Impairment (WPAI) Questionnaire.

RESULTS

Of the 81 participants (54% male), 69% had shoulder pain for over 12 months. Substantial HRQoL impairment was evident (mean reduction from population norms 0.33 AQoL units, 95% CI -0.38 to -0.27; minimal important difference 0.06 AQoL units). High or very high psychological distress was three times more prevalent among participants than the general population (relative risk 3.67, 95% CI 2.94 to 4.59). One-quarter of participants had ceased paid employment due to shoulder pain and 77% reported shoulder-related impairment at work.

CONCLUSIONS

The broader impacts of painful shoulder conditions on younger people extend well beyond pain and upper limb functional limitations. In particular, the work-related impacts should form a routine part of patient assessment and rehabilitation.Implications for rehabilitationPersistent shoulder pain in younger people (aged 20-55 years) is associated with substantially reduced health-related quality of life and greater psychological distress, compared to population norms, as well as work participation and productivity impacts.As rotator cuff conditions, shoulder capsule pathology, and glenohumeral instability are relatively common, our data suggest that persistent shoulder pain is likely to have a high community impact among people of working age.Information resources that people with painful shoulder conditions can share with their families, employers, and colleagues may assist others to better understand the broader impacts of these conditions.Work-related challenges associated with shoulder pain should be considered within routine clinical care, and may require referral to an occupational health clinician or vocational rehabilitation service.

Return to Work After Shoulder Replacement for Glenohumeral Osteoarthritis Is Similar When Hemiarthroplasty Is Compared to Total Shoulder Arthroplasty

BACKGROUND

Return to work after shoulder arthroplasty for glenohumeral osteoarthritis (OA) is an important consideration for an aging workforce.

QUESTIONS/PURPOSES

The aim of this study was to compare the shoulder function, pain levels, and rate of return to work in patients treated with anatomic total shoulder arthroplasty (aTSA) versus humeral hemiarthroplasty (HHA).

METHODS

A retrospective review of consecutive HHA patients was performed of our institution's shoulder arthroplasty registry. Inclusion criteria were pre-operative diagnosis of end-stage OA and more than 2 years' follow-up. HHA patients were statistically matched to aTSA patients and then screened for pre-operative work status; 26 HHA and 23 aTSA patients worked before surgery. There was no difference in average age (HHA, 62.4 years; aTSA, 61.7 years) or follow-up (HHA, 67.5 months; aTSA, 66.9 months).

RESULTS

Average American Shoulder and Elbow Surgeons (ASES) scores (HHA, 37.6 to 70.3; aTSA, 35.6 to 80.1) and visual analogue scale (VAS) for pain scores (HHA, 6.1 to 2.3; aTSA, 6.5 to 0.6) improved in both groups. However, HHA patients had worse final VAS scores, and aTSA patients were more satisfied (100% vs 77%); 61.5% of HHA patients returned to work post-operatively versus 87.0% of aTSA patients. There was no difference in time to return to work (HHA, 1.9 ± 2.3 months; aTSA, 1.3 ± 1.0 months).

CONCLUSION

Patients with shoulder OA undergoing aTSA have higher rates of return to work, function, and satisfaction than those undergoing HHA.

Resurfacing hemiarthroplasty versus stemmed hemiarthroplasty for glenohumeral osteoarthritis: a meta-analysis

Background

Though total shoulder arthroplasty (TSA) has been an acknowledged treatment option for glenohumeral osteoarthritis, resurfacing hemiarthroplasty (RHA) and stemmed hemiarthroplasty (SHA) may be preferred in some circumstances by surgeons, especially for treating young or active patients. However, decision-making between the RHA and SHA is controversial. Therefore, we conducted a meta-analysis to systematically compare two surgical procedures in terms of postoperative functional outcomes, range of motion (ROM), pain relief, complication rates, risk of revision.

Methods

The PubMed, Embase, Web of Science and Cochrane Library were searched from inception to January 1, 2020, for all articles that compared the clinical effectiveness and safety of RHA with SHA. All eligible studies were selected based on certain screening criteria. Two investigators independently conducted the quality assessment and extracted the data. Fixed-effect and random-effect models were used for pooled results according to the degree of heterogeneity. All statistical analyses were performed by employing Stata software 14.0.

Results

A total of six comparative studies involving 2568 shoulders (1356 RHA and 1212 SHA) were included in the final analysis. Patients were followed up for at least 1 year in each study. Pooled results showed that RHA was associated with a better visual analog scale (SMD 0.61, p = 0.001) but higher revision rates (OR 1.50, p = 0.016) when compared to SHA. There were no significant differences in functional outcomes, such as Constant-Murley score (SMD 0.06, P = 0.878), American Shoulder and Elbow Surgeons score (SMD 0.05, P = 0.880), Western Ontario Osteoarthritis of the Shoulder index (SMD 0.43, p = 0.258) and quick-Disabilities of the Arm, Shoulder and Hand score (SMD 0.06, p = 0.669). In addition, no differences were observed in forward flexion (SMD 0.16, p = 0.622), external rotation (SMD -0.17, P = 0.741) and overall complication rates (OR 1.42, p = 0.198).

Conclusion

This is the first meta-analysis to investigate the clinical efficacy and safety of RHA in comparison with SHA for the treatment of glenohumeral osteoarthritis. The results demonstrated that the two surgical techniques were equivalent in terms of postoperative functional outcomes and complication rate. However, RHA provided greater pain relief but posed a higher risk for revision than SHA. More high-quality studies with long-term follow up are warranted to give more convincing evidence.

Reverse versus anatomical shoulder arthroplasty in patients with intact rotator cuff

PURPOSE

The study objective was to compare the clinical results of reverse total shoulder arthroplasty (rTSA) and anatomical total shoulder arthroplasty (aTSA) in patients with osteoarthritis and intact rotator cuff. We hypothesised that the clinical results using rTSA would be comparable with those obtained with aTSA in this group of patients.

METHODS

The study included 51 patients with shoulder osteoarthritis and intact rotator cuff who underwent rTSA or aTSA. The range of motion, Constant-Murley score and strength in external rotation were recorded pre-operatively and at the two year follow-up. Subjective post-operative results were measured using the subjective shoulder value (SSV) score and a satisfaction questionnaire.

RESULTS

The post-operative improvement was significant in both groups, subjectively and concerning all parameters of the Constant-Murley score. Post-operatively, no significant difference was noted between the two groups for active anterior elevation (AAE), active external rotation (ER), internal rotation (IR) or Constant-Murley score (67 ± 12 in the rTSA group vs 71 ± 11 in the aTSA group). An exception was the Constant-Murley range of motion sub-score, which was better in the aTSA group (p = 0.028). No significant complications necessitating revision surgery were encountered.

DISCUSSION

Our findings are consistent with previous studies showing good results of rTSA with shoulder osteoarthritis and intact rotator cuff with a good restoration of the IR, similar to that obtained with aTSA.

CONCLUSION

The rTSA is a valid option for shoulder osteoarthritis and intact rotator cuff in older adult patients.

Complications and implant survivorship following primary reverse total shoulder arthroplasty in patients younger than 65 years: a systematic review

BACKGROUND

Concerns exist regarding the complication rates and implant survivorship of reverse total shoulder arthroplasty (RTSA) in younger patients.

METHODS

A systematic review of the literature regarding the existing evidence on RTSA in patients younger than 65 years was performed using the CENTRAL (Cochrane Central Register of Controlled Trials), PubMed, and Embase databases on June 9, 2019. Articles published between 1995 and 2019 with combinations of the following keywords were identified: "reverse shoulder arthroplasty" and "65," "60," and/or "55." Complications, reoperations, and revisions were recorded. Reoperation-free survival and implant survival rates were grouped at 2, 5, and 10 years. Range of motion and clinical outcomes, along with postoperative radiographic results, were recorded.

RESULTS

Data from 7 studies with a total of 286 shoulders were obtained for quantitative analysis. The mean patient age was 58.4 years (mean age range, 48.9-60.4 years), and the mean follow-up period was 4.7 years (mean follow-up range, 3.0-7.8 years). The overall rate of complications was 18.6%; reoperations, 14.4%; and revisions, 11.2%. The reoperation-free survival rate was 97% at 2 years, 88%-90% at 5 years, and 76% at 10 years. The implant survival rate was 99% at 2 years, 91%-98% at 5 years, and 88% at 10 years. Active abduction, forward elevation, and external rotation significantly improved from preoperatively to postoperatively. All clinical outcome measures significantly improved from preoperatively to postoperatively, with no decline seen over time. The overall rate of infrascapular notching was 22.7% at final follow-up.

CONCLUSION

RTSA is safe and effective in patients younger than 65 years. Complication, reoperation, and revision rates were similar to those seen in older patient cohorts, without an increase in revisions owing to aseptic loosening. Clinical outcome scores showed significant and lasting improvements.

Defining the younger patient: age as a predictive factor for outcomes in shoulder arthroplasty

BACKGROUND

The purpose of this study was to define an age cutoff at which clinical outcomes and revision rates differ for patients undergoing primary anatomic total shoulder arthroplasty (TSA) and patients undergoing primary reverse shoulder arthroplasty (RSA).

METHODS

This retrospective cohort study included 1250 primary shoulder arthroplasties (1131 patients) with minimum 2-year clinical follow-up (mean, 50 months [range, 24-146 months]). TSA (n = 518; mean age, 68.1 years [range, 28-90 years]) was performed for osteoarthritis in most cases (99%), whereas the primary diagnoses for RSA (n = 732; mean age, 70.8 years [range, 22-91 years]) included rotator cuff arthropathy (35%), massive cuff tear without osteoarthritis (29.8%), and osteoarthritis (20.5%). Outcomes included range of motion, the American Shoulder and Elbow Surgeons (ASES) score, and the revision rate. The relationship between age at the time of surgery in 5-year increments (46-50 years, 51-55 years, and so on) and the revision rate was examined to identify the age cutoff; this was then used to assess clinical outcomes.

RESULTS

In patients younger than 65 years, TSA was associated with a 3.4-fold increased risk of revision (P = .01). RSA performed in patients younger than 60 years was associated with a 4.8-fold increased risk of revision (P < .001). TSA patients aged 65 years or older and RSA patients aged 60 years or older had better total ASES scores (82 vs. 77 [P = .03] and 72 vs. 62 [P = .002], respectively) and better internal rotation (interquartile range, TSA 5-6 vs. 4-5 [P = .002] and RSA 4-5 vs 3-4 [P = .04])-where 6 represents T4 to T6 and 4 represents T11 to L1-than their younger counterparts.

CONCLUSION

Age at index arthroplasty affects outcomes and the risk of revision. Primary TSA patients younger than 65 years and RSA patients younger than 60 years have a significantly increased revision risk. These age cutoffs are also correlated with differences in ASES scores and internal rotation.

Improvement in sleep quality after total shoulder arthroplasty

Objective: Poor sleep quality due to nocturnal pain is increasingly reported as a major symptom in advanced glenohumeral arthritis. The current study aimed to evaluate preoperative and postoperative sleep quality, shoulder pain, and function in patients who underwent total shoulder arthroplasty (TSA). Preoperative factors contributing to delayed improvements in sleep quality were examined.Methods: Patients scheduled for anatomic or reverse TSA due to glenohumeral arthritis were included. Patients completed the Pittsburgh Sleep Quality Index (PSQI) and American Shoulder and Elbow Surgeons (ASES) survey preoperatively, and at 6 weeks, 3 months, 6 months, and 1 year following surgery. A higher PSQI score (maximum 21) indicated greater sleep disturbance.Results: Seventy-four patients (34 males, 40 females), with a mean age of 65.8 years were prospectively enrolled. Eighty-four percent of patients reported preoperative PSQI scores indicative of sleep disturbance (6 or greater), with a mean of 10.1 ± 4.3. The PSQI score significantly improved to 7.7 at 6 weeks (P = .003), and to 6.1 at 3 months (P = .08). At 12 months, the PSQI was within normal limits (less than or equal to 5) with a mean score of 4.3. A normal PSQI score was achieved by 40.8%, at 6 weeks, 50% at 3 months, 53.7% at 6 months, and 73.9% at 1 year. The ASES score significantly improved from 32.6 ± 17.2 at baseline to 58.4 at 6 weeks (p < .001), 76.1 at 3 months (p < .001), and 85.3 at 12 months. Linear regression demonstrated that the ASES and PSQI scores were negatively associated with each other at each time point. Body mass index and female gender were associated with a delayed return to baseline sleep quality.Conclusion: Shoulder-related sleep disturbance significantly improved at 6 weeks following TSA, and normalized for most patients by 1 year post-operatively. Enhanced sleep quality after TSA was directly related to improved functional outcomes.

Same-day discharge is not inferior to longer length of in-hospital stay for 90-day readmissions following shoulder arthroplasty

BACKGROUND

Shoulder arthroplasty is a common orthopedic procedure, performed historically in the inpatient setting. However, interest in same-day discharge has increased. We sought to evaluate 90-day readmission, 90-day emergency department (ED) visit, 90-day deep infection, 90-day venous thromboembolism (VTE), and 1-year mortality after same-day shoulder arthroplasty compared with an inpatient stay.

METHODS

We conducted a retrospective cohort study using data from an integrated health care system's Shoulder Arthroplasty Registry. A total of 6503 elective primary unilateral total shoulder and reverse total shoulder arthroplasties performed between 2005 and 2016 were included; 405 (6%) had same-day discharge. The likelihood of 90-day events, including readmission, ED visit, deep infection, and VTE, and 1-year mortality after same-day discharge was compared with 1- to 4-night inpatient stay using generalized estimating equations with noninferiority testing, adjusting for age, sex, body mass index, race, American Society of Anesthesiologists classification, select comorbidities, osteoarthritis, anesthesia type, procedure type, and surgeon effect.

RESULTS

We failed to observe a difference between same-day discharge and 1- to 4-night stay in terms of 90-day readmission, 90-day ED visit, and 1-year mortality. Same-day discharge was not inferior to 1- to 4-night stay regarding 90-day readmission, but we did not have evidence to support noninferiority for 90-day ED visits or 1-year mortality. Ninety-day deep infections and VTE were too infrequent for adjusted analysis.

CONCLUSIONS

We found same-day shoulder arthroplasty not to be inferior to an inpatient stay for 90-day readmission. Future investigation into the reasons for readmission and ED visit after same-day shoulder arthroplasty and interventions to mitigate these adverse events is needed.

Pre-operative factors affecting the indications for anatomical and reverse total shoulder arthroplasty in primary osteoarthritis and outcome comparison in patients aged seventy years and older

BACKGROUND

We evaluated the pre-operative factors affecting anatomical and reverse total shoulder arthroplasty (TSA and RTSA) indications in primary osteoarthritis and compared outcomes in patients aged 70 years and older.

METHODS

Fifty-eight patients received a TSA with an all-polyethylene glenoid component (APGC) or an RTSA with/without glenoid lateralization and the same curved short-stem humeral component. Active anterior and lateral elevation (AAE, ALE), internal and external rotation (IR, ER), pain, and the Constant-Murley score (CS) were recorded pre and post-operatively. Pre-operative rotator cuff (RC) fatty infiltration (FI) and modified Walch glenoid morphology were assessed. Humeral and glenoid component radiological outcomes were recorded.

RESULTS

RTSA were older than TSA patients (p = 0.006), had lower pre-operative AAE (p < 0.001), ALE (p < 0.001), IR (p = 0.002), pain (p = 0.008) and CS (p < 0.001), and greater supraspinatus FI (p < 0.001). At a mean of 28.8 months, both implants yielded significantly different post-operative scores and similar complication rates. Both groups achieved similar post-operative AAE, ER, and IR; ALE was higher in TSA (p = 0.006); and AAE and ALE delta scores were higher in RTSA (p = 0.045 and p = 0.033, respectively). Radiolucent line rates were higher around the TSA APGC than the RTSA baseplate (p = 0.001). High-grade RC FI adversely affected mobility improvement. Humeral cortical thinning was significantly higher in TSA (p = 0.001).

CONCLUSION

RTSA patients were older, had poorer pre-operative active mobility, and had greater RC FI than TSA. Both devices provided good mid-term clinical and ROM improvement.

Arthroscopic Management of Glenohumeral Arthritis

Glenohumeral arthritis in the young adult is a particularly challenging condition for which optimal treatment algorithms have yet to be established. Arthroscopic joint-preserving treatments have the advantage of delaying arthroplasty in this younger population while maintaining the patient's natural anatomy and do not appear to compromise later arthroplasty. Various surgical techniques are available such that the overall procedure is tailored to the patient's individual pathology. Most short- and mid-term studies show good outcomes with low conversion to total shoulder arthroplasty and sustained improvements in functional outcome scores.

Reverse shoulder arthroplasty in patients aged 65 years or younger: a systematic review of the literature

Background

Reverse shoulder arthroplasty (RSA) is offered to young patients with a failed previous arthroplasty or a cuff-deficient shoulder, but the overall results are still uncertain. We conducted a systematic review of the literature to report the midterm outcomes and complications of RSA in patients younger than 65 years.

Methods

A search of the MEDLINE and Cochrane electronic databases identified clinical studies reporting the results, at a minimum 2-year follow-up, of patients younger than 65 years treated with an RSA. The methodologic quality was assessed with the Methodological Index for Non-Randomized Studies score by 2 independent reviewers. Complications, reoperations, range of motion, functional scores, and radiologic outcomes were analyzed.

Results

Eight articles were included, with a total of 417 patients. The mean age at surgery was 56 years (range, 21-65 years). RSA was used as a primary arthroplasty in 79% of cases and revision of a failed arthroplasty in 21%. In primary cases, the indications were cuff tear arthropathy and/or massive irreparable cuff tear in 72% of cases. The overall complication rate was 17% (range, 7%-38%), with the most common complications being instability (5%) and infection (4%). The reintervention rate was 10% at 4 years, with implant revision in 7% of cases. The mean weighted American Shoulder and Elbow Surgeons score, active forward elevation, and external rotation were 64 points, 121°, and 29°, respectively.

Conclusions

RSA provides reliable clinical improvements in patients younger than 65 years with a cuff-deficient shoulder or failed arthroplasty. The complication and revision rates are comparable to those in older patients.

Mid- to long-term follow-up of shoulder arthroplasty for primary glenohumeral osteoarthritis in patients aged 60 or under

BACKGROUND

Shoulder arthroplasty in young patients with primary glenohumeral osteoarthritis is an area of continued controversy.

METHODS

A retrospective multicenter study was performed for all patients aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with a minimum of 24-month follow-up. Clinical and functional outcomes, complications, and need for revision surgery were analyzed. Survivorship analysis using revision arthroplasty as an endpoint was determined.

RESULTS

A total of 202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). TSA survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up. A total of 31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean follow-up of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up. TSA resulted in a significantly better range of motion, pain, subjective shoulder value, and Constant score compared with HA.

CONCLUSION

In young patients with primary glenohumeral osteoarthritis, TSA resulted in significantly better functional and subjective outcomes with no significant difference in longitudinal survivorship compared with patients treated with HA.

Analysis of 90-Day Readmissions After Total Shoulder Arthroplasty

BACKGROUND

The number of total shoulder arthroplasty (TSA) procedures performed annually is increasing as a result of an aging population and an increased access to subspecialty-trained upper extremity arthroplasty surgeons. An up-to-date analysis of the incidence of, risk factors for, and reasons for 90-day readmissions in primary anatomic TSA has yet to be performed.

PURPOSE

To characterize 90-day readmissions on a national level. An understanding of these data will help to predict resource utilization and expenses in shoulder arthroplasty.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

All adult patients undergoing elective primary TSA in 2014 who were included in the National Readmission Database were included in the analysis. Two cohorts were created according to 90-day readmission status. Multivariable analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified, and total hospital resource utilization was calculated.

RESULTS

An estimated 26,023 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. There was no difference in comorbidity burden between the cohorts. Medicare payer status (odds ratio [OR], 1.63; 95% CI, 1.00-2.65; P = .05), transfer to a skilled nurse facility (OR, 1.50; 95% CI, 1.05-2.14; P = .02), and chronic obstructive pulmonary disease (OR, 1.32; 95% CI, 1.04-1.66; P = .02) were identified as predictors of 90-day readmission. Female sex decreased odds of 90-day readmission (OR, 0.72; 95% CI, 0.59-0.87; P = .001). Ninety-day readmissions were associated with significant cost increases (P < .001). The most common identifiable reason for related readmissions was a hardware-related complication at all time points.

CONCLUSION

While uncommon, 90-day readmissions after primary TSA are associated with significant patient morbidity and ultimately substantial hospital costs. Truncating readmission analysis at a 30-day period will miss most arthroplasty-related hospital readmissions.

Return to Sport Following Hemiarthroplasty With Concentric Reaming Versus Total Shoulder Arthroplasty: A Matched Pair Analysis

The purpose of this study was to establish functional outcomes regarding return to sport activity for patients receiving anatomical total shoulder arthroplasty (aTSA) vs the ream and run procedure (hemi RR). Patients who underwent hemi RR and who underwent aTSA with a polyethylene glenoid component for end-stage glenohumeral arthritis were retrospectively identified from 2000 to 2014. Patients were matched regarding age, body mass index, sex, and hand dominance. Patients were surveyed to determine their level of sport and satisfaction after surgery. At a mean follow-up of 69.1±24.8 months, a total of 26 hemi RR and 30 aTSA patients met inclusion/exclusion criteria. Mean±SD age at the time of surgery was 53.0±8.5 years. There was no statistical difference between the two cohorts regarding patients who reported no postoperative problems (69.2% vs 76.7%, P=.529), reoperation (11.5% vs 6.7%, P=.522), return to overall sport (94.4% vs 86.4%, P=.395), return to high-demand upper-extremity sport (92.3% vs 81.3%, P=.390), and return to same or better level of intensity sport (83.3% vs 72.7%, P=.424). Patients returned to sport at a mean of 7.5±5.7 months and 6.2±3.6 months in the hemi RR and aTSA cohorts, respectively (P=.485). Radiographic measurements of medialization (mean, -2.4±5.0 vs -2.2±5.7; P=.913) and postoperative decentering (mean, 3.6%±2.6% vs 4.3%±3.3%; P=.795) were equivalent for the two cohorts. Hemi RR was found to have high and equivalent rates of sporting outcomes, clinical outcomes, and radiographic outcomes compared with aTSA. As appropriately indicated patients are counseled for surgery, realistic expectations regarding sports should be discussed. [Orthopedics. 2019; 42(5):276-284.].

Modified frailty index is an effective risk-stratification tool for patients undergoing total shoulder arthroplasty

BACKGROUND

Frailty, as quantified by the modified frailty index (mFI), has emerged as a promising method to identify patients at high risk of complications after surgery. Several studies have shown that frailty, as opposed to age, is more predictive of adverse surgical outcomes. We hypothesized that a 5-item mFI could be used to identify patients at elevated risk of complications after total shoulder arthroplasty (TSA).

METHODS

We identified patients aged 50 years or older who underwent TSA in the American College of Surgeons National Surgical Quality Improvement Program database. Pearson χ² analysis and linear regression were used to determine the association of the mFI score with 30-day postoperative complications, reoperation, readmission, length of stay (LOS), adverse hospital discharge, and mortality rate.

RESULTS

The study included 9861 patients with a mean age of 70 years. As the mFI score increased from 0 to 2 or greater, the following rates increased: postoperative complications from 4.2% to 9.4%, readmission from 1.6% to 4.4%, adverse hospital discharge from 6.3% to 19.6%, and LOS from 1.88 days to 2.43 days (P < .001). Multivariate analysis showed that patients with an mFI score of 2 or greater were over twice as likely to sustain a postoperative complication (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.86-3.10), readmission (OR, 2.80; 95% CI, 1.88-4.17), reoperation (OR, 1.82; 95% CI, 1.02-3.25), and adverse hospital discharge (OR, 3.14; 95% CI, 2.51-3.92). These effects were all significantly higher compared with age.

CONCLUSION

Frailty is associated with increased rates of 30-day postoperative complications, readmission, reoperation, adverse hospital discharge, and hospital LOS after TSA. Use of a simple frailty evaluation may help inform decision making and risk assessment when considering TSA.

Predicting outstanding results after reverse shoulder arthroplasty using percentage of maximal outcome improvement

BACKGROUND

The purpose of this study was to determine whether thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) score and American Shoulder and Elbow Surgeons (ASES) score exist that predict excellent patient satisfaction after reverse shoulder arthroplasty (RSA).

METHODS

Patients undergoing RSA with a single implant system were evaluated preoperatively and at a minimum 2-year follow-up. Receiver operating characteristic curve analysis determined thresholds to predict excellent patient satisfaction by evaluating the percentage of maximal improvement for SST and ASES scores. Preoperative factors were analyzed as independent predictors for achieving SST and ASES score thresholds.

RESULTS

There were 198 (SST score) and 196 (ASES score) patients who met inclusion criteria. For SST and ASES scores, receiver operating characteristic curve analysis identified 61.3% (P < .001) and 68.2% (P < .001) maximal improvement as the threshold for maximal predictability of excellent satisfaction, respectively. Significant positive correlation between the percentage of maximum score achieved and excellent patient satisfaction for both groups was found (r = 0.440 [P < .001] for SST score; r = 0.417 [P < .001] for ASES score). Surgery on the dominant hand, greater baseline visual analog scale pain score, and cuff arthropathy were independent predictors for achieving the SST and ASES score threshold.

CONCLUSION

Thresholds for the achievement of excellent satisfaction after RSA were 61.3% of maximal SST score improvement and 68.3% of maximal ASES score improvement. Independent predictors of achieving these thresholds were dominant-sided surgery and higher baseline visual analog scale pain scores for the SST score and rotator cuff arthropathy for the ASES score.

Insurance Payer Type and Patient Income Are Associated with Outcomes after Total Shoulder Arthroplasty

OBJECTIVE

To assess the independent association of insurance and patient income with total shoulder arthroplasty (TSA) outcomes.

METHODS

We used the 1998-2014 US National Inpatient Sample. We used multivariable-adjusted logistic regression to examine whether insurance type and the patient's median household income (based on postal code) were independently associated with healthcare use (discharge destination, hospital stay duration, total hospital charges) and in-hospital complications post-TSA based on the diagnostic codes (fracture, infection, transfusion, or revision surgery). We calculated the OR and 95% CI.

RESULTS

Among the 349,046 projected TSA hospitalizations, the mean age was 68.6 years, 54% were female, and 73% white. Compared to private insurance, Medicaid and Medicare (government insurance) users were associated with significantly higher adjusted OR (95% CI) of (1) discharge to a rehabilitation facility, 2.16 (1.72-2.70) and 2.27 (2.04-2.52); (2) hospital stay > 2 days, 1.65 (1.45-1.87) and 1.60 (1.52-1.69); and (3) transfusion, 1.35 (1.05-1.75) and 1.39 (1.24-1.56), respectively. Medicaid was associated with a higher risk of fracture [1.74 (1.07-2.84)] and Medicare user with a higher risk of infection [2.63 (1.24-5.57)]; neither were associated with revision. Compared to the highest income quartile, the lowest income quartile was significantly associated with (OR, 95% CI): (1) discharge to a rehabilitation facility (0.89, 0.83-0.96); (2) hospital stay > 2 days (0.84, 0.80-0.89); (3) hospital charges above the median (1.19, 1.14-1.25); (4) transfusion (0.73, 0.66-0.81); and (5) revision (0.49, 0.30-0.80), but not infection or fracture.

CONCLUSION

This information can help to risk-stratify patients post-TSA. Future assessments of modifiable mediators of these complications are needed.

Return to work after shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

With the rising incidence of shoulder arthroplasty, there is increasing emphasis on improving functional outcomes and ability to return to work (RTW). The purpose of this study was to determine the rate of RTW after shoulder arthroplasty.

METHODS

This systematic review and meta-analysis were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of 4 electronic databases was performed from database conception through April 2018 to identify studies reporting data on RTW after shoulder arthroplasty. The primary outcome was the rate of RTW after shoulder arthroplasty. Random-effects meta-analysis was used to pool the rate of RTW across studies.

RESULTS

Seven studies were reviewed, including 447 patients at an average follow-up of 4.4 years (range, 1.0-12.6 years). The overall rate of RTW was 63.6% (95% confidence interval, 58.8%-68.2%) at a mean 2.3 months postoperatively (range, 0.3-24.0 months). RTW was significantly lower for patients with heavy-intensity occupations vs. all intensity types (61.7% vs. 67.6%; P = .04). RTW did not differ between anatomic total shoulder arthroplasty (63.4%) and hemiarthroplasty (66.1%) or reverse total shoulder arthroplasty (61.5%; P = .53). There were no significant differences in RTW among underlying diagnoses (osteoarthritis, 64.4%; cuff tear arthropathy, 65.6%; proximal humerus fracture, 69.1%; P = .41) or by workers' compensation status (61.2% vs. 65.3%; P = .41).

CONCLUSIONS

A majority of patients return to work after shoulder arthroplasty at an average of 2.3 months postoperatively. Those with heavy-intensity occupation return at significantly lower rates, whereas no differences in RTW by arthroplasty type, underlying diagnosis, or workers' compensation were found.

Results of total shoulder arthroplasty in patients aged 55 years or younger versus those older than 55 years: an analysis of 1135 patients with over 2 years of follow-up

BACKGROUND

The results of anatomic total shoulder arthroplasty (TSA) in younger patients have not been clearly elucidated. The purpose of this study was to compare early outcomes after TSA in patients aged 55 years or younger versus patients older than 55 years.

METHODS

A total of 1135 patients who were treated with TSA for glenohumeral arthritis and had a mean follow-up period of over 4 years were retrospectively reviewed. Etiologies included osteoarthritis (n = 1044), osteonecrosis (n = 35), inflammatory arthritis (n = 34), and post-traumatic arthritis (n = 22). Validated outcome measures, range of motion, and patient satisfaction were recorded. Preoperative and postoperative metrics were compared, and a multivariate analysis was performed to isolate age from sex, body mass index, previous surgery, and diagnosis as independent factors.

RESULTS

Female patients, patients with a history of surgery, and patients with a diagnosis of osteonecrosis were more likely to undergo TSA when aged 55 years or younger. Both age groups showed similar preoperative range of motion and showed no differences in recorded outcome scores. Postoperatively, patients older than 55 years had slightly greater active abduction (P = .004) and internal rotation (P = .030). A higher percentage of patients older than 55 years rated their outcome as better or much better compared with those aged 55 years or younger (P = .003).

CONCLUSIONS

Female sex, a history of surgery, and a diagnosis of osteonecrosis were associated with undergoing TSA when aged 55 years or younger. Despite similar preoperative function and minor differences in postoperative range of motion and outcome scores, patients aged 55 years or younger reported lower overall satisfaction with their TSA.

Preoperative Comorbidities and Postoperative Complications Do Not Influence Patient-Reported Satisfaction Following Humeral Head Resurfacing: Mid- to Long-term Follow-up of 106 Patients

Background

Humeral head resurfacing (HHR) has emerged as an alternative treatment for glenohumeral osteoarthritis. We investigated the outcomes of HHR using validated patient-reported outcome (PRO) measures.

Methods

A retrospective review was performed on 213 patients who underwent HHR. A PRO follow-up was performed by administering a questionnaire including the American Shoulder and Elbow Society (ASES) score, Brophy activity survey, short form of the Disabilities of the Arm, Shoulder and Hand (quickDASH) survey, and general shoulder function. PRO scores were stratified by comorbidities and complications.

Results

Survey responses were received from 106 patients (51%), with a mean follow-up of 5.6 ± 1.8 years (range: 9 months to 6.1 years). Preoperative comorbidities were associated with significantly higher quickDASH scores. Postoperative complications were associated with significantly higher rates of current pain, higher visual analog scale scores, night pain, lower subjective shoulder values, and lower ASES pain and total scores. No differences in patient satisfaction were identified between the cohorts with and without preoperative comorbidities and between the cohorts with and without postoperative complications.

Conclusion

In our cross-sectional analysis of mid- to long-term outcomes following HHR, preoperative comorbidities, or postoperative complications had no impact on patient-perceived postoperative satisfaction or most PROs. HHR is clinically viable in a wide variety of patients. Future work is necessary to compare the efficacy of HHR compared with more traditional total shoulder arthroplasty and stemmed hemiarthroplasty regarding long-term outcomes and appropriate indications.

[Endoprosthetic replacement of the proximal humerus in revision shoulder arthroplasty]

OBJECTIVE

Reconstruction of proximal humeral bone defects in the setting of shoulder revision arthroplasty by implantation of a modular humeral component.

INDICATIONS

Severe segmental humeral bone defects in revision total shoulder arthroplasty, after tumor resection, trauma, pathological fractures, post-infectious or after failed osteosynthesis.

CONTRAINDICATIONS

Acute or chronic local infections, large diaphyseal bone defects preventing adequate anchorage of the prosthesis, very short life expectancy (<3 months).

SURGICAL TECHNIQUE

Removal of the implant using an extended deltopectoral approach. Periarticular arthrolysis with preservation of neurovascular structures. Resection of the meta-diaphyseal bone and reconstruction of the humeral length with the help of different extension sleeves and a modular humeral component. Soft tissue management is crucial, especially with reverse shoulder arthroplasty.

POSTOPERATIVE MANAGEMENT

Three weeks postoperatively immobilization in a shoulder sling, active assisted movement therapy by gradual pain-adapted increase of movement, muscle coordination, and strength.

RESULTS

The results of 11 consecutive patients treated with a modular humeral component due to a failed shoulder arthroplasty between 2008 and 2016 were evaluated retrospectively. Mean length of reconstruction was 100 mm. Due to recurrent dislocations one patient required revision and conversion to a reverse component. No cases of aseptic loosening or periprosthetic infection were observed.

Predicting outstanding results after anatomic total shoulder arthroplasty using percentage of maximal outcome improvement

BACKGROUND

The purpose of this study was to determine whether thresholds in the percentage of maximal improvement in the Simple Shoulder Test (SST) or American Shoulder and Elbow Surgeons (ASES) score exist for predicting "excellent" patient satisfaction after total shoulder arthroplasty (TSA).

METHODS

A retrospective query identified patients who underwent TSA with a minimum of 2 years' follow-up. Preoperative and postoperative SST and ASES scores and postoperative patient satisfaction were recorded. Receiver operating characteristic curve analyses were performed to determine thresholds in the percentage of maximal improvement in the SST and ASES scores that predict excellent satisfaction. Univariate and multivariate analyses determined preoperative factors that predicted achievement of these thresholds.

RESULTS

A total of 301 and 319 patients had at least 2 years' follow-up for the SST score and ASES score, respectively. We determined 72.1% of maximal improvement in the SST score to be the threshold for excellent satisfaction (area under the curve, 0.777; 95% confidence interval, 0.712-0.841; P < .001). We determined 75.6% of maximal improvement in the ASES score to be the threshold for excellent satisfaction (area under the curve, 0.799; 95% confidence interval, 0.743-0.856; P < .001). Both groups showed significant positive correlations between percentage of maximal score achieved and excellent satisfaction (r = 0.396 for SST score [P < .001] and r = 0.325 for ASES score [P < .001]). Younger age was the only independent predictor for achieving the SST score threshold. No independent predictors existed for the ASES score threshold.

CONCLUSION

Achievement of 72.1% of maximal SST score improvement and achievement of 75.6% of maximal ASES score improvement represent thresholds for achievement of excellent satisfaction after TSA. Most preoperative factors did not have an impact on the likelihood of achieving these thresholds.

Comparative analysis of work-related outcomes in hemiarthroplasty with concentric glenoid reaming and total shoulder arthroplasty

BACKGROUND

Anatomic total shoulder arthroplasty (aTSA) has demonstrated high levels of return to work, although there are fears of glenoid component loosening with higher work demand.

METHODS

A retrospective query was performed of all patients who received hemiarthroplasty with ream-and-run resurfacing (Hemi RR) between 2005 and 2014. Included patients were matched to an aTSA cohort by age, body mass index, sex, and hand dominance. Preoperative and postoperative work status, by level of duty and occupation, was collected.

RESULTS

Twenty-five patients receiving Hemi RR and 28 patients receiving TSA completed this questionnaire (82.8% compliance). Mean follow-up was 69.1 ± 24.8 months. In total, 100% of Hemi RR patients returned to work, and 89.3% of TSA patients returned to work (P = .091). The Hemi RR patients had higher rates of return to work for heavy-duty workers only (7 of 7 vs. 2 of 4, P = .038), although only 1 patient in the TSA group reported failure to work was due to shoulder reasons. Mean duration of return to work was 2.5 ± 4.8 months for patients receiving Hemi RR and 1.98 ± 2.6 months for those receiving TSA (P = .653).

CONCLUSIONS

Hemi RR had a high return to heavy-duty work, likely due to fewer surgeon-imposed restrictions. The results of this study may help manage return to work expectations after Hemi RR according to the level of duty and suggest Hemi RR is a viable option for heavy-duty laborers with end-stage glenohumeral arthritis.

Novel exploration of customized 3D printed shoulder prosthesis in revision of total shoulder arthroplasty: A case report

RATIONALE

This paper describes the application of individual customized 3-dimensional (3D) printed macro-porous Ti6Al4 V shoulder prosthesis in the revision of total shoulder arthroplasty (TSA) for the patient with severe bone defects.

PATIENT CONCERNS

A 47-year-old male had been under proximal humeral resection and TSA due to shoulder chondrosarcoma 6 years ago, but a second surgery to insert a new prosthesis was then performed because the prosthesis became loose 2 months ago leaving severe bone defects which conventional prosthesis was not suitable for revision of TSA. American Shoulder and Elbow Surgeons' Form (ASES), Neer and Constant-Murley score were 36, 39, and 39, respectively.

DIAGNOSES

The patient was diagnosed with shoulder bone defects and restriction of the shoulder movement.

INTERVENTIONS

3D printed shoulder model and computer-aided design (CAD) were used for prosthesis design and surgical simulation. The novel 3D printed titanium alloy shoulder prosthesis was customized subsequently to be used in the revision of TSA. The patient was followed up regularly after surgery. The ASES, Neer Shoulder score and Constant-Murley Shoulder score were evaluated during pre-operation, post-operation, and follow-up.

OUTCOMES

Prosthesis was successfully implanted to complete anatomic reconstruction intraoperatively. The scores of ASES, Neer, and Constant-Murley were gradually increased after the operation. According to the X-ray, the bone healed satisfactorily without change of prosthetic position at 3rd and 12th months after the operation. The function of shoulder could meet the requirements of daily activities.

LESSONS

The application of customized 3D printed titanium alloy shoulder prosthesis in the revision of TSA achieves satisfactory results. It provides a novel method for the similar revision surgery with severe bone defects.

Arthroscopic Management of Glenohumeral Arthritis: A Joint Preservation Approach

Treatment of young, active patients with primary glenohumeral osteoarthritis (GHOA) is challenging because shoulder arthroplasty may not be ideal in this population. In the past two decades, joint-preserving arthroscopic management options for GHOA, including débridement, have been used to treat different pathologies related to GHOA to reduce pain, to improve function, and to delay or even avoid arthroplasty. Key aspects of comprehensively addressing GHOA arthroscopically include chondroplasty, synovectomy, loose body removal, humeral osteoplasty with excision of the goat's beard osteophyte, capsular release, subacromial and subcoracoid decompression, axillary nerve decompression, and biceps tenodesis. Although data are still emerging, clinical studies report that an arthroscopic approach to glenohumeral arthritis using these various procedures reduces pain, improves function, and improves clinical outcome scores in the short- to mid-term follow-up period. Additional high-level studies are warranted to evaluate long-term outcomes and durability following this procedure.

Assessment of anatomical and reverse total shoulder arthroplasty with the scapula-weighted Constant-Murley score

AIM OF THE STUDY

To evaluate total (TSA) and reverse total shoulder arthroplasty (RTSA) using the Constant-Murley score (CMS) and the scapula-weighted (SW) CMS, an integrated outcome measure that takes into account the compensatory movements of the scapula.

METHODS

Twenty-five consecutive patients, 12 with TSA and 13 with RTSA, underwent kinematic analysis before and after shoulder replacement. Measurements included flexion (FLEX) and abduction (ABD) for the humerus and Protraction-Retraction (PR-RE), Medio-Lateral rotation (ME-LA), and Posterior-Anterior tilting (P-A) for the scapula. They were recorded at baseline (T0) and at six (T1) and 12 months (T2). Reference data were obtained from 31 control shoulders.

RESULTS

At T1, differences in CMS and SW-CMS were not significant in either group, whereas values at T2 were significantly lower in RTSA patients (p = 0.310 and p = 0.327, respectively). In TSA shoulders, the compensatory scapular movements in FLEX were all reduced from T0 to T2, whereas P-A was increased in ABD. In RTSA patients, the compensatory scapular movements in FLEX showed a general reduction at T1, with an increase in P-A at T2, whereas in ABD, all increased at T1 and decreased at T2 except for P-A, which did not decrease.

DISCUSSION

The SW-CMS showed that the physiological scapulothoracic motion was not restored in TSA and RTSA patients; it may be used as a reference for the gradual progression of deltoid and scapular muscle rehabilitation.

CONCLUSIONS

The worse CMS and SW-CMS scores found in RTSA patients at six months may be due to the biomechanics of the reverse prosthesis and to the weakness of deltoid and periscapular muscles.

Fatty infiltration and muscle atrophy of the rotator cuff in stemless total shoulder arthroplasty: a prospective cohort study

BACKGROUND

The influence of preoperative rotator cuff fatty infiltration (FI) and muscle atrophy (MA) on the postoperative outcome of total shoulder arthroplasty (TSA) has only rarely been investigated and reported in the literature. We hypothesized that more FI and MA would be associated with a worse postoperative functional outcome.

METHODS

This prospective cohort study included 63 patients (31 female and 32 male patients; mean age, 71 years [range, 53-89 years; standard deviation, 7 years]) with primary osteoarthritis of the shoulder operated on with anatomic stemless TSA. Preoperatively and at 3 months and 1 year after the operation, the functional outcome (QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score) and range of motion (ROM) (goniometer) and strength (dynamometer) for abduction at the scapular plane and for external rotation were measured. The degree of preoperative FI and MA was evaluated using computed tomography scans according to the Goutallier classification and Warner classification, respectively, for the supraspinatus and infraspinatus.

RESULTS

We found clinically and statistically significant improvements in functional outcome, strength, and ROM at both 3 months and 1 year of follow-up compared with those preoperatively. The Pearson correlation coefficient (r) showed significant correlations between preoperative supraspinatus and infraspinatus FI and MA and preoperative and 1-year postoperative shoulder abduction and external rotation strength but not ROM. However, we found no influence of the rotator cuff FI and MA on the functional outcome after TSA.

CONCLUSION

We demonstrated a significant correlation between rotator cuff FI and MA and strength but not ROM of the shoulder joint.

Anatomical total shoulder arthroplasty used for glenohumeral osteoarthritis has higher survival rates than hemiarthroplasty: a Nordic registry-based study

OBJECTIVE

To report the10-year survival rates of different shoulder arthroplasty types used for glenohumeral osteoarthritis.

DESIGN

Data from 2004 to 2013 was prospectively collected by the national shoulder arthroplasty registers in Denmark, Norway and Sweden and merged into a harmonized dataset under the umbrella of the Nordic Arthroplasty Register Association. The common dataset included data that all three registers could deliver and where consensus regarding definitions could be made. Revision was defined as removal or exchange of any component or the addition of a glenoid component.

RESULTS

The cumulative survival rates at 10 years after resurfacing hemiarthroplasty (RHA) (n = 1,923), stemmed hemiarthroplasty (SHA) (n = 1,587) and anatomical total shoulder arthroplasty (TSA) (n = 2,340) were 0.85, 0.93 and 0.96 respectively (P < 0.001, Log rank test). RHA (HR: 2.5; CI 1.9-3.4, P < 0.001) and SHA (HR: 1.4; CI 1.0-2.0, P < 0.04) had an increased risk of revision compared to TSA. Gender, age and period of surgery were included in the Cox regression model. For patients below 55 years, the 10-year cumulative survival rates were 0.75 (RHA, n = 354), 0.81 (SHA, n = 146), and 0.87 (TSA, n = 201).

CONCLUSIONS

Anatomical TSA had the highest implant-survival rate. Young patients had, independently of the arthroplasty type, lower implant-survival rates. The treatment of young patients with end-stage osteoarthritis remains a challenge.

Higher preoperative sensitivity to pain and pain at rest are associated with worse functional outcome after stemless total shoulder arthroplasty

Aims

The aims of this study were to investigate any possible relationship between a preoperative sensitivity to pain and the degree of pain at rest and on exertion with postoperative function in patients who underwent stemless total shoulder arthroplasty (TSA).

Patients and Methods

In this prospective study, we included 63 patients who underwent stemless TSA and were available for evaluation one year postoperatively. There were 31 women and 32 men; their mean age was 71 years (53 to 89). The pain threshold, which was measured using a Pain Matcher (PM) unit, the degree of pain (visual analogue scale at rest and on exertion, and function using the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), were recorded preoperatively, as well as three and 12 months postoperatively.

Results

We found an inverse relationship between both the preoperative PM threshold and pain (VAS) at rest and the 12-month postoperative QuickDASH score (Pearson correlation coefficient (r) ≥ 0.4, p < 0.05). A linear regression analysis showed that the preoperative PM threshold on the affected side and preoperative pain (VAS) at rest were the only factors associated with the QuickDASH score at 12 months.

Conclusion

These findings indicate the importance of central sensitization in the restoration of function after TSA. Further studies are required to investigate whether extra analgesia and rehabilitation could influence the outcome in at risk patients. Cite this article: Bone Joint J 2018;100-B:480–4.

[Options in joint-preserving surgical treatment of osteoarthritis]

BACKGROUND

The treatment of glenohumeral arthritis represents a major challenge in highly active younger patients. In these patients, an endoprosthetic treatment often achieves only unsatisfactory results with a limited lifetime of the implant.

OBJECTIVES

The aim of the study was to identify joint-preserving therapies for glenohumeral arthritis.

MATERIALS AND METHODS

For this study, an extensive and selective literature search was performed.

RESULTS

There are several options available for joint-preserving treatment of glenohumeral arthritis. In addition to arthroscopic debridement with treatment of concomitant pathologies, CAM procedures (CAM: comprehensive arthroscopic management) according to Millett, as well as the interposition of allografts are other options. For all therapy options, an improved range of motion and pain reduction is described. A joint gap of <2 mm, bipolar cartilage lesions and age are described as risk factors for failure of the therapies.

DISCUSSION

Short and mid-term results have been described for arthroscopic debridement, but there are no long-term and high-quality studies to enable us to make clear recommendations. The CAM procedure and the interposition of an allograft are demanding procedures that should be reserved for experienced arthroscopists. The therapies are an option for younger patients in accordance with individual decisions and realistic expectations.

Revision Total Shoulder Arthroplasty is Associated with Increased Thirty-Day Postoperative Complications and Wound Infections Relative to Primary Total Shoulder Arthroplasty

BACKGROUND

With an increasing volume of primary total shoulder arthroplasties (TSA), the number of revision TSA cases is expected to increase as well. However, the postoperative medical morbidity of revision TSA has not been clearly described.

QUESTIONS/PURPOSES

The purpose of this study was to determine the rate of postoperative complications following revision TSA, relative to primary TSA. In addition, we sought to identify independent predictors of complications, as well as to compare operative time and postoperative length of stay between primary and revision TSA.

METHODS

Patients who underwent primary/revision TSA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Differences in complications, readmission rates, operative time, length of stay, and predictors of complications were evaluated using bivariate and multivariate analyses.

RESULTS

A total of 10,371 primary TSA (95.4%) and 496 revision TSA cases (4.6%) were identified. The overall complication rate was 6.5% in primary and 10.7% in revision TSA patients (p < 0.001). Multivariate analysis identified an increased risk of any complication (odds ratio 1.73, p < 0.001), major complication (2.08, p = 0.001), and wound infection (3.45, p = 0.001) in revision TSA patients, relative to primary cases. Operative time was increased in revision cases (mean ± standard deviation, 125 ± 62.5), relative to primary (115 ± 47.7, p < 0.001). Age > 75, female sex, history of diabetes or chronic obstructive pulmonary disease, and American Society of Anesthesiologists classification ≥ 3 were associated with increased risk of any complication. Smoking history was the only significant predictor of wound infection.

CONCLUSION

Revision TSA, in comparison to primary, poses an increased risk of postoperative complications, particularly wound infections. A history of smoking was an independent predictor of wound infections.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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