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

Whether the Indications for Reverse Shoulder Arthroplasty Should Continue to Be Expanded? A Systematic Review and Meta-Analysis

BACKGROUND

It is still unclear whether reverse total shoulder arthroplasty (RTSA) has advantages over traditional hemiarthroplasty (HA) and anatomic total shoulder arthroplasty (ATSA) in the treatment of complex shoulder joint diseases. Therefore, this study aims to evaluate the clinical effectiveness of RTSA in the treatment of complex shoulder joint diseases and further determine whether it is necessary to expand the indications of RTSA.

METHOD

We conducted a systematic search of studies published between January 1, 2012 and May 31, 2023 in PubMed, Embase, and Cochrane databases. The experimental group included patients who underwent primary reverse total shoulder arthroplasty (RTSA), while the control group consisted of patients who underwent primary hemiarthroplasty (HA) or anatomic total shoulder arthroplasty (ATSA). The minimum follow-up period was 1 year, and a random-effects model was utilized for data synthesis.

RESULTS

A total of 45 studies were included in the meta-analysis. Compare to HA, RTSA showed significant advantages in postoperative ASES scores (p = 0.004), forward flexion (p < 0.0001), and abduction (p < 0.0001). Compare to ATSA, RTSA showed significantly lower postoperative Constant scores (p = 0.004), ASES scores (p = 0.001), SST scores (p < 0.0001), forward flexion (p < 0.0001), abduction (p = 0.011), internal rotation (p < 0.0001), and external rotation (p < 0.0001). Further meta regression analysis was conducted, considering factors such as region, age, gender ratio, and follow-up time, excluding the influence of relevant factors. Overall, RTSA did not demonstrate advantages in postoperative functional scores and range of motion. In terms of complication and revision rates, RTSA had lower rates compared to HA and ATSA, except for the complication rate, where there was no significant difference between RTSA and ATSA (p = 0.521), but statistically significant differences were observed in other measures.

CONCLUSION

RTSA demonstrates better clinical efficacy compared to HA but is inferior to ATSA. It can be considered for expanding treatment options for elderly patients with 3 or 4-part proximal humeral fractures, but it is not suitable for treating end-stage shoulder arthritis and humeral head necrosis. Overall, the decision to use RTSA should be carefully evaluated based on the extent of the patient's rotator cuff injury.

Reverse versus anatomic total shoulder arthroplasty for glenohumeral osteoarthritis with intact cuff: a meta-analysis of clinical outcomes

BACKGROUND

Anatomic and reverse total shoulder arthroplasty (RSA) (total shoulder arthroplasty [TSA]) have surged in popularity in recent years. While RSA is Food and Drug Administration approved for cases of rotator cuff tear arthropathy, indications have expanded to include, among others, primary glenohumeral osteoarthritis (GHOA).

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) were queried through November 2023. Inclusion criteria consisted of studies that compared the utility of TSA to that of RSA for the treatment of GHOA with intact rotator cuff with respect to adverse events, patient-reported outcomes, and range of motion (ROM). The Risk Of Bias In Non-randomised Studies - of Interventions tool was used to assess the risk of bias in the included nonrandomized studies, and Review Manager 5.4 was used for statistical analysis. P values <.05 were deemed significant.

RESULTS

Fourteen studies met the above inclusion criteria. Twelve studies reported adverse outcomes, with the RSA group having a lower rate of complications (odds ratio = 0.54, P = .004) and reoperations (odds ratio = 0.31, P < .001) relative to TSA at an average follow-up of 3.4 years. Four studies reported Shoulder Pain and Disability Index and University of California Los Angeles scores, while 5 reported Simple Shoulder Test scores. These studies showed superior Shoulder Pain and Disability Index (P = .040), University of California Los Angeles (P = .006), and Simple Shoulder Test (P = .040) scores among the RSA group. No significant differences were seen with regards to other patient-reported outcomes. Ten studies reported on ROM, and the RSA group had a significantly lower external rotation relative to the TSA group (P < .001) while other ROM parameters did not show statistically significant differences.

CONCLUSION

The present study provides support for RSA as a reasonable surgical option for patients with GHOA and an intact rotator cuff, with lower rates of adverse events and better outcomes relative to TSA, although at the expense of decreased external rotation. Patient education and counseling is key in order to decide optimal treatment as part of a shared decision-making process, as well as setting appropriate expectations.

Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty (RSA) has been increasingly utilized for a variety of shoulder pathologies that are difficult to treat with anatomical total shoulder arthroplasty (TSA). Few studies have compared the outcomes of TSA vs. RSA in patients with cuff intact glenohumeral osteoarthritis and poor preoperative forward elevation. This study aimed to determine whether there is a difference in functional outcomes and postoperative range of motion (ROM) between TSA and RSA in these patients.

METHODS

This retrospective cohort study included 116 patients who underwent RSA or TSA between 2013 and 2022 for the treatment of rotator cuff intact primary osteoarthritis with restricted preoperative forward flexion (FF) and a minimum 1-year follow-up. Each arthroplasty group was divided into 2 subgroups: patients with preoperative FF between 91° and 120° or FF lower than or equal to 90°. Patients' clinical outcomes, including active ROM, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective shoulder value were collected. Clinical and radiographic complications were evaluated.

RESULTS

There was no significant difference between RSA and TSA in terms of sex (58.3% male vs. 62.2% male, P = .692), or follow-up duration (20.1 months vs. 17.7 months, P = .230). However, the RSA cohort was significantly older (72.0 ± 8.2 vs. 65.4 ± 10.6, P = .012) and weaker in FF and (ER) before surgery (P < .001). There was no difference between RSA (57 patients) and TSA (59 patients) in visual analog scale pain score (1.2 ± 2.3 vs. 1.3 ± 2.3, P = .925), subjective shoulder value score (90 ± 15 vs. 90 ± 15, P = .859), or American Shoulder and Elbow Surgeons score (78.4 ± 20.5 vs. 82.1 ± 23.2, P = .476). Postoperative active ROM was statistically similar between RSA and TSA cohorts in FF (145 ± 26 vs. 146 ± 23, P = .728) and ER (39 ± 15 vs. 41 ± 15, P = .584). However, internal rotation was lower in the RSA cohort (P < .001). This was also true in each subgroup. RSA led to faster postoperative FF and ER achievement at 3 months (P < .001). There was no statistically significant difference in complication rates between cohorts.

CONCLUSION

This study demonstrates that patients with glenohumeral osteoarthritis who have a structurally intact rotator cuff but limited preoperative forward elevation can achieve predictable clinical improvement in pain, ROM, and function after either TSA or RSA. Reverse arthroplasty may be a reliable treatment option in patients at risk for developing rotator cuff failure.

Patients 75 years or older with primary glenohumeral arthritis and an intact rotator cuff show similar clinical improvement after reverse or anatomic total shoulder arthroplasty

BACKGROUND

The optimal management of primary glenohumeral arthritis (GHOA) in the elderly is an ongoing topic of debate. The purpose of this study was to compare functional outcomes and complications in patients aged 75 years or older treated with anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) for primary GHOA with an intact rotator cuff.

METHODS

A retrospective study was performed on a prospectively maintained database which was queried for patients 75 years of age or older who underwent TSA or RSA for primary GHOA with an intact rotator cuff at a single institution between 2012 and 2021 with minimum 2-year follow-up. Patient-reported outcomes (PROs), including Visual Analog Scale for pain, American Shoulder and Elbow Surgeons, and Subjective Shoulder Value, as well as active range of motion including forward flexion, external rotation, internal rotation, were collected preoperatively and postoperatively. Complications, reoperations, and satisfaction were also recorded. The percentage of patients achieving clinically significant improvement was evaluated with the minimally clinical important difference, substantial clinical benefit, and patient acceptable symptomatic state for each PRO.

RESULTS

One-hundred and 4 patients were available for analysis, including 67 TSA patients and 37 RSAs with a mean follow-up of 39.4 months. Preoperative baseline characteristics, PROs, and range of motion were similar between groups. RSA was more commonly performed for eccentric glenoid wear (Walch B2/B3, 62% vs. 22%; P < .001). While clinical outcomes improved comparably in both groups, the TSA cohort showed significantly greater improvement in external rotation (36° vs. 26°; P = .013). Both cohorts had low revision (3% for TSA vs. 0% for RSA) and complication (7% for TSA vs. 5% for RSA; P = .677) rates. Satisfaction was similar in both groups (93% for TSA vs. 92% for RSA; P = .900). Clinically significant improvement was comparable between groups based on the American Shoulder and Elbow Surgeons score (minimally clinical important difference, 93% for TSA vs. 100% for RSA; substantial clinical benefit, 82% vs. 95%; patient acceptable symptomatic state, 67% vs. 78%; P > .05).

CONCLUSION

In this retrospective small sample size comparison study, TSA and RSA provide similar short-term clinical outcomes for patients 75 years and older with primary GHOA and an intact rotator cuff. Complication and revision rates are comparably low at short-term follow-up. Our data suggests that advanced age alone should not be used as a decision-making tool for TSA vs. RSA in the setting of primary GHOA with an intact rotator cuff.

Complication rates following reverse and anatomic shoulder replacement in treatment of glenohumeral arthritis: a 10-year Medicare review study

BACKGROUND

We sought to compare the complication rates after anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) for primary glenohumeral arthritis in a Medicare population.

METHODS

Patients who underwent a shoulder arthroplasty were identified from the 5% subset of Medicare parts A/B between 2009 and 2019. Patients with less than 1-year follow-up were excluded. A total of 8846 patients with a diagnosis of glenohumeral arthritis were then subdivided into those who received aTSA (5935 patients) and RSA (2911 patients). A multivariate Cox regression analysis was then performed comparing complication rates at 3 months, 6 months, 1 year, 2 years, and 5 years.

RESULTS

Statistically significant increased rates of instability (hazard ratio [HR] = 1.46), fracture of the scapula (HR = 7.76), infections (HR = 1.45), early revision (HR = 1.79), and all complications (HR = 1.32) were seen in the RSA group. There was no significant difference in revision rate at 5 years between the 2 groups. There was no difference in patient characteristics or comorbid conditions (smoking status, diabetes, Charlson score, etc.) or hospital characteristics (location, teaching status, public vs. private, etc.) between the 2 groups.

CONCLUSION

An increased rate of early complications was observed with the use of RSA compared with aTSA for the treatment of primary glenohumeral arthritis, including instability, scapula fracture, infection, and all cause complication. No difference in revision rate between RSA and aTSA at 5 years was observed.

Anatomic Total Shoulder Arthroplasty Versus Reverse Total Shoulder Arthroplasty in Patients Aged Over 70 Without a Full-Thickness Rotator Cuff Tear: A Systematic Review and Meta-Analysis

Introduction

This systematic review and meta-analysis compared the revision rates, complications, and outcomes in anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA) performed for primary glenohumeral osteoarthritis in patients aged over 70 years without a full-thickness rotator cuff tear.

Materials and Methods

We performed a systematic literature search identifying comparative studies meeting the above patient criteria and published from January 2010 to May 2022 from 3 databases: MEDLINE, EMBASE, and Cochrane Library. We performed the systematic review in accordance with PRISMA guidelines and the study was prospectively registered on PROSPERO.

Results

From the 1798 studies identified from the initial literature search, 4 met our inclusion criteria. Two thousand seven hundred thirty-one shoulder arthroplasties (1472 aTSA and 1259 rTSA) were evaluated with a minimum follow up of 2 years. A statistically significant lower revision rate was observed in rTSA compared to aTSA (odds ratio [OR] 0.50, 95% confidence interval [CI]: 0.30, 0.84, p < .05). No significant difference was noted between aTSA and rTSA in overall complication rate (OR 0.98, 95% CI 0.34, 2.86, p = .97) while aTSA displayed a statistically significant improved postoperative Constant-Murley score [aTSA: 80(75; 82), rTSA: 68(66; 76.5), p < .001].

Conclusion

Higher revision rates were identified following aTSA in our study population, although admittedly this is within retrospective studies. aTSA displayed equal functional results and postoperative complications compared to rTSA in patients over 70 without a full-thickness rotator cuff tear. Given these similar results a shoulder surgeon must carefully consider each patient individually prior to deciding the optimal form of arthroplasty to offer.

Outcomes of anatomic and reverse total shoulder arthroplasty in patients over the age of 70: a systematic review

Background

Both anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) reliably improve pain and function for a variety of indications. However, there remain concerns about these procedures among elderly patients due to their general health, the potential for lesser functional gain, and the possible need for revision at an even older age. The purpose of this review is to compare the clinical outcomes, radiographic outcomes, and complications of ATSA and RTSA among patients older than 70 years.

Methods

A systematic review was performed using searches of PubMed, Embase, and Cochrane databases. The inclusion criteria were studies with patients older than 70 years who were treated with a primary ATSA or RTSA and clinical results reported at a minimum of 2 years. All indications for primary RTSA except for tumor were included. Outcomes of interest included patient-reported outcomes (PROs), range of motion, patient satisfaction, radiographic changes, complication and revision rates, and implant survival.

Results

A total of 24 studies met the inclusion criteria. At a mean follow-up of 3.4 years for ATSA and 3.1 years for RTSA, there were significant improvements in pain, range of motion, and PROs for both prostheses. Patients who underwent ATSA generally had better motion and functional outcomes compared to those who underwent RTSA, though these comparisons were made across different indications for arthroplasty. The satisfaction rate was 90.9% after ATSA and 90.8% after RTSA. Furthermore, 10.2% of ATSA patients and 9.9% of RTSA patients experienced a surgical complication, whereas 2.3% of ATSA and 2.2% of RTSA patients underwent a revision. Secondary rotator cuff tear was the most common complication after ATSA, occurring in 3.7% of patients, but only 1.1% of patients required revision surgery. Both ATSA and RTSA implant survivorship was reported to range from 93.1% to 98.9% at 5- and 8-year follow-up, respectively. Patient mortality was estimated to be 19.3% with a mean time to death of 6.1 years.

Conclusions

Elderly patients with primary osteoarthritis and an intact rotator cuff can have predictable pain relief, restoration of functional range of motion, and significant improvement in PROs after ATSA with low complication rates. Secondary rotator cuff failure and revision arthroplasty occur infrequently at early to mid-term follow-up. Although elderly patients who underwent ATSA generally had better functional outcomes compared to those who underwent RTSA for differing indications, patient satisfaction after both procedures were similar.

Is stemless total shoulder arthroplasty indicated in elderly patients?

BACKGROUND AND HYPOTHESIS

Stemmed anatomic total shoulder arthroplasty has represented the gold standard for the treatment of glenohumeral osteoarthritis with an intact rotator cuff for decades. To the author's knowledge, no study has specifically examined the outcomes of stemless, modular total shoulder arthroplasty in elderly patients. The hypothesis of this study was that stemless anatomic total shoulder arthroplasty in elderly patients (age ≥70 years) would have equivalent clinical and radiographic outcomes compared with a younger population (age <70 years).

MATERIALS AND METHODS

A prospectively collected database of patients undergoing primary, modular, stemless anatomic total shoulder arthroplasty for osteoarthritis was retrospectively reviewed. Patient-determined outcomes including the Western Ontario Osteoarthritis Index (WOOS) score, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Simple Shoulder Test score, and Shoulder Activity Level score were recorded preoperatively and postoperatively at 1 year and 2 years. Preoperative and 1-year postoperative range of motion was recorded. Postoperative radiographs were examined to assess for radiographic evidence of complications.

RESULTS

Stemless arthroplasty was planned in 116 patients. Seven patients underwent conversion intraoperatively to a stemmed prosthesis. There was no difference between patients aged <70 yr and those aged ≥70 years who required intraoperative deviation from the preoperative plan to a stemmed prosthesis (5.8% vs 6.4%, P = .90). At the time of stemless arthroplasty, 64 patients were aged <70 yr and 44 patients were aged ≥70 years. Between the 2 groups, there were no clinically or statistically significant differences in WOOS, ASES, and SANE scores at baseline, 1-year follow-up, or 2-year follow-up. The changes in all scores from baseline to 2 years were similar between the group aged <70 yr and the group aged ≥70 years. There was no difference in the percentage of patients achieving the minimal clinically important difference or substantial clinical benefit in either group after shoulder arthroplasty at 2-year follow-up. There was no difference between the 2 groups in terms of final postoperative range of motion or change in range of motion for any metric examined. There was no evidence of radiographic complications in either group.

CONCLUSIONS

Age ≥70 years does not appear to be a contraindication to stemless anatomic total shoulder arthroplasty. Postoperative improvements in patient-determined outcome scores, the percentage of patients achieving clinically important outcomes for the ASES, SANE, and WOOS scores, and postoperative range of motion were similar between patients aged <70 yr and those aged ≥70 years. There was no difference between the groups regarding the patients who required intraoperative deviation from the preoperatively planned stemless prosthesis to a stemmed prosthesis. Neither age group demonstrated a radiographically apparent complication.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Comparison of Reverse and Anatomic Total Shoulder Arthroplasty in Patients With an Intact Rotator Cuff and No Previous Surgery

INTRODUCTION

This study's purpose is to compare clinical and radiographic outcomes of primary anatomic total shoulder arthroplasty (aTSA) and primary reverse total shoulder arthroplasty (rTSA) patients with osteoarthritis (OA) and an intact rotator cuff with no previous history of shoulder surgery using a single platform TSA system at a minimum follow-up of 2 years.

METHODS

A total of 370 aTSA patients and 370 rTSA patients matched for age, sex, and length of follow-up from an international multi-institutional Western Institutional Review Board approved registry with a minimum 2-year follow-up were reviewed for this study. All patients had a diagnosis of OA, an intact rotator cuff, and no previous shoulder surgery. All patients were evaluated and scored preoperatively and at latest follow-up using six outcome scoring metrics and four active range of motion measurements.

RESULTS

Mean follow-up was 41 months, and the mean age was 73 years. Preoperatively, the rTSA patients had lower outcome metrics and less motion. Postoperatively, aTSA and rTSA patients had similar clinical outcomes, motion, and function, with the only exception being greater external rotation in aTSA exceeding the minimal clinically important difference. Pain relief was excellent, and patient satisfaction was high in both groups. Humeral radiolucent lines were similar in both groups (8%). Complications were significantly higher with aTSA (aTSA = 4.9%; rTSA = 2.2%; P = 0.045), but revisions were similar (aTSA = 3.2%; rTSA = 1.4%; P = 0.086).

CONCLUSION

At a mean of 41 month follow-up, primary aTSA and rTSA patients with OA and an intact rotator cuff with no previous history of shoulder surgery had similar clinical and radiographic outcomes. Greater external rotation was noted in aTSA patients at follow-up. However, aTSA patients had a significantly greater rate of complications compared with rTSA patients. rTSA is a viable treatment option in patients with an intact rotator cuff and no previous shoulder surgery, offering similar clinical outcomes with a lower complication rate.

LEVEL OF EVIDENCE

Level III.

Clinical and radiographic outcomes following reverse total shoulder arthroplasty in patients 60 years of age and younger

BACKGROUND

Although initially indicated for use in older patients, reverse total shoulder arthroplasty (rTSA) is being increasingly used in younger patients. The purpose of this study is to compare the clinical and radiographic outcomes of patients aged <60 years to those aged 60-79 years following primary rTSA.

METHODS

154 patients aged <60 years and 1763 patients aged 60-79 years were identified from an international multi-institutional Western Institutional Review Board-approved registry with a minimum 2 years' follow-up. All patients were evaluated and scored preoperatively and at latest follow-up using 5 outcome scoring metrics and 4 active range of motion (ROM) measurements.

RESULTS

Patients aged <60 years were more often male (P = .023), had a higher body mass index (P = .001), higher rates of previous surgery (57% vs. 27%, P < .001), higher rates of post-traumatic arthritis (11% vs. 5%, P < .001) and inflammatory arthropathy (13% vs. 4%, P < .001), and lower rates of rotator cuff tear arthropathy (25% vs. 38%, P = .006). There were no differences in ROM between the groups but patients aged <60 years had significantly lower function and outcome metric scores and higher pain scores at latest follow-up. Adverse event rates were similar between the 2 groups, but patients aged <60 years were more likely to require revision (5.2% vs. 1.8%, P = .004). Patients aged <60 years also had lower satisfaction scores (much better/better 86% vs. 92%, P = .006).

CONCLUSION

At a mean follow-up of 47 months, primary rTSA patients aged <60 years had worse clinical outcomes compared with those aged 60-79 years, with lower outcome scores, increased pain, lower function scores, and less patient satisfaction. Patients aged <60 years had higher rates of previous surgery, inflammatory arthropathy, and post-traumatic arthritis, whereas those aged 60-79 years had higher rates of rotator cuff tear arthropathy. Although complications were similar, younger patients had 3 times the risk of revision rTSA.

Impact of fatty infiltration of the rotator cuff on reverse total shoulder arthroplasty outcomes: a systematic review

Background and hypothesis

The impact of preoperative fatty infiltration of specific rotator cuff muscles on the outcomes of reverse total shoulder arthroplasty (rTSA) has not been well defined. Preoperative fatty infiltration of the shoulder musculature will negatively affect rTSA outcomes.

Methods

A comprehensive literature review was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses using PubMed, Embase, OVID Medline, Scopus, Cinahl, Web of Science, and Cochrane databases for original, English-language studies evaluating effect of fatty infiltration of shoulder musculature on rTSA outcomes published from January 1, 2000 to present. Blinded reviewers conducted multiple screens. All included studies were graded based on the level of evidence, and data concerning patient demographics and postoperative outcomes were extracted.

Results

A total of 11 articles were included, including one level I article, three level III articles, and seven level IV articles. The review consisted of 720 patients and 731 shoulders (320 women and 157 men), with a mean age of 72.4 years. A single deltopectoral approach was performed for a majority of studies (627/731 shoulders), followed by a superolateral approach (70/731 shoulders) and a single transdeltoid approach (4/731 patients). Eleven studies reported data specifically about preoperative fatty infiltration of the rotator cuff musculature; the teres minor was studied most widely (298/731 shoulders), followed by the subscapularis (256/731 shoulders) and infraspinatus (232/731 shoulders). The Constant score (562/731 shoulders) and American Shoulder and Elbow Surgeons score (284/731 shoulders) were the most common recorded outcome scores. Fatty infiltration of the teres minor, supraspinatus, and infraspinatus was associated with worse range of motion after rTSA.

Conclusion

Preoperative fatty infiltration of the rotator cuff, particularly of the teres minor and infraspinatus, has a negative impact on subjective patient outcomes and restoration of range of motion, especially external rotation, after rTSA. The impact of fatty infiltration of the other rotator cuff muscles remains unclear, which may be due to intersurgeon differences in the handling of the remaining rotator cuff muscles or differences in implant design. The evaluated literature provides information on which patients can be educated about probable outcomes and restoration of function after rTSA.

Is reverse total shoulder arthroplasty (rTSA) more advantageous than anatomic TSA (aTSA) for osteoarthritis with intact cuff tendon? A systematic review and meta-analysis

PURPOSE

We aimed to compare the outcomes and complications of anatomical shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) for primary glenohumeral osteoarthritis with intact cuff tissue.

MATERIALS AND METHODS

The MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 2, 2021 using the PRISMA guidelines. Studies were included if they directly compared aTSA and rTSA for treating primary glenohumeral arthritis. A meta-analysis was performed using six studies that compared radiologic outcomes, functional scores, and range of motion (ROM). All the data were pooled using a random-effects model. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as dichotomous data, while continuous data were analyzed using mean differences with 95% CIs.

RESULTS

Two independent researchers reviewed 1,061 studies. Six studies met the inclusion criteria. The range of motion, especially external rotation, was better for aTSA than for rTSA (MD = - 10.28, 95% CI: - 16.69 to - 3.88, P = 0.002). Functional scores showed no difference between aTSA and rTSA. Glenoid loosening (OR = 0.17, 95% CI: 0.06-0.50, P = 0.001) was more common with aTSA, and scapula notching (OR = 10.63, 95% CI: 1.73-65.27, P = 0.01) with rTSA. In the mid-term follow-up, the overall revision rate showed no difference between aTSA and rTSA, with a pooled OR of 0.33 (95% CI: 0.07-1.57, P = 0.16).

CONCLUSION

A better ROM was achieved after aTSA than after rTSA. There was no difference in the revision rate at mid-term follow-up between aTSA and rTSA. Glenoid loosening was more common with aTSA, and scapula notching with rTSA.

LEVEL OF EVIDENCE

Level IV, Meta-analysis.

Musculoskeletal pain in Parkinson's disease: a narrative review

The prevalence of musculoskeletal (MSK) pain in people with Parkinson's disease (PD) is higher than that of age-matched controls. In this review, we outline what is known about MSK pain in PD, focusing on the neck, shoulder, knee, hip and low back. We also compare what is known about MSK pain in PD to what is known in older adults without PD. Finally, we outline areas of for future research related to MSK pain in people with PD.

A kinematic and electromyographic comparison of a Grammont-style reverse arthroplasty combined with a l'Episcopo transfer compared to a lateralized humeral component reverse for restoration of active external rotation

PURPOSE

To assess kinematic and electromyographic findings of two designs of reverse total shoulder arthroplasty (RTSA). We tested two hypotheses: (H₁) Grammont-style (RTSA) with l'Episcopo tendon transfer gains similar postoperative kinematic findings of a lateralized humeral component RTSA without a tendon transfer; (H₂) RTSA with lateralized humeral component induces earlier shoulder muscle activation during shoulder motion compared with standard Grammont prosthesis with l'Episcopo transfer.

METHODS

Twenty-five patients with a cuff tear arthropathy, pseudoparalysis, and a positive dropping sign were sequentially included. A Grammont-style RTSA with a l'Episcopo tendon transfer was implanted in 13 patients (medialized humerus and transfer group) and an on-lay curved-stem RTSA in 12 (lateralized humerus group). Constant score; the disabilities of the arm, shoulder, and hand (DASH) score; and active shoulder range of motion (flexion, abduction, external rotation, and internal rotation) were measured pre- and postoperatively. Upper limb kinematic and surface electromyography (EMG) (anterior and posterior deltoid; upper, middle, and lower trapezius; and the upper and lower latissimus dorsi muscles) were recorded during active range of motion.

RESULTS

At > 24 months of follow-up, the Constant and DASH scores and active shoulder range of motion improved in both groups (p < 0.0001). Internal rotation was significantly higher in the lateralized humerus group than in the medialized humerus and transfer group (p = 0.004). The dropping sign was found in 0/12 patients in the lateralized humerus group and in 5/13 patients in the medialized humerus and transfer group (p < 0.001). Kinematic findings were similar between groups (p = 0.286). A pattern of earlier muscle activation in the lateralized humerus group was found as compared to the transfer group as follows: (i) posterior deltoid during external rotation (p = 0.004); (ii) upper latissimus dorsi and middle and lower trapezius during flexion (p = 0.004, p = 0.005, and p = 0.042, respectively); (iii) lower latissimus dorsi during abduction (p = 0.016).

CONCLUSION

RTSA with a lateralized humeral component provided similar active external rotation restoration to a Grammont-style RTSA with a l'Episcopo procedure in patients with a dropping sign. The posterior deltoid muscle underwent earlier activation during active external rotation in the lateralized humerus RTSA group as compared to the tendon transfer group. Our findings demonstrated the H₁ and only partially demonstrated the H₂ of the study.

Primary reverse shoulder replacement with a short stem: A systematic literature review

Background

Total shoulder arthroplasty implant designs have continued to evolve over the years. One recent change has been the shortening of the humeral component to preserve bone stock and to facilitate revision surgery. Despite promising clinical results, radiographic bone adaptions occur frequently in short-stem total shoulder arthroplasty, and limited data exist on short-stem reverse shoulder arthroplasty (RSA). The purpose of this systematic review was to provide an overview about the functional and radiographic outcomes after an uncemented short-stem RSA, as well as identify areas of clinical importance that are underreported in the current literature.

Methods

A systematic review of the literature was performed in accordance with the PRISMA guidelines using PubMed, Cochrane Central Register of Controlled Trials, and EMBASE. Clinical outcome studies reporting on short-stem RSA outcomes with evidence level I-IV were included. Demographics, clinical and radiological outcomes, as well as complications and revision data were systematically analyzed and described.

Results

Ten studies, published between 2014 and 2019, reporting on 555 shoulders with a mean follow-up of 32 months (range, 20-99.6 months) met the inclusion criteria. For all studies cuff tear arthropathy was the main indication for RSA (36%), followed by primary osteoarthritis (20%). Clinical outcome was reported in nine of ten studies, with range of motion improving in all studies. Six of the seven studies that used the Constant score (CS) demonstrated significant improvement (27.9 points to 69.3 points in weighted means). All studies reported on radiographic changes and bone adaptions. Among these, scapular notching was the most commonly observed (60 out of 327 cases, 18%) but without any described implication on clinical outcomes. No stem loosening was recorded at any final follow-up. A total of 63 complications (12.9%) were reported, with scapula fractures being the most commonly reported complication. Revision surgery was necessary in 24 cases (4.9%).

Conclusion

Good clinical results, comparable with long-stem RSAs, are reported at short-term follow-up for short-stem RSAs. Humeral bone adaptions occur frequently but aseptic stem loosening is not a matter of concern at short-term follow-up. An area of clinical importance that is under-reported is the relation between filling ratio and stem alignment in short-stem RSA.

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.