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

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Functional outcomes of reverse total shoulder arthroplasty in Boileau class 1 and class 2 proximal humeral fracture sequelae: A meta-analysis and systematic review

Background

Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae.

Methods

A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed.

Findings

Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%.

Conclusion

Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.

Simultaneous removal of a locking plate and implantation of a reversed shoulder prosthesis in elderly patients suffering from fracture sequelae of the proximal humerus

PURPOSE

Open reduction and internal fixation with a locking plate are performed frequently to treat fractures of the proximal humerus. Avascular necrosis and non-union or malunion are potential complications of this procedure, which lead to specific fracture sequelae. The aim of this study was to investigate the clinical and radiological results of patients treated by removal of a failed locking plate of the proximal humerus and simultaneous implantation of a reverse total shoulder prosthesis.

METHODS

Twenty-one patients (f = 17, m = 4; mean age 70 years) out of 29 patients were available for follow-up after a mean period of 45 (30-65) months. At follow-up, all patients were assessed with the constant score and the ASES score as well as plain radiographs.

RESULTS

In comparison with the preoperative values, abduction (31° vs. 115°; p < 0.001) and forward flexion (34° vs. 121°; p < 0.001) improved until follow-up, while the pain score on a visual analog scale decreased (6.7 vs. 0.9; p < 0.001). At follow-up, the mean ASES score rated 73 and the constant score rated 62. The radiologic findings included scapular notching (n = 7; 33%), radiolucency (n = 4; 19%), heterotopic ossifications (n = 3; 14%), and stress shielding (n = 4; 19%).

CONCLUSION

Reverse total shoulder arthroplasty is a useful instrument for the treatment of failed locking plate osteosynthesis of the proximal humerus in elderly patients. The patients benefit from both pain relief and improved shoulder function. The rate of radiologic changes like scapular notching, radiolucency, stress-shielding and heterotopic ossifications at follow-up is notable.

The Schulthess local Shoulder Arthroplasty Registry (SAR): cohort profile

PURPOSE

Clinical registries are essential for evaluation of surgical outcomes. The Schulthess Shoulder Arthroplasty Registry (SAR) was established in 2006 to evaluate safety, function, quality-of-life and patient satisfaction in patients undergoing shoulder arthroplasty.

PARTICIPANTS

Adult patients undergoing anatomic or reverse shoulder joint replacement at the Schulthess Klinik, a high-volume, leading orthopaedic surgery centre in Zürich, Switzerland.

FINDINGS TO DATE

Between March 2006 and December 2019, the registry covered 98% of eligible operations. Overall, 2332 patients were enrolled with a total of 2796 operations and 11 147 person-years of follow-up. Mean age at baseline was 71 (range: 20-95), 65% were women. Most common indication was rotator cuff tears with osteoarthritis (42%) and the mean preoperative Constant Score was 31 (±15). The most frequent arthroplasty type was reverse, increasing from 61% in 2006-2010 to 86% in 2015-2019. Functional recovery peaked at 12-month postoperatively and did not show a clinically relevant deterioration during the first ten follow-up years. Since its establishment, the registry was used to address multiple pertinent clinical and methodological questions. Primary focus was on comparing different implant configurations (eg, glenosphere diameter) and surgical techniques (eg, latissimus dorsi transfer) to maximise functional recovery. Additionally, the cohort contributed to the determination of the clinical relevance and validity of radiological monitoring of cortical bone resorption and scapular notching. Finally, SAR data helped to demonstrate that returning to sports was among key patient expectations after reverse shoulder arthroplasty.

FUTURE PLANS

As first patients are approaching the 15 years follow-up landmark, the registry will continue providing essential data on long-term functional outcomes, implant stability, revision rates and aetiologies as well as patient satisfaction and quality-of-life. In addition to research and quality-control, the cohort data will be brought back to the patients by bolstering real-time clinical decision support.

Operative Management of Proximal Humerus Nonunions in Adults: A Systematic Review

OBJECTIVES

To characterize the literature on operative interventions for proximal humerus nonunions in adults. Second, to identify prognostic factors associated with outcomes for locked plate open reduction and internal fixation (ORIF).

DATA SOURCES

PubMed, EMBASE, MEDLINE, Scopus, and Cochrane databases were searched for articles from 1990 to 2020.

STUDY SELECTION

Studies reporting outcomes of proximal humerus nonunions managed with ORIF, hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA (RTSA) were included. Studies failing to stratify outcomes by treatment or fracture sequelae were excluded.

DATA EXTRACTION

Two authors independently extracted data and appraised study quality using MINORS score.

DATA SYNTHESIS

Descriptive statistics were reported. Outcomes for ORIF and arthroplasty groups were not compared due to differing patient populations.

CONCLUSIONS

Thirty-seven articles were included, representing 508 patients (246 ORIF, 137 HA/TSA, and 125 RTSA). Patients managed by ORIF were younger with simpler fracture patterns than those managed by arthroplasty. Regarding ORIF, locked plates achieved highest union rates (97.0%), but clinical outcomes were comparable with all plate fixation constructs [forward flexion (FF): 123-144°; external rotation: 42-46°; Constant score: 75-84]. Complication and reoperation rates for ORIF were 26.0% and 14.6%, respectively. Furthermore, subgroup analysis of locked plate ORIF demonstrated shorter consolidation time with initial conservative fracture management (4.3 vs. 6.0 months) and autograft use (3.9 vs. 5.5 months). With arthroplasty, RTSA demonstrated greater forward flexion (109.4° vs. 97.2°) but less external rotation (16.5° vs. 36.8°) than HA/TSA. Complication and reoperation rates were 18.2% and 10.9% for HA/TSA and 21.6% and 14.4% for RTSA, respectively.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.