Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005 to 2006

Primary Total Shoulder Arthroplasty is Superior to Hemiarthroplasty for the Treatment of Glenohumeral Arthritis: Analysis of 5-year Outcomes in a Large Surgical Database

Background

Total shoulder arthroplasty (TSA) is the preferred treatment for glenohumeral arthritis refractory to nonoperative measures. However, some surgeons have argued for a role for hemiarthroplasty (HA) in the setting of a smooth glenoid that articulates appropriately with the humeral head. The purpose of this study is to evaluate long-term revision rates and short-term postoperative complications in patients undergoing either HA or TSA for glenohumeral arthritis.

Methods

A retrospective review of patients who underwent HA and TSA was conducted using a commercially available national database. Demographics, postoperative complications, risk factors, revision rates, and costs were analyzed using 2 sample t-tests, chi-squared tests, and multivariate logistic regressions.

Results

Patients were stratified by operation: (1) HA (n = 1615) or 2) TSA (n = 7845). Patients undergoing primary TSA had higher rates of prior ipsilateral rotator cuff repair and corticosteroid injections. At 2 years, patients who underwent HA, 3.0% of patients had revision surgery, compared to 1.6% of patients who underwent TSA (P = .002); at 5 years, 3.7% of the HA cohort (P < .0001) had revision surgery, compared to 1.9% of patients who underwent TSA.

Conclusions

Patients undergoing TSA or RTSA for glenohumeral arthritis had higher preoperative co-morbidities but had no difference in short-term complication rates with a lower risk of revision surgery at both 2-year and 5-year follow-up when compared to HA. Increasing age, female sex, hyperlipidemia, postoperative infection, shoulder instability, and thromboembolism all independently increased odds for revision shoulder arthroplasty for glenohumeral arthritis.

Level of evidence Level

III.

[The shoulder and elbow register of the DVSE-trend monitoring or early warning system? : A literature-based analysis]

The endoprosthesis register (SEPR) of the D‑A-CH Association for Shoulder and Elbow Surgery e. V. (DVSE) collects data on the implantation of shoulder and elbow endoprostheses. The question arises as to whether the data is only used to monitor trends in arthroplasty, or whether it can also be used as an early warning system for risks and possible complications. The existing literature on the SEPR was analyzed and compared with other national endoprosthesis registries. The SEPR of the DVSE enables the collection and analysis of epidemiological data on primary implantation, follow-up and revision in shoulder and elbow endoprosthetics. It is an instrument of quality control and contributes to ensuring the greatest possible patient safety. It is used for the early detection of risks and potential requirements associated with shoulder and elbow arthroplasty.

Do preoperative factors and implant design features influence humeral stem extraction efforts?

BACKGROUND

Variations in humeral component designs in hemiarthroplasty and anatomic total shoulder arthroplasty cases can impact the degree of difficulty during a revision surgery that necessitates the removal of the humeral stem. However, no metric exists to define stem extraction effort nor to identify associated factors that contribute to extraction difficulty. The purpose of this study is to describe a method to quantify stem extraction difficulty and to define features that will impact the effort during stem removal.

METHODS

This was a retrospective review of 58 patients undergoing revision of hemiarthroplasty or anatomic total shoulder arthroplasty requiring stem extraction. Each included patient had existing preoperative radiographic examination, an intraoperative video of the stem removal process, and explants available for analysis by 3 surgeons. The following factors were assessed for the impact on extraction difficulty: (1) preoperative features such as cement use, fill of proximal humerus, and stem design features; (2) intraoperative data on extraction time and bone removal; and (3) postoperative findings related to extraction artifacts (EAs). A scoring system was established to distinguish easy (Easy group) and difficult (Difficult group) stem removal cases and further used to identify the features that may affect intraoperative difficulty of stem removal.

RESULTS

The Difficult group accounted for 26% (15/58) of the study population with an 18-minute average stem extraction time, average EA count of 69, and 35 mm of bone removed. The Easy group accounted for 74% (43/58) of patients, with a 4-minute average extraction time, average EA count of 23, and 10 mm of bone removed. Logistic regression model was able to correctly classify 82% of the cases, explaining 26.7% of the variance in humeral stem removal with cement and proximal coating variables. The likelihood of cemented stem removal being difficult is 5 times greater compared to an uncemented stem, and having proximal coating doubles the likelihood of a difficult stem removal compared to cases with no coating.

CONCLUSIONS

Quantifying stem extraction difficulty is possible with intraoperative video as well as explant analysis. Preoperative features of the fixation type and specific features of stem design such as proximal coating will impact difficulty of stem extraction.

Gender Influences on Shoulder Arthroplasty

PURPOSE OF REVIEW

As the incidence of shoulder arthroplasty continues to increase, there is growing interest in patient-based factors that may predict outcomes. Based on existing literature demonstrating gender-based disparities following total hip and knee arthroplasty, gender may also influence shoulder arthroplasty. The purpose of this review is to discuss the recent literature on the influence of gender on shoulder arthroplasty, focusing on differences in preoperative parameters, perioperative complications, and postoperative outcomes.

RECENT FINDINGS

While both female and male patients generally benefit from shoulder arthroplasty, several differences may exist in preoperative factors, acute perioperative complications, and postoperative outcomes. Preoperatively, female patients undergo shoulder arthroplasty at an older age compared to their male counterparts. They may also have greater levels of preoperative disability and different preoperative expectations. Perioperatively, female patients may be at increased risk of extended length of stay, postoperative thromboembolic events, and blood transfusion. Postoperatively, female patients may achieve lower postoperative functional scores and decreased range of motion compared to male patients. Differences in postoperative functional scores may be influenced by gender-based differences in activities of daily living. Finally, female patients may be at greater risk for periprosthetic fracture and aseptic loosening while male patients appear to be at greater risk for periprosthetic infection and revision surgery. Current literature on the influence of gender on shoulder arthroplasty is limited and conflicting. Further research is necessary to delineate how gender affects patients at the pre- and postoperative levels to better inform decision-making and outcomes.

Surgical Trends of Shoulder Arthroplasty: Nationwide Epidemiologic Study in South Korea

Background

The aim of this study was to determine the nationwide shoulder arthroplasty trends in South Korea based on an analysis of nationwide data acquired from the Korean Health Insurance Review and Assessment Service (HIRA).

Methods

We analyzed a nationwide database acquired from the HIRA that covered 2008 to 2017. International Classification of Diseases, 10th Revision (ICD-10) codes and procedure codes were used to identify patients who underwent shoulder arthroplasty, including total shoulder arthroplasty (TSA), hemiarthroplasty (HA), and revision shoulder arthroplasty.

Results

From 2008 to 2017, a total of 19,831 shoulder arthroplasties were performed; there were 16,162 TSAs and 3,669 hemiarthroplasties. During the 10-year study period, there was an exponential increase in the incidence of TSA (from 513 cases in 2008 to 3,583 cases in 2017), while the number of hemiarthroplasties remained steady. The most common diagnoses for TSA were rotator cuff tears (6,304 cases, 39.0%) and osteoarthritis (6,589 cases, 40.8%) for all 9 years. Osteoarthritis was the most common reason for TSA during the first 3 years (2008-2010), but rotator cuff tears ultimately surpassed osteoarthritis during the last 3 years (2015-2017). HA was performed to treat proximal humerus fracture (1,770 cases, 48.2%) and osteoarthritis (774 cases, 21.1%). In terms of hospital types, the rate of TSA in hospitals with 30-100 inpatient beds increased from 21.83% to 46.27%, while the rates of the other types of surgery decreased. A total of 430 revision surgeries were performed during the study period, and infection (152 cases, 35.3%) was the most common reason for revision surgery.

Conclusions

Overall, the total count and incidence of TSA, unlike HA, increased rapidly between 2008 and 2017 in South Korea. Moreover, at the end of the study period, nearly half of the TSAs were performed in small hospitals (30 to 100 beds). Rotator cuff tears were the leading cause of TSA at the end of the study period. These findings revealed an explosive increase in reverse TSA surgery.

Projections of Primary and Revision Shoulder Arthroplasty until 2040: Facing a Massive Rise in Fracture-Related Procedures

Although the demand for shoulder arthroplasties has reached its highest number worldwide, there remains a lack of epidemiologic data regarding recent and future trends. In this study, data for all shoulder arthroplasties (hemiarthroplasty, reverse/anatomic shoulder arthroplasty) from the nationwide inpatient statistics of Germany (2010–2019) and population forecasts until 2040 were gathered. A Poisson and a negative binomial approach using monotone B-splines were modeled for all types of prostheses to project the annual number and incidence of primary and revision arthroplasty. Additionally, trends in main indicators were also gathered and expected changes were calculated. Overall, the number of primary shoulder replacements is set to increase significantly by 2040, reaching at least 37,000 (95% CI 32,000–44,000) procedures per year. This trend is mainly attributable to an about 10-fold increased use of fracture-related reverse shoulder arthroplasty in patients over 80 years of age, although the number of procedures in younger patients will also rise substantially. In contrast, hemiarthroplasties will significantly decrease. The number of revision procedures is projected to increase subsequently, although the revision burden is forecast to decline. Using these country-specific projection approaches, a massive increase of primary and revision shoulder arthroplasties is expected by 2040, mainly due to a rising number of fracture-related procedures. These growth rates are substantially higher than those from hip or knee arthroplasty. As these trends are similar in most Western countries, this draws attention to the international issue, of: if healthcare systems will be able to allocate human and financial resources adequately, and if future research and fracture-prevention programs may help to temper this rising burden in the upcoming decades.

Targeting repeatability of a less obtrusive surgical navigation procedure for total shoulder arthroplasty

PURPOSE

Surgical navigation systems have demonstrated improvements in alignment accuracy in a number of arthroplasty procedures, but they have not yet been widely adopted for use in total shoulder arthroplasty (TSA). We believe this is due in part to the obtrusiveness of conventional optical tracking systems, as well as the need for additional intraoperative steps such as calibration and registration. The purpose of this study is to evaluate the feasibility of adapting a less-intrusive dental navigation system for use in TSA.

METHODS

We developed a proof-of-concept system based on validated laser-engraved surgical tools recently introduced for use in dental surgery that are calibrated once when manufactured and not recalibrated at time of use. The design also features a notably smaller bone-mounted tracker that can be tracked from a wide range of viewing angles. To assess our system's performance, we modified the dental surgical software to support guidance of a TSA procedure. We then conducted a user study in which three participants with varying surgical experience used the system to drill 30 holes in a glenoid model. Using a coordinate measuring machine, we determined the resulting drilled trajectory and compared this to the pre-planned trajectory. Since we used a model glenoid rather than anatomical specimens, we report on targeting precision rather than overall procedure precision or accuracy.

RESULTS

We found targeting precision < 1 mm (standard deviation) for locating the entry hole and <  ~ 1° (SD) for both version and inclination. The latter value was markedly lower than the end-to-end angular precision achieved by previously reported TSA navigation systems (approximately 3°-5° SD).

CONCLUSION

We conclude that variability during the targeting phase represents a small fraction of the overall variability exhibited by existing systems, so a less obtrusive navigation system for TSA based on laser-engraved tooling is likely feasible, which could improve the uptake rates of surgical navigation for TSA, thereby potentially leading to improved overall surgical outcomes.

Epidemiology and Treatment of Radial Head Fractures: A Database Analysis of Over 70,000 Inpatient Cases

PURPOSE

We aimed to study the epidemiology of radial head fractures within a single national registry database while analyzing trends in available treatments.

METHODS

A retrospective analysis of data from 2007 to 2016 provided by a national inpatient database registry was performed using the International Classification of Diseases code for radial head fractures and associated German Procedure Classification (OPS) codes. All surgical interventions were evaluated according to fracture type, patient sex and age, and distribution differences over the last decade to detect changes in the treatment trends. The number of major revision procedures was identified and the revision burden for each procedure calculated.

RESULTS

Overall, 70,118 radial head fractures were included, with the annual number rising over 20% during this period. Women were significantly older than men (peak incidence, 55-64 years vs 30-39 years) and more frequently injured (women-to-men, 1.3:1). Surgical interventions increased during the study period, with locking plate fixation of comminuted fractures and radial head arthroplasty (RHA) becoming increasingly performed while radial head resections decreased. The revision burden differed significantly between the fixation techniques, with an increased occurrence of RHA revision procedures more recently.

CONCLUSIONS

The data show a higher number and incidence of surgical procedures, especially for comminuted radial head fractures over the study period. Open reduction and internal fixation remains the most frequently used option, with the use of new fixation devices (eg, locking plates) increasing. The use of RHA more than doubled over the past 10 years while the number of radial head resections decreased.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Risk Factors for Re-Revision Surgery in Shoulder Arthroplasty

INTRODUCTION

Revision shoulder arthroplasty is an expensive undertaking with notable morbidity to the patient and less predictable outcomes. Therefore, it is important to avoid even further surgery in these patients. We sought to report the annual revision burden from a large integrated healthcare system and identify patient and operative factors that may predispose patients to revision failure, necessitating further surgery.

METHODS

Annual revision burden as a proportion of the overall shoulder arthroplasties performed from 2005 to 2017 was obtained. Patients who underwent aseptic revision between 2005 and 2017 comprised the study sample. Patient characteristics evaluated for re-revision risk included age, sex, body mass index (BMI), race, and diabetes status, whereas surgical characteristics included surgeon cumulative revision volume, revision procedure type, and top reason for revision by primary procedure type. Multivariable Cox proportional hazards regression was used to evaluate the association between the specified factors and re-revision risk.

RESULTS

From 2005 to 2017, revisions represented 5.3% to 7.8% of all shoulder arthroplasty procedures performed. Factors associated with re-revision surgery risk by procedure type included increasing BMI and hemiarthroplasty revision procedure compared with reverse total shoulder arthroplasty (RTSA) revision procedure for hemiarthroplasty primaries; diabetes, revision because of instability, and lower cumulative surgeon revision procedure volume for RTSA primaries; and TSA revision procedure compared with RTSA revision procedure for TSA primaries.

CONCLUSION

The annual revision shoulder arthroplasty volume increased over the study period. Patient factors, including BMI and diabetes were associated with higher re-revision risks for hemiarthroplasty and RTSA primaries, respectively. RTSA revised for instability had a higher risk of re-revision compared with other indications. TSA and hemiarthroplasty requiring aseptic revision may be best treated with RTSA as opposed to another TSA or hemiarthroplasty. Further studies are needed to verify these findings and identify how the mechanism of failure may affect the procedure selection in the revision setting.

LEVEL OF EVIDENCE

Level III.

Software simulations of changing offsets and thus soft tissue tension when revising anatomic to reverse total shoulder arthroplasty in convertible platform systems

BACKGROUND

Revision shoulder arthroplasty may involve the need to remove a well-fixed humeral stem. To avoid this, convertible platform systems have been introduced. The biomechanics of reverse total shoulder arthroplasty (rTSA) differs from anatomic shoulder arthroplasty (aTSA). The different humeral osteotomy and soft tissue tension may jeopardize the optimal results of the converted rTSA. The aim was to evaluate the radiographic parameters of soft tissue distraction when converting an aTSA to rTSA in a platform system and assess the capability of conversion without "over-stuffing" the shoulder in the "best-case scenario".

METHODS

Radiographic analysis of soft tissue distraction parameters: difference in acromio-humeral distance, difference in lateral humeral offset and difference in latero-inferior displacement were evaluated in aTSA and in the converted rTSA in six different implants. Image analysing software was used on 10 non-deformed osteoarthritic shoulder X-rays to simulate conversion.

RESULTS

The greatest increase in arm length was found for Tornier Ascend Flex (26.8 ± 3.6 mm) while the smallest increase was observed with Lima SMR (19.3 ± 4 mm). The humerus remained most lateralized with the Zimmer Anatomical/Inverse ( - 1.4 ± 2.9 mm) while Lima SMR ( - 15.8 ± 2.7 mm) was more medialized. The greatest increase in latero-inferior distance was found in the onlay systems. A group analysis of onlay rTSA showed an increase of 46% in arm length (p < 0.0001), 83% larger humeral offset (p < 0.0001) and 144% increase in latero-inferior distraction (p < 0.0001) when compared to inlay rTSA.

CONCLUSION

The conversion of aTSA to rTSA using a convertible platform system may lead to significant increase in radiographic parameters corresponding to soft tissue tension. This may alter the biomechanics, restrict the convertibility or jeopardize the optimal clinical outcome of rTSA even in the best-case scenario.

Risk Factors and Complications for Revision Shoulder Arthroplasty

BACKGROUND

Revision shoulder arthroplasty has become increasingly common as primary arthroplasty has become more widespread.

QUESTIONS/PURPOSES

We sought to answer two questions: What are the risks factors for revision shoulder arthroplasty? What are the complications associated with revision shoulder arthroplasty?

METHODS

A retrospective search of a national insurance database from the years 2013 to 2016 was undertaken for billing codes of patients undergoing revision shoulder arthroplasty. The odds ratios for revision of various patient demographic characteristics and comorbidities were determined. The incidences of various complications within 90 days of revision were determined.

RESULTS

A total of 824 cases of revision shoulder arthroplasty were found. Eighty-seven patients (10.5%) had infections prior to revision and 133 patients (16.1%) had dislocations prior to revision. Of the risk factors examined, smoking status was associated with the highest odds ratio for revision (8.1). Additionally, depression, Charlson Comorbidity Index (CCI), male gender, renal failure, and diabetes were significant risks factors for revision. The most common complication of revision shoulder arthroplasty was found to be surgical site infection, affecting 10.9% of patients. In the time period studied, 89 patients underwent more than one revision shoulder arthroplasty.

CONCLUSION

Despite limitations inherent in database studies, this data may have utility for surgeons in pre-operative counseling of patients on their risk.

Shoulder arthroplasty. Comorbidity as prognostic factor

Introduction

Preoperative comorbidity seems to be an important factor for the functional recovery of patients after shoulder replacement, but few studies support this correlation.The purpose of this study was to clinically evaluate the influence of comorbidity in restoring function after shoulder replacement.

Methods

We performed a retrospective analysis of shoulder replacement accomplished at our institution from 2005 to 2016 (n = 70). Demographic data, number of comorbidities, preoperative drugs, type of arthroplasty, and postoperative complications were collected. Functional results were evaluated according to the QuickDASH questionnaire.

Results

QuickDASH as continuous data was directly correlated with number of drugs prior to the surgical intervention (R = 0.270, p = 0.024) and number of comorbidities (R = 0.280, p = 0,016); especially neurological disorders (R = 0.338, p = 0.004) and osteoporosis (R = 0.0242, p = 0.043). The QuickDASH score is inversely correlated with patient satisfaction (R = -0.621, p < 0.01) and with gender (male) (R = -0.469, p < 0.001).When the patients were divided into 2 equally sized groups according to the QuickDASH score, statistical significance was found between the group with the worst outcome and female sex (91.2%) (p < 0.001), neurological disorders (p = 0.004), alcohol consumption (p = 0.028) and when shoulder arthroplasty is due to proximal humeral fracture (p = 0.002).

Conclusion

Better functional results are obtained in patients with less comorbidities.Worse functional results are obtained in patients taking more drugs, in women, alcohol consumers and those after proximal humeral fractures. Preoperative clinical status must be optimized and the patients' comorbidities should be carefully taken into accounting order to ascertain the correct shoulder arthroplasty.

Anatomical shoulder arthroplasty in epileptic patients with instability arthropathy and persistent seizures

PURPOSE

Epileptic seizures can cause shoulder dislocation, recurrent instability and eventually arthritis. The purpose of this study was to report the results, complications and rate of revision surgery following anatomical shoulder arthroplasty in epileptic patients with instability arthropathy.

METHODS

A consecutive series of eight patients with epilepsy underwent anatomical shoulder arthroplasty for recurrent shoulder instability and were retrospectively reviewed after a mean of 4.7 years (range, 2-7.5 years). These included three total shoulder replacements and five humeral resurfacing hemiarthroplasty procedures.

RESULTS

Mean age of the cohort was 33 years (range, 17-44). All patients experienced post-operative grand mal seizures. Two patients with hemiarthroplasty required further surgery due to painful glenoid erosion. No residual cases of instability were noted. Mean active forward elevation and external rotation improved following surgery. The Oxford Shoulder Score improved from 15 pre-operatively (range, 7-22) to 26 post-operatively (range, 12-45) ( p = 0.031). This was accompanied by an increase in the mean Subjective Shoulder Value, which improved from 29 (range, 10-80) pre-operatively to 53 (range, 15-90) post-operatively ( p=0.042).

CONCLUSIONS

Anatomical shoulder arthroplasty may offer a solution for the treatment of instability arthropathy in patients with epilepsy and persistent seizures.

What Factors are Predictive of Patient-reported Outcomes? A Prospective Study of 337 Shoulder Arthroplasties

BACKGROUND

Although shoulder arthroplasties generally are effective in improving patients' comfort and function, the results are variable for reasons that are not well understood.

QUESTIONS/PURPOSES

We posed two questions: (1) What factors are associated with better 2-year outcomes after shoulder arthroplasty? (2) What are the sensitivities, specificities, and positive and negative predictive values of a multivariate predictive model for better outcome?

METHODS

Three hundred thirty-nine patients having a shoulder arthroplasty (hemiarthroplasty, arthroplasty for cuff tear arthropathy, ream and run arthroplasty, total shoulder or reverse total shoulder arthroplasty) between August 24, 2010 and December 31, 2012 consented to participate in this prospective study. Two patients were excluded because they were missing baseline variables. Forty-three patients were missing 2-year data. Univariate and multivariate analyses determined the relationship of baseline patient, shoulder, and surgical characteristics to a "better" outcome, defined as an improvement of at least 30% of the maximal possible improvement in the Simple Shoulder Test. The results were used to develop a predictive model, the accuracy of which was tested using a 10-fold cross-validation.

RESULTS

After controlling for potentially relevant confounding variables, the multivariate analysis showed that the factors significantly associated with better outcomes were American Society of Anesthesiologists Class I (odds ratio [OR], 1.94; 95% CI, 1.03-3.65; p = 0.041), shoulder problem not related to work (OR, 5.36; 95% CI, 2.15-13.37; p < 0.001), lower baseline Simple Shoulder Test score (OR, 1.32; 95% CI, 1.23-1.42; p < 0.001), no prior shoulder surgery (OR, 1.79; 95% CI, 1.18-2.70; p = 0.006), humeral head not superiorly displaced on the AP radiograph (OR, 2.14; 95% CI, 1.15-4.02; p = 0.017), and glenoid type other than A1 (OR, 4.47; 95% CI, 2.24-8.94; p < 0.001). Neither preoperative glenoid version nor posterior decentering of the humeral head on the glenoid were associated with the outcomes. The model predictive of a better result was driven mainly by the six factors listed above. The area under the receiver operating characteristic curve generated from the cross-validated enhanced predictive model was 0.79 (generally values of 0.7 to 0.8 are considered fair and values of 0.8 to 0.9 are considered good). The false-positive fraction and the true-positive fraction depended on the cutoff probability selected (ie, the selected probability above which the prediction would be classified as a better outcome). A cutoff probability of 0.68 yielded the best performance of the model with cross-validation predictions of better outcomes for 236 patients (80%) and worse outcomes for 58 patients (20%); sensitivity of 91% (95% CI, 88%-95%); specificity of 65% (95% CI, 53%-77%); positive predictive value of 92% (95% CI, 88%-95%); and negative predictive value of 64% (95% CI, 51%-76%).

CONCLUSIONS

We found six easy-to-determine preoperative patient and shoulder factors that were significantly associated with better outcomes of shoulder arthroplasty. A model based on these characteristics had good predictive properties for identifying patients likely to have a better outcome from shoulder arthroplasty. Future research could refine this model with larger patient populations from multiple practices.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Gender differences in expectations and outcomes for total shoulder arthroplasty: a prospective cohort study

BACKGROUND

Gender has an impact on the expectations and the outcomes of orthopedic procedures. The data examining the effect of gender on total shoulder arthroplasty (TSA) are limited but suggest that women may have worse outcomes. We performed a prospective comparison between men and women with regard to expectations and midterm functional outcomes for TSA.

METHODS

The study prospectively enrolled 63 patients receiving a TSA with a minimum of 3 years of follow-up. The cohort included 36 men and 27 women with a mean age of 60.8 years for men (range, 37-79 years) and 66.4 years (P = .01) for women (range, 52-77 years.) Each patient was given a preoperative survey in which patients were asked to select 3 expectations they most hoped to gain from surgery. Functional outcomes were measured with American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores.

RESULTS

There were differences in expectations between the genders. Men chose exercise or participation in sports (24/36) whereas women chose to maintain daily routine and chores (18/27) (P < .01) as their top expectation. Both, however, chose to sleep through the night similarly as the next most important expectation. Each achieved their expectations at similar and high rates. American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores, respectively, increased significantly but did not differ between genders.

CONCLUSION

TSA results in excellent improvement of functional outcomes for both men and women without a significant difference at midterm follow-up. Men, on average, are younger and value participation in sports. Women hope to improve their ability to do their daily routine and chores. Both value sleeping through the night.

Shoulder arthroplasty in Germany: 2005-2012

INTRODUCTION

The field of shoulder endoprothetics has undergone a rapid development in the last years. The purpose of the study was to provide an overview of the development of shoulder arthroplasties in Germany from 2005 until 2012. This study hypothesized that the surgical procedures of the shoulder joint is still increasing and have not reached a plateau until 2012.

METHODS

Data of the German federal statistical office from 2005 until 2012 were analyzed to quantify hemiarthroplasty, anatomic total shoulder and reversed total shoulder arthroplasty rates depending on age, gender and main coded indications. Procedure codes and diagnosis were analyzed for each year. Comparative analyses were used to visualize the difference between the types of shoulder endoprostheses.

RESULTS

A total number of 139.272 shoulder arthroplasties were performed between 2005 and 2012. Total should arthroplasties have increased continuously until 2009. In 2009 more total shoulder arthroplasties have been performed than hemiprothesis implantations, which have culminated in 2008. All in all, women have been treated 3-fold higher than men regarding hemiarthroplasty, total shoulder arthroplasties or reversed total shoulder arthroplasties. Under the age of 60 years the majority of treated patients were male.

CONCLUSION

Since 2005 shoulder arthroplasties are still increasing in Germany, whereas a slight reduction could be detected for shoulder hemiarthroplasty from 2009 up until 2012. Meanwhile total shoulder arthroplasties and reversed total shoulder arthroplasties are still increasing. Women have experienced a 3-fold higher hemiarthroplasty, total shoulder and reversed shoulder arthroplasties than men except for individual younger than 60 years.

Platform systems in shoulder arthroplasty

A platform system for shoulder arthroplasty can include a convertible modular humeral stem and/or a metal-backed glenoid component to facilitate straightforward conversion from either a hemiarthroplasty or anatomic total shoulder arthroplasty to a subsequent anatomic total shoulder arthroplasty, or more frequently, reverse total shoulder arthroplasty without any revision to the stem and/or glenoid baseplate. Recent studies have demonstrated a decreased rate of intraoperative humeral fracture, complications, and blood loss when a platform system is used and the humeral stem is not exchanged during revision arthroplasty. Future studies with larger patient cohorts are necessary to truly evaluate the potential value and limitations of this technology.

Factors Affecting Length of Stay, Readmission, and Revision After Shoulder Arthroplasty: A Population-Based Study

BACKGROUND

Increased length of hospital stay, hospital readmission, and revision surgery are adverse outcomes that increase the cost of elective orthopaedic procedures, such as shoulder arthroplasty. Awareness of the factors related to these adverse outcomes will help surgeons and medical centers design strategies for minimizing their occurrence and for managing their associated costs.

METHODS

We analyzed data from the New York Statewide Planning and Research Cooperative System on 17,311 primary shoulder arthroplasties performed from 1998 to 2011 to identify factors associated with extended lengths of hospitalization after surgery, readmission within ninety days, and surgical revision.

RESULTS

The factors associated with each of these three adverse outcomes were different. Longer lengths of hospital stay were associated with female sex, advanced patient age, Medicaid insurance, comorbidities, fracture as the diagnosis for arthroplasty, higher hospital case volumes, and lower surgeon case volumes. Readmission was associated with advanced patient age and medical comorbidities. The most common diagnoses for readmission within ninety days were fluid and electrolyte imbalance (28%), acute pulmonary problems (21%), cardiac arrhythmia (20%), heart failure (15%), acute myocardial infarction (10%), and urinary tract infection (10%). Revision was associated with younger patient age and osteoarthritis or traumatic arthritis. The most common diagnoses at the time of revision surgery were unspecified mechanical complications of the implant (60%), shoulder pain (18%), dislocation of the prosthetic joint (12%), component loosening (10%), a broken prosthesis (8%), a cuff tear (7%), and infection (7%).

CONCLUSIONS

A small number of easily identified characteristics (sex, age, race, insurance type, comorbidities, diagnosis, and provider case volumes) were significantly associated with longer lengths of stay, readmission, and revision surgery. Consideration of these factors and their effects may guide efforts to improve patient safety and to manage the costs associated with these adverse outcomes.

National trends and perioperative outcomes in primary and revision total shoulder arthroplasty: Trends in total shoulder arthroplasty

INTRODUCTION

Total shoulder arthroplasty (TSA) is a highly successful procedure for management of glenohumeral arthritis, fractures and rotator cuff tears. The purpose of this study was to evaluate patient demographics, perioperative outcomes and assess recent national trends in both primary and revision TSA.

METHODS

The National Hospital Discharge Survey database was searched for patients admitted to US hospitals for primary and revision TSA from 2001 to 2010.

RESULTS

A total of 1,297 patients who underwent primary TSA and 184 patients who underwent revision TSA were identified. The rates of primary TSA (r = 0.88) and revision TSA (r = 0.85) both demonstrated a strong positive correlation with time. The mean patient age of the primary group was significantly higher than the revision group. Gender was not significantly different between the groups. There was no significant difference in the racial make-up between the revision and primary groups. African Americans accounted for 3.3 % of primaries versus 4.3 % of revisions (p = 0.615). Revision TSA patients had a significantly longer average LOS (3.06 days vs 2.46 days, p < 0.01), more medical comorbidities (6.0 vs 5.1 comorbidities, p < 0.01) and a higher rate of developing a myocardial infarction (2.2 % versus 0 %, p < 0.01) than the primary TSA group.

CONCLUSIONS

This study demonstrates that the rate of TSA is rapidly increasing in the US, with over a four-fold increase in revisions and five-fold increase in primaries over the ten years studied.