Instability after reverse total shoulder arthroplasty

Subscapularis Repair in Reverse Total Shoulder Arthroplasty: Differences in Outcomes Based on Preoperative Quality of Subscapularis Tendon

Purpose

This study examines the influence of preoperative fatty infiltration (FI) of the subscapularis tendon (SBS) on outcomes following reverse total shoulder arthroplasty (rTSA) with SBS repair.

Methods

A cohort of 161 rTSA patients with SBS repair, followed for a mean of 45.3 months, was divided into three groups based on FI: Group A (intact upper and lower portions, n = 85), Group B (intact lower portions, n = 44), and Group C (fatty infiltrated in both portions, n = 32). The mean age was 74.5 years (range: 65-95).

Results

Preoperative FI displayed significant disparity among the groups: Group A (1.18 ± 0.60), Group B (2.95 ± 0.56), and Group C (4.0 ± 0.00) (p < .001). Group A exhibited a more positive trend in activities of daily living, particularly in toileting ability (81% in Group A, 68% in Group B, and 72% in Group C), although without statistical significance (p = 0.220). Complication rates varied: Group A had seven acromial fractures (8%), three cases of instability (3%), and six instances of scapular notching (7%). Group B experienced four acromial fractures (9%) and four cases of scapular notching (9%), while Group C had only one case of scapular notching (3%) (p = 0.733).

Conclusion

In cases characterized by favorable preoperative SBS quality, there was an elevation in functional internal rotation (IR) post-surgery, accompanied by an increased incidence of postoperative complications. Hence, careful consideration is advised when determining the necessity for SBS repair.

Level of Evidence

Level III, retrospective comparative study.

Intraoperative repair of functional subscapularis during RSA by deltopectoral approach could improve internal rotation but does not prevent anterior dislocation

INTRODUCTION

The role of the subscapularis following reverse shoulder arthroplasty (RSA) remains controversial as repair could restore adequate internal rotation and shoulder stability, but might compromise external rotation. The purpose of this multi-centre study, on a large cohort of RSAs performed using the deltopectoral approach, was to determine the effect of subscapularis preoperative status and intraoperative repair on range of motion, clinical scores and rates of complications at a minimum follow-up of 2 years.

HYPOTHESIS

Repair of a functional subscapularis grants better internal rotation and stability without compromising external rotation.

MATERIALS AND METHODS

We retrospectively reviewed records of all RSAs (n=916) performed by 14 surgeons that participated in a large national society symposium, and excluded 234 operated by the anterosuperior approach, 42 operated for rheumatoid arthritis, fractures, instability or post traumatic sequalae, and eight that had adjuvant latissimus dorsi tendon transfer (LDTT). This left 632 RSAs, in which the subscapularis was detached in 594, and repaired after detachment in 495. Patients completed pre- and postoperative Constant Score and postoperative Subjective Shoulder Value (SSV). Active forward elevation, active external rotation (ER), and active internal rotation (IR) were recorded pre- and postoperatively. Complications following RSA that required conservative treatment, reoperation without implant removal, as well as reoperation with implant removal were recorded.

RESULTS

Of the initial cohort of 632 shoulders, 120 (19%) were lost to follow-up, 12 (2%) died due to causes unrelated to RSA, and 26 (4%) were revised with implant removal. Of the remaining 474 shoulders, 259 (55%) had a functional repaired subscapularis (Group FR), 59 (12%) had a non-functional repaired subscapularis (Group nFR), whereas 68 (14%) had a not repaired subscapularis (Group nR). Comparison of patient demographics revealed no significant differences among the three groups. Postoperative Constant Score (p=0.031) and SSV (p=0.016) were significantly different among the three groups, but effect sizes were small and not clinically relevant. Differences in postoperative ER as well as postoperative IR were not significant among the three groups: 91 (35%) gained functional IR in Group FR, 11 (19%) in Group nFR, and 13 (19%) in Group nR. Three shoulders (1.2%) reported subjective instability and 1 (0.4%) dislocated in Group FR, but none in either Groups nFR or nR.

DISCUSSION

Despite statistically significant differences in Constant Score and SSV among the three groups, the clinical relevance of these differences is negligible, so repair of functional subscapularis has little or no influence on functional outcomes. During RSA by deltopectoral approach, repair of a functional subscapularis could slightly improve internal rotation in some patients but does not compromise external rotation, forward elevation or clinical scores, while repair of a non-functional subscapularis, compared to non-repair, did not improve range of motion or clinical scores.

LEVEL OF EVIDENCE

III; retrospective comparative.

Rotator cuff tears

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

Impact of accumulating risk factors on the incidence of dislocation after primary reverse total shoulder arthroplasty using a medial glenoid-lateral humerus onlay prosthesis

BACKGROUND

The aim of this study was to facilitate preoperative identification of patients at risk for dislocation after reverse total shoulder arthroplasty (rTSA) using the Equinoxe rTSA prosthesis (medialized glenoid, lateralized onlay humerus with a 145° neck-shaft angle) and quantify the impact of accumulating risk factors on the occurrence of dislocation.

METHODS

We retrospectively analyzed 10,023 primary rTSA patients from an international multicenter database of a single platform shoulder prosthesis and quantified the dislocation rate associated with multiple combinations of previously identified risk factors. To adapt our statistical results for prospective identification of patients most at-risk for dislocation, we stratified our data set by multiple risk factor combinations and calculated the odds ratio for each cohort to quantify the impact of accumulating risk factors on dislocation.

RESULTS

Of the 10,023 primary rTSA patients, 136 (52 female, 83 male, 1 unknown) were reported to have a dislocation for a rate of 1.4%. Patients with zero risk factors were rare, where only 12.7% of patients (1268 of 10,023) had no risk factors, and only 0.5% of these (6 of 1268) had a report of dislocation. The dislocation rate increased in patient cohorts with an increasing number of risk factors. Specifically, the dislocation rate increased from 0.9% for a patient cohort with 1 risk factor to 1.0% for 2 risk factors, 1.6% for 3 risk factors, 2.7% for 4 risk factors, 5.3% for 5 risk factors, and 7.3% for 6 risk factors. Stratifying dislocation rate by multiple risk factor combinations identified numerous cohorts with either an elevated risk or a diminished risk for dislocation.

DISCUSSION

This multicenter study of 10,023 rTSA patients demonstrated that 1.4% of the patients experienced dislocation with one specific medialized glenoid-lateralized humerus onlay rTSA prosthesis. Stratifying patients by multiple combinations of risk factors demonstrated the impact of accumulating risk factors on the incidence of dislocation. rTSA patients with the greatest risk of dislocation were those of male sex, age ≤67 years at the time of surgery, patients with body mass index ≥31, patients who received cemented humeral stems, patients who received glenospheres having a diameter >40 mm, and/or patients who received expanded or laterally offset glenospheres. Patients with these risk factors who are considering rTSA using a medial glenoid-lateral humerus should be made aware of their elevated dislocation risk profile.

A Virtual Assistant to Guide Early Postoperative Rehabilitation after Reverse Shoulder Arthroplasty: A Pilot Randomized Trial

INTRODUCTION

Rehabilitation can improve outcomes after reverse shoulder arthroplasty (RSA). However, low adherence to rehabilitation and compliance rates are some of the main barriers. To address this public health issue, the goal of this research was to pilot test and evaluate the effectiveness of a chatbot to promote adherence to home rehabilitation in patients undergoing RSA.

METHODS

A randomized pilot trial including patients undergoing RSA and early postoperative rehabilitation was performed. The control group received standard home rehabilitation; the experimental group received the same intervention supervised with a chatbot, with automated interactions that included messages to inform, motivate, and remember the days and exercises for 12 weeks. Compliance with rehabilitation and clinical measures of shoulder function, pain, and quality of life were assessed.

RESULTS

31 patients (17 experimental) with an average age of 70.4 (3.6) completed the intervention. Compliance was higher in the experimental group (77% vs. 65%; OR95% = 2.4 (0.5 to 11.4)). Statistically significant between-group differences with a CI of 95% were found in the QuickDASH questionnaire and self-reported quality of life. No differences were found in the rest of the measures.

CONCLUSIONS

This pilot study suggests that the chatbot tool can be useful in promoting compliance with early postoperative home rehabilitation in patients undergoing RSA. Future randomized trials with adequate power are warranted to determine the clinical impact of the proposal.

Impact of constrained humeral liner on impingement-free range of motion and impingement type in reverse shoulder arthroplasty using a computer simulation

BACKGROUND

Dislocation is a major complication of reverse total shoulder arthroplasty (RSA). The humeral liner may be changed to a constrained type when stability does not improve by increasing glenosphere size or lateralization with implants, and patients, particularly women with obesity, have risks of periprosthetic instability that may be secondary to hinge adduction on the thorax, but there are few reports on its impact on the range of motion (ROM). This study aimed to determine the influence of humeral liner constraint on impingement-free ROM and impingement type using an RSA computer simulation model.

METHODS

A virtual simulation model was created using 3D measurement software for conducting a simulation study. This study included 25 patients with rotator cuff tears and rotator cuff tear arthropathy. Impingement-free ROM and impingement patterns were measured during flexion, extension, abduction, adduction, external rotation, and internal rotation. Twenty-five cases with a total of 4 patterns of 2 multiplied by 2, making a total of 100 simulations: glenosphere (38 mm normal type vs. lateralized type) and humeral liner constraint (normal type vs. constrained type). There were 4 combinations: normal glenosphere and normal humeral liner, normal glenosphere and constrained humeral liner, lateralized glenosphere and normal humeral liner, and lateralized glenosphere and constrained humeral liner.

RESULTS

Significant differences were found in all impingement-free ROM in 1-way analysis of variance (abduction: P = .01, adduction: P < .01, flexion: P = .01, extension: P = .02, external rotation: P < .01, and internal rotation: P < .01). Tukey's post hoc tests showed that the impingement-free ROM was reduced during abduction, external rotation, and internal rotation with the combination of the normal glenosphere and constrained humeral liner compared with the other combinations, and improved by glenoid lateralization compared with the combination of the lateralized glenosphere and constrained humeral liner. In the impingement pattern, the Pearson χ2 test showed significantly greater proportion of impingement of the humeral liner into the superior part of the glenoid neck in abduction occurring in the combination of the normal glenosphere and constrained humeral liner group compared with the other groups (P < .01). Bonferroni post hoc tests revealed that the combination of the normal glenosphere and constrained humeral liner was significantly different from that of the lateralized glenosphere and constrained humeral liner (P < .01). Using constrained liners resulted in early impingement on the superior part of the glenoid neck in the normal glenosphere, whereas glenoid lateralization increased impingement-free ROM.

CONCLUSION

This RSA computer simulation model demonstrated that constrained humeral liners led to decreased impingement-free ROM. However, using the lateralized glenosphere improved abduction ROM.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

II, prospective cohort study.

TRIAL REGISTRATION

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

Subscapularis repair for reverse shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

The purpose of this study is to perform a systematic review of the literature evaluating the importance of subscapularis repair in patients who underwent reverse shoulder arthroplasty (RSA).

METHODS

A systematic search of articles in PubMed, EMBASE, and the Cochrane Library databases was carried out according to the PRISMA guidelines. Cohort studies comparing RSA with subscapularis repair vs. RSA without subscapularis repair were included. All statistical analysis was performed using Review Manager. A P value of <.05 was considered to be statistically significant.

RESULTS

Seventeen studies with 2620 patients were included. Subscapularis repair resulted in less instability compared to without subscapularis repair (0.8% vs. 4.2%, P = .04), and there were no significant differences in rate of instability with lateralization (0.6% vs. 1.6%, P = .40), revision rates (2.6% vs. 3.9%, P = .62), and complication rates (7.7% vs. 4.9%, P = .21). Subscapularis repair had improved American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores (83.6 vs. 80.2, P = .02) and Constant scores (72.6 vs. 68.9, P < .01) but there was not a significant difference in visual analog scale pain scores (1.2 vs. 1.6, P = .11). Subscapularis repair had a significant difference in forward flexion (140° vs. 137°, P = .04) and internal rotation score (5.5 vs. 4.6, P = .001); however, there was no significant difference in external rotation (35° vs. 35°, P = .80) and abduction (117° vs. 123°, P = .13).

CONCLUSION

This study found that RSA with subscapularis repair demonstrated a reduction in the occurrence of implant instability with medialized implants. However, subscapularis repair did not yield improvements in revision rates, complications, or instability with lateralized implants. Additionally, other outcome measures such as ASES, Constant score, and range of motion exhibited statistically significant improvements with subscapularis repair but did not surpass clinically significant thresholds.

No difference in complications between two-week vs. six-week duration of sling immobilization after reverse total shoulder arthroplasty

Background

The purpose of our study was to compare the outcomes and complications after a two- vs. six-week duration of sling immobilization following reverse total shoulder arthroplasty (rTSA).

Methods

We conducted a retrospective review from our institutional database on 960 patients treated by primary rTSA between 2011 and 2021. Patients were separated into two cohorts of postoperative sling immobilization (a two-week and six-week group). Multivariate analysis was conducted to evaluate what factors were associated with patients experiencing either a postoperative complication or requiring reoperation.

Results

A total of 276 patients were instructed to keep their operative arm in a sling for six weeks postoperatively, and 684 patients discontinued use at two weeks. There was no difference in postoperative complication rate (15.0% vs. 12.0%, P = .21), dislocation rate (P = .79), acromion stress fractures (P = .06), implant loosening (P = .15), and periprosthetic joint infections (P = .48) between the six- and two-week sling cohorts. In the immediate 90-day postoperative time period, no difference was seen in the reoperation rates (P = .73).

Discussion

Shorter duration of sling immobilization (two weeks) does not incur additional risk of complications compared to standard duration (six weeks) of sling immobilization following rTSA.

Early rehabilitation after reverse total shoulder prosthesis on fracture of proximal humerus in elderly patients provides better functional outcome

PURPOSE

Reverse total shoulder arthroplasty (RSA) has revolutionized the management of proximal humerus fractures (PHF) in the elderly patients. There is few or no consensus regarding to management of postoperative rehabilitation in elderly patients. An early rehabilitation from D1 allowed better functional results compared to rehabilitation started to D30 independently from tuberosities consolidation.

METHODS

94 patients operated on for PHF were evaluated retrospectively, with a minimum radio-clinical follow-up of 2 years. Clinical evaluation included mobilities and four functional scores: ASES, quick DASH, gross constant, weighted constant. Radiological evaluation was performed on a frontal shoulder X-ray with evaluation of tuberosities' consolidation.

RESULTS

The mean follow-up was 45 ± 19 months (24-88 months). Early rehabilitation was significantly associated with a better Constant Score (71.1 ± 17.2 vs. 56.4 ± 15.8; p < 0.001), better adjusted Constant score (92.4 ± 14.2 vs. 80.3 ± 19.5; p < 0.001), better quick DASH (22.8 ± 19.8 vs. 36.7 ± 21.3; p < 0.01), better ASES (78.6 ± 20.2 vs. 63 ± 22; p < 0.001).

CONCLUSION

In traumatology, functional result of RSA seems not related in tuberosities' union but in rehabilitation in order to limit postoperative stiffness of operated shoulder. An early rehabilitation is related with better clinical and functional results, independently of tuberosities' union.

LEVEL OF EVIDENCE

3, control-case study.

The lifetime revision risk of primary anatomic and reverse total shoulder arthroplasty

BACKGROUND

Implant survival in total shoulder arthroplasty (TSA) is currently defined with reference to a set time period (eg, 5-year implant survival). This is a difficult concept for patients to understand, especially for younger patients who have more years of life remaining. Our study aims to calculate a patient's lifetime revision risk after primary anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty-a more meaningful projection of revision risk over a patient's remaining lifetime.

METHODS

The New Zealand Joint Registry (NZJR) and national death data was used to calculate the incidence of revision and mortality in all patients who underwent primary aTSA and rTSA in New Zealand between 1999 and 2021. Lifetime revision risk was calculated using previously described methods, and this risk was stratified by age (46-90 years, 5-year bins), sex, and procedure type (aTSA and rTSA).

RESULTS

In total, there were 4346 patients in the aTSA cohort and 7384 patients in the rTSA cohort. Lifetime revision risk was highest in the youngest age group (46-50 years) at 35.8% (95% CI 34.5%-37.0%) for aTSA and 30.9% (95% CI 29.9%-32.0%) for rTSA, with risk decreasing with increasing age. Across all age groups, the lifetime revision risk was higher for aTSA compared to rTSA. By sex, females reported higher lifetime revision risk for each age group in the aTSA cohort whereas males reported higher lifetime revision risk for each group in the rTSA cohort.

CONCLUSIONS

Our study demonstrates that younger patients have higher lifetime revision risk after total shoulder arthroplasty. Our results highlight the long-term revision risks associated with the trend of offering shoulder arthroplasty to younger patients. The data may be used among various health care stakeholders to inform the surgical decision-making process and plan for future health care resource use.

Understanding risk for early dislocation resulting in reoperation within 90 days of reverse total shoulder arthroplasty: extreme rare event detection through cost-sensitive machine learning

BACKGROUND

Reliable prediction of postoperative dislocation after reverse total shoulder arthroplasty (RSA) would inform patient counseling as well as surgical and postoperative decision making. Understanding interactions between multiple risk factors is important to identify those patients most at risk of this rare but costly complication. To better understand these interactions, a game theory-based approach was undertaken to develop machine learning models capable of predicting dislocation-related 90-day readmission following RSA.

MATERIAL & METHODS

A retrospective review of the Nationwide Readmissions Database was performed to identify patients who underwent RSA between 2016 and 2018 with a subsequent readmission for prosthetic dislocation. Of the 74,697 index procedures included in the data set, 740 (1%) experienced a dislocation resulting in hospital readmission within 90 days. Five machine learning algorithms were evaluated for their ability to predict dislocation leading to hospital readmission within 90 days of RSA. Shapley additive explanation (SHAP) values were calculated for the top-performing models to quantify the importance of features and understand variable interaction effects, with hierarchical clustering used to identify cohorts of patients with similar risk factor combinations.

RESULTS

Of the 5 models evaluated, the extreme gradient boosting algorithm was the most reliable in predicting dislocation (C statistic = 0.71, F2 score = 0.07, recall = 0.84, Brier score = 0.21). SHAP value analysis revealed multifactorial explanations for dislocation risk, with presence of a preoperative humerus fracture; disposition involving discharge or transfer to a skilled nursing facility, intermediate care facility, or other nonroutine facility; and Medicaid as the expected primary payer resulting in strong, positive, and unidirectional effects on increasing dislocation risk. In contrast, factors such as comorbidity burden, index procedure complexity and duration, age, sex, and presence or absence of preoperative glenohumeral osteoarthritis displayed bidirectional influences on risk, indicating potential protective effects for these variables and opportunities for risk mitigation. Hierarchical clustering using SHAP values identified patients with similar risk factor combinations.

CONCLUSION

Machine learning can reliably predict patients at risk for postoperative dislocation resulting in hospital readmission within 90 days of RSA. Although individual risk for dislocation varies significantly based on unique combinations of patient characteristics, SHAP analysis revealed a particularly at-risk cohort consisting of young, male patients with high comorbidity burdens who are indicated for RSA after a humerus fracture. These patients may require additional modifications in postoperative activity, physical therapy, and counseling on risk-reducing measures to prevent early dislocation after RSA.

Shoulder joint arthroplasty in young patients: Analysis of 8742 patients from the Australian Orthopaedic Association National Joint Replacement Registry

Background

Shoulder replacement is a reliable treatment for the relief of pain and improvement of function in patients with glenohumeral arthritis, rotator cuff arthropathy, osteonecrosis and fracture. Limited data is available comparing revision rates for the different types of shoulder replacement when used in younger patients. This study aims to compare the survivorship of hemi resurfacing, stemmed hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty in younger patients using data from a large national arthroplasty registry.

Methods

Data from the Australian Orthopaedic Association National Joint Replacement Registry was obtained for the period 16 April 2004-31 December 2018. The study population included all shoulder arthroplasty patients aged <65 years. These were stratified into two groups: <55 years and 55-64 years. A total of 8742 primary shoulder arthroplasty procedures were analysed (1936 procedures in the <55 years and 6806 in the 55-64 years age group).

Results

In the <55 years age group, there was no difference in revision rate for total shoulder arthroplasty versus reverse total shoulder arthroplasty at any time point. Reverse total shoulder arthroplasty had a lower revision rate after six months when compared to hemi resurfacing (HRA) (p = 0.031). Also, reverse total shoulder arthroplasty had a higher early rate of revision in the first 12 months compared to hemiarthroplasty (p = 0.018). However, from 2 years reverse total shoulder arthroplasty had a lower revision rate overall (p = 0.029).In the 55-64 years patient age group, reverse total shoulder arthroplasty had a lower earlier revision rate. This was statistically significant compared to hemi resurfacing (HRA) (p = 0.028), hemiarthroplasty (p = 0.049) and total shoulder arthroplasty (p < 0.001).

Conclusion

This study demonstrated that for patients aged <55 years there was no significant difference in the rate of revision when total shoulder arthroplasty and reverse total shoulder arthroplasty were compared. reverse total shoulder arthroplasty had a lower rate of revision when compared to hemi resurfacing and hemiarthroplasty after 2 years. reverse total shoulder arthroplasty had the lowest comparative revision rate in patients aged 55-64 years overall.

Rehabilitation following shoulder arthroplasty: a survey of current clinical practice patterns of Italian physiotherapists

BACKGROUND

The incidence of Total Shoulder Arthroplasty (TSA) and Reverse Total Shoulder Arthroplasty (RTSA) is constantly increasing. As a result, the interest in post-surgical rehabilitation has grown, since it is crucial in order to achieve full recovery and successful outcomes. The first aim of this study is to investigate the Italian physiotherapists (PTs) clinical practice in the management of patients with TSA and RTSA and to compare it with the best evidence available in the literature. The second purpose of this study is to assess any existing difference between the survey answers and the different sample subgroups.

MATERIALS AND METHODS

This cross-sectional observation study was designed following the CHERRIES checklist and the STROBE guidelines. A 4-sections survey with a total of 30 questions was developed for investigating post-surgery rehabilitation management in patient with TSA and RTSA. The survey was sent to Italian PTs from December 2020 until February 2021.

RESULTS

Six-hundred and seven PTs completed the survey regarding both TSA and RTSA; 43.5% of participants (n = 264/607) stated that TSA is more likely to dislocate during abduction and external rotation. Regarding reverse prosthesis, 53.5% (n = 325/607) affirmed RTSA is more likely to dislocate during internal rotation, adduction and extension. In order to recover passive Range of Motion (pROM), 62.1% (n = 377/607) of participants reported that they gain anterior flexion, abduction, internal rotation, external rotation up to 30°, with full pROM in all directions granted at 6-12 weeks. Regarding the active ROM (aROM), 44.2% (n = 268/607) of participants stated that they use active-assisted procedures within a range under 90° of elevation and abduction at 3-4 weeks and higher than 90° at 6-12 weeks, with full recovery at a 3-month mark. Sixty-five point seven percent of the sample (n = 399/607) declared that, during the rehabilitation of patients with TSA, they tend to focus on strengthening the scapular and rotator cuff muscles, deltoid, biceps and triceps. Conversely, 68.0% (n = 413/607) of participants stated that, for the rehabilitation of patients with RTSA, they preferably focus on strengthening the periscapular and deltoid muscles. Finally, 33.1% (n = 201/607) of participants indicated the instability of the glenoid prosthetic component as the most frequent complication in patients with TSA, while 42.5% (n = 258/607) of PTs identified scapular neck erosion as the most frequent post-RTSA surgery complication.

CONCLUSIONS

The clinical practice of Italian PTs effectively reflects the indications of the literature as far as the strengthening of the main muscle groups and the prevention of movements, which may result in a dislocation, are concerned. Some differences emerged in the clinical practice of Italian PTs, regarding the restoration of active and passive movement, the starting and progression of muscle strengthening and the return to sport (RTS). These differences are actually quite representative of the current knowledge in post-surgical rehabilitation for shoulder prosthesis in the rehabilitation field.

LEVEL OF EVIDENCE

V.

Evaluation of the Painful Total Shoulder Arthroplasty

Despite the overall success of anatomic and reverse total shoulder arthroplasties (aTSA and rTSA), some patients continue to have or develop pain postoperatively. As the number of shoulder arthroplasties continues to increase in the United States, it is important that surgeons are able to recognize, diagnose, and treat the various pathologies. Some painful etiologies are specific to either aTSA or rTSA, and others can occur with both implant types. Infections, stiffness, neurologic syndromes, polyethylene wear, aseptic implant loosening, and metal allergies occur, regardless of implant choice. However, after an aTSA, subscapularis repair failure, superior rotator cuff tear, and joint overstuffing can result in shoulder pain. After a rTSA, specific causes of postoperative pain include instability, scapular notching, acromial or scapular spine fractures, subcoracoid pain, and neurologic injury. Regardless of the diagnosis, the surgeon must be methodical in the evaluation and, when appropriate, use blood work, advanced imaging studies, joint aspirations, shoulder arthroscopy, and nerve studies. Once diagnosed, appropriate treatment should be undertaken to resolve the cause of the pain or at least minimize the effect of the pain on the patient's outcome.

What is the middle term survival of reverse shoulder arthroplasty? A retrospective observational registry-based study

PURPOSE

The use of reverse total shoulder arthroplasty has increased over the last decade. Like any other implant it is associated with complications sometimes leading to revision. We carried out a registry-based study in order to find possible risk factors associated with the need of revision surgery.

METHODS

The RIPO registry was analyzed from July 2008 to December 2018 collecting available data. Two groups (degenerative or fracture) were formed and compared to determine possible risk factors difference in revision surgery.

RESULTS

A total of 7,966 shoulder prosthesis were implanted. There was a 1.5% intra or peri-operative complication rate. The revision rate was 4.0% at a mean follow-up of 4.4 years. A total of 3,073 reverse total shoulder prosthesis were implanted and available for follow-up. An increase of revision rate (the most frequent causes being aseptic loosening, infection and instability) was found in patients younger than 65 years and in male patients. Two groups were then formed on the basis of the primary diagnosis: osteoarthritis and proximal humerus fracture. Comparison between the two groups showed an increase in instability requiring revision in the fracture group.

CONCLUSION

Reverse shoulder prosthesis is a valid treatment option both in the elective and in the trauma settings, but young and male patients should be informed of the inherently increased risk of revision and prosthesis used in the fracture setting should be evaluated more thoroughly to prevent instability.

[Revision surgery in reverse shoulder arthroplasty : Management of the most common complications]

BACKGROUND

In recent years, the number of reverse shoulder arthroplasty implantations has increased continuously and a higher number of revision surgeries due to complications can be expected in the future. Current data show a mean complication rate for RSA of around 4%. The most common complications are instability, infection, component loosening, and periprosthetic fracture.

TREATMENT OPTIONS

Revision surgery for RSA is challenging, and an individual treatment plan is necessary. For prosthetic instability, different operative or non-operative treatment options are available. Revision surgery for periprosthetic infection with replacement of the prosthesis is usually necessary for infection management. The treatment of periprosthetic fractures is based on techniques of general fracture treatment and depends on the fracture type. Knowledge of complications and risk factors may decrease complication rates in primary reverse shoulder arthroplasty in the future.

Intraoperative and early postoperative complications of reverse shoulder arthroplasty: A current concepts review

Background

Reverse shoulder arthroplasty is a common procedure performed for a variety of shoulder pathologies.

Aims and objectives

This current concept review evaluates the intraoperative and early postoperative complications, with a specific focus given to neurological and vascular injury, fracture, dislocation and venous thromboembolism.

Conclusion

A detailed knowledge of potential complications will allow surgeons to mitigate risk and maximise outcomes.

Survivorship analysis of revision reverse total shoulder arthroplasty

BACKGROUND

The expansion of indications for reverse total shoulder arthroplasty (RTSA) has resulted in a rapid increase in the incidence of subsequent revision procedures. The purpose of this study was to identify the incidence and risk factors for re-revision shoulder arthroplasty after first revision RTSA.

METHODS

We retrospectively queried our institutional shoulder arthroplasty database of prospectively collected data from 2003 to 2019. To assess revision implant survival, patients were censored on the date of re-revision surgery or, if the revision arthroplasty was not revised, at the most recent follow-up or their date of death. Patients with a prior infection, concern for infection at the time of revision, antibiotic spacer, or oncologic indication for primary arthroplasty were excluded. A total of 186 revision RTSAs were included, with 32 undergoing re-revision shoulder arthroplasty. The Kaplan-Meier method and bivariate Cox regression were used to assess the relationship of patient and surgical characteristics on implant survivorship. Multivariate Cox regression was performed to identify independent predictors of re-revision.

RESULTS

Re-revision shoulder arthroplasty was most commonly performed for instability (34%), infection (28%), and glenoid loosening (19%). Overall re-revision rates at 6 months (7%), 1 year (9%), and 2 years (13%) were relatively low; however, the rate of re-revision increased at 5 years (35%). Men underwent re-revision more often than women within the first 6 months after revision RTSA (12% vs. 2%; P = .025), but not thereafter. On multivariate analysis, increased estimated blood loss was associated with a greater risk of undergoing re-revision shoulder arthroplasty (hazard ratio: 41.16 [3.34-506.50]; P = .004).

CONCLUSION

The rate of re-revision after revision RTSA is low in the first 2 years postoperatively (13%) but increases to 35% at 5 years. Increased estimated blood loss, which may reflect greater operative complexity, was identified as a risk factor that may confer an increased chance of re-revision after revision RTSA. Knowledge of risk factors for re-revision after revision RTSA can aid surgeons and patients in preoperative counseling.

Risk Factors for Dislocation After Reverse Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis

Instability after reverse total shoulder arthroplasty (RTSA) is a dreaded complication. Risk factors for postoperative instability are uncertain. The goal of this systematic review was to quantitatively and qualitatively analyze the risk factors for instability after RTSA. Of 1183 studies identified, 12 studies involving 3810 patients were included. The mean age was 68.8 years, and the mean follow-up was 46 months. The pooled rate of dislocation after RTSA was 4.0%. Several patient-specific and implant-specific risk factors have been identified, and especially the implant-specific risk factors appear avoidable with current knowledge, implant design, and technology. [Orthopedics. 2022;45(6):e303-e308.].

Subscapularis repair in reverse total shoulder arthroplasty: a systematic review and descriptive synthesis of cadaveric biomechanical strength outcomes

Hypothesis/Background

There is no consensus on whether to repair the subscapularis in the setting of reverse total shoulder arthroplasty (rTSA). There have been an assortment of studies showing mixed results regarding shoulder stability and postoperative strength outcomes when looking at subscapularis repair in rTSA. The purpose of this systematic review was to investigate differences in biomechanical strength outcomes of cadaveric subscapularis repair vs. no repair in rTSA.Increased force will be required to move the shoulder through normal range of motion (ROM) in cadaveric rTSA shoulders with the subscapularis repaired when compared with no subscapularis repair.

Methods

A comprehensive literature review was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The databases used to search the keywords used for the concepts of subscapularis, reverse total shoulder arthroplasty, and muscle strength were PubMed (includes MEDLINE), Embase, Web of Science, Cochrane Reviews and Trials, and Scopus. Original, English-language cadaveric studies evaluating rTSA and subscapularis management were included, with subscapularis repair surgical techniques and strength outcomes being evaluated for each article meeting inclusion criteria.

Results

The search yielded 4113 articles that were screened for inclusion criteria by 4 authors. Two articles met inclusion criteria and were subsequently included in the final full-text review. A total of 11 shoulders were represented between these 2 studies. Heterogeneity of the data across the 2 studies did not allow for meta-analysis. Hansen et al found that repair of the subscapularis with rTSA significantly increased the mean joint reaction force and the force required by the posterior deltoid, total deltoid, infraspinatus, teres minor, total posterior rotator cuff, and pectoralis major muscles. Giles et al found that rotator cuff repair and glenosphere lateralization both increased total joint load.

Conclusion

The present review of biomechanical literature shows that repair of the subscapularis in the setting of rTSA can effectively restore shoulder strength by increasing joint reactive forces and ROM force requirements of other rotator cuff muscles and of the deltoid muscle. Available biomechanical evidence is limited, and further biomechanical studies evaluating the strength of various subscapularis repair techniques are needed to evaluate the effects of these techniques on joint reactive forces and muscle forces required for ROM.

Risk factors of instability following reverse total shoulder arthroplasty in patients with no history of shoulder surgery

Introduction

As its indications expand, reverse total shoulder arthroplasty (rTSA) utilization continues to increase. Though relatively uncommon, instability following rTSA can be associated with significant morbidity and need for subsequent revision and treatment. This case control study aims to characterize factors leading to instability after rTSA, especially in those with no previous shoulder surgery.

Methods

194 rTSAs performed within the study period with appropriate operative indications and follow-up were included. Risk factors used in analysis included age, gender, BMI, ASA class, Charlson comorbidity index (CCI), glenosphere, tray, and liner size. Data was analyzed using a hierarchical binary logistical regression to create a predictive model for instability.

Results

Seven patients sustained a post-operative dislocation. Mean time to dislocation was 60.4 weeks. Five required open reduction with placement of either a larger humeral tray or polyethylene spacer. One required open reduction with osteophyte removal, and one was converted to a resection arthroplasty. Dislocators were more likely to have a larger BMI (p = 0.002), higher ASA classification (p = 0.09), and larger liner size (p = 0.01).

Conclusion

This study demonstrates a large series of patients successfully treated with rTSA. Dislocations were an uncommon complication, but were clearly associated with higher patient BMI, ASA classification, and increased liner size.

Compressed autograft biceps tendon augmentation of subscapularis repair following shoulder arthroplasty

Subscapularis integrity is correlated with function following shoulder arthroplasty. Failure of healing, particularly following anatomic total shoulder arthroplasty, is associated with poor outcomes and the need for revision. Graft augmentation has been used to increase healing following rotator cuff repair but has not been commonly advocated for augmenting the subscapularis following shoulder arthroplasty. The long head biceps tendon is typically tenodesed and discarded during shoulder arthroplasty. Rather than discarding the tendon, the tendon may be compressed and applied to the subscapularis as a biologic scaffold to potentially improve subscapularis healing following shoulder arthroplasty.

Complication and revision rates after reverse total shoulder revision from hemiarthroplasty: a systematic review

Background

Thus, the purpose of the present study was to (1) characterize common postoperative complications and (2) quantify the rates of revision in patients undergoing hemiarthroplasty to reverse total shoulder arthroplasty revisional surgery. We hypothesize that hardware loosenings will be the most common complication to occur in the sample, with the humeral component being the most common loosening.

Methods

This systematic review adhered to PRISMA reporting guideline. For our inclusion criteria, we included any study that contained intraoperative and/or postoperative complication data, and revision rates on patients who had undergone revision reverse total shoulder arthroplasty due to a failed hemiarthroplasty. Complications include neurologic injury, deep surgical site infections, hardware loosening/prosthetic instability, and postoperative fractures (acromion, glenoid, and humeral fractures).

Results

The study contained 22 studies that assessed complications from shoulders that had revision reverse total shoulder arthroplasty from a hemiarthroplasty, with a total sample of 925 shoulders. We found that the most common complication to occur was hardware loosenings (5.3%), and of the hardware loosenings, humeral loosenings (3.8%) were the most common. The revision rate was found to be 10.7%.

Conclusion

This systematic review found that revision reverse total shoulder arthroplasty for failed hemiarthroplasty has a high overall complication and reintervention rates, specifically for hardware loosening and revision rates.

Total Shoulder Arthroplasty: Antibiotic Allergies Increase Risk of Postoperative Complications

BACKGROUND

Periprosthetic infections after total shoulder arthroplasty (TSA) are associated with devastating complications and prolonged treatment. Patients with identified antibiotic allergy (ABX) may be at increased risk for complications because of suboptimal preincisional prophylaxis. This study aims to quantify the risk of postoperative outcomes and complications for patients undergoing TSA with a history of ABX.

METHODS

Retrospective cohort analysis of patient data was conducted using the PearlDiver Patient Records Database. Patients who underwent TSA for osteoarthritis were identified using Current Procedural Terminology and International Classification of Diseases codes and were stratified based on self-reported (1) penicillin, (2) sulfonamide, or (3) other antibiotic allergies. We analyzed patient demographics, comorbidities, 90-day medical complications, and rate of revision at 30 days, 90 days, 1 year, and 2 years.

RESULTS

In total, 85,606 patients who underwent TSA for osteoarthritis from 2010 to 2018 were identified, of whom 7,836 (9.15%) had a reported ABX. Univariate analysis found the ABX cohort was younger (67.5 versus 67.7 year; P = 0.042), more often female (67.57% versus 54.79%; P < 0.001), and more likely to have Elixhauser comorbidities than nonallergic control subjects. Multivariate analysis found patients who reported ABX had increased likelihood of periprosthetic joint infection (PJI) within 30 days (odds ratio [OR]: 3.129), 1 year (OR: 2.016), and 2 years of surgery (OR: 2.221). Patients with reported ABX had increased likelihood of postoperative anemia (OR: 1.126), blood transfusion (OR: 1.238), and readmission (OR: 1.585) within 90 days of surgery. Patients with penicillin allergy had a greater incidence of revision due to PJI at 30 days (OR: 4.811), 90 days (OR: 2.91), 1 year (OR: 2.105), and 2 years (OR: 2.72). Rates of reported ABX increased from 2010 to 2018 (8.60% to 10.91%; P = 0.001) in patients undergoing TSA.

CONCLUSION

Patients undergoing TSA with a history of ABX had a higher risk of readmission, postoperative anemia, blood transfusions, and PJI. These findings support critical assessment and clarification of reported allergies before TSA and possibly the use of preoperative allergy testing.

LEVEL OF EVIDENCE

Level 3 therapeutic study.

Short-term comparative outcomes between reverse shoulder arthroplasty for shoulder trauma and shoulder arthritis: a Southeast Asian experience

Background

Reverse shoulder arthroplasty (RSA), first introduced as a management option for cuff tear arthropathy, is now an accepted treatment for complex proximal humeral fractures. Few studies have identified whether the outcomes of RSA for shoulder trauma are comparable to those of RSA for shoulder arthritis.

Methods

This is a retrospective, single-institution cohort study of all patients who underwent RSA at our institution between January 2013 and December 2019. In total, 49 patients met the inclusion criteria. As outcomes, we evaluated the 1-year American Shoulder and Elbow Surgeons (ASES) and Constant shoulder scores, postoperative shoulder range of motion, intra- and postoperative complications, and cumulative revision rate. The patients were grouped based on preoperative diagnosis to compare postoperative outcomes across two broad groups.

Results

The median follow-up period was 32.8 months (interquartile range, 12.6–66.6 months). The 1-year visual analog scale, range of motion, and Constant and ASES functional scores were comparable between RSAs performed to treat shoulder trauma and that performed for arthritis. The overall complication rate was 20.4%, with patients with a preoperative diagnosis of arthritis having significantly more complications than those with a preoperative diagnosis of trauma (34.8% vs. 7.7%).

Conclusions

Patients who underwent RSA due to a proximal humeral fracture or dislocation did not fare worse than those who underwent RSA for arthritis at 1 year, in terms of both functional and radiological outcomes.

Patient Reported Outcomes and Range of Motion After Reverse Total Shoulder Arthroplasty With and Without Subscapularis Repair

Background

In performing reverse total shoulder arthroplasty (rTSA), the role of repairing the subscapularis has been debated. Our objective was to determine the effect of subscapularis repair following rTSA on postoperative shoulder ranges of motion and patient reported outcome scores (PROs).

Methods

A prospective registry was reviewed to establish a cohort of primary rTSA patients with a 135-degree humeral implant, with a minimum of 2 years of follow-up. Variables collected included demographics, subscapularis repair information, diagnosis, glenosphere size, and glenoid lateralization information. Outcomes collected were range of motion measurements, subscapularis strength, and multiple generic and shoulder PROs. Multivariable linear regression models were created to predict these 2-year outcomes.

Results

The 143-patient cohort had a mean age of 69 years with 68% of patients undergoing subscapularis repair. After adjustment in the multivariable models, whether the subscapularis was repaired did not significantly predict a 2-year forward elevation, external rotation, internal rotation, subscapularis strength, Western Ontario Osteoarthritis of the Shoulder score, VR-12 scores, Constant Score, or American Shoulder and Elbow Surgeons Shoulder Scores. Increased glenoid lateralization significantly predicted greater internal rotation, higher VR-12 physical score, and higher Constant Score. There were no dislocations in either group.

Conclusions

After adjusting for patient and implant factors, subscapularis repair was not associated with a 2-year postoperative range of motion, strength, or any PROs suggesting that repairing the subscapularis may not affect functional outcome. Increased glenoid lateralization through the baseplate and glenosphere independently predicted better internal rotation, VR-12 physical score, and Constant Scores indicating a benefit to lateralization during rTSA.

Systematic review of prevalence, risk factors, and management of instability following reverse shoulder arthroplasty

Background

Since its approval for use, reverse shoulder arthroplasty (RSA) has become the primary treatment for cuff tear arthropathy, with indications expanding more recently to include revision fracture, osteoarthritis with significant glenoid bone loss, tumor, and chronic instability. Instability is a well-described postoperative complication, occurring in 1to 31% of relatively small cohorts and case series. Given the relative infrequency of instability, there remains a need for a comprehensive review of instability with a focus on risk factors and management. Our goal of this systematic review is to describe the prevalence, risk factors, and management strategies for instability following RSA.

Methods

A systematic review of the PubMed, EMBASE, MEDLINE, Scopus, and Cochrane Library databases was performed according to PRISMA guidelines. Inclusion criteria included primary RSA cohorts ≥ 100 patients, revision RSA cohorts of any size, and minimum 1-year follow-up. The primary outcome of interest was postoperative instability. MINORS criteria were used to assess study bias. Descriptive statistical analysis was performed with data reported as ranges.

Results

Seventeen studies that included 7885 cases of RSA were reviewed. The mean follow-up ranged from 12 to 84 months. Mean age ranged from 64 to 77 years old, and males represented 19 to 39% of cohorts. There were 204 (2.5%) dislocations in 7885 cases, accounting for a rate of instability from 0.4 to 49% across all studies. By intervention, instability rates ranged from 1 to 5% (primary RSA cases), 1 to 49% (revision RSA cases only), and 0.4 to 10% (mixed cohorts). Subscapularis insufficiency and proximal humerus fractures, and fracture sequelae (malunion and nonunion) were identified as risk factors for instability. Closed reduction and casting and revision RSA were reported as successful treatment strategies with acceptable rates of stable prostheses (28-100% and 55-100%, respectively, across studies). Hemiarthroplasty or resection arthroplasty due to recurrent instability was not uncommon after 2 or more episodes of instability.

Conclusion

Instability following RSA occurs infrequently (1-5%) following primary RSA and more commonly following revision RSA (1-49%). RSA for acute proximal humerus fracture and fracture sequelae carries a higher risk of instability. Subscapularis repair appears to be a protective factor. While instability may be successfully treated with closed management or revision RSA, recurrent instability may ultimately require hemiarthroplasty or resection arthroplasty.

Acromiohumeral cerclage in reverse total shoulder arthroplasty for recurrent instability

BACKGROUND

Recurrent shoulder instability after reverse total shoulder arthroplasty (rTSA) presents a challenging clinical problem. A handful of cases have been reported describing stability achieved only after revision rTSA with cerclage augmentation. We describe an acromiohumeral cerclage technique, where the humeral component is fixed with a nonabsorbable, high-tensile suture tape looped through transosseous acromial drill tunnels as an augment to salvage shoulder stability.

METHODS

All patients treated with acromiohumeral cerclage in rTSA for instability between November 1, 2015, and February 1, 2020, with minimum 1-year follow-up were included. Demographic information, baseline preoperative and postoperative range of motion at most recent follow-up, American Shoulder and Elbow Surgeons (ASES) shoulder scores, and visual analog scale (VAS) scores were recorded and compared.

RESULTS

Ten patients, 4 female and 6 male, aged 64.3 ± 7.4 years (range, 53-77 years) with the mean postoperative follow-up of 23 months were included; 90% underwent surgery on the dominant side. Patients underwent an average of 2.1 ± 1.9 prior revisions (range, 0-7), over an average of 10.4 months (range, 0-72 months), before revision with suture cerclage augmentation was performed. All patients either had significant past shoulder history at other institutions and/or comorbidities that added significant complexity to their cases, with an average of 0.6 ± 0.9 (range, 0-3) prior other shoulder operations performed before their initial rTSA. The average decrease in VAS score among the 10 patients was 4.3 ± 2.7 (P < .05), ranging from 0 to 8 points. The average increase in ASES score was 51.3 ± 21 (P < .05), ranging from 13.3 to 69.9 points. The average increase in active forward elevation for 8 patients was 79° ± 39° (P = .0008), ranging from 40° to 160°. All patients have remained stable with well-positioned prostheses since their final operations with no recurrent dislocations or acromial complications. Two patients unable to travel for an office visit were contacted via phone and answered questions to obtain postoperative ASES and VAS scores.

CONCLUSION

Acromiohumeral cerclage suture augmentation in revision rTSA may be a useful, simple surgical strategy to employ with other revision and augmentation techniques to treat cases of recurrent, chronic instability, particularly in the setting of multiple revisions.

Soft Tissue Management in Shoulder Arthroplasty

Total shoulder arthroplasty is a rapidly growing field, with more procedures performed each year. An important aspect of shoulder arthroplasty surgery is the management of soft tissues. Good functional outcomes in shoulder arthroplasty are significantly dependent on the repair of the rotator cuff tendons and proper release of the shoulder capsule. The success of any shoulder arthroplasty is predicated upon the meticulous handling of these tissues. The surgeon's ability to execute appropriate soft tissue techniques will facilitate easier surgery by increasing exposure and lead to better outcomes for the patient.

Instability after reverse total shoulder arthroplasty: risk factors and how to avoid them

Instability after RTSA (4’7%) remains a complication with limited salvage options... or not? We conducted a study of the incidence, predisposing factors, and treatment of RTSA instability to risk stratify patient and identify the most reliable treatment methods. We retrospectively searched for RTSAs performed between 2008 and 2017 at our institution by one surgeon using the same technique. We identified post- operative dislocations or symptoms of instability. 103 patients underwent 103 RTSAs (97 primary, 6 revision). 6 patients had 5 dislocations (3 in primary RTSAs, 3 in revision RTSAs). Mean time from surgery to diagnosis was 32.6 days (range, 10-60 days). One dislocation occurred immediately after surgery, 0 after falls, 3 from low-energy mechanisms of injury, and 2 without known inciting events. All dislocations were treated in the operating room; no dislocation was successfully treated with simple closed reduction in the clinic. Although dislocation after RTSA is uncommon, the risk is higher for patients with higher BMI and for patients undergoing revision surgery. The highest risk of instability occurs in RTSAs done for severe proximal humerus fracture; where the anatomy of the shoulder is changed. In these cases, approximately one in four patients will have a recurrent dislocation. In patients with persistent instability or with risk factors for instability, consideration should be given for use of larger glenospheres and increasing the lateral offset at the time of RTSA. Besides, peri- glenoid release, the suitable tension of the soft tissues tend to be the key of the stability.

Remote Follow-up of Shoulder Arthroplasty Patients During COVID-19 Pandemic - Is This the way Forward?

Background

The COVID-19 Pandemic has affected the way health care systems function across the globe. Apart from eliminating the risk of being in a vulnerable environment during the pandemic such as a hospital setting, virtual arthroplasty follow-up reduces the demand on funding and resources on the National Health Services (NHS).

Methods

We retrospectively reviewed our shoulder arthroplasty patients (55) operated between October 2018 to November 2020 at both our hospital sites. For remote follow-up, patients were contacted on a scheduled appointment date via telephone by an orthopaedic surgeon to enquire about their wound, pain and function. Patients were questioned as per questionnaire from the Oxford Shoulder Score (OSS) and American Shoulder and Elbow Surgeons (ASES) Standardised Assessment form.

Results

50 patients were included in the final data set after excluding those who had died (5 patients). All patients had had final x-rays with full Covid-19 precautions at the time of final follow-up. No patient had wound problems except one who had concerns of wound appearance. There were no cases of notching, impingement, deep infection, dislocation or nerve injury. Of the 50 patients, 40 (80%) patients were satisfied to have a remote follow-up. 36 (72%) patients said they wouldn't mind a remote follow-up appointment.

Conclusion

Remote follow-up via audio consultation may be an effective alternative to in person visits after shoulder arthroplasty. Patients in this series demonstrated a high level of satisfaction with virtual visits and post-operative complications were effectively identified.

Minimum 2-year outcomes of reverse total shoulder arthroplasty for fracture: how does acute arthroplasty compare with salvage?

BACKGROUND

The objective of our study was to compare patient-reported outcome measures, range of motion (ROM), complication rates, and reoperation rates after reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures between patients treated acutely (≤30 days after injury), those treated after initial nonoperative treatment (>30 days after injury), and those treated after failed open reduction-internal fixation. Secondarily, we aimed to identify any patient-, injury-, or surgery-related factors independently associated with our response variables.

METHODS

We identified 576 patients who sustained a proximal humeral fracture treated with primary or revision shoulder arthroplasty between January 2003 and August 2018. The final cohort included 153 patients. Multivariable analysis was used to assess whether explanatory variables were associated with our response variables.

RESULTS

Initial nonoperative treatment compared with acute rTSA was associated with worse Shoulder Subjective Value (P = .04), Shoulder Pain and Disability Index score (P = .03), and Shoulder Pain and Disability Index disability subscale score (P = .03). Only depression was independently associated with worse visual analog scale pain score (P = .04). There was no significant difference in postoperative ROM between the initial treatment groups. Older age was associated with decreased ROM in all planes. Additionally, ipsilateral upper-extremity injury was associated with decreased active abduction (P = .03), and cemented humeral stems were associated with decreased passive abduction (P = .03). Initial nonoperative treatment was associated with increased complication rates (odds ratio, 3.65; 95% confidence interval, 1.11-12.01), and male sex was associated with higher rates of reoperation (odds ratio, 3.53; 95% confidence interval, 1.31-9.51).

CONCLUSIONS

Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. Patients who undergo rTSA after failed open reduction-internal fixation show no difference in patient-reported outcomes compared with those who undergo acute rTSA. In addition, male patients are at higher risk of reoperation, whereas older patients are at risk of decreased ROM. Patients with preoperative depression are at risk of increased pain at 2 years after surgery.

Bony increased-offset reverse shoulder arthroplasty (BIO-RSA) associated with eccentric glenosphere and an onlay 135° humeral component : Clinical and Radiological Outcomes at a minimum 2 year follow-up

Background

Various implant designs have been proposed to increase active range of motion (ROM) and avoid notching in patients treated by reverse total shoulder arthroplasty (RSA). The purpose of this study was to investigate the efficacy and safety of an onlay prosthesis design combining a 135° humeral neck-shaft angle with the glenoid component lateralized and inferiorized.

Methods

A retrospective descriptive study was conducted of the clinical and radiological outcomes at the final follow-up (≥24 months) of all RSAs performed by the same surgeon between September 2015 and December 2016 in the study center. At the last follow-up, patients were clinically assessed for ROM, Constant score, and subjective shoulder value and radiologically for scapular notching and glenoid radiolucent lines. Patients were followed up radiographically at 1 month and clinically at between 6 and 12 months (midterm) and again at between 24 and 48 months (final follow-up). Scapular notching was graded as per the Sirveaux classification at the last follow-up on anterior-posterior radiographs.

Results

Seventy-nine RSAs were included with a mean follow-up time of 31 months. The mean Constant score at the final follow-up was 42 points higher than before surgery (69 vs. 27, P < .001). There were also significant postoperative improvements in ROM (active anterior elevation, active external rotation, and active internal rotation). The final means for motions were 133° for active anterior elevation, 32° active external rotation, and level 7 for active internal rotation. The overall notching rate was 3% (2/67), and there were no cases of severe notching. Radiolucent lines were observed in 8 of 70 prostheses (11.5%) around the peg, and they were observed in 9 prostheses (13%) around the screws. Among the 79 RSAs included, there were 11 complications (13.9%) (two infections, two fractures, four cases of glenoid component loosening, and three cases of instability), 2 reoperations, and 4 prosthesis revisions.

Conclusion

This study shows that an RSA design with a 135° humeral neck-shaft angle and an inferiorized and lateralized glenoid component is associated with significant improvements in active ROM, especially in rotation, and a low notching rate. However, rates of 3.8% for dislocation and 5% for glenoid loosening are certainly a concern at such a short follow-up of two years. Future studies with a larger population are needed to confirm these rates.

Surgical learning curve in reverse shoulder arthroplasty for proximal humerus fractures

Background

Fracture reverse shoulder arthroplasty (fRSA) in geriatric, complex dislocated proximal humerus fractures is becoming the standard treatment next to conservative treatment. fRSA is a multifaceted, reasonably challenging procedure of which functional outcomes and complication rates are likely to depend on the experience of the surgeon. The goal of this study was to determine whether there is a learning curve for fRSA.

Methods

All patients with a dislocated multipart proximal humerus fracture that were treated with an fRSA between 2013 and 2019 in a specialized institution were included. The functional outcomes (Constant Shoulder Score, Oxford Shoulder Score, and range of motion), complications, and operation time of fRSA were assessed with linear regression plots and cumulative summation analysis to establish whether a learning curve was present.

Results

In this cohort study, 50 patients were included. They had a mean age of 77.1 years and were treated with an fRSA by one trauma surgeon. Learning curves were distinguished for functional outcomes, complications, and operation time based on learning targets for daily activity and the mean complications and operation time. Results indicated that an optimal treatment is achieved after performing 20 fRSAs.

Conclusion

The results show that functional outcomes of PHFs treated with an fRSA improve with surgical experience. Also, outcomes are getting less variable after about 20 procedures. Surgeons starting this procedure should be aware of the learning curve and, therefore, should consider guidance from an experienced surgeon to swiftly optimize functional outcomes and prevent unnecessary complications.

Mechanical complications and fractures after reverse shoulder arthroplasty related to different design types and their rates: part I

The initial reverse shoulder arthroplasty (RSA), designed by Paul Grammont, was intended to treat rotator cuff tear arthropathy in elderly patients. In the early experience, high complication rates (up to 24%) and revision rates (up to 50%) were reported.The most common complications reported were scapular notching, whereas clinically more relevant complications such as instability and acromial fractures were less commonly described.Zumstein et al defined a 'complication' following RSA as any intraoperative or postoperative event that was likely to have a negative influence on the patient's final outcome.High rates of complications related to the Grammont RSA design led to development of non-Grammont designs, with 135 or 145 degrees of humeral inclination, multiple options for glenosphere size and eccentricity, improved baseplate fixation which facilitated glenoid-sided lateralization, and the option of humeral-sided lateralization.Improved implant characteristics combined with surgeon experience led to a dramatic fall in the majority of complications. However, we still lack a suitable solution for several complications, such as acromial stress fracture. Cite this article: EFORT Open Rev 2021;6:1097-1108. DOI: 10.1302/2058-5241.6.210039.

Reverse shoulder arthroplasty used for revision of reverse shoulder arthroplasty: a systematic review

Background

As reverse shoulder arthroplasty (RSA) cases increase, so too will the need to revise subsequent failures. Many of the complications associated with revising anatomic total shoulder and hemiarthroplasty have been adequately addressed by RSA including glenoid bone deficiency, instability, and functional outcomes. However, the risk for complication when revising a failed reverse prosthesis may be more pronounced with increased bone and soft tissue deficiency. The ability for the reversed prosthesis to accommodate these insufficiencies following a prior reversed prosthesis is unclear.

Methods

PubMed, Embase, and Google Scholar were queried for articles which fit the inclusion criteria of a reversed prosthesis used to revise a failed primary reverse prosthesis with a minimum follow-up of 12 months and clinical outcome reporting.

Results

After exclusions, 9 studies reporting on 242 reverse shoulders with a mean follow-up of 40.29 months were analyzed. The differences between preoperative and postoperative weighted means were not significant for Constant (P = .26), American Shoulder and Elbow Surgeons Shoulder score (P = .61), SSV (P = .57), and visual analog scale for pain (P = .48). Functional improvements in elevation (74°-102°) and external rotation (18°-21°) were consistent with those reported for primary reverse procedures, although differences in preoperative and postoperative measures were not statistically significant. Patient satisfaction was 89% with a major complication rate of 25%.

Discussion

The reverse shoulder prosthesis has proven satisfactory in revising hemiarthroplasty and anatomic total shoulder arthroplasty. The current results indicate RSA is also a satisfactory treatment option when revising a prior reverse prosthesis. Inherent to revision shoulder surgery is the obstacle of humeral and glenoid bone loss, an attenuated soft-tissue envelope, and instability. The reverse prosthesis may adequately address these commonly confronted difficulties with its inherent design characteristics. RSA provides a secure glenoid fixation for bone grafting, the ability to increase construct stability with component sizing, and a reliance on the deltoid for function. As our learning about revision of RSA improves, so will our ability to preemptively address potential issues which may lead to decreased complications in these cases. Despite the 25% rate of major complication, patients reported satisfaction of 89% which demonstrates the improvements in function and pain relief that are provided by the reverse prosthesis.

Dislocation after reverse total shoulder arthroplasty using contemporary medialized modular systems. Can we still consider it such a frequent complication?

INTRODUCTION

Improvement in reverse total shoulder arthroplasty (RTSA) prosthesis and technique has reduced the initially high complication and revision rates associated with this implant. However, instability continues to be a leading cause of reoperation after RTSA, being related in previous studies with medialized designs. The aim of this study was to determine the dislocation rate with the employment of two medialized modular systems of RTSA in our institution.

MATERIALS AND METHODS

A retrospective review of two different modular systems of RTSA (SMR Modular Shoulder System and Delta XTEND Reverse Shoulder) was performed between 2009 and 2017 with a minimum 3-year follow-up. Baseline demographic, clinical (Constant, ASES and ROM), and radiographic data were collected. Characteristics of postoperative instability cases were also evaluated.

RESULTS

237 primary RTSA (41% SMR/59% Delta) and 34 revision RTSA (44% SMR/56% Delta) with a mean follow-up of 75.6 ± 5.2 months (79.2 SMR/86.3 Delta, p = .586) were included in the present study. Indications for primary RTSA were osteoarthritis, rotator cuff tear arthropathy and massive irreparable rotator cuff tear (64%), acute fracture (32%), and fracture sequelae (4%). Subscapularis tendon was always repaired in degenerative pathology and tuberosities reattached in traumatic cases. The mean age of the global series was 76.5 ± 5.3 years (75.8 SMR/78.6 Delta, p = .104) with a mean Constant/ASES score at final follow-up of 68.5 ± 4.3/72.9 ± 20.3 (71/68 SMR and 69/74 Delta, p = .653 and .642). Only 2 patients (one acute fracture and one fracture sequelae) suffered an early postoperative anterior dislocation (before 3 months) which represents a rate of .84% in primary cases and .73% including revision surgery. Closed reduction manoeuvres were not successful, and both patients required revision surgery. At the end follow-up, both were stable and had no further dislocations.

CONCLUSION

The dislocation rate after RTSA with the employment of two contemporary modular systems with a medialized centre of rotation is extremely low, especially when compared with the previously published series with the original Grammont design. Acute fracture and fracture sequelae were the main diagnoses associated with this instability. The reasons for the low dislocation rate are multifactorial, but the improvement in the baseplate position according to the more recent standards of "ideal position" and technical aspects such as subscapularis repair or tuberosity reattachment in fractures probably play an important role in this aspect.

Case Report: Watching and Waiting? A Case of Incomplete Glenosphere Seating With Spontaneous Reversal in Reverse Shoulder Arthroplasty

Introduction: Reverse shoulder arthroplasty is a useful procedure with broadening applications, but it has the best outcomes when used for rotator cuff tear arthropathy. However, this procedure is not without complications. While scapular notching and aseptic loosening are more common complications that have been extensively studied in the literature, dissociation of the glenoid component and incomplete glenosphere seating has not received much attention. Specifically, little research has explored appropriate management of incomplete seating of the glenosphere component, and no gold standard for treatment of this complication has emerged.

Methods: In the case described here, an elderly patient with an incompletely seated glenosphere component post-operatively opted to pursue conservative management in order to avoid revision surgery if possible.

Results: The partially engaged, superiorly directed components in this case exhibited spontaneous complete and symmetric seating of the glenosphere between six and twelve months post-operatively, indicating that conservative management of this complication in low-demand patients may be a viable option to avoid the risks associated with revision surgery.

Conclusion: Further research should be pursued to explore what patient and prosthesis design factors may be suited to observation with serial radiographs when incomplete seating of the glenosphere component occurs.

Lateralized versus nonlateralized reverse total shoulder arthroplasty

Throughout the history of reverse total shoulder arthroplasty, the extent of lateral offset has changed considerably from "too lateral" to "too medial" and has been lately swinging back towards a point somewhere in between. Nonlateralized designs minimize shear forces on the glenoid and decrease force required by the deltoid. Glenoid lateralization decreases impingement and scapular notching and improves range of motion. Humeral lateralization achieves a more anatomic position of the tuberosities while maintaining a nonlateralized center of rotation. Several factors play a role in choosing the extent of lateral offset and method of lateralization.

Role of Subscapularis Tendon Repair in Reverse Total Shoulder Arthroplasty

In anatomic total shoulder arthroplasty (TSA), subscapularis repair is essential for shoulder stability and function postoperatively; however, the role of subscapularis repair in reverse TSA remains unclear. Some evidence suggests that subscapularis repair is associated with improved postoperative stability and range of motion, whereas other evidence indicates that repair is unnecessary and has no effect on clinical outcomes. In this review, we will analyze the existing literature addressing subscapularis repair during reverse TSA and discuss the effect of medialized and lateralized prosthesis designs on the utility of tendon repair.

The relationship between glenoid inclination and instability following primary reverse shoulder arthroplasty

PURPOSE

Despite advances in implant design and surgical technique, instability remains the most common early complication and reason for early revision after reverse shoulder arthroplasty (RSA). The purpose of this study is to evaluate the glenoid implant inclination, as measured by the β-angle, as an independent risk factor for instability after primary RSA.

METHODS

A retrospective case-control study was conducted matching cases with instability after primary RSA using a single implant to controls without instability. Controls were matched to age, sex, body mass index, and baseplate type (1:3 ratio of cases to controls). The preoperative, postoperative, and the change in pre- to postoperative glenoid inclination (β-angle) were compared between groups.

RESULTS

Thirty-four cases (mean age, 66.2 years) were matched to 102 controls (mean age, 67.0 years). There was a wide range of postoperative (63° to 100°) and pre- to postoperative change (-16.5° to +30.5°) in β-angles collectively. There was no significant difference in the postoperative β-angle (mean, 80.8° vs. 82.7°, P = .19) or the change in β-angle (mean, +1.7° vs. +3.4°, P = .35) between cases and controls, respectively. Regression analysis demonstrated no increased odds of instability with the postoperative β-angle, odds ratio 0.965 (confidence interval [CI] = 0.916-1.02, P = .19). Likewise, for the preoperative to postoperative change in β-angle, there was no significantly increased odds of instability, odds ratio 0.978 (CI = 0.934-1.03, P = .35). Finally, there was no difference in risk of instability in patients whose implant positioning resulted in a net superior increase in inclination, relative risk 0.85 (95% CI = 0.46-1.56, P = .28).

CONCLUSIONS

Neither the final prosthetic glenoid inclination nor the change in glenoid inclination, as measured by the β-angle, significantly influences the risk of prosthetic instability after primary RSA.

The rate of 2nd revision for shoulder arthroplasty as analyzed by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)

Background and purpose - The increase in shoulder arthroplasty may lead to a burden of revision surgery. This study compared the rate of (2nd) revision following aseptic 1st revision shoulder arthroplasty, considering the type of primary, and the class and type of the revision.Patients and methods - All aseptic 1st revisions of primary total reverse shoulder arthroplasty (rTSA group) and of primary total stemmed and stemless total shoulder arthroplasty (non-rTSA group) procedures reported to our national registry between April 2004 to December 2018 were included. The rate of 2nd revision was determined using Kaplan-Meier estimates and comparisons were made using Cox proportional hazards models.Results - There was an increased risk of 2nd revision in the 1st month only for the rTSA group (n = 700) compared with the non-rTSA group (n = 991); hazard ratio (HR) = 4.8 (95% CI 2.2-9). The cumulative percentage of 2nd revisions (CPR) was 24% in the rTSA group and 20% in the non-rTSA group at 8 years. There was an increased risk of 2nd revision for the type (cup vs. head) HR = 2.2 (CI 1.2-4.2), but not class of revision for the rTSA group. Minor (> 3 months) vs. major class revision, and humeral revision vs. all other revision types were second revision risk factors for the non-rTSA group.Interpretation - The CPR of revision shoulder arthroplasty was > 20% at 8 years and was influenced by the type of primary, the class, and the type of revision. The most common reasons for 2nd revision were instability/dislocation, loosening, and infection.

Reverse total shoulder arthroplasty clinical and patient-reported outcomes and complications stratified by preoperative diagnosis: a systematic review

OBJECTIVE

This systematic review aimed to investigate differences in clinical outcomes, patient-reported outcomes (PROs), and complication types and rates among preoperative diagnoses following reverse total shoulder arthroplasty (RTSA): rotator cuff tear arthropathy, primary osteoarthritis, massive irreparable rotator cuff tear, proximal humeral fracture, rheumatoid arthritis (RA), and revision of anatomic arthroplasty (Rev).

LITERATURE SEARCH

Three electronic databases were searched from inception to January 2020.

STUDY SELECTION CRITERIA

The inclusion criteria were (1) patients with a minimum age of 60 years who underwent RTSA for the stated preoperative diagnoses, (2) a minimum of 2 years' follow-up, and (3) preoperative and postoperative values for clinical outcomes and PROs.

DATA SYNTHESIS

Risk of bias was determined by the Methodological Index for Non-randomized Studies tool and the modified Downs and Black tool. Weighted means for clinical outcomes and PROs were calculated for each preoperative diagnosis.

RESULTS

A total of 53 studies were included, of which 36 (68%) were level IV retrospective case series. According to the Methodological Index for Non-randomized Studies tool, 33 studies (62%) showed a high risk of bias; the 3 randomized controlled trials showed a low risk of bias on the modified Downs and Black tool. RTSA improved clinical outcomes and PROs for all preoperative diagnoses. The Rev group had poorer final outcomes as noted by a lower American Shoulder and Elbow Surgeons score (69) and lower pain score (1.8) compared with the other preoperative diagnoses (78-82 and 0.4-1.4, respectively). The RA group showed the highest complication rate (28%), whereas the osteoarthritis group showed the lowest rate (1.4%).

CONCLUSION

Studies in the RTSA literature predominantly showed a high risk of bias. All preoperative diagnoses showed improvements; Rev patients showed the worse clinical outcomes and PROs, and RA patients showed higher complication rates. The preoperative diagnosis in RTSA patients can impact outcomes and complications.

Subscapularis-sparing approaches in shoulder arthroplasty: A systematic review

Background

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

Methods

Medline, Embase, PubMed, and CENTRAL were searched.

Results

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

Conclusion

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

Anatomic factors influencing the anterior stability of reverse total shoulder arthroplasty

BACKGROUND

Several factors affect the stability of the reverse shoulder arthroplasty. The influence of bony anatomy on anterior stability remains unclear. This study aimed to identify the correlations between bony anatomy and anterior dislocation forces.

METHODS

The differences in anterior dislocation force in reverse total shoulder arthroplasty reported in a previous biomechanical study were used to analyze the anatomic factors influencing anterior stability. The critical shoulder angle, glenocoracoid distance in 2 planes, and glenoid inclination were measured in the tested specimens using 3-dimensional computed tomographic scans and radiographs. Anatomic parameters were then correlated with the anterior dislocation forces.

RESULTS

The critical shoulder angle had no correlation with anterior stability. The glenocoracoid distance in anteroposterior direction showed a negative correlation with the stability of a reverse shoulder arthroplasty with a 9-mm lateralized glenosphere and 155° humeral inclination in 30° and 60° glenohumeral abduction with the arm in 30° external rotation (r = -0.662, P = .004; r = -0.794, P = .011) and 30° glenohumeral abduction with neutral rotation (r = -0.614, P = .009). Using the same hardware configuration, the anterior stability had a negative correlation with the glenocoracoid distance in the mediolateral direction in 30° of glenohumeral abduction with the arm in 0° and 30° of external rotation (r = -0.542, P = .025; r = -0.497, P = .042).

CONCLUSION

The distance between the coracoid tip and glenoid in 2 planes had a significant negative correlation with the anterior stability of the reverse shoulder arthroplasty with a lateralized glenosphere and 155° humeral inclination. The findings suggest that only glenoid lateralization is influenced by the bony anatomy.

Tuberosity healing in reverse shoulder arthroplasty in traumatology: Use of an offset modular system with bone graft

INTRODUCTION

Reverse shoulder arthroplasty (RSA) has become a common treatment in displaced proximal humeral fracture (PHF) in elderly patients due to inconstant results with osteosynthesis or hemiarthroplasty. RSA allows a good anterior elevation but rotational results are more random and depend on tuberosity healing.

HYPOTHESIS

Use of an offset modular system (OMS) on the prothesis improve tuberosity healing and functional results.

MATERIAL AND METHODS

This retrospective cohort analysed radiological and clinical outcomes at least one year after the use of RSA Humelock II Reversed (Fx Solutions) after a displaced PHF Neer 3 or 4 in patients over 70 years. The first criterion was tuberosity healing with or without the use of the OMS device on radiographs. The second criterion was a clinical analysis of active range of motion (ROM), anterior elevation (AAE), external and internal rotations (ER, IR), Constant, DASH, SSV, VAS scores according to tuberosity healing. We also analysed radiological and clinical complications.

RESULTS

We analysed from November 2013 to May 2018 thirty-four RSA. Mean age was 78±5,7 years, mean follow up was 18±7,2 months and the mean tuberosity healing rate was 79%. Mean ROM were: 117±24 (AAE), 18̊±18 (ER) and L2 (IR). On the first analysis, healing tuberosity with cage was present on 24 (92%) patients versus 3 (37,5%) without (p<0,005). The second analysis showed a non-significant improvement on ER, IR, Constant, DASH and SSV. Complications found were three removal of prothesis after infection, one axillary nerve lesion, one ulnar paraesthesia and one humeral loosening.

CONCLUSION

The use of the OMS cage allows a better consolidation of tuberosities in a significant way but no significant clinical effects was highlighted due to a small patient number in the study.

LEVEL OF EVIDENCE

level III, retrospective cohort.

Reverse Shoulder Arthroplasty with <i>Latissimus Dorsi</i> Transfer for Humerus Fractures Sequelae

Relevance. Fractures of the proximal humerus occupy the 3rd place in the structure of fractures in the elderly. Failure to treat these injuries leads to irreversible changes in the shoulder. The main treatment for the latter is arthroplasty. The surgical treatment of this category of patients is still a difficult task. The purpose of this study was to compare the effectiveness of standard reverse arthroplasty with reverse arthroplasty in combination with the reconstruction of the external rotators of the shoulder or transposition of the latissimus dorsi. Materials and Methods. The retrospective evaluation of treatment results of 96 patients with consequences of shoulder injuries was conducted. Of these, 51 patients underwent standard reverse arthroplasty (group I), and 45 patients (group II) underwent arthroplasty with reconstruction of the external rotators of the shoulder or transposition of the latissimus dorsi. The female patients accounted for 68.8%. The duration of the injury varied from 8 months to 2.5 years, the follow-up — from 1 to 7 years (Me = 3.5). The results were assessed with VAS, ASES, UCLA scales. Results. The positive outcomes were observed in most patients. Complications: dislocations of the endoprosthesis occurred in 16.7%, infectious complications — in 5.2%, shoulder component instability — in 2.1%, fracture of the humeral diaphysis — in 3.1%, neurovascular bundle injury — in 2.1% of cases. In the patients of group I, dislocations occurred significantly more often than in the patients of group II. To reduce the risk of complications, a rational tactic has been developed for treating patients with consequences of shoulder injuries. If electroneuromyography values from the deltoid muscle were less than 40% of the contralateral side, or if mineral bone density T-score was less than 2.5 SD, arthroplasty was not performed. During arthroplasty, it is necessary to perform the direct suturing of the of the infraspinatus and teres minor tendons to the humerus. If it is impossible, the latissimus dorsi transfer is indicated. Conclusion. Reverse arthroplasty in the treatment of the humerus fractures sequelae is an effective technique. To reduce the risk of complications, it is necessary to provide the additional stability of the endoprosthesis by reconstruction of the external rotators or latissimus dorsi transfer. It is advisable to refrain from arthroplasty in cases of severe deltoid hypotrophy and severe osteoporosis.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II

Background

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous.

Methods

Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests.

Results

The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%.

Conclusions

Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.

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.