Effects of obesity on clinical and functional outcomes following anatomic and reverse total shoulder arthroplasty

Functionality, complications, and survivorship of total shoulder arthroplasty in patients under 60 years old

Background

As total shoulder arthroplasty (TSA) expands to younger patients, it is crucial to weigh the benefits of early intervention against potential complications and implant longevity in patients under 60 years of age. This study examines mid-term outcomes in this patient subset.

Methods

Between 2009 and 2019, a retrospective analysis was conducted on 50 patients (25 male, 25 female) who underwent anatomic TSA (TSA) under the age of 60 with minimum 5 years follow-up. Demographic and baseline variables were extracted from medical records. Pre-operative and post-operative outcomes of range of motion (ROM) and strength were recorded. Patient-reported outcomes (PROs) were obtained.

Results

Fifty patients were followed for an average of 8.7 ± 2.4 years, having a mean age of 54.1 ± 8.4 years. Comparison of pre-operative and post-operative measurements revealed significant improvements in active ROM, including external rotation (ER) (p < 0.0001), forward elevation (FE) (p < 0.0001), and internal rotation (IR) (p = 0.0001). There were significant improvements in functional strength scores, including ER (p = 0.0005) and FE (p = 0.0002). PROs included visual analog scale (VAS) (2.2 ± 2.6), Single Assessment Numeric Evaluation (SANE) (80.3 ± 17.6), American Shoulder and Elbow Surgeons (ASES) score (76.4 ± 22.8), and Simple Shoulder Test (SST) (8.9 ± 3.2). The 5-year and 10-year implant survival rates were found to be 98.0 % and 83.3 %, respectively. There were 7 postoperative complications in 5 patients (14.0 %), including glenoid loosening (n = 2), infection (n = 1), atraumatic instability (n = 1), lesser tuberosity avulsion (n = 1), painful arthroplasty (n = 1) and traumatic rotator cuff insufficiency (n = 1). Subsequently, all 5 patients underwent revision shoulder arthroplasty at an average of 6.5 years after the initial procedure.

Conclusion

Positive mid to long-term outcomes, including significant improvements in ROM and strength, along with high 5-year and 10-year implant survival rates support TSA as an effective treatment option for patients under the age of 60.

Predictive factors influencing internal rotation following reverse total shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is increasingly used as a treatment modality for various pathologies. The purpose of this review is to identify preoperative risk factors associated with loss of internal rotation (IR) after RTSA.

METHODS

A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Ovid MEDLINE, Ovid Embase, and Scopus were queried. The inclusion criteria were as follows: articles in English language, minimum 1-year follow-up postoperatively, study published after 2012, a minimum of 10 patients in a series, RTSA surgery for any indication, and explicitly reported IR. The exclusion criteria were as follows: articles whose full text was unavailable or that were unable to be translated to English language, a follow-up of less than 1 year, case reports or series of less than 10 cases, review articles, studies in which tendon transfers were performed at the time of surgery, procedures that were not RTSA, and studies in which the range of motion in IR was not reported.

RESULTS

The search yielded 3792 titles, and 1497 duplicate records were removed before screening. Ultimately, 16 studies met the inclusion criteria with a total of 5124 patients who underwent RTSA. Three studies found that poor preoperative functional IR served as a significant risk factor for poor postoperative IR. Eight studies addressed the impact of subscapularis, with 4 reporting no difference in IR based on subscapularis repair and 4 reporting significant improvements with subscapularis repair. Among studies with sufficient power, BMI was found to be inversely correlated with degree of IR after RTSA. Preoperative opioid use was found to negatively affect IR. Other studies showed that glenoid retroversion, component lateralization, and individualized component positioning affected postoperative IR.

CONCLUSIONS

This study found that preoperative IR, individualized implant version, preoperative opioid use, increased body mass index and increased glenoid lateralization were all found to have a significant impact on IR after RTSA. Studies that analyzed the impact of subscapularis repair reported conflicting results.

Obesity is associated with improvement in functional outcome but lower internal rotation after reverse shoulder arthroplasty

Background

The role of obesity as an independent risk factor for increased complications following reverse shoulder arthroplasty (RSA) continues to generate debate. While no standardized body mass index (BMI) cutoff values for shoulder arthroplasty exist, many surgeons are concerned about the potential for poor outcomes and decreased range of motion (ROM) in patients with a high BMI. The purpose of this study was to compare functional outcomes in obese and nonobese patients preoperatively and at short-term follow-up after RSA.

Methods

A retrospective review was performed of a prospectively maintained, multicenter database of primary RSAs performed by 14 surgeons between 2015 and 2019 with minimum 2-year follow-up. A total of 245 patients met the study criteria, including 111 obese (BMI >30) and 134 nonobese (BMI <30) patients. Patient-reported outcomes (PROs) as well as ROM measurements were compared between the 2 groups.

Results

At baseline, obese patients had significantly lower American Shoulder and Elbow Surgeons (36.6 vs. 42.0, P = .014), Western Ontario Osteoarthritis of the Shoulder scores (33.1 vs. 37.8, P = .043), external rotation at 90° (19° vs. 28°, P = .007), internal rotation (IR) spinal level (L5 vs. L4, P = .002), and belly press strength (P = .003) compared to the nonobese cohort. There were no statistical differences in 2-year outcomes (PROs, ROM, and strength) other than a worse IR (spinal level) in the low BMI group (L4 vs. L3, P = .002). In linear regression analyses controlling for confounding variables, increasing BMI was negatively correlated with preoperative external rotation (B = -0.591, P = .034) and preoperative IR spinal level (B = 0.089, P = .002). Increasing BMI was not correlated with postoperative external rotation at 90° (B = 0.189, P = .490) but was associated with worse postoperative IR by spinal level (B = 0.066, P = .043).

Conclusions

Obese patients have greater restrictions in external and internal rotation as well as American Shoulder and Elbow Surgeons and Western Ontario Osteoarthritis of the Shoulder scores at baseline prior to RSA. However, there are no major differences in postoperative PROs or ROM measurements between obese and nonobese patients apart from a worse active IR by spinal level in the obese group (L4 vs. L3, P = .002). This study suggests that an RSA procedure does not need to be restricted solely based on BMI.

How using body mass index cutoffs to determine eligibility for total shoulder arthroplasty affects health care disparities

BACKGROUND

The prevalence of obesity in the United States is continuously rising and is associated with increased morbidity, mortality, and health care costs. Body mass index (BMI) has been used as a risk stratification and counseling tool for patients undergoing total joint arthroplasty in an effort to focus on outcome-driven care. Although the use of BMI cutoffs may have benefits in minimizing complications when selecting patients for total shoulder arthroplasty (TSA), it may impact access to care for some patient populations and further increase disparities. The purpose of this study is to determine the implications of using BMI cutoffs on the eligibility for TSA among different ethnic and gender patient populations.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify 20,872 patients who underwent anatomic and reverse TSA between 2015 and 2019. Patient demographics, including age, sex, race and ethnicity, and BMI, were compared between eligible and ineligible patients based on BMI for 5 cutoff values: 30, 35, 40, 45, and 50 kg/m2.

RESULTS

Of the total patient population studied, the mean age was 69 years, 55% were female, and the mean BMI was 31 kg/m2. For all BMI subgroups, there were more ineligible than eligible patients who were female or Black (P < .001). The relative rate of eligibility for Black patients was lower in each BMI cutoff group, whereas the relative rate of eligibility for White and Asian patients was higher for each group. There were more eligible than ineligible Asian patients for BMI cutoffs of 30 and 35 kg/m2 (both P < .001), and there were no differences in eligibility and ineligibility in Hispanic patients (P > .05). Furthermore, White patients were more eligible than ineligible for all BMI cutoff groups (P < .001).

CONCLUSIONS

Enforcing BMI cutoffs for access to TSA may limit the procedure for female or Black patients for all BMI cutoffs, thus furthering the health care disparities these populations already face. However, there are more eligible than ineligible White patients for all BMI cutoff groups, which indicates a disparity in the access to TSA based on sex and race. Physicians may inadvertently increase health care disparities observed in TSA if they use BMI as the sole risk stratification tool for patients, even though BMI has been known to increase complications after TSA. Moreover, orthopedic surgeons should only use BMI as one of many factors in a more holistic process when determining if a patient should undergo TSA.

Reverse Shoulder Arthroplasty Patients Younger Than 60 Years Old Exhibit Lower Clinically Significant Single Assessment Numeric Evaluation (SANE) Scores Compared to Older Patients

INTRODUCTION

The incidence of reverse shoulder arthroplasty (RTSA) in the United States has increased. Patients under 60 years old with failed rotator cuff repairs or degenerative joint disease with glenoid deformity may be candidates for RTSA and contribute to this increase. The single assessment numeric evaluation (SANE) score is a reliable post-operative scoring technique when compared with other post-operative measures. This study aimed to compare the effect of age on the likelihood of reaching clinically significant SANE scores following RTSA.

METHODS

A multicenter retrospective review was performed with a consecutive series of RTSA from December 2015 to September 2021. Patients were stratified into groups based on their age at the time of operation: (1) less than 60 years old, (2) 60-69 years old, (3) 70-79 years old, and (3) greater than 80 years old. The proportions of patients in all cohorts reaching and surpassing clinically significant thresholds at each visit were determined. Likelihood ratios were determined for each age cohort to compare the likelihood of reaching clinically significant SANE scores.

RESULTS

A total of 292 of 885 (33%) patients had completed survey data over two years and were included in the study. The 70-79-year-old group was 3.152 (p=.035) times more likely to achieve minimal clinically important difference (MCID) and 2.125 (p=.048) times more likely to achieve patient-acceptable symptomatic state (PASS) compared with patients <60 years old. The cohort who was 80+ years old was also 4.867 (p=.045) times more likely to achieve MCID compared to the <60-year-old cohort. The <60 cohort had the lowest proportion of all patient cohorts achieving MCID.

CONCLUSION

A lower proportion of patients younger than 60 years old undergoing RTSA achieved clinically significant post-operative SANE scores. The 70-79-year-old age group was more likely to reach MCID and PASS, and the patients who were 80+ years old were more likely to reach MCID compared to patients younger than 60 years old.

Does Reverse Shoulder Arthroplasty Improve Function and Quality of Life in Patients With Rotator Cuff Tear Arthropathy?

Background This study aims to determine the change in functional capacity and quality of life in patients who underwent reverse shoulder arthroplasty (RSA) due to rotator cuff tear arthropathy (RCTA). Methodology A total of 89 patients who underwent RSA due to RCTA between 2016 and 2022 were included in the study, as examined by the senior author. The Constant-Murley Score (CMS) was used for functional assessment, whereas the Short Form-36 (SF-36) was used for quality-of-life evaluation. The assessment scores before and after the surgery were compared to the reference values of CMS and SF-36 scores, as determined by reference studies, based on age groups. The change in functional capacity and quality of life with RSA was calculated. In addition, the impact of age and body mass index (BMI) on the results was examined. Results No differences were found in demographic data except for BMI (p = 0.026). CMS did not reach the reference values of a normal shoulder during the 12-month postoperative period. However, a significant increase of 156% in comparison to the preoperative values was detected (p < 0.001). In the postoperative period, there was a statistically significant improvement in SF-36 scores compared to preoperative scores, except for social functioning (p = 0.099) and vitality (p = 0.255) (for all other parameters, p < 0.001). In patients under the age of 65 years, all parameters except for physical functioning, physical role, and social functioning statistically reached the reference values. A decrease in CMS scores was noted with an increase in BMI, and the negative correlation further increased in the postoperative period (preoperative: r = -0.274, 12-month postoperative: r = -0.476). Conclusions RSA performed for RCTA leads to an improvement in functional outcomes and quality of life. Although there was a considerable improvement after surgery for CMS compared to preoperatively, it was observed that normal shoulder reference values ​​could not be reached. For SF-36, it was observed that it reached normal shoulder reference values, especially in patients over 65 years of age.

Does glenohumeral offset affect clinical outcomes in a lateralized reverse total shoulder arthroplasty?

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) exhibits high rates of success and low complication rates. rTSA has undergone numerous design adaptations over recent years, and lateralization of implant components provides theoretical and biomechanical benefits in stability and range of motion (ROM) as well as decreased rates of notching. However, the magnitude of implant lateralization and its effect on these outcomes is less well understood. The purpose of this study was to evaluate how increasing glenohumeral offset affects outcomes after rTSA, specifically in a lateralized humerus + medialized glenoid implant model.

METHODS

Primary rTSA using a lateralized humeral + medialized glenoid implant model performed at a single academic institution between 2012 and 2018 were retrospectively reviewed. Patient-reported outcome (PRO) parameters and clinical outcomes including ROM were evaluated both pre- and postoperatively. Pre- and postoperative radiographs were analyzed for measurement of glenohumeral offset, defined as the acromial-tuberosity offset (ATO) distance on the anteroposterior radiograph.

RESULTS

A total of 130 rTSAs were included in the analysis, with a mean follow-up of 35 mo. The mean postoperative absolute ATO was 16 mm, and the mean delta ATO (difference from pre- to postoperatively) was 4.6 mm further lateralized. Among all study patients, improvements in all ROM parameters and all PROs were observed from pre- to postoperative assessments. When assessing for the effects of lateralization on these outcomes, multivariate analysis failed to reveal a significant effect from the absolute postoperative ATO or the delta ATO on any outcome parameter.

CONCLUSIONS

rTSA using a lateralized humeral + medialized glenoid implant model exhibits excellent clinical outcomes in ROM and PROs. However, the magnitude of lateralization as measured radiographically by the ATO did not significantly affect these outcomes; patients exhibited universally good outcomes irrespective of the degree of offset restoration.

Does body mass index influence long-term outcomes after anatomic total shoulder arthroplasty?

BACKGROUND

As of 2018, upwards of 42% of the US adult population was considered obese based on body mass index (BMI) scales. With the annual number of total joint replacements increasing, this study aimed to evaluate the impact BMI has on anatomic total shoulder arthroplasty (aTSA) outcomes.

METHODS

This was a retrospective analysis of 128 shoulders requiring primary aTSA. Patients were stratified into 3 cohorts based on their BMI at surgery: underweight/normal weight (U/NW; BMI ≤25.0), overweight (25.0 < BMI ≤ 30.0), and obese (BMI >30.0). BMI was separately analyzed as a continuous variable. Clinical endpoints were range of motion scores, including forward elevation, external rotation, and internal rotation, and patient-reported outcomes, including visual analog scale (VAS) scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, and the Simple Shoulder Test (SST). Survivorship curves were calculated using Kaplan-Meier analysis.

RESULTS

Forty-four, 50, and 34 patient shoulders were in the U/NW, overweight, and obese cohorts, respectively. The mean follow-up time was 11.4 years. The U/NW cohort had more females (73%) compared with the overweight (34%; P = .0030) and obese (35%; P = .0015) groups; no differences were seen in revision rates. BMI was negatively correlated with age at surgery (r = -0.19, P = .014); it was not correlated with any of the 6 postoperative clinical endpoints. All 3 cohorts saw significant improvements in forward elevation, external rotation, internal rotation and VAS, ASES, and SST scores when compared preoperatively to postoperatively (P < .001). There were no significant differences between the 3 cohorts with respect to postoperative range of motion. Postoperative ASES scores were higher for the overweight cohort (82.6 ± 18.6) compared with both the U/NW (63.0 ± 25.1) and obese cohorts (70.5 ± 26.8) (P < .001). The overweight cohort also had higher SST (P = .0012) postoperative scores compared with the U/NW and obese cohorts; VAS scores were comparable between groups (P = .12). The nonobese (BMI <30) group (n = 94) showed 5-, 10-, and 15-year implant survival of 98.9%, 94.9%, and 83.9%, respectively compared to 97.1%, 93.7%, and 87.0% in the obese (BMI ≥30) group (n = 34). The log rank test revealed no significant difference in survival curves (P = .82).

CONCLUSION

To our knowledge, this is the longest follow-up study analyzing clinical endpoints stratified by BMI for aTSA. We saw that patients with a higher BMI required shoulder replacement at a significantly younger age. However, we also report that regardless of BMI, all patients saw significant improvements in patient-reported outcomes and range of motion scores postoperatively.

Obesity does not associate with 5-year surgical complications following anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty

BACKGROUND

Although obesity has been shown to increase the risk of short-term medical complications following total shoulder arthroplasty (TSA), evidence is lacking on the influence of obesity on longer-term surgical complications such as revision. The purpose of this study was to assess the association of increasing obesity with 2- and 5-year all-cause revision, periprosthetic joint infection (PJI), aseptic loosening, and manipulation under anesthesia (MUA) among patients undergoing reverse total shoulder arthroplasty (RTSA) or TSA.

METHODS

Patients who underwent RTSA or TSA with a minimum 5-year follow-up were identified in a national claims database (PearlDiver Technologies). Patients with obesity (body mass index [BMI] ≥30) were compared to patients who are normal or overweight (18.5 ≤ BMI < 30). Those with obesity were further stratified to those with class I or II obesity (30 ≤ BMI < 40) and those with class III obesity (BMI ≥ 40). Outcomes for comparison included all-cause revision, PJI, aseptic loosening, and MUA within 2 or 5 years. These cohorts were compared using univariate and multivariable analysis.

RESULTS

Patients with obesity had no significant difference in any surgical complication within 2 or 5 years for both those who underwent TSA or RTSA. After stratifying by class I or II obesity and class III obesity, there was still no significant difference in surgical complications with 2 or 5 years for both TSA patients and RTSA patients.

DISCUSSION

Obesity, when other major comorbidities are controlled for, was not associated with increased risk of long-term surgical complications after shoulder replacement surgery.

The influence of preoperative rotator cuff cross-sectional area and strength on postoperative outcomes in reverse shoulder arthroplasty

BACKGROUND

Although preoperative function and range of motion (ROM) are determinants of postoperative outcome following reverse shoulder arthroplasty (RSA), there is limited data on the influence of preoperative rotator cuff status. The purpose of this study was to evaluate the relationship between preoperative rotator cuff physiologic cross-sectional area (PCSA) and strength on postoperative RSA outcome.

METHODS

A retrospective review was conducted on 53 primary RSAs from a multicenter database performed between 2015 and 2019 using a 135° humeral neck-shaft angle. Preoperative magnetic resonance imaging and computed tomographic scans were used to assess the PCSA of the subscapularis, supraspinatus, infraspinatus, and teres minor. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, ROM, and strength were measured preoperatively and at a minimum of 2 years postoperatively. Correlation coefficients were used to determine the relationship between variables.

RESULTS

There were no significant correlations between preoperative PCSA of any rotator cuff muscles and postoperative ASES scores. Preoperative subscapularis PCSA positively correlated with change in belly press (BP) strength following RSA (⍴ = 0.37, P = .006). Preoperative abduction strength was significantly correlated with postoperative abduction strength (⍴ = 0.297, P = .006). Preoperative external rotation (ER) strength was significantly correlated with postoperative ER (⍴ = 0.378, P = .005) and abduction (⍴ = 0.304; P = .032) strength. Preoperative BP strength negatively correlated with postoperative ASES (⍴ = -0.283, P = .042) but positively correlated with postoperative BP (⍴ = 0.411, P = .001) and abduction (⍴ = 0.367, P = .009) strength.

CONCLUSION

With the use of a 135° humeral implant, there is limited correlation between preoperative PCSA and postoperative outcomes 2 years following RSA; the only significant correlation was between preoperative subscapularis PCSA and postoperative BP strength. Preoperative strength is positively correlated with postoperative strength but not ROM or ASES scores.

Biodegradable balloon spacer for massive irreparable rotator cuff tears is associated with improved functional outcomes, low revisions, and complications rate at minimum one year follow-up

PURPOSE

This study was designed to investigate the efficacy of the InSpace balloon spacer with a specific focus on clinical and patient-related parameters, functional scores InSpace durability, and satisfaction in patients with massive irreparable rotator cuff tears (IRCT) at minimum one year follow-up.

METHODS

Between 2010 and 2018, patients with symptomatic IRCTs were treated with InSpace balloon implantation. Demographic characteristics, concomitant procedures, and patient's reported outcomes (PROMs) were obtained as well as satisfaction rate and willingness to undergo the procedure again. Need for subsequent surgery and conversion to reverse total shoulder arthroplasty (RTSA) and time to conversion were also evaluated.

RESULTS

Seventy-eight patients (mean age of 70 years, range 46-86) who underwent an InSpace (OrthoSpace, Inc., Caesarea, Israel) balloon implantation were included. Mean follow-up was 56 months (median = 49.6, range 16-129 months). Sixteen out of our 29 pseudoparalytic patients (55.2%) exceed 90° of forward flexion post-surgery with mean improvement of 73° (20-150). Patients older than 65 years of age displayed a statistically significant improved ASES score (60.6 to 46.4, P < 0.05). Patients who underwent a subscapularis (SSC) repair demonstrated a superior ASES score (63.4 compared to 50.4, P = 0.06).

CONCLUSIONS

Based on the current study, spacer implantation is a low-risk, clinically effective treatment for the patients with IRCTs. Patient-specific parameters such as age, BMI, and gender should be considered during patient selection process. SSC tendon tears should be repaired if needed. Improvement in function and symptoms from this procedure may negate or delay the need for RTSA even for some of the pseudoparalytic patients.