Patient satisfaction and clinical outcomes of reverse shoulder arthroplasty: a minimum of 10 years' follow-up

Functional and radiographic outcomes of reverse shoulder arthroplasty with a minimum follow-up of 10 years

BACKGROUND

The use of reverse shoulder arthroplasty (RSA) is becoming increasingly prevalent. However, few studies have been published reporting the long-term outcomes of RSA. This study aims to report the clinical, radiographic, and patient-reported outcomes of the Delta Xtend reverse shoulder prosthesis, performed by a single surgeon and with a minimum follow-up of 10 years.

METHODS

All RSA procedures performed between 2005 and 2012 were identified. Patients were contacted and invited for a follow-up visit including clinical assessment, radiographs, and patient-reported outcome measures. Patients with a follow-up of less than 10 years were excluded. The revision-free implant survival was calculated at 10 years. Between 2005 and 2012, 119 procedures in 116 patients meeting inclusion criteria were identified. Of these patients, 35 were deceased before reaching the 10-year follow-up and 23 could not be reached. In total, 63 RSAs could be included in 61 patients (response rate: 75%). The median follow-up was 11.7 years (interquartile range [IQR]: 10.5-13.2).

RESULTS

Of the 61 patients, 7 patients underwent a revision after a median of 3 years (IQR: 0.2-9.8) during the total follow-up period. The 10-year implant survival was 94% (95% confidence interval: 84-98). At final follow-up, the median anterior elevation was 135° (IQR: 130°-160°), the median abduction was 120° (IQR: 100°-135°), and the median level reached with internal rotation was L5 (IQR: sacrum-L5). The median Auto-Constant score was 68 (IQR: 53-78), the median Subjective Shoulder Value was 80 (IQR: 70-93), and the median pain score was 0.2/10 (IQR: 0-2). In total, radiographs could be obtained in 25 patients (40%). Scapular notching occurred in 10 patients (40%), which was classified as Sirveaux-Nerot grade IV in 3 patients (12%). Ossification occurred in 10 patients (40%), and stress shielding in 2 patients (8%). Radiolucencies were observed around the humeral component in 24 patients (96%) and around the glenoid component in 13 patients (52%).

CONCLUSION

The long-term results of RSA with a Delta Xtend prosthesis are favorable, with long-term improvement in range of motion and patient-reported outcome measures, and a satisfactory implant survival rate. Interestingly, the radiographical analysis showed high prevalence of signs associated with loosening, which did not seem to translate to high complication rates or inferior results.

The subcoracoid distance is correlated with pain and internal rotation after reverse shoulder arthroplasty

Background

A proposed etiology of anterior shoulder pain and limited internal rotation after reverse shoulder arthroplasty (RSA) is impingement of the humeral component on the coracoid or conjoint tendon. The primary goal of this study was to investigate radiographic surrogates for potential coracoid or conjoint tendon impingement and their relationship to postoperative pain and internal rotation after RSA.

Methods

A retrospective review of a clinical registry was performed to identify patients with (1) primary RSA, (2) minimum 2-year clinical follow-up, and (3) satisfactory postoperative axillary lateral radiographs. The primary radiographic measurement of interest was the subcoracoid distance (SCD), defined as the distance between the posterior aspect of the coracoid and the anterior glenosphere. Additional measurements were as follows: anterior glenosphere overhang, posterior glenosphere overhang, native glenoid width, lateralization of glenosphere relative to the coracoid tip, lateralization shoulder angle, and distalization shoulder angle. The primary clinical outcome of interest was the 2-year postoperative Visual Analog Scale score. Secondary outcomes were (1) internal rotation (IR) defined by spinal level (IRspine), (2) IR at 90 degrees of abduction, (3) American Shoulder and Elbow Surgeons score, (4) forward flexion, and (5) external rotation at 0 degrees of abduction. Linear regression analyses were used to evaluate the relationship of the various radiographic measures on the clinical outcomes of interest.

Results

Two hundred seventeen patients were included. There was a statistically significant relationship between the SCD and Visual Analog Scale scores: B = -0.497, P = .047. There was a statistically significant relationship between the SCD and IRspine: B = -1.667, P < .001. Metallic lateralization was also positively associated with improving IRspine; increasing body mass index was negatively associated. There was a statistically significant relationship between the SCD and IR at 90 degrees of abduction: B = 5.844, P = .034.

Conclusion

For RSA with a 135° neck shaft angle and lateralized glenoid, the postoperative SCD has a significant association with pain and IR. Decreasing SCD was associated with increased pain and decreased IR, indicating that coracoid or conjoint tendon impingement may be an important and potentially under-recognized etiology of pain and decreased IR following RSA. Further investigations aimed toward identifying a critical SCD to improve pain and IR may allow surgeons to preoperatively plan component position to improve clinical outcomes after RSA.

Five-Year Mortality Rates Following Elective Shoulder Arthroplasty and Shoulder Arthroplasty for Fracture in Patients Over Age 65

Background

To effectively counsel patients prior to shoulder arthroplasty, surgeons should understand the overall life trajectory and life expectancy of patients in the context of the patient's shoulder pathology and medical comorbidities. Such an understanding can influence both operative and nonoperative decision-making and implant choices. This study evaluated 5-year mortality following shoulder arthroplasty in patients ≥65 years old and identified associated risk factors.

Methods

We utilized Centers for Medicare & Medicaid Services Fee-for-Service inpatient and outpatient claims data to investigate the 5-year mortality rate following shoulder arthroplasty procedures performed from 2014 to 2016. The impact of patient demographics, including fracture diagnosis, year fixed effects, and state fixed effects; patient comorbidities; and hospital-level characteristics on 5-year mortality rates were assessed with use of a Cox proportional hazards regression model. A p value of <0.05 was considered significant.

Results

A total of 108,667 shoulder arthroplasty cases (96,104 nonfracture and 12,563 fracture) were examined. The cohort was 62.7% female and 5.8% non-White and had a mean age at surgery of 74.3 years. The mean 5-year mortality rate was 16.6% across all shoulder arthroplasty cases, 14.9% for nonfracture cases, and 29.9% for fracture cases. The trend toward higher mortality in the fracture group compared with the nonfracture group was sustained throughout the 5-year postoperative period, with a fracture diagnosis being associated with a hazard ratio of 1.63 for mortality (p < 0.001). Medical comorbidities were associated with an increased risk of mortality, with liver disease bearing the highest hazard ratio (3.07; p < 0.001), followed by chronic kidney disease (2.59; p < 0.001), chronic obstructive pulmonary disease (1.92; p < 0.001), and congestive heart failure (1.90; p < 0.001).

Conclusions

The mean 5-year mortality following shoulder arthroplasty was 16.6%. Patients with a fracture diagnosis had a significantly higher 5-year mortality risk (29.9%) than those with a nonfracture diagnosis (14.9%). Medical comorbidities had the greatest impact on mortality risk, with chronic liver and kidney disease being the most noteworthy. This novel longer-term data can help with patient education and risk stratification prior to undergoing shoulder replacement.

Level of Evidence

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

Periprosthetic shoulder infection management: one-stage should be the way: a systematic review and meta-analysis

BACKGROUND

There is still no consensus among surgeons on whether to perform a 1- or 2-stage surgical revision in infected shoulder arthroplasties. The aim of this systematic review and meta-analysis is to rigorously synthesize published studies evaluating the clinical outcomes, recurrence of infection, and other clinical complications in order to discuss which is the best strategy for treating periprosthetic joint infection after shoulder arthroplasty.

METHODS

Upon research using the PubMed, Scopus, and Web of Science databases, in November 2022, studies that presented 1- or 2-stage surgical revision as a treatment for periprosthetic joint infection after shoulder arthroplasty and assessed the reinfection rate on these patients, as well as other clinical outcomes, with a minimum follow-up of 12 months, were included. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) score. Reinfection and complication rates were extracted, and pooled estimates were calculated using the random-effect model.

RESULTS

After careful screening, 44 studies were included, 5 reporting on 1-stage and 30 on 2-stage revisions and 9 assessing both strategies. A total of 185 shoulders were reported in 1-stage revision studies, whereas 526 shoulders were reported in 2-stage revision studies. The overall pooled random-effects reinfection rate was 6.68% (95% confidence interval [CI]: 3.76-10.13), with low heterogeneity (I2 = 28%, P = .03). One-stage revision showed a reinfection rate of 1.14% (95% CI: 0.00-4.88), whereas 2-stage revision analysis revealed a reinfection rate of 8.81% (95% CI: 4.96-13.33). There were significant statistical differences between 1- and 2-stage reinfection rates (P = .04). The overall pooled rate for other clinical complications was 16.76% (95% CI: 9.49-25.15), with high heterogeneity (I2 = 70%, P < .01). One-stage revision had a complication rate of 6.11% (95% CI: 1.58-12.39), whereas the 2-stage revision complication rate was 21.26% (95% CI: 11.51-32.54). This difference was statistically significant (P = .03).

CONCLUSIONS

This is the first systematic review and meta-analysis showing significant statistical differences between 1- and 2-stage surgical revision in infected shoulder arthroplasties. Provided the right conditions exist, 1-stage revision shows better results in infection control, with lower clinical complications and possible better clinical outcomes.

Managing rotator cuff tear arthropathy: a role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty

BACKGROUND

Disabling cuff tear arthropathy (CTA) is commonly managed with reverse shoulder arthroplasty (RSA). However, for patients with CTA having preserved active elevation, cuff tear arthropathy hemiarthroplasty (CTAH) may offer a cost-effective alternative that avoids the complications unique to RSA. We sought to determine the characteristics and outcomes of a series of patients with CTA managed with these procedures.

MATERIALS AND METHODS

We retrospectively reviewed 103 patients with CTA treated with shoulder arthroplasty, the type of which was determined by the patient's ability to actively elevate the arm. Outcome measures included the change in the Simple Shoulder Test (SST), the percent maximum improvement in SST (%MPI), and the percentage of patients exceeding the minimal clinically important difference for the change in SST and %MPI. Postoperative x-rays were evaluated to assess the positions of the center of rotation and the greater tuberosity for each implant.

RESULTS

Forty-four percent of the 103 patients were managed with CTAH while 56% were managed with RSA. Both arthroplasties resulted in clinically significant improvement. Patients having RSA improved from a mean preoperative SST score of 1.7 (interquartile range [IQR], 0.0-3.0) to a postoperative score of 6.3 (IQR, 2.3-10.0) (P < .01). Patients having CTAH improved from a preoperative SST score of 3.1 (IQR, 1.0-4.0) to a postoperative score of 7.6 (IQR, 5.0-10.) (P < .001). These improvements exceeded the minimal clinically important difference. Instability accounted for most of the RSA complications; however, it did not account for any CTAH complications. The postoperative position of the center of rotation and greater tuberosity on anteroposterior radiographs did not correlate with the clinical outcomes for either procedure.

CONCLUSION

For 103 patients with CTA, clinically significant improvement was achieved with appropriately indicated CTAH and RSA. In view of the lower cost of the CTAH implant, it may provide a cost-effective alternative to RSA for patients with retained active elevation.

When is a Reverse Shoulder Arthroplasty Indicated for a Rotator Cuff Tear?

Rotator cuff tears are the most frequent shoulder injury in patients over 50 years old. Treatment of rotator cuff tears is individualized based on the age, demands, and symptoms of the patient. Nonoperative treatment may often be effective, especially in lower-demand or elderly patients. Surgical repair is indicated after failure of nonoperative treatment or in patients whose high-demand lifestyle requires full strength and function of the shoulder. In older patients, larger tears are less likely to heal and rotator cuff repair may not reliable. In cases of failed previous rotator cuff repair, there may not be enough viable tissue for complete repair. If there is underlying arthritis, a rotator cuff repair is unlikely to resolve all symptoms, and treatment to care for the arthritis and rotator cuff tear is indicated. Reverse shoulder arthroplasty provides the surgical answer for these scenarios and is now being used for numerous indications of shoulder pathology.

Mid-term outcomes following reverse total shoulder arthroplasty

PURPOSE

The utilization of reverse total shoulder arthroplasty now exceeds the incidence of anatomic shoulder arthroplasty. Previous mid-to-long-term studies on rTSA have reported a decrease in shoulder function as follow-up increased. The purpose of this study was to provide data on mid-term outcomes and implant survival in a series focusing on reverse total shoulder arthroplasty.

MATERIALS AND METHODS

Demographic information such as age at surgery, revision surgery status, BMI, and smoking status were recorded. The clinical endpoints measured in this study were range of motion scores (forward elevation, external rotation, internal rotation) and patient reported outcomes (VAS, ASES, SST). Radiographic variables captured included preoperative glenoid morphology, humeral lucency, and glenoid loosening.

RESULTS

Fifty-six shoulders were included in this study. The overall mean age at surgery was 72.5 ± 7.2 years with an average follow-up time of 6.8 ± 3.5 years. The mean BMI was 28.1 ± 5.5. All measurements of range of motion saw significant and sustained improvements. Overall, forward elevation improved from 82° preoperatively to 133° postoperatively (p < 0.01). External rotation improved from 23° preoperatively to 36° (p < 0.01), while internal rotation improved from L3 to L1 (p = 0.05). ASES scores improved from 31 preoperatively to 70 postoperatively (p < 0.01). SST scores improved from 2 preoperatively to 7 (p < 0.01). VAS pain index scores improved from 6 to 2 following surgery (p < 0.01). Postoperative scapular notching was seen in 18 patients at final follow-up. Glenoid loosening was seen in 3 shoulders. Humeral loosening was seen in 18 shoulders. Tuberosity resorption was seen in 8 shoulders. The 5 year survival estimate was 98%, and the 10 year survival estimate was 83%.

CONCLUSION

In this series, we found that rTSA provides mid-term improvements in range of motion in patients while reducing pain levels. When considered together, this demonstrates that most patients undergoing rTSA can have excellent use of their shoulder from age at surgery to end-of-life.

Clinical outcomes are unchanged after a mean of 12 years after reverse shoulder arthroplasty: a long-term re-evaluation

Background

The medium-term results of reverse shoulder arthroplasty (RSA) that has been performed by a single surgeon have been previously reported. The purpose of this study was to investigate the minimum 10-year clinical and radiographic outcomes of these patients.

Methods

In this prospective cohort study, 27 patients were evaluated after RSA for massive rotator cuff tear with or without eccentric osteoarthritis (OA) or concentric OA with the Constant-Murley Score (CMS), range of motion (ROM), and a radiologic assessment.

Results

At a mean 12-year follow-up, the CMS and ROM were significantly improved when compared with the baseline values (all P < .001). Once stratified by diagnosis, no difference in the ROM or total CMS was found between patients with massive rotator cuff tear with/without eccentric OA and those with concentric OA. Neither ROM nor CMS decreased when compared to the mid-term values of the previous study, for both the overall population and the diagnosis-stratified groups. Scapular notching was reported in 66.7% of cases that was similar to the data reported at mid-term follow-up. The calcification rate was 59.3% at the long-term evaluation, and there were no differences between the same case-series population (51.9%; P = .785) and the whole population at mid-term follow-up (47%; P = .358).

Conclusion

RSA led to excellent clinical and functional outcomes for patients up to 17 years postoperatively, and there was no decrease in the CMS over time. No loosening of implants was noted, and the rate of scapular notching was 66%, mostly grade 1 or 2.

Long-term outcomes after osteochondral allograft transplantation to the humeral head

BACKGROUND

Long-term outcomes of osteochondral allograft (OCA) transplantation to the humeral head have been sparsely reported in the literature.

PURPOSE

To evaluate outcomes and survivorship of OCA transplantation to the humeral head in patients with osteochondral defects at a minimum of 10 years of follow-up.

METHODS

A registry of patients who underwent humeral head OCA transplantation between 2004 and 2012 was reviewed. Patients completed pre and postoperative surveys including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, Short Form 12 (SF-12), and the visual analog scale. Failure was defined by conversion to shoulder arthroplasty.

RESULTS

Fifteen of 21 (71%) patients with a minimum of ten year of follow-up (mean: 14.2 ± 2.40) were identified. Mean patient age was 26.1 ± 8.8 years at the time of transplantation and eight (53%) patients were male. Surgery was performed on the dominant shoulder in 11 of the 15 (73%) cases. The use of local anesthetic delivered via an intra-articular pain pump was the most often reported underlying etiology of chondral injury (n = 9; 60%). Eight (53%) patients were treated with an allograft plug, while seven (47%) patients were treated with a mushroom cap allograft. At final follow-up, mean American Shoulder and Elbow Surgeons (49.9 to 81.1; P = .048) and Simple Shoulder Test (43.1 to 83.3; P = .010) significantly improved compared to baseline. Changes in mean SF-12 physical (41.4 to 48.1; P = .354), SF-12 mental (57.5 to 51.8; P = .354), and visual analog scale (4.0 to 2.8; P = .618) did not reach statistical significance. Eight (53%) patients required conversion to shoulder arthroplasty at an average of 4.8 ± 4.7 years (range: 0.6-13.2). Kaplan-Meier graft survival probabilities were 60% at 10 years and 41% at 15 years.

CONCLUSION

OCA transplantation to the humeral head can result in acceptable long-term function for patients with osteochondral defects. While patient-reported outcomes metrics were generally improved compared to baseline, OCA graft survival probabilities diminished with time. The findings from this study can be used to counsel future patients with significant glenohumeral cartilage injuries and set expectations about the potential for further surgery.

Massive and Irreparable Rotator Cuff Tears: A Review of Current Definitions and Concepts

Background

While massive and irreparable rotator cuff tears (MIRCTs) have been abundantly studied, inconsistent definitions in the literature and theories about pain and dysfunction related to them can be difficult to navigate when considering an individual patient.

Purpose

To review the current literature for definitions and critical concepts that drive decision-making for MIRCTs.

Study Design

Narrative review.

Methods

A search of the PubMed database was performed to conduct a comprehensive literature review on MIRCTs. A total of 97 studies were included.

Results

Recent literature reflects added attention to clarifying the definitions of "massive, "irreparable," and "pseudoparalysis." In addition, numerous recent studies have added to the understanding of what generates pain and dysfunction from this condition and have reported on new techniques for addressing them.

Conclusion

The current literature provides a nuanced set of definitions and conceptual foundations on MIRCTs. These can be used to better define these complex conditions in patients when comparing current surgical techniques to address MIRCTs, as well as when interpreting the results of new techniques. While the number of effective treatment options has increased, high-quality and comparative evidence on treatments for MIRCTs is lacking.

Does reverse shoulder arthroplasty improve emotional status and quality of life in patients with rotator cuff insufficiency? Prospective sequential follow-up study

BACKGROUND

The purpose of this study was to investigate sequential changes of emotional status and quality of life after reverse shoulder arthroplasty (RSA) for rotator cuff insufficiency and to determine the predictors that can affect postoperative clinical outcomes. This study was conducted to prove the hypothesis that RSA would improve emotional status and quality of life.

METHODS

Fifty patients undergoing RSA for rotator cuff insufficiency were prospectively included. Evaluation using the visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value, Hospital Anxiety and Depression Scale (HADS), and Abbreviated scale of World Health Organization Quality of Life (WHOQOL-BREF) was performed before surgery and at 1.5, 3, 6, and 12 months after surgery.

RESULTS

The mean visual analog scale pain score, HADS-depression score, and HADS-anxiety score showed a significant decrease from 6.6, 13.3, and 13.9 before surgery to 1.5, 3.9, and 3.7 after 12 months after surgery, respectively (all P < .001). The mean ASES score, WHOQOL-BREF score, and subjective shoulder value showed a significant improvement from 28.5, 32.3, and 23.6% to 81.3, 79.1, and 78.4%, respectively (all P < .001). All outcome measurements showed a significant improvement from 6 weeks after RSA. In multivariate analysis, age was an independent predictor of the final ASES score and WHOQOL-BREF score (P = .037 and .004, respectively).

CONCLUSION

This study showed a sequential improvement of emotional status and quality of life as well as functional recovery with pain relief from 6 weeks after RSA in patients with rotator cuff insufficiency. Especially, younger patients had better postoperative functional ability and quality of life. These findings suggest that RSA for rotator cuff insufficiency provides a rapid improvement of emotional status and quality of life.

Do patients with poor early clinical outcomes after reverse total shoulder arthroplasty ultimately improve?

BACKGROUND

Although most patients undergoing reverse total shoulder arthroplasty (rTSA) have substantial improvement in pain and function at early follow-up, improvements in pain and range of motion progress more slowly during postoperative rehabilitation in a subset of patients. The purpose of this study was to define a patient's risk of persistent shoulder dysfunction beyond the early postoperative period and identify risk factors for persistent poor performance.

METHODS

We retrospectively reviewed 292 primary rTSAs with early poor performance and a preoperative diagnosis of osteoarthritis, cuff tear arthropathy, or rotator cuff tear from a multicenter database. Early poor performance was defined as a postoperative American Shoulder and Elbow Surgeons (ASES) score below the 20th percentile at 3 months (58 points) or 6 months (65 points) postoperatively. Persistent poor performance at 2 years was defined as failure to achieve the patient acceptable symptomatic state for rTSA (77.3 points for the ASES score). The primary outcome was the rate of persistent poor performance. Secondarily, we compared the clinical outcomes of persistent poor performers vs. shoulders that improved at 2-year follow-up and assessed risk factors for persistent poor performance.

RESULTS

At 2-year follow-up, 61% of patients (n = 178) with poor performance at either 3- or 6-month follow-up had persistent poor performance. The rate increased to 85% if poor performance occurred at both 3- and 6-month follow-up. The minimal clinically important difference and substantial clinical benefit for range of motion and outcome scores were exceeded by early poor performers at rates of 83%-92% and 60%-77%, respectively, at 2-year follow-up. On multivariate logistic regression analysis, independent predictors of persistent poor performance after rTSA were lack of hypertension (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.13-0.57; P < .001), heart disease (OR, 2.89; 95% CI, 1.24-6.77; P = .011), uncemented humeral fixation (OR, 0.11; 95% CI, 0.01-1.18; P = .037), previous shoulder surgery (OR, 2.14; 95% CI, 1.06-4.30; P = .031), lower preoperative ASES score (OR, 0.92; 95% CI, 0.87-0.97; P = .002), and lower preoperative subjective rating of pain at its worst (OR, 0.73; 95% CI, 0.54-0.99; P = .038).

DISCUSSION

Despite the fact that 85% of rTSA patients with an ASES score below the 20th percentile at early follow-up exceeded the minimal clinically important difference for improvement in the ASES score at 2-year clinical follow-up, 61% still had persistent poor performance, with failure to achieve the patient acceptable symptomatic state for the ASES score. Persistent poor performance after rTSA was best predicted by a history of shoulder surgery and a poorer preoperative ASES score. These findings can aid surgeons when counseling patients both preoperatively and postoperatively. In the setting of early poor performance, the risk of persistent poor performance must be balanced against the potential outcomes of revision surgery when considering early surgical intervention.

Outpatient shoulder arthroplasty in the COVID-19 era: 90-day complications and risk factors

BACKGROUND

With the COVID-19 pandemic placing an increased burden on health care systems, shoulder arthroplasties are more commonly being performed as outpatient procedures. The purpose of this study was to characterize the 90-day episode-of-care complications of consecutive shoulder arthroplasties defaulted for outpatient surgery without using a prior algorithm for patient selection and to assess for their risk factors. We hypothesized that outpatient shoulder arthroplasty would be a safe procedure for all patients, regardless of patient demographics and comorbidities.

METHODS

A retrospective review of consecutive patients who underwent planned outpatient anatomic or reverse total shoulder arthroplasty between March 2020 and January 2022 with 3-month follow-up was performed. All patients were scheduled for outpatient surgery regardless of medical comorbidities. Patient demographics; pre/postoperative patient-reported outcomes including visual analog scale, subjective shoulder value, and American Shoulder and Elbow Surgeons score; pre/postoperative range of motion; and complications were collected from medical chart review. Multivariate logistic regression was used to identify predictors of the following outcomes: 1. Unplanned overnight hospital stay, 2. 90-day unplanned emergency department (ED)/clinic visit, 3. 90-day hospital readmission, 4. 90-day complications requiring revision.

RESULTS

One hundred twenty-seven patients (47% male, 17% tobacco users, 18% diabetics) with a mean age 69 ± 9 years were identified, of whom 92 underwent reverse total shoulder arthroplasty and 35 underwent anatomic total shoulder arthroplasty. All patient-reported outcomes and range of motion were significantly improved at 3 months. There were 15 unplanned overnight hospital stays (11.8%) after the procedure. Within 90 days postoperatively, there were 17 unplanned ED/clinic visits (13.4%), 7 hospital readmissions (5.5%), and 4 complications requiring revision (3.1%). Factors predictive of unplanned overnight stay included age above 70 years (odds ratio [OR], 36.80 [95% confidence interval [CI], 2.20-615.49]; P = .012), tobacco use (OR, 12.90 [95% CI, 1.23-135.31]; P = .033), and American Society of Anesthesiologists status of 3 (OR, 13.84 [95% CI, 1.22-156.57]; P = .034). The only factor predictive of unplanned ED/clinic visit was age over 70 years old (OR, 7.52 [95% CI, 1.26-45.45]; P = .027). No factors were predictive of 90-day hospital readmission or revision.

CONCLUSION

Outpatient shoulder arthroplasty is a safe procedure with excellent outcomes and low rates of readmissions and can be considered as the default plan for all patient undergoing shoulder arthroplasty. Patients who are above 70 years of age, use tobacco, and have ASA score of 3, however, may be less suitable for outpatient arthroplasty and should be counseled regarding the higher risk of unplanned overnight hospitalization.

Outcomes of instability after reverse shoulder arthroplasty: reoperation and persistent instability are common

HYPOTHESIS

Although risk factors for instability after reverse shoulder arthroplasty (RSA) have been extensively studied, the outcomes of patients who experience instability are unknown. The purpose of this study was to evaluate functional outcomes in patients with instability after RSA.

METHODS

We retrospectively identified patients with instability after RSA with a minimum of 2 years' follow-up from an institutional database. Baseline data were recorded, and all patients we contacted to obtain clinical outcome scores. Patients who required revision surgery and those treated successfully with closed reduction were compared.

RESULTS

Fifty patients were included. Of these patients, 40 (80%) required revision surgery whereas 10 (20%) were treated successfully with closed reduction. At an average follow-up of 63.7 months (range, 24-123 months), outcome scores did not differ between groups. Patients who required revision surgery were more likely to have undergone previous shoulder surgery, prior to their index arthroplasty (P = .031). Seventeen patients (42.5%) reported recurrent instability following revision surgery, and 14 (35.0%) required additional revision surgery. Ultimately, stability was never achieved in 7 of 50 patients (14%) after their index instability event.

CONCLUSION

Although instability after RSA can commonly be corrected with reasonable functional results, multiple procedures may be needed and some patients may experience persistent instability.