Long-term clinical and radiographic outcomes of total shoulder arthroplasty in patients under age 60 years

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.

The influence of depression on clinical outcomes of total shoulder arthroplasty: a systematic Review

PURPOSE

Much of the current literature on total shoulder arthroplasty (TSA) has assessed the impact of preoperative medical comorbidities on postoperative clinical outcomes. The literature concerning the impact of psychological disorders such as depression on TSA has increased in popularity in recent years, but there lacks a thorough review of the influence of depression on postoperative pain and functional outcomes.

METHODS

We queried PubMed/MEDLINE and identified six clinical studies that evaluated the influence of a psychiatric diagnosis of depression on patient outcomes after TSA. Studies that discussed the impacts of depression on TSA, including PROs or adverse events in adults, were included. Studies focused on other psychologic pathology, non-TSA shoulder treatments, or TSA not for primary osteoarthritis were excluded. Non-clinical studies, systematic reviews, letters to the editor, commentaries, dissertations, books, and book chapters were excluded.

RESULTS

Three cohort studies described patient-reported pain and functional outcomes and three database studies assessed the risk of postoperative complications. Cohort studies demonstrated that the prevalence of depression in patients undergoing TSA decreased from preoperatively to 12-months postoperatively. Two studies demonstrated that depression is an independent predictor of less pre- to postoperative improvement in the ASES score at minimum 2-year follow-up; however, one study found the difference between patients with and without depression did not exceed the minimum clinically important difference. Database studies demonstrated that depression was associated with higher rates of blood transfusion (n = 1, OR = 1.8), anemia (n = 1, OR = 1.65), wound infection (n = 2, OR = 1.41-2.09), prosthetic revision (n = 1, OR = 1.92), and length of hospital stay (n = 3, LOS = 2.5-3 days).

CONCLUSION

Although patients with a preoperative diagnosis of depression undergoing TSA can achieve satisfactory relief of shoulder pain and restoration of function, they may experience poorer patient-reported outcomes and a higher risk of postoperative adverse events compared to their peers. Surgeons should be cognizant of the influence of depression in their patients to facilitate proper patient selection that maximizes patient satisfaction, function, and minimizes the risk of adverse events following TSA.

LEVEL OF EVIDENCE

Level IV.

Anatomical total shoulder arthroplasty revision to reverse shoulder arthroplasty using convertible glenoid: a systematic review of clinical and radiological outcomes

PURPOSE

The aim of the present systematic review is to collect all the available evidence regarding the clinical and radiological results of revision to reverse shoulder arthroplasty (RSA) of modular anatomic shoulder prostheses (TSA) using a convertible metal-backed glenoid (MBG).

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies investigating revision of TSA to RSA utilizing a convertible MBG and reporting clinical and radiological outcomes were identified.

RESULTS

A total of five studies on the use of convertible modular glenoid component in the setting of TSA revision to RSA were finally included in the present systematic review. A total of 60 procedures were reported. Mean operative times was 65 min. Intraoperative complications included 3 cases of glenoid loosening. Only one case of dislocation was reported as postoperative complication. At mean follow-up of 32.3 months post-revision, no glenoid loosening was reported, VAS score decreased from 7.7 to 1.5, Constant Score increased from 24.8 to 57.6.

CONCLUSIONS

Revision to RSA after failed TSA using a convertible modular glenoid component was associated with a low rate of intraoperative and postoperative complications, low surgical time and led to good results in term of pain relieve and functional outcomes. Given the complexity and risk associated with revision of anatomic shoulder prosthesis having a convertible glenoid may help to simplify the procedure and improve clinical results.

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.

Improved functional, radiographic and patient-reported outcomes at midterm follow-up for shoulder arthroplasty patients 75 years and older

Background

Current discussion centers around the appropriateness of shoulder arthroplasty in elderly patients, and whether anatomic and reverse total shoulder arthroplasty yield acceptable results in this population. The purpose of this study was to examine midterm outcomes in patients 75 years and older who underwent either procedure.

Methods

A retrospective review was performed on patients who underwent anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) between 2000 and 2018. Inclusion criteria was patient age ≥75 years at time of surgery and ≥1 years postoperative follow-up. Primary outcomes were differences in Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, and range of motion. A secondary outcome was revision surgery.

Results

22 patients who underwent aTSA and 17 patients who underwent rTSA were included. Mean age at surgery was 79 and 80 in the aTSA and rTSA groups, respectively. Mean postoperative follow-up was 6.6 years across both cohorts. Anatomic TSA patients experienced improvements in VAS (7 preop vs. 1 postop; p < 0.001), ASES (16 vs. 75; p < 0.001), and SST (2 vs. 8; p < 0.001) scores. Reverse TSA patients also experienced improvements in VAS (7 vs. 1; p < 0.001), ASES (29 vs. 74; p < 0.001), and SST (1 vs. 7; p < 0.001) scores. Anatomic TSA patients experienced improved external rotation (17° vs. 53°; p < 0.001), forward elevation (108° vs. 155°; p < 0.001), and internal rotation (L5 vs. T10; p < 0.001). Reverse TSA patients experienced improved forward elevation (52° vs. 126°; p < 0.001). 21 aTSA patients (100%) and 16 rTSA patients (94%) experienced survival free from revision. 100% of aTSA and rTSA patients experienced survival free from loosening.

Conclusion

Both aTSA and rTSA can be performed in the elderly population with acceptable midterm outcomes, suggesting that implant survival and patient satisfaction have the potential to endure through the end of life.

Level of evidence

IV.

Does age at surgery influence short-term outcomes and readmissions following anatomic total shoulder arthroplasty?

Background

Increasing age has been associated with adverse outcomes in various orthopedic procedures including anatomic total shoulder arthroplasty (aTSA). Moreover, both indications and the ages at which the procedure is done has expanded. For these reasons, it is important to characterize the impact age has on complication and readmission rates following shoulder replacement.

Methods

The National Readmissions Database was used to identify patients who underwent aTSA between the years 2016-2018. Patients were stratified into five cohorts based on age at surgery: 18-49, 50-59, 60-69, 70-79, and 80+ years old. We analyzed and compared data related to patient demographics, length of stay, readmission and complication rates, and healthcare charges. A multivariate analysis was used to identify the independent impact of age on complication rates.

Results

42,505 patients were included with 1,541, 6,552, 16,364, 14,694, 3,354, patients in the 18-49, 50-59, 60-69, 70-79, and 80+ years old cohorts respectively. Length of stay had a stepwise increase with age increases (p < 0.001), however total charges were comparable between cohorts (p = 0.40). Older patients were more likely to experience intraoperative complications, pulmonary embolism complications, and postoperative infection, but were less likely to experience hardware, surgical site, and prosthetic joint complications. Older patients had higher rates of readmission. Age was an independent predictor for higher 30-/90-day readmission, postoperative/intraoperative complication, and respiratory complication rates. Increasing age provided a protective measure for prosthetic complications surgical site infection.

Conclusion

This study identified multiple differences in complication rates following aTSA based on age at surgery. Overall, age had varying effects on intraoperative and postoperative complication rates at short-term follow-up. However, increasing age was associated with longer lengths of stay and increased readmission rates. Surgeons should be aware of the identified complications that are most prevalent in each age group and use this information to avoid adverse outcomes following shoulder replacement surgery.

The impact of tobacco use on clinical outcomes and long-term survivorship after anatomic total shoulder arthroplasty

Introduction

Postoperative outcomes following total shoulder arthroplasty can be affected by preoperative health factors such as tobacco usage.

Methods

The charts of patients who underwent anatomic total shoulder arthroplasty were retrospectively analyzed and stratified based on smoking status. The primary data included range of motion and patient reported outcomes. Additionally, demographic, radiographic, and survivorship analyses were conducted. All data were analyzed using statistical inference.

Results

There were 78, 49, and 16 non-smoker, former smoker, and current smoker shoulders respectively with no significant differences in sex, American Society of Anesthesiologists status, body mass index, or mean follow-up time (average: 10.7 yrs). Smokers (51.5 ± 10.4 years) were younger than both non-smokers (64.9 ± 8.1 years; p < 0.01) and former smokers (65.1 ± 9.1years; p < 0.01) at the time of surgery. For non-smokers and former smokers, all range of motion and patient reported outcome scores significantly improved. Smokers reported significant improvements in all patient reported outcomes and external and internal rotation. Visual Analog Scale, American Shoulder and Elbow, and Simple Shoulder Test scores were lower for smokers comparatively, but these differences did not reach significance. Forward elevation was higher postoperatively for non-smokers (149.7o ± 17.2o) and former smokers (147.1o ± 26.0o) compared to current smokers (130.9o ± 41.2o; p = 0.017). No differences between the cohorts were found in the radiographic analysis. Revision rates were lower in the non-smoking cohort (7.7%) compared to both former (20.4%; p = 0.036) and current smokers (37.5%; p < 0.01). Survival curves showed that non-smoker implants lasted longer than those of current smokers.

Conclusion

After a decade, patients generally had improved shoulder range of motion, functionality, and pain regardless of smoking status. However, current smokers required shoulder replacements sooner and revision surgery more frequently.

A comparison of pegged and keeled glenoid clinical outcomes at long-term follow-up after total shoulder arthroplasty

Background

The two main glenoid types used in total shoulder arthroplasty (TSA) are the pegged and keeled glenoid designs. We aimed to determine if a pegged glenoid is superior to a keeled glenoid at long-term follow-up as measured by range of motion (ROM), patient reported outcomes (PROs), and radiographic glenoid loosening.

Methods

We retrospectively reviewed all patients undergoing TSA by a single surgeon at an urban, academic hospital. The cohort was stratified into two groups based on glenoid type - one group consisting of keeled implants and a second group consisting of pegged implants. For each patient, forward elevation (FE), internal rotation (IR), external rotation (ER), visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) shoulder score, and simple shoulder test (SST) scores were collected preoperatively and at the most recent follow-up visit. Radiographic variables included acromiohumeral interval (AHI) and glenoid loosening.

Results

After applying exclusion criteria, 144 TSAs were included in our study. Of these, 42 (29.2%) had keeled glenoids and 102 (70.8%) had pegged glenoids. Patients with a pegged glenoid implant were older (67.4 vs. 60.7 years; p < 0.001) and had a shorter follow-up time (9.3 vs. 14.4 years; p < 0.001) than patients with a keeled glenoid implant. At the most recent follow-up visit, there were no significant differences among postoperative FE, ER, AHI, or PROs. However, pegged glenoid implants provided significantly more internal rotation (T11 vs. L1; p = 0.010) and were less likely to show evidence of radiographic glenoid loosening (16.7% vs. 42.9%; p=<0.001). Revision rates were not significantly different between the pegged and keeled groups (6.9% vs. 14.3%; p = 0.158).

Conclusion

Although a pegged design correlated with superior internal rotation and less radiographic glenoid loosening, both pegged and keeled glenoid designs offered favorable long-term clinical outcomes following TSA over the long-term.

Shoulder arthroplasty following solid organ transplant: A systematic review and meta-analysis

Introduction

The purpose of this study is to report a systematic review and meta-analysis of solid organ transplant (SOT) patients undergoing shoulder arthroplasty to compare functional and radiographic outcomes, demographics, and complications with non-transplant patients.

Methods

Studies were included if they examined patients undergoing shoulder arthroplasty in the setting of prior solid organ transplantation and included post operative range of motion, patient-reported outcomes, complications, or revisions. Studies were excluded if they were national database analyses or lacked clinical data. Pubmed, MEDLine, Scopus, and Web of Science were queried using relevant search terms in July 2022. Data was pooled, weighted, and a paired t-test and chi-square analysis was performed.

Results

There were 71 SOT and 159 non-SOT shoulders included in the study. The most common indication for surgery was avascular necrosis (n = 26) in the solid organ transplant group and osteoarthritis (n = 60) in the non-SOT group. Forward elevation, external rotation, ASES, and VAS pain scores improved significantly in both cohorts following surgery. There was no significant difference in age at surgery (p-value = 0.20), postoperative forward elevation (p-value = 0.08), postoperative external rotation (0.84), and postoperative ASES scores (p-value = 0.11) between the two cohorts. VAS pain scores were significantly lower in the SOT cohort (p-value<0.01). The risk of death was significantly higher in the SOT group (p-value<0.01). but the rate of overall complications (p = 0.47), surgical complication (p-value = 0.79), or revision surgery (p-value = 1.00) was not significantly different between the two cohorts.

Conclusion

Shoulder arthroplasty is a safe, effective option in patients following solid organ transplant. There is not an increased risk of adverse outcomes, and SOT patients had comparable range of motion and patient-reported outcomes when compared to their non-SOT peers.

Level of evidence

III.