A pilot-study focusing on internal rotation after reverse total shoulder arthroplasty using the Activities of Daily Living which require Internal Rotation (ADLIR) score

Lateralising reverse shoulder arthroplasty using bony increased offset (BIO-RSA) or increasing glenoid component diameter: comparison of clinical, radiographic and patient reported outcomes in a matched cohort

BACKGROUND

This study aims to compare the range of motion (ROM) of reverse shoulder arthroplasty lateralised by bony increased offset (BIO-RSA) using a standard 38-mm (mm) component to regular reverse shoulder arthroplasty (RSA) lateralised by using a 42-mm glenoid component. The secondary aims are to compare patient-reported and radiographic outcomes between the two groups.

MATERIALS AND METHODS

All patients with a BIO-RSA and size 38 glenosphere were retrospectively identified and matched to patients with a regular RSA and size 42 glenosphere. Matched patients were invited for a follow-up visit. ROM was assessed as well as radiographic outcomes (lateralisation, distalisation, inferior overhang, scapular notching, heterotopic bone formation, radiolucency, stress shielding, bone graft healing and viability and complications) and patient-reported outcomes (subjective shoulder value, Constant score, American Shoulder and Elbow Surgeons, activities of daily living which require internal rotation, activities of daily living which require external rotation and a visual analogue scale for pain). Outcomes were compared between the two groups.

RESULTS

In total, 38 BIO-RSAs with a size 38 glenosphere were matched to 38 regular RSAs with a size 42 glenosphere. Of the 76 matched patients, 74 could be contacted and 70 (95%) were included. At the final follow-up, there were no differences between the two groups in ROM, patient-reported outcomes or radiographic outcomes (p > 0.485).

CONCLUSIONS

Using a larger glenosphere is a feasible alternative to BIO-RSA for lateralising RSA, providing comparable ROM, patient-reported and radiographic results, while potentially decreasing costs, operative time and complication rates.

LEVEL OF EVIDENCE III

Reverse shoulder arthroplasty with a 155° neck-shaft angle inlay implant design without reattachment of the subscapularis tendon results in satisfactory functional internal rotation and no instability: a cohort study

BACKGROUND

The aim of this study was to use the Activities of Daily Living which require Internal Rotation (ADLIR) questionnaire to assess the functional internal rotation in patients who had undergone reverse shoulder arthroplasty (RSA) without reattachment of the subscapularis (SSc) tendon at a minimum follow-up of 2 years. The secondary aim was to report the objective range of motion (ROM) and the rate of postoperative instability.

MATERIALS AND METHODS

All consecutive primary RSA procedures without reattachment of the SSc tendon that were performed using a Delta Xtend prosthesis (an inlay system with a 155° neck-shaft angle) between January 2015 and December 2020 were identified to ensure a minimum follow-up of 2 years. Patients were contacted and requested to fill in several questionnaires, including the ADLIR and Auto-Constant scores.

RESULTS

In total, 210 patients met the inclusion criteria; among those patients, 187 could be contacted and 151 completed questionnaires (response rate: 81%). The SSc tendon was fully detached without repair in all cases, and a superolateral approach was used in 130 (86%) cases. The median follow-up was 4.5 years (range: 2.0-7.6). At final follow-up, the mean ADLIR score was 88/100 (interquartile range (IQR): 81-96). The median level reached in internal rotation was the 3rd lumbar vertebra (IQR: lumbosacral region-12th thoracic vertebra). Of the 210 eligible patients, one required a revision for a dislocation within the first month after primary surgery. With regards to regression analysis with ADLIR score as the outcome, none of the factors were associated with the ADLIR score, although age and smoking approached significance (0.0677 and 0.0594, respectively). None of the explanatory variables were associated with ROM in internal rotation (p > 0.05).

CONCLUSIONS

This study demonstrates that satisfactory ADLIR scores and internal rotation ROM were obtained at mid-term follow-up after RSA leaving the SSc detached. Leaving the SSc detached also did not lead to high instability rates; only one out of 210 prostheses was revised for dislocation within the first month after primary surgery.

LEVEL OF EVIDENCE III

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.

Outcomes of combined anterior latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tears

BACKGROUND

Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in loss of active elevation, loss of internal rotation, and pseudoparalysis. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients are limited. The purpose of this study was to evaluate the clinical and radiologic outcomes of combined anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with IASRCTs without reconstruction of the superior rotator cuff and capsular portion.

METHODS

This retrospective study was conducted between 2015 and 2018. We included patients who underwent combined aLDTM tendon transfer for IASRCTs. Clinical outcomes included visual analog scale for pain, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder scores, activities of daily living requiring active internal rotation score, active range of motion, subscapularis-specific physical examination, and rate of return to work. Radiographic analyses included the assessment of acromiohumeral distance, Hamada grade for cuff tear arthropathy, rate of anterior glenohumeral subluxation reduction, and transferred tendon integrity at 2 years postoperatively.

RESULTS

The mean follow-up period was 38.1 ± 13.7 (range: 24-63) months. Of the patients, 30 (mean age: 64.1 years) met the study criteria. Postoperatively, mean Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles, and activities of daily living requiring active internal rotation scores improved from 47.4 to 69.9 (P < .001), 44.9 to 79.2 (P < .001), 20.0 to 28.7 (P < .001), and 13.2 to 26.9 (P < .001), respectively. The mean active range of motion was significantly increased postoperatively for both forward elevation (P < .001) and internal rotation at the back (P < .001). Of the patients, 24 (83%) returned to their previous work. No significant progression of cuff tear arthropathy was observed at final follow-up (Hamada grade: preoperative 1.3 ± 0.5 to postoperative 1.5 ± 0.7; p=0.155). Fifteen of 30 patients (50%) restored the anterior glenohumeral subluxation that was apparent preoperatively. One patient presented with transient axillary nerve palsy after surgery. Two patients presented with partial nonretracted tears of the transferred tendon.

CONCLUSION

This minimum 2-year follow-up study demonstrated that combined aLDTM tendon transfer without reconstruction of the superior rotator cuff and capsular portion was a viable treatment option with favorable clinical and radiologic outcomes for patients with IASRCTs.