Heterotopic ossification after reverse total shoulder arthroplasty

Heterotopic Ossification After Shoulder Arthroplasty: A Systematic Review

INTRODUCTION

Shoulder arthroplasty is increasing in incidence over time. One potential complication that is not well studied following shoulder arthroplasty is heterotopic ossification (HO), the abnormal growth of extraskeletal bone in soft tissue. HO has been described as a complication in total hip arthroplasty literature but less described in the setting of shoulder arthroplasty. The aim of this systematic review is to present available evidence regarding the incidence, risk factors, and potential management of HO after shoulder arthroplasty.

METHODS

A systematic search was conducted in June 2023 using Pubmed, Embase, and Ovid Medline databases to retrieve all relevant studies evaluating the occurrence of HO after shoulder arthroplasty. The search was done in duplicate, and a quality assessment of all studies was included.

RESULTS

A total of 170 studies were retrieved, of which 6 were included, involving 1,028 patients undergoing shoulder arthroplasty with 1,038 operated shoulders. HO developed postoperatively in 28% of the included shoulders and was symptomatic in 12% with most cases occurring in shoulders that developed osteoarthritis and cuff tear arthropathy. Men appear to have an increased risk of developing HO post shoulder arthroplasty. Fewer than 2% of HO shoulders went on to have revision surgery, and no notable differences were observed in the postoperative mean elevation and external rotation angles of non-HO and HO shoulders. In addition, no reported benefit of the use of nonsteroidal anti-inflammatory drugs was found against the formation of HO after shoulder arthroplasty.

CONCLUSION

HO occurs in 28% of shoulder arthroplasties in our review. Most of these were asymptomatic in the reviewed articles. Male patients and revision surgery with osteoarthritis and cuff tear arthroplasty seem to be at higher risk of developing HO post shoulder arthroplasty. Nonsteroidal anti-inflammatory drugs seem to not prevent the development of HO after shoulder arthroplasty; yet, future studies are needed to verify this claim.

LEVEL OF EVIDENCE

Level III; Systematic Review.

Uncemented versus cemented humeral fixation during reverse total shoulder arthroplasty for proximal humerus fracture

Introduction

Over time, the use of reverse total shoulder arthroplasty (RTSA) treating proximal humerus fractures (PHFs) and fracture sequelae has grown significantly due to its demonstrated effectiveness over open reduction internal fixation (ORIF) and hemiarthroplasty (HA). Cemented humeral stems have been widely utilized in RTSA for PHF, however cementless alternatives have become increasingly popular. This study seeks to analyze outcomes and complications in patients undergoing RTSA for fracture with uncemented and cemented stems at mid-term follow-up.

Methods

Patient records were queried for all patients who underwent reverse total shoulder arthroplasty for fracture with between January 7, 2009 and January 10, 2019 and completed a minimum follow-up of 2 years. Demographics characteristics, post-operative functional measurements, complications, and radiographs were assessed. A 5-year Kaplan-Meier survival analysis was performed.

Results

A total of 23 patients encompassing 11 cemented and 12 uncemented stems met the inclusion criteria. The mean age of the uncemented cohort was 70.0 ± 9.8 years with a mean follow-up of 2.6 ± 1.3 years while the mean age of the cemented cohort was 68.9 ± 9.2 years with a mean follow-up of 2.9 ± 1.1 years. No differences in strength, range of motion, or survival between groups were observed. Two patients in the cemented cohort demonstrated humeral component loosening on follow-up radiographs.

Discussion

Uncemented and cemented humeral fixation during RTSA for proximal humerus fracture leads to similar outcomes, and thus both are safe and effective methods of achieving humeral fixation in fracture patients.

Clinical, functional and radiographic outcomes of inverted-bearing reverse shoulder arthroplasty at minimum two year follow-up

Background

Inverted-Bearing Reverse Shoulder Arthroplasty (IB-RSA) is an alternative reverse bearing construct characterized by an ultrahigh molecular weight polyethylene glenosphere combined with a cobalt-chromium metallic humeral liner. This concept was designed both to minimize bearing wear as well as reduce the potential for scapular notching (SN) seen with more traditional-bearing RSA systems. This study reports on clinical outcomes, functional scores, pain scores, and radiographic incidence of SN in a series of IB-RSA at a minimum of two-year follow-up.

Methods

A retrospective study was conducted on patients who underwent an IB-RSA between 2016 and 2019, with a minimum follow-up period of two years. Patients were evaluated clinically for disabilities of the arm, shoulder and hand (DASH) score, American Shoulder and Elbow Surgeons score (ASES), EQ-5D Health Questionnaire, Global Rating of Change score (GRC), Single Assessment Numeric Evaluation score (SANE) and range of motion (ROM). Presence and grade of radiographic SN was assessed using the classification of Sirveaux at 6, 12, 24 months and at the last x-ray available.

Results

61 consecutive patients were assessed at a mean postoperative follow-up of 37 months (range, 24-72 months). IB-RSA exhibited high overall outcome scores including DASH (38.3 +/-5), ASES (83 +/- 6), GRC (4 +/-0.6), and SANE (83 +/-11). ROM was assessed in 41 patients with 135 ± 21 of elevation, 23 ± 12 of external rotation, and 5 ± 2 for internal rotation. SN was radiographically present in 23 (38%) patients (twenty grade 1, three grade 2) in the final follow-up, with all cases showing evidence of mechanical notching while no grade 3 or 4 cases were observed. The SN did not progress in most of the patients after the first year (P > .05). The presence of SN did not influence on clinical outcome scores as DASH, ASES, EQ-5D Health Questionnaire, GRC, SANE (P > .05), or active ROM (P > .05).

Conclusion

IB-RSA demonstrates high patient-reported and functional outcome scores at a minimum of two years follow-up. We report only low-grade SN with little progression after the first year. There was no correlation between SN and clinical outcomes.

Clinical Outcomes Do Not Deteriorate Over Time Following Primary Reverse Total Shoulder Arthroplasty: Minimum 10-Year Follow-up of 135 Shoulders

Background

Reverse total shoulder arthroplasty (RTSA) offers satisfactory mid-term outcomes for a variety of pathologies, but long-term follow-up data are limited. This study demonstrates the long-term clinical and radiographic outcomes as well as the predictive factors for an inferior outcome following RTSA.

Methods

Using the prospective database of a single, tertiary referral center, we included all primary RTSAs that were performed during the study period and had a minimum 10-year follow-up. Clinical outcomes included the absolute Constant-Murley score (CS), relative CS, Subjective Shoulder Value (SSV), range of motion, pain, complication rate, and reintervention rate. Radiographic measurements included the critical shoulder angle (CSA), lateralization shoulder angle (LSA), distalization shoulder angle (DSA), reverse shoulder angle (RSA), acromiohumeral distance (ACHD), center of rotation, glenoid component height, notching, radiolucent lines, heterotopic ossification, and tuberosity resorption.

Results

A total of 135 shoulders (133 patients) were available for analysis at a mean follow-up of 10.9 ± 1.6 years. The mean age was 69 ± 8 years, and 76 shoulders (76 patients; 56%) were female. For most of the clinical outcomes, initial improvements were observed in the short term and were sustained in the long term without notable deterioration, with >10-year follow-up values of 64 ± 16 for the absolute CS, 79% ± 18% for the relative CS, 79% ± 21% for the SSV, and 14 ± 3 for the CS for pain. However, after initial improvement, deterioration was seen for flexion and external rotation, with values of 117° ± 26° and 25° ± 18°, respectively, at the final follow-up. Scapular notching, heterotopic ossification, and radiolucent lines of <2 mm progressed during the study period. Younger age (p = 0.040), grade-II notching (p = 0.048), tuberosity resorption (p = 0.015), and radiolucent lines of <2 mm around the glenoid (p = 0.015) were predictive of an inferior outcome. The complication rate was 28%, with a reintervention rate of 11%.

Conclusions

RTSA provided improved long-term results that did not significantly deteriorate over time for most of the clinical parameters. Negative clinical outcome predictors were younger age, grade-II notching, tuberosity resorption, and radiolucent lines of <2 mm around the glenoid.

Level of Evidence

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

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.

Femoral head allograft for glenoid bone loss in primary reverse shoulder arthroplasty: functional and radiologic outcomes

BACKGROUND

Several techniques have been adopted during primary reverse shoulder arthroplasty (RSA) to manage glenoid bone defect. Among bone grafts, humeral head autograft is currently the mainstream option. However, autologous humeral heads may be unavailable or inadequate, and allografts may be a viable alternative. The aim of the present study was to evaluate the functional and radiologic outcomes of femoral head allografts for glenoid bone defects in primary RSA.

METHODS

We conducted a retrospective study with prospective data collection enrolling 20 consecutive patients who underwent RSA with femoral head allografts for glenoid bone defects. Indications for surgery were eccentric cuff tear arthropathy in 10 cases (50%), concentric osteoarthritis in 9 cases (45%), and fracture sequelae in 1 case (5%). Each patient was evaluated preoperatively and at follow-up by radiologic and computed tomography (CT) and by assessing the range of motion (ROM) and the Constant-Murley score (CMS). A CT-based software, a patient-specific 3D model of the scapula, and patient-specific instrumentation were used to shape the graft and to assess the position of K-wire for the central peg. Postoperatively, CT scans were used to identify graft incorporation and resorption.

RESULTS

After a median follow-up of 26.5 months (24-38), ROM and CMS showed a statistically significant improvement (all P = .001). The median measures of the graft were as follows: 28 mm (28-29) for diameter, 22° (10°-31°) for angle, 4 mm (2-8 mm) for minimum thickness, and 15 mm (11-21 mm) for maximum thickness. Before the surgery, the median glenoid version was 21.8° (16.5°-33.5°) for the retroverted glenoids and -13.5° (-23° to -12°) for the anteverted glenoids. At the follow-up, the median postoperative baseplate retroversion was 5.7° (2.2°-1.5°) (P = .001), and this value was close to the 4° retroversion planned on the preoperative CT-based software. Postoperative major complications were noted in 4 patients: 2 dislocations, 1 baseplate failure following a high-energy trauma, and 1 septic baseplate failure. Partial graft resorption without glenoid component failure was observed in 3 cases that did not require revision surgery.

CONCLUSION

The femoral head allograft for glenoid bone loss in primary RSA restores shoulder function, with CMS values comparable to those of sex- and age-matched healthy individuals. A high rate of incorporation of the graft and satisfactory correction of the glenoid version can be expected after surgery. The management of glenoid bone defects remains a challenging procedure, and a 15% risk of major complication must be considered.

A Systematic Review of Heterotopic Ossification Following Shoulder Arthroplasty: Is There a Clinical Value?

This systematic review aims to assess the contemporary literature on the incidence rate, functional scores, and clinical outcomes of heterotopic ossification (HO) following shoulder arthroplasty. We conducted a thorough literature search on EMBASE, MEDLINE, and Ortho Search to identify studies that directly compared patients with and without HO following hemiarthroplasty, anatomic total shoulder arthroplasty (aTSA), or reverse total shoulder arthroplasty (rTSA). We included studies with a minimum follow-up period of one year published from January 2000 to March 2023. We excluded case reports, editorials, and reviews. We performed the systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of the 297 studies initially identified, seven met our inclusion criteria. These studies evaluated a total of 1,134 arthroplasties (212 hemiarthroplasties, 376 aTSAs, and 546 rTSAs). The mean follow-up period was 30.52 (12-120) months and the mean age was 68.69 (20-92). The overall incidence rate of HO was 26.8% (304/1,134). Male gender was associated with a higher incidence rate of HO in three studies. No statistically significant difference was noted in symptoms at follow-up or in Constant-Murley score at two years of follow-up (HO vs. non-HO: 70 vs. 75, p = 0.081). Only one study reported a significant difference in the post-arthroplasty range of motion, specifically in forward elevation (121° vs. 133°, p = 0.0087) and external rotation (19° vs. 25°, p-value = 0.0266). We conclude that HO after shoulder arthroplasty does not display a significant impact on postoperative symptoms or functional outcomes in the majority of patients. To fully comprehend its effect, further research and consensus among experts is necessary.

Impact of tuberosity treatment in reverse shoulder arthroplasty after proximal humeral fractures: A multicentre study

BACKGROUND

To assess how tuberosity treatment affects the short-term clinical outcome of patients with complex proximal humeral fractures (PHFs) treated with reverse shoulder arthroplasty (RSA).

METHODS

This is a multicentre study on 90 patients affected by acute PHFs (Neer type-4/11C3.2 in 80% of patients, and a Neer type 3/11B3.2 in 20%) treated with RSA and followed at an average of 34 months. Patients were divided into two groups (reconstructed and non-reconstructed tuberosity) according to the surgical fixation of the tuberosities. Then, the "reconstructed tuberosity" was divided into "healed" and "non-healed" groups. All patients were clinically evaluated in terms of ROM and strength in elevation, as well as with 0-10 numerical rating scale (NRS), Constant and Murley Score (CMS), DASH Score, and EQ-VAS. X-rays in anteroposterior and Neer views were performed.

RESULTS

Based on the status of the tuberosities, 18.9% were non-reconstructed (17 patients) and 81.1% were reconstructed (73 patients): out of these, 11 were correctly healed, 42 healed with malposition, and 20 were reabsorbed. Instability was found in 2/73 patients in the reconstructed group, and in 4/17 patients in the non-reconstructed group. NRS (1.4 vs 0.5), DASH (23.1 vs 13.9), and EQ-VAS (78.1 vs 83.7) scores had better final values in the non-reconstructed group (p < 0.05). However, the non-correctly healed tuberosity group (excision + resorption + malposition/migration) showed worse strength, as well as clinical scores when compared to the correctly healed tuberosity group.

CONCLUSION

RSA ensures satisfactory functional results for PHFs. Patients with a successfully reconstructed tuberosity have an overall better outcome. However, in this series most of the reconstructed cases presented tuberosity reabsorption, malposition, or migration, which led to lower results. Thus, tuberosity reconstruction must be carefully considered and tuberosity reabsorption or migration factors should be investigated, to optimize tuberosity reconstruction and provide to a higher number of patients a better outcome of RSA for the treatment of PHFs.

Radiological changes, infections and neurological complications after reverse shoulder arthroplasty related to different design types and their rates: Part II

Early reported complication rates with the Grammont-type reverse shoulder arthroplasty (RSA) were very high, up to 24%.A 'problem' is defined as an intraoperative or postoperative event that is not likely to affect the patient's final outcome, such as intraoperative cement extravasation and radiographic changes. A 'complication' is defined as an intraoperative or postoperative event that is likely to affect the patient's final outcome, including infection, neurologic injury and intrathoracic central glenoid screw placement.Radiographic changes around the glenoid or humeral components of the RSA are very frequently observed and described in the literature.High complication rates related to the Grammont RSA design led to development of non-Grammont designs which led to a dramatic fall in the majority of complications.The percentage of radiological changes after RSA is not negligible and remains unsolved, despite a decrease in its occurrence in the last decade. However, such changes should be now considered as simple problems because they rarely have a negative influence on the patient's final outcome, and their prevalence has dramatically decreased.With further changes in indications and designs for RSA, it is crucial to accurately track the rates and types of complications to justify its new designs and increased indications. Cite this article: EFORT Open Rev 2021;6:1109-1121. DOI: 10.1302/2058-5241.6.210040.

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.

Mid-term outcomes of bony increased offset-reverse total shoulder arthroplasty in the Asian population

Background

To evaluate clinical and radiological outcomes of bony increased offset-reverse total shoulder arthroplasty (BIO-RSA) in the Asian population at mid-term follow-up.

Methods

From June 2012 to August 2017 at a single center, 43 patients underwent BIO-RSA, and 38 patients with minimum 2 years follow-up were enrolled. We evaluated the clinical and radiological outcomes, and complications at the last follow-up. In addition, we divided these patients into notching and no-notching groups and compared the demographics, preoperative, and postoperative characteristics of patients.

Results

Visual analogue scale, American Shoulder and Elbow Surgeons, University of California-Los Angeles Shoulder Scale, and Simple Shoulder Test scores improved significantly from preoperative (5.00, 3.93, 1.72, 3.94) to postoperative (1.72, 78.91, 28.34, 7.66) (p<0.05) outcomes. All range of motion except internal rotation improved significantly at the final follow-up (p<0.05), and the bone graft was well-incorporated with the native glenoid in all patients (100%). However, scapular notching was observed in 20 of 38 patients (53%). In the comparison between notching and no-notching groups (18 vs. 20 patients), there were no significant differences in demographics, radiological parameters, and clinical outcomes except acromion-greater tuberosity (AT) distance (p=0.003). Intraoperative complications included three metaphyseal fractures and one inferior screw malposition. Postoperative complications included ectopic ossification, scapular neck stress fracture, humeral stem relaxation, and late infection in one case each.

Conclusions

BIO-RSA showed improved clinical outcomes at mid-term follow-up in Asian population. However, we observed higher scapular notching compared to the previous studies. In addition, adequate glenoid lateralization with appropriate humeral lengthening (AT distance) might reduce scapular notching.

Reverse or Hemi Shoulder Arthroplasty in Proximal Humerus Fractures: A Single-Blinded Prospective Multicenter Randomized Clinical Trial

OBJECTIVES

To compare outcomes between hemiarthroplasty (HA) and reversed shoulder arthroplasty (RSA) as a treatment for dislocated 3-part and 4-part proximal humerus fractures in the elderly population.

DESIGN

Prospective multicenter randomized controlled trial.

SETTING

Three Level-1 trauma centers.

PATIENTS/PARTICIPANTS

This study included 31 patients of which 14 were randomized into the HA group and 17 into the RSA group.

INTERVENTION

Patients randomized to the HA group were treated with a cemented-stem Aequalis-fracture HA and patients randomized to the RSA group with a cemented-stem Aequalis-fracture RSA.

MAIN OUTCOME MEASUREMENTS

Primary outcomes consisted of range of motion and constant score. Secondary outcomes were the visual analog scale for pain, DASH score, SF-12 scores, and radiographic outcomes.

RESULTS

After 6 and 12 months of follow-up, RSA showed a significant higher anterior elevation (105 degrees vs. 80 degrees, P = 0.002 and 110 degrees vs. 90 degrees, P = 0.02, respectively) and constant score (60 vs. 41, P = 0.01 and 51 vs. 32, P = 0.05, respectively) compared with HA. There were no significant differences in external and internal rotation. Also, visual analog scale pain, DASH scores, SF-12 scores, and radiological healing of the tuberosities and heterotopic ossification did not show any significant differences between groups.

CONCLUSION

RSA showed significant superior functional outcomes for anterior elevation and constant score compared with HA for dislocated 3-part and 4-part proximal humerus fractures after short-term follow-up.

LEVEL OF EVIDENCE

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

Characteristic heterotopic ossification of the proximal humerus after total shoulder arthroplasty

OBJECTIVE

A bony spur in a characteristic location involving the proximal humerus is identified on post-operative radiographs in some patients with history of total shoulder arthroplasty. The spur is theorized to represent heterotopic ossification near the attachment site of the pectoralis major tendon on the proximal humerus which is partially detached and then reattached during total shoulder arthroplasty. In this study, we determine the morphology, incidence, demographic associations, and clinical impact of this finding.

MATERIALS AND METHODS

This is a single-center, retrospective study of 500 patients who underwent total shoulder arthroplasty (250 standard and 250 reverse technique) between 2012 and 2017. Pre- and post-operative shoulder radiographs were reviewed to identify and measure the characteristic spur; inter-observer agreement was evaluated between the two reviewers. Incidence, demographic associations, and clinical significance were then determined.

RESULTS

The study group included 268 men and 234 women with a mean age of 70 (42-89) years, and clinical follow-up of 25 (1-84) months. Characteristic heterotopic ossification was seen in 88 patients (17.6%) and was first noted radiographically at a mean (interquartile range) of 12.1 (11.5-12.8) months after surgery. Male sex (adjusted odds ratio (95% confidence interval), 3.00 (0.68-5.34), p < 0.001) was independently associated with heterotopic ossification. No significant relationships between heterotopic ossification and adverse clinical outcomes were observed.

CONCLUSION

Characteristic heterotopic ossification of the proximal humerus in patients status post total shoulder arthroplasty is a common imaging finding that is not associated with adverse clinical outcomes.

Reverse total shoulder arthroplasty

AIMS

This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH).

METHODS

A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and patient-reported outcome measures (PROMs). Meta-analysis was conducted on the reported proportion of complications, weighted by sample size, and PROMs were pooled using the reported standardized mean difference (SMD). Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROSPERO (CRD42020193041).

RESULTS

A total of 42 studies met the inclusion and exclusion criteria. Rates of scapular notching were found to be significantly higher in MGMH implants (52% (95% confidence interval (CI) 40 to 63)) compared with MGLH ((18% (95% CI 6 to 34)) and LGMH (12% (95% CI 3 to 26)). Higher rates of glenoid loosening were seen in MGMH implants (6% (95% CI 3 to 10)) than in MGLH implants (0% (95% CI 0 to 2)). However, strength of evidence for this finding was low. No significant differences were identified in any other complication, and there were no significant differences observed in PROMs between implant philosophies.

CONCLUSION

This systematic review has found significant improvement in PROMS and low complication rates across the implant philosophies studied. Scapular notching was the only complication found definitely to have significantly higher prevalence with the MGMH implant design. Cite this article: Bone Joint J 2021;103-B(5):813-821.

Lateralization and Decreased Neck-Shaft Angle Reduces Scapular Notching and Heterotopic Ossification

BACKGROUND

Lateralization of the glenosphere in reverse shoulder arthroplasty likely mitigates scapular notching; however, there is a paucity of data evaluating the effect of heterotopic ossification (HO) at the inferior aspect of the glenoid neck.

METHODS

We retrospectively reviewed 107 consecutive reverse shoulder arthroplasty patients between April 2013 and April 2016. During the study period, the surgeon switched from a 2.5-mm lateral center of rotation and a 155° neck-shaft angle (NSA) to a 6- or 10-mm lateralized design with a 135° NSA. Preoperative and minimum 2-year postoperative patient-reported outcomes and range of motion were collected. Two-year postoperative radiographs were evaluated for scapular notching and HO.

RESULTS

The lateralized center of rotation implant was 72% less likely to develop HO and 85% less likely to produce scapular notching than the medialized prosthesis.

CONCLUSION

Implants with laterally offset glenospheres and 135° NSA may decrease postoperative HO and scapular notching.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Severe Heterotopic Ossification with Proximal Entrapment of the Ulnar Nerve following Primary Anterior Shoulder Dislocation

Heterotopic ossifications (HO) in the shoulder are rare. The effectiveness of conservative treatment is limited, and therefore, symptomatic cases are usually treated surgically. However, there are no guidelines for the surgical treatment of HO. Herein, we report the case of a 45-year-old man with severe HO and proximal entrapment of the ulnar nerve following primary anterior shoulder dislocation without concomitant injuries (e.g., fracture and rotator cuff tears). Surgical intervention was indicated, including resection of HO and neurolysis of the brachial plexus. Nine months after surgery, the patient presented with restored shoulder function, pain relief, and good patient satisfaction. The case shows that the ulnar nerve can also be impaired due to HO following shoulder dislocation.

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.

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

Background

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this 2-part study was to systematically review each of the most common complications of RSA, limiting each search to publications in 2010 or later. In this part (part I), we examined (1) scapular notching (SN), (2) periprosthetic infection (PJI), (3) mechanical failure (glenoid or humeral component), and (4) neurologic injury (NI).

Methods

Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Overall, 113 studies on SN, 62 on PJI, 34 on mechanical failure, and 48 on NI were included in our reviews. Univariate analysis was performed with the χ² or Fisher exact test.

Results

The Grammont design had a higher SN rate vs. all other designs combined (42.5% vs. 12.3%, P < .001). The onlay humeral design had a lower rate than the lateralized glenoid design (10.5% vs. 14.8%, P < .001). The PJI rate was 2.4% for primary RSA and 2.6% for revision RSA. The incidence of glenoid and humeral component loosening was 2.3% and 1.4%, respectively. The Grammont design had an increased NI rate vs. all other designs combined (0.9% vs. 0.1%, P = .04).

Conclusions

Focused systematic reviews of the recent literature with a large volume of RSAs demonstrate that with the use of non-Grammont modern prosthesis designs, complications including SN, PJI, glenoid component loosening, and NI are significantly reduced compared with previous studies. As the indications for RSA continue to expand, it is imperative to accurately track the rates and types of complications to justify its cost and increased indications.

Massive Heterotopic Ossification in the Subdeltoid Space after Shoulder Surgery and Symptomatic Improvement from Conservative Treatment: A Case Report

Background

We herein report a case of heterotopic ossification (HO) in the subdeltoid space after open resection and rotator cuff repair in a patient with refractory calcific tendinitis.

Case

A 56-year-old man was admitted to our hospital because of right shoulder pain and difficulty in raising his arm. The patient was diagnosed with calcific tendinitis with contracture of the right shoulder joint and was scheduled for surgery because of refractory shoulder pain. Calcium removal was performed using a mini-open approach. Postoperative radiographs showed no calcium deposits. There was mild residual pain at 3 months postoperatively, and the range of motion (ROM) had deteriorated when compared to preoperative levels. A massive ossified shadow was observed in the subdeltoid space on radiographs. Etidronate disodium was orally administered, and the patient continued to undergo careful rehabilitation. HO occurred at 3 months postoperatively, matured at 1 year postoperatively, and showed no progression between 1 year and 2 years postoperatively. The clinical symptoms corresponded with the image findings, and restricted ROM and decreased shoulder function scores were observed at 3 months postoperatively. Although the ROM remained restricted and the function score remained low until 1 year postoperatively, a gradual recovery was achieved at 2 years postoperatively, and the patient did not require reoperation.

Discussion

Although early diagnosis, evaluation, and resection are recommended for treating HO, the maturation of bone may lead to symptomatic improvement and the prevention of reoperation, provided that careful rehabilitative measures are performed to avoid ankyloses.

Clavicular osteotomy in complicated revision of total shoulder arthroplasty: indications, surgical technique, and outcomes

PURPOSE

Adequate exposure in revision of total shoulder arthroplasty (TSA) is important for optimal prosthesis placement and functional results. A clavicular osteotomy in difficult cases of revision TSA is a useful surgical technique that increases the superior exposure area, provides safer dissection, minimizes damage to the anterior deltoid muscle, improves glenoid access, and allows for superior dislocation of the humeral component. There is a paucity of literature analyzing the clavicular osteotomy during challenging cases of revision TSA. The aims of this study were to describe the application, surgical technique, and outcomes of revision TSA with a clavicular osteotomy.

METHODS

This was a retrospective study of consecutive patients who underwent revision TSA with a clavicle osteotomy at a single institution (2004-2016). A curved longitudinal clavicular osteotomy is created parallel to the origin of the anterior deltoid muscle. This allows for lateral reflection of the osteotomy and anterior deltoid muscle to significantly increase superior exposure and reduce damage to remaining deltoid muscle fibres. Osteotomy closure is simple with four or five Nice knot osteosutures. The Constant-Murley score and osteotomy healing were assessed at every follow-up. All complications were reviewed.

RESULTS

Forty patients who had a mean age of 63.8 years (range 37-87) at time of surgery and mean follow-up duration of 34 months (range 12-88) were analyzed. Pre-operative Constant-Murley scores improved significantly from 32 ± 19.0 to 58 ± 15.0 (p < 0.001) at one year and 65 ± 13.1 (p < 0.001) at two years. Primary osteotomy healing and callus formation were evident in 95% of cases by three months. Five patients developed post-operative complications (13%) related to the clavicular osteotomy: three mid-diaphyseal clavicular fractures sustained after trauma (8%), one clavicular stress fracture (3%), and case of one loosening (3%). Three patients (8%) required surgical revision of the osteotomy (two internal fixation and one revision osteosuturing). No neurovascular injuries or scapular fractures were encountered.

CONCLUSION

A curved longitudinal clavicular osteotomy is beneficial in difficult revision TSA and is another tool in the arsenal of experienced shoulder surgeons who manage these challenging cases. This surgical technique increases glenoid exposure, facilitates superior dislocation of the humeral component, minimizes anterior deltoid damage, and reduces the risk of neurovascular injuries. All clavicular complications occurred within four months prior to osteotomy union, with many sustained due to trauma. However, patients who developed a complication had comparable shoulder function as those without.

Risk factors for heterotopic ossification in operatively treated proximal humeral fractures

AIMS

Heterotopic ossification (HO) is a potentially devastating complication of the surgical treatment of a proximal humeral fracture. The literature on the rate and risk factors for the development of HO under these circumstances is lacking. The aim of this study was to determine the incidence and risk factors for the development of HO in these patients.

METHODS

A retrospective analysis of 170 patients who underwent operative treatment for a proximal humeral fracture between 2005 and 2016, in a single institution, was undertaken. The mean follow-up was 18.2 months (1.5 to 140). The presence of HO was identified on follow-up radiographs.

RESULTS

The incidence of HO was 15% (n = 26). Our multivariate model revealed that male sex (odds ratio (OR) 3.57, 95% confidence interval (CI) 1.30 to 9.80 compared to female) and dislocation as the initial injury (OR 5.01, 95% CI 1.31 to 19.22) were significantly associated with the formation of HO (p < 0.05) while no significant associations were seen for the age of the patient, the characteristics of the injury, or the type of operative treatment.

CONCLUSION

This retrospective radiological study is the first to investigate the association between the method of surgical treatment for a proximal humeral fracture and the formation of HO postoperatively. We found that male sex and dislocation as the initial injury were risk factors for HO formation, whereas the method of surgical treatment, the age of the patient, and the pattern of the fracture were not predictive of HO formation. While additional studies are needed, these findings can help to identify those at an increased risk for HO formation under these circumstances. Cite this article: Bone Joint J 2020;102-B(4):539-544.

Surgical Management of Shoulder Heterotopic Ossification

The formation of heterotopic ossification around the shoulder is a rare but potentially debilitating condition. It is found most commonly around the hip and is usually associated with an inciting event such as trauma, burn, previous surgery, or traumatic brain/spinal cord injury. The formation of shoulder heterotopic ossification following arthroscopic surgery is very uncommon, with few data pertaining to it in the current literature. Formation of heterotopic ossification in the shoulder after arthroscopic surgery typically occurs around the acromioclavicular joint and in the subacromial space. This location may lead to chronic pain and decreased mobility. The purpose of this article is to describe an arthroscopic technique for excision of heterotopic ossification.

Establishing maximum medical improvement following reverse total shoulder arthroplasty for rotator cuff deficiency

BACKGROUND

Since US Food and Drug Administration approval of the reverse prosthesis in 2003, the incidence of shoulder arthroplasty in the United States has risen dramatically. With increasing demand, efforts have shifted from traditional volume-based health care models to more patient-centered care. The purpose of this systematic literature review is to establish the time point of maximum medical improvement (MMI) following reverse total shoulder arthroplasty (rTSA).

MATERIALS AND METHODS

We conducted a systematic review of studies reporting validated patient-reported outcome measures (PROMs) across multiple postoperative time points following rTSA. Established minimal clinically important difference values for PROMs specific to shoulder arthroplasty were used to determine significant clinical improvement. The time point beyond which significant improvement did not occur was established as MMI.

RESULTS

MMI occurred at 1 postoperative year following rTSA. When preoperative measures were compared with 1-year postoperative outcomes, all but 1 PROM demonstrated significant clinical improvement (P < .001). There were no significant improvements between any 2 subsequent time points beyond 1 year (P > .050). Range of motion significantly improved between preoperative and 1-year levels (P < .001). No PROMs or range-of-motion parameters significantly improved beyond 1 year (P > .999).

CONCLUSIONS

Patients achieved MMI at 1 postoperative year following rTSA. Patients showed rapid improvements in subjective symptoms within the first 3 months and continued to gradually improve until 1 year. Surgeons should counsel patients with these evidence-based expectations for clinical recovery, particularly the time frame of expected improvements in pain, function, and range of motion, as well as risks of and plans of action for postoperative complications.

Lateralized Center of Rotation and Lower Neck-Shaft Angle Are Associated With Lower Rates of Scapular Notching and Heterotopic Ossification and Improved Pain for Reverse Shoulder Arthroplasty at 1 Year

Heterotopic ossification and scapular notching are common following reverse total shoulder arthroplasty. Compared with the original Grammont-style prosthesis with a medialized center of rotation (COR) and a 155° neck-shaft angle, lateralization of COR and reduction of neck-shaft angle have been associated with decreased incidence of scapular notching. The authors hypothesized that these design features may also be effective in reducing heterotopic ossification after reverse total shoulder arthroplasty. Ninety-seven consecutive patients who underwent reverse total shoulder arthroplasty performed by a single surgeon were included in the study. Forty-eight patients received a Grammont-style prosthesis, and 49 received a prosthesis with either 6 mm or 10 mm of lateral COR offset and a 135° neck-shaft angle. Radiographs at 1-year follow-up were reviewed by 2 surgeons for notching and heterotopic ossification. Patient-reported outcome scores and range of motion were also compared between the groups. More patients in the Grammont-style group showed scapular notching (Grammont, 35.4%; lateral COR, 12.2%; P=.018) and heterotopic ossification (Grammont, 47.9%; lateral COR, 22.4%; P=.009). The lateralized COR group reported lower pain on the visual analog scale (Grammont mean, 1.1; lateral COR mean, 0.5; P=.01) and trended toward better American Shoulder and Elbow Surgeons scores (Grammont mean, 77.2; lateral COR mean, 83.4; P=.05). However, range of motion was similar between the 2 groups. Compared with the Grammont-style prosthesis, the lateralized COR prosthesis with a decreased neck-shaft angle resulted in a lower incidence of both scapular notching and heterotopic ossification as well as better pain scores and a trend toward improved function at 1 year after reverse total shoulder arthroplasty. [Orthopedics. 2018; 41(4):230-236.].

Clinical and radiological outcomes after reverse shoulder arthroplasty with less medialized endoprosthesis after mean follow-up time of 45 months

INTRODUCTION

The purpose of this study was to evaluate outcomes after reverse shoulder arthroplasty for the treatment of complex three- and four-fragment proximal humeral fractures after mean follow-up time of 45 months and to compare our results with the results published by other authors.

MATERIALS AND METHODS

Retrospectively we have analyzed 27 consecutive patients after total arthroplasty with less medialized reverse shoulder prosthesis used for the treatment of complex proximal humeral fracture. The median age and standard deviation was 67.5 ± 7.3 years (range 55-85). The average follow-up time was 45 months. Shoulder function was evaluated using Simple Shoulder Test and Constant scale. Patient satisfaction about the treatment was evaluated using Likert-type questionnaire. All patients were investigated radiologically for possible complications using standard lateral and anterior views.

RESULTS

All patients were satisfied (74%) or highly satisfied (26%). The mean total Constant-Murley score was 57.6 pts. (range 37.4-80.2). Mean total Simple Shoulder Test score was 73.5 pts. (range 49.8-100). There were two cases with heterotopic ossification and one with greater tubercle malposition. We found no signs of scapular notching, implant failure or loosening.

CONCLUSIONS

Results after reverse arthroplasty for complex proximal humeral fractures yield good clinical, functional, and radiological outcomes after mean follow-up time of 45 months. Results are comparable to other studies published in the recent literature.