Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff: A Concise 5-Year Follow-up of a Previous Report

The effect of reverse shoulder arthroplasty design and surgical indications on deltoid and rotator cuff muscle length

BACKGROUND

Advancements in surgical planning, technique, and prosthesis design have improved adaptation to patient anatomy in reverse total shoulder arthroplasty (rTSA). Postoperative changes in deltoid and rotator cuff muscle length are important and may vary based on preoperative indications and prosthesis selection. The purpose of this study is to demonstrate the changes in deltoid and rotator cuff muscle length for planned rTSA using the spectrum of prosthesis configurations in both glenohumeral arthritis (GHOA) and rotator cuff tear arthropathy (RCA).

METHODS

Ten shoulder arthroplasty surgeons used preoperative planning software to plan rTSA cases for 20 subjects (10 GHOA, 10 RCA) following surgical guidelines. Each surgeon planned each case using 3 prosthesis configurations: (1) 8-mm lateralized glenosphere and 135° neck-shaft angle (135 + 8), (2) 4-mm lateralized glenosphere and 145° neck-shaft angle (145 + 4), and (3) 0-mm lateralized glenosphere and 155° neck-shaft angle (155 + 0). Pre- and postoperative deltoid and rotator cuff muscle lengths and percentage-change were calculated and compared between prosthesis configurations within each indication. Different muscle lines of action were included representing the deltoid, subscapularis, infraspinatus, and teres minor.

RESULTS

Preoperatively, the RCA cohort had significantly shorter muscle lines of action in the posterior, lateral, and anterior deltoid (P < .001), a longer inferior subscapularis (P = .022), and a longer teres minor (P = .001) than the GHOA cohort. ANOVA and post-hoc analysis showed that postplanning lengths of each deltoid action line were greater in the 155 + 0 configuration compared to the 135 + 8 configuration in the RCA cohort (P < .001, P = .003, P = .032, respectively), and postplanning lengths of the anterior and middle deltoid action lines were also greater for the same comparison in the GHOA cohort (P = .004 and P = .017, respectively). There were no significant differences in postplanning deltoid lengths between the 135 + 8 and 145 + 4 configurations in either diagnosis cohort (P > .05). All postplanning rotator cuff muscle lengths (subscapularis, infraspinatus, and teres minor) differed significantly (P < .001) between all prosthesis configurations in both diagnosis cohorts, with the 135 + 8 configuration resulting in the longest lengths and the 155 + 0 configuration resulting in the shortest lengths.

CONCLUSION

Automated preoperative planning software calculates the lengths of muscle action lines, which vary between GHOA and RCA diagnoses. Varying rTSA implant geometries result in predictable differences in deltoid lengthening and rotator cuff shortening. Shoulder prostheses with a more lateralized center of rotation show greater rotator cuff muscle length and similar deltoid muscle length when compared to medialized designs with similar deltoid lengthening. Surgeons can use this software to understand the impact of implant geometry on muscle length.

Reverse shoulder arthroplasty for patients with cuff tear arthropathy: do clinical outcomes differ by inlay vs. onlay design?

BACKGROUND

The influence of position of the humeral tray (inlay or onlay) on clinical outcomes in reverse shoulder arthroplasty (RSA) is a topic of debate. The purpose of this study was to compare clinical and radiographic outcomes of patients with cuff tear arthropathy treated with RSA systems with inlay or onlay humeral tray design, similar neck-shaft angles, and lateralized glenospheres.

METHODS

This was a retrospective study of prospectively obtained data from 1 tertiary care center. We identified all patients who underwent primary RSA between 2009 and 2017 (N = 511). We included 102 patients with diagnosed cuff tear arthropathy treated with RSA prostheses with a lateralized glenosphere and 135° neck-shaft angle (with either an inlay or onlay humeral tray design) who had a minimum of 2 years of follow-up (mean, 44 months; range, 24-125 months). Sixty-three patients (62%) had an inlay humeral tray (inlay group) and 39 (38%) had an onlay tray (onlay group). All patients underwent preoperative and postoperative evaluations, including measures of patient-reported outcomes (PROs), shoulder range of motion (ROM) testing, and radiographic imaging. Clinical relevance of changes in PROs and ROM was evaluated using published values for minimal clinically important differences.

RESULTS

The 2 groups did not differ by demographic characteristics except for a higher proportion of women in the inlay group (75%) than in the onlay group (56%) (P = .04). Preoperative PROs and ROM were not significantly different between groups. At final follow-up, PROs and ROM were not different between groups in terms of statistical significance or clinical relevance. We found no significant differences in the rate of baseplate loosening (inlay, 3.2% vs. onlay, 5.1%, P = .63), revision surgery (inlay, 0% vs. onlay 5.1%, P = .07), acromial stress fracture (inlay, 3.2% vs. onlay, 5.1%, P = .63), prosthesis dislocation (inlay, 0% vs. onlay, 2.6%, P = .20), or scapular notching (inlay, 21% vs. onlay, 7.7%, P = .08).

CONCLUSION

At 2-year minimum follow-up, the position of the humeral tray in RSA prostheses (either inlay or onlay) for cuff tear arthropathy was not associated with PROs, shoulder ROM, or rates of complications, including baseplate loosening, acromial stress fracture, and scapular notching.

Effectiveness of Delayed Surgical Treatment for Distal Radius Fractures With Loss of Reduction

PURPOSE

This study investigated the effectiveness of volar plate surgery in patients with distal radius fractures (DRFs) initially treated nonsurgically but later experiencing reduction loss during follow-ups. Specifically, it assessed the impact of early surgery (E) (<3 weeks) versus delayed surgery (D) (3-6 weeks) on wrist function in surgically treated DRFs.

METHODS

This retrospective study included 131 patients who underwent surgery after loss of reduction. Among them, 42 patients had delayed surgery, whereas 89 received early surgical treatment. The mean follow-up duration was 18 months. The primary outcome measure was Disabilities of the Arm, Shoulder, and Hand scores. Secondary outcomes included Short Form-12 physical component summary and mental component summary scores, postoperative range of motion, and radiological measurements such as radial length, radial inclination angle, and volar tilt angle. Fracture types were categorized using Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification based on radiological images.

RESULTS

All 131 DRFs achieved radiological union. Mean Disabilities of the Arm, Shoulder, and Hand scores were 8.0 (range, 0-78) and 10.8 (range, 0-73) for groups E and D, respectively, and the difference was not considered clinically relevant. Short Form-12 physical component summary scores (49.4 for E; 45.3 for D) and Short Form-12 mental component summary scores (52.3 for E; 53.5 for D) were similar in the two groups. Radiological measurements and range of motion were similar in the two groups. Complications, including carpal tunnel syndrome, superficial radial nerve neuropraxia, and complex regional pain syndrome, occurred in 12 (13.5%) E group patients and 9 (21.4%) D group patients.

CONCLUSIONS

Clinical and radiological results of early and delayed surgery after loss of reduction in secondary displaced DRF were similar. However, complication rates were higher in delayed surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

A two-year comparison of reverse total shoulder arthroplasty mini-humeral tray and augmented mini-glenoid baseplate implants vs. standard implants

BACKGROUND

Patients who undergo reverse total shoulder arthroplasty (RTSA) are getting younger with greater function expectations. This retrospective, longitudinal study of prospectively collected data compared perceived shoulder function and strength, active shoulder mobility, radiographic evidence of scapular notching, and implant survival over the initial 2-years post-RTSA among patient groups who received either standard central fixation point liner and glenoid baseplate implants, or lower size profile mini-humeral tray with offset trunnion options and mini-augmented glenoid baseplate implants.

MATERIALS AND METHODS

Patients who underwent primary RTSA using standard central fixation point liner and glenoid baseplate implants (Group 1, n = 180) were compared with patients who underwent primary RTSA using lower size profile mini-humeral tray with offset trunnion options and mini-augmented glenoid baseplate implants (Group 2, n = 53) for active shoulder mobility, American Shoulder and Elbow Surgeons (ASES) score, perceived ability to lift 10 lbs (4.5 kg) overhead, radiographic evidence of scapular notching, and implant survival. Data was collected pre-surgery, 6-weeks, 6-months, 1-year, and 2-years post-RTSA (p ≤ 0.05).

RESULTS

More Group 2 patients had more complex B or C Walch glenoid morphology, while Group 1 had more A1 or A2 types (p ≤ 0.001). Group 2 had greater active shoulder flexion at 6-months, 1-year, and 2-years (p ≤ 0.018) and external rotation (in adduction) at 6-months and 2-years (p ≤ 0.004) compared to Group 1, with higher ASES scores at 6-months and 2-years (p ≤ 0.026) (with small-to-medium effect sizes), and with more patients meeting or exceeding the minimal clinically important difference (MCID) at 2-years (p = 0.045) and patient acceptable symptomatic state (PASS) levels at 6-months, 1-year and 2-years (p ≤ 0.045). Scapular notching was identified in six of 53 (11.3%) Group 2 patients and in 32 of 180 (17.7%) Group 1 patients. Group 1 patients had more grade 2 or greater scapular notching grades compared to Group 2 (p = 0.04). Implant survival was comparable with Group 1 = eight of 180 (4.4%) and Group 2 = 1 of 53 (1.9%) of patients requiring removal for 95.6% and 98.1% implant survival, respectively.

CONCLUSION

Limited scapular notching and excellent implant survival was observed in both groups. Despite including individuals with more complex glenoid deficiency, patients receiving the lower size profile implants generally displayed better active shoulder mobility and perceived shoulder function compared to those who received standard implants. These patients also more frequently met or exceeded the MCID by 2-years post-RTSA and PASS levels by 6-months, 1-year, and 2-years post-RTSA, with lower scapular notching grades.

LEVEL OF EVIDENCE

Retrospective comparative study.

The effect of eccentric glenoid reaming in reverse shoulder artrhoplasty for glenohumeral osteoarthritis

Background

The objective of this study was to evaluate the abilitiy of eccentric reaming in reverse total shoulder arthroplasty (RSA), in patients with glenohumeral osteoarthritis (GHOA), to correct preoperative glenoid retroversion and to compare with cuff tear arthopaty (CTA) cases.

Methods

Fifty-nine patients who underwent RSA with GHOA or CTA diagnosis between 2013 and 2022 and who had pre- and postoperative computed tomography scans were included in the study. Preoperative glenoid version and postoperative glenoid component versions of 17 patients with GHOA and 40 patients with CTA were measured by Friedman method.

Results

The median preoperative glenoid versions in GHOA and CTA groups were measured as 16° and 4° retroverted respectively (p < 0.01). The median postoperative glenoid component versions in GHOA and CTA groups were 5° and 3° retroverted respectively (p = 0.09). The version change differences between the two groups varied significantly (p < 0.01).

Conclusions

GHOA is related with higher preoperative glenoid retroversion compared to CTA. However; with eccentric glenoid reaming, adequate version correction and similar postoperative glenoid version can be achieved in GHOA compared to CTA when performing a RSA.

Level of evidence

Level III. Retrospective study. Treatment study.

Mini-augmented glenoid baseplate and mini-humeral tray reverse total shoulder arthroplasty implant comparisons: two-year clinical outcomes

BACKGROUND

Augmented glenoid baseplate and offset humeral tray reverse total shoulder arthroplasty (RTSA) implants may decrease the mechanical impingement that creates scapular notching and improve shoulder function. This study evaluated the clinical efficacy of three different RTSA glenoid baseplate and offset humeral tray combinations for patient-reported shoulder function, pain and instability, radiographic imaging evidence of glenoid baseplate or humeral stem subsidence and migration, bony changes associated with implant loosening, and scapular notching over the initial 2 years post-RTSA. Primary outcomes included active shoulder mobility, perceived function, pain, instability, scapular notching, and implant survival.

METHODS

Sixty-seven patients from 6 research sites received one of three different glenoid baseplate and humeral tray combinations. Group 1 (n = 21) received a mini-augmented glenoid baseplate with a standard humeral tray; Group 2 (n = 23) received a standard glenoid baseplate and a mini-humeral tray with 3 trunnion offset options; Group 3 (n = 23) received both a mini-augmented glenoid baseplate and a mini-humeral tray with 3 trunnion offset options. Subjects underwent radiologic evaluation, completed the ASES scale, the EQ-5D-5L quality of life scale, VAS shoulder pain and instability questions, and active shoulder mobility measurements pre-operatively, and 6-weeks, 6-months, 1-2 years post-RTSA.

RESULTS

Improved active shoulder mobility, quality of life, perceived function, decreased shoulder pain and instability, excellent implant survival and minimal scapular notching were observed for all groups. Group 3 had better overall active shoulder mobility than the other groups and better perceived function than Group 1.

CONCLUSION

The group that received the mini-augmented glenoid baseplate and mini-humeral tray combination had better overall active shoulder flexion, external rotation at 90° abduction, and internal rotation. This group also had better perceived shoulder function compared to the group that received a mini-augmented glenoid baseplate with a standard humeral tray.

Reverse total shoulder arthroplasty pain and function: new perspectives from a 10-year multicenter study at the 7-year follow-up

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) can decrease shoulder pain and improve function. However, results reportedly deteriorate as patients approach mid-term follow-up and little is known about how this impacts physical health-related quality of life (PHRQOL) and mental health-related quality of life (MHRQOL). The study hypothesis was that shoulder function, pain, and medication use for pain would influence PHRQOL and MHRQOL.

METHODS

This prospective cohort study involving subjects from 6 orthopedic clinics and 12 fellowship-trained surgeons evaluated the influence of RTSA on PHRQOL, MHRQOL, shoulder function, pain, instability, and medication use over the initial 7 years of a 10-year study, and device survivorship and revision rates. Clinical examination, the American Shoulder and Elbow Surgeons (ASES) score, Short Form (SF)-12 PHRQOL and MHRQOL assessments, the single assessment numeric shoulder function evaluation (SANE), visual analog scale (VAS) shoulder pain and instability scores, shoulder pain, medication use for pain, surgery satisfaction, survivorship and revision rate data were collected pre-RTSA, and at 6-week, 6-month, 1-year, 2-year, 3-year, 5-year, and 7-year follow-ups.

RESULTS

Two hundred participants (108 female) of 69 ± 8.3 years of age, with gross rotator cuff deficiency (poor tissue quality or impaired dynamic stability) (n = 92), glenohumeral joint osteoarthritis (n = 88), failed primary total shoulder arthroplasty (n = 8), non-united humeral head fracture (n = 6) or 3-4 section comminuted humeral head fracture (n = 6) underwent pre-RTSA evaluation. Device survivorship was 94%. Friedman two-way ANOVA and Wilcoxon test pairwise comparisons revealed that compared to pre-RTSA, median active shoulder flexion (+ 25°) and external rotation (+ 10°) mobility improved by 6 months (p < 0.0001) and remained improved. Shoulder flexion (+ 1 grade), abduction, external rotation (+ 0.5 grade), and internal rotation strength (+ 1 grade) also improved by 6 months (p < 0.0001) and remained improved. ASES (+ 26.8), SANE (+ 17.5) and VAS pain (- 5.7) scores improved by 6 weeks (p < 0.0001) and remained improved, as medication use for shoulder pain decreased (- 24.6%) (p < 0.0001). SF-12 PHRQOL scores improved by 6 months (+ 11.5) and remained improved (p < 0.0001). Significant Spearman Rho correlations were observed between shoulder function (ASES or SANE) and SF-12 PHRQOL (r ≥ 0.52) and MHRQOL (r ≥ 0.20) scores (p < 0.0001) supporting the relationship between shoulder function and quality of life. Trend analysis revealed changing shoulder function, pain, and PHRQOL relationships between 2 and 3 years, and 5 and 7 years post-RTSA (Chi-Square, p < 0.05).

CONCLUSION

Excellent device survival and good-to-excellent perceived shoulder function, and PHRQOL improvements were observed. Secondary objectives of improved shoulder mobility, strength, pain and instability were also achieved. In contrast to previous reports, subjects did not display shoulder mobility or perceived function deterioration by the 7-year follow-up. Following chronic pain relief at 6 weeks post-RTSA, subjects appear to balance PHRQOL and shoulder pain relationships at the 6-month and 1-year post-RTSA follow-ups. Careful evaluation at this time may help patients with higher pain levels and lower function expectations reverse these trends, or patients with lower pain levels and higher function expectations to optimize RTSA use and longevity.

Anatomic shoulder arthroplasty with high side reaming versus reverse shoulder arthroplasty for eccentric glenoid wear patterns with an intact rotator cuff: comparing early versus midterm outcomes with minimum 7 years of follow-up

BACKGROUND

Eccentric glenoid bone loss patterns (B- and C-type glenoid) pose a difficult challenge when performing shoulder arthroplasty. Anatomic total shoulder arthroplasty with preferential high-side reaming (ATSA + HSR) has been an accepted method to treat this problem. Reverse shoulder arthroplasty (RSA) has become an alternative method to manage these cases with eccentric glenoid wear. The purpose of this study was to compare the early 2-year outcomes with the midterm outcomes for patients who underwent ATSA + HSR vs. RSA for eccentric glenoid wear patterns with an intact rotator cuff.

MATERIALS AND METHODS

From 2008 to 2014 there were 242 shoulder arthroplasties performed in the setting of eccentric glenoid wear patterns. Of that initial cohort 101 ATSA + HSR and 93 RSA had both 2-year and final follow-up with a minimum of 7 years from surgery. American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST), range of motion, patient satisfaction, and radiographs were evaluated for each cohort and contrasted at the 2-year follow-up point and last follow-up time point.

RESULTS

The average follow-up in the ATSA + HSR cohort was 8.3 years compared with 7.8 years in the RSA cohort. At the 2-year follow-up point, the ATSA + HSR group had better average ASES scores (85 vs. 80 [P < .001]), SST scores (10 vs. 9.6 [P < .001]), forward elevation (162° vs. 151° [P < .001]), external rotation (47° vs. 42° [P < .001]), and internal rotation (IR) (80% full IR vs. 55% full IR [P < .001]). At the 2-year follow-up, 95% of the ATSA + HSR cohort were satisfied compared with 93% in the RSA cohort. At the final follow-up, the RSA group had better average ASES scores (80 vs. 77 [P < .001]) and SST scores (9.4 vs. 8 [P < .001]) and a similar forward elevation (152° vs. 149° [P = .025]). The ATSA + HSR had better external rotation (45° vs. 41° [P < .001]) and IR (74% full IR vs. 54% full IR [P = .005]). Patient satisfaction at the final follow-up had decreased to 82% in the ATSA + HSR group, compared with 95% satisfied in the RSA group. Of the initial ATSA + HSR cohort, 8% of patients had undergone revision compared with 2% in the RSA cohort.

CONCLUSION

ATSA with HSR had better outcome scores and range of motion with a similar patient satisfaction rating to RSA at the 2-year point. Over time, the ATSA + HSR results deteriorated, and at the final midterm follow-up, the RSA group had more durable results with better outcome scores, a higher patient satisfaction rating, and a lower revision rate.