Surgical options for the young patient with glenohumeral arthritis

[Arthroplastic borderline cases in pediatric and adolescent rheumatology]

Shoulder joint involvement in juvenile idiopathic arthritis (JIA) is common; however, it is first clinically manifested only after a delay. Initially, the aim should be to preserve the joint for as long as possible by means of adequate drug treatment and arthroscopic synovectomy. If definitive joint destruction nevertheless occurs hemiarthroplasty, anatomical and reverse shoulder arthroplasty are available. Hemiarthroplasty can result in pain amelioration and was the gold standard for a long time but it remains inferior to total shoulder arthroplasty in terms of pain reduction, improvement of the range of motion and durability. Reverse shoulder arthroplasty can also be used even in young patients with JIA, particularly when rotator cuffs are also involved. A metaphyseal fixation of the short stem and a modular design of the prosthesis make these attractive, even with respect to the inevitable necessity for revisions.

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.

Partial Shoulder Arthroplasty Guided by Three-dimensional Prototyping

Three-dimensional (3D) printing technology is a reality in medicine. In Orthopedics and Traumatology, 3D printing guides a precise and tailored surgical treatment. Understanding and disseminating its applicability, use, and outcomes can foster academicism and improve patient care. This is a report of a rare case of a female young adult patient with osteonecrosis of the humeral head due to avascular necrosis developed in early childhood. The treatment was tailored and optimized with 3D printing, which helped determine the steps for partial humeral arthroplasty.

Pharmacologic interventions for primary glenohumeral osteoarthritis

ABSTRACT

Primary glenohumeral osteoarthritis is a multifactorial condition with a complex cause that affects patients across different age groups, impairing physiologic and psychologic well-being, and substantially reducing patient quality of life and overall productivity. To effectively manage this condition, healthcare providers need to be well informed about treatment guidelines, as well as the available therapeutic options and the evidence supporting their use. Nonsurgical interventions should be regarded as the primary treatment option, particularly for patients in the initial phases of this condition. No conclusive guidelines exist for treating young and active patients, and the literature lacks high-quality data to evaluate the efficacy, safety, and long-term consequences of several interventions, regardless of patient characteristics and expectations.

The impact of glenoid parameters and implant overstuffing on functional outcomes of shoulder hemiarthroplasty in patients with glenohumeral joint arthritis

PURPOSE

The outcomes of shoulder hemiarthroplasty are highly dependent on the baseline glenoid morphology and the rotator cuff integrity. The objective of this study was to assess whether certain glenoid parameters and implant overstuffing are associated with worse clinical outcomes following shoulder hemiarthroplasty.

METHODS

We retrospectively reviewed 25 patients who underwent shoulder hemiarthroplasty for shoulder arthritis, with a mean follow-up of 5.3 years. The baseline glenoid morphology, the glenoid wear rate, the proximal humeral head migration and implant overstuffing were evaluated radiologically in all patients. The radiological parameters were correlated with the functional outcomes.

RESULTS

The Constant-Murley score, the ASES score, and the OSS score were significantly better for patients with a concentric baseline glenoid compared to those with an eccentric glenoid. The Constant-Murley score and the ASES score were also improved in patients without implant overstuffing compared to patients with implant overstuffing (p < 0.05). However, glenoid wear was not associated with worse functional outcomes (p = 0.23 for Constant-Murley score, p = 0.15 for ASES score and p = 0.27 for OSS score). Last, a worse Constant-Murley score was strongly correlated with proximal humeral head migration (p < 0.001), while worse ASES and OSS scores were moderately correlated with proximal humeral head migration (p < 0.001).

CONCLUSION

Our findings indicate that the results of hemiarthroplasty can be improved through careful selection of patients upon the baseline glenoid type morphology and proper implant sizing to avoid implant overstuffing. Moreover, glenoid wear is not associated with worse clinical outcomes, therefore shoulder hemiarthroplasty should be reconsidered as an alternative in younger patients with shoulder arthritis.

Survivorship of shoulder arthroplasty in young patients with osteoarthritis: an analysis of the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

The treatment of shoulder osteoarthritis in the young patient remains challenging. The higher functional demands and higher expectations of the young patient cohort are often coupled with increased failure and revision rates. Consequently, shoulder surgeons are faced with a unique challenge with implant selection. The aim of this study was to compare the survivorship and reasons for revision of 5 classes of shoulder arthroplasty in patients aged <55 years with a primary diagnosis of osteoarthritis by use of data from a large national arthroplasty registry.

METHODS

The study population included all primary shoulder arthroplasty procedures undertaken for osteoarthritis in patients aged <55 years and reported to the registry between September 1999 and December 2021. Procedures were grouped into the following classes: total shoulder arthroplasty (TSA), hemiarthroplasty resurfacing (HRA), hemiarthroplasty stemmed metallic head (HSMH), hemiarthroplasty stemmed pyrocarbon head (HSPH), and reverse total shoulder arthroplasty (RTSA). The outcome measure was the cumulative percent revision, which was defined using Kaplan-Meier estimates of survivorship to describe the time to the first revision. Hazard ratios (HRs) were calculated from Cox proportional hazards models, adjusting for age and sex, to compare revision rates among groups.

RESULTS

There were 1564 shoulder arthroplasty procedures in patients aged <55 years, of which 361 (23.1%) were HRA, 70 (4.5%) were HSMH, 159 (10.2%) were HSPH, 714 (45.7%) were TSA, and 260 (16.6%) were RTSA. HRA had a higher rate of revision than RTSA after 1 year (HRA = 2.51 (95% CI 1.30, 4.83), P = .005), with no difference prior to that time. In addition, HSMH had a higher rate of revision than RTSA for the entire period (HR, 2.69 [95% confidence interval, 1.28-5.63], P = .008). There was no significant difference in the rate of revision for HSPH and TSA when they were compared with RTSA. Glenoid erosion was the most common cause of revision for HRA (28.6% of revisions) and HSMH (50%). Instability/dislocation was the leading cause of revision for RTSA (41.7%) and HSPH (28.6%), and for TSA, the majority of revisions were for either instability/dislocation (20.6%) or loosening (18.6%).

CONCLUSION

These results should be interpreted within the context of the lack of availability of long-term data on RTSA and HSPH stems. RTSA outperforms all implants regarding revision rates at mid-term follow-up. The high early dislocation rate associated with RTSA, as well as the lack of revision options available to address this, indicates that careful selection of patients and a greater appreciation of anatomic risk factors are needed in the future.

Shoulder joint arthroplasty in young patients: Analysis of 8742 patients from the Australian Orthopaedic Association National Joint Replacement Registry

Background

Shoulder replacement is a reliable treatment for the relief of pain and improvement of function in patients with glenohumeral arthritis, rotator cuff arthropathy, osteonecrosis and fracture. Limited data is available comparing revision rates for the different types of shoulder replacement when used in younger patients. This study aims to compare the survivorship of hemi resurfacing, stemmed hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty in younger patients using data from a large national arthroplasty registry.

Methods

Data from the Australian Orthopaedic Association National Joint Replacement Registry was obtained for the period 16 April 2004-31 December 2018. The study population included all shoulder arthroplasty patients aged <65 years. These were stratified into two groups: <55 years and 55-64 years. A total of 8742 primary shoulder arthroplasty procedures were analysed (1936 procedures in the <55 years and 6806 in the 55-64 years age group).

Results

In the <55 years age group, there was no difference in revision rate for total shoulder arthroplasty versus reverse total shoulder arthroplasty at any time point. Reverse total shoulder arthroplasty had a lower revision rate after six months when compared to hemi resurfacing (HRA) (p = 0.031). Also, reverse total shoulder arthroplasty had a higher early rate of revision in the first 12 months compared to hemiarthroplasty (p = 0.018). However, from 2 years reverse total shoulder arthroplasty had a lower revision rate overall (p = 0.029).In the 55-64 years patient age group, reverse total shoulder arthroplasty had a lower earlier revision rate. This was statistically significant compared to hemi resurfacing (HRA) (p = 0.028), hemiarthroplasty (p = 0.049) and total shoulder arthroplasty (p < 0.001).

Conclusion

This study demonstrated that for patients aged <55 years there was no significant difference in the rate of revision when total shoulder arthroplasty and reverse total shoulder arthroplasty were compared. reverse total shoulder arthroplasty had a lower rate of revision when compared to hemi resurfacing and hemiarthroplasty after 2 years. reverse total shoulder arthroplasty had the lowest comparative revision rate in patients aged 55-64 years overall.

Biceps Tenodesis in Patients Age 35 Years and Younger Yields Favorable Clinical Outcomes With Variable Rates of Return to Sport and Complications: A Systematic Review

PURPOSE

To systematically evaluate reported clinical outcomes, return-to-sport (RTS) rates, and complications following biceps tenodesis in patients aged 35 years and younger and compare outcomes between overhead and nonoverhead athletes.

METHODS

A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through August 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies that evaluated clinical outcomes following biceps tenodesis in patients aged 35 years or younger were included. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Clinical outcomes, RTS rates, and complications were aggregated.

RESULTS

Nine studies from 2011 to 2022 comprising 161 patients (mean age, 25 years; range, 19.7-28.9 years) were included. At an average follow-up of 59 months, postoperative American Shoulder and Elbow Surgeons score ranged from 81.6 to 96 and the mean visual analog scale score ranged from 0 to 2.1. Mean overall RTS rate ranged from 35% to 100% for the entire patient cohort 35% to 86% among overhead athletes, and 46% to 100% among nonoverhead athletes. Among the overhead athletes, 24 were baseball pitchers. 17% to 100% able to return to sport at any level. Complications were reported in 0% to 19% of patients. 0 to 18% of patients underwent revision surgery.

CONCLUSIONS

Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported RTS rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure.

LEVEL OF EVIDENCE

IV; Systematic Review of Level III and IV studies.

Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management

PURPOSE OF REVIEW

Avascular necrosis (AVN) and posttraumatic arthritis (PTA) are common complications following both conservative treatment and open reduction and internal fixation (ORIF) of proximal humerus fractures (PHFs). Despite the frequent utilization of ORIF, information regarding these leading causes of failure is limited. This review includes a discussion of incidence, risk factors, and evaluation of AVN and PTA following PHF. The mechanisms of treatment options and associated outcomes are also reviewed.

RECENT FINDINGS

Recent best available evidence demonstrates significant rates of AVN and PTA following ORIF of PHF. This is particularly true of complex fracture patterns. A thorough workup is required in the setting of failure caused by AVN and PTA. This includes a careful patient history, clinical exam, plain film radiographs, and CT scans. EMG and/or aspiration may also be indicated. Special consideration is given to the examination of the deltoid muscle, neurovascular status, rotator cuff function, and the possibility of infection. Biological supplementation, anatomic total shoulder replacement (aTSA), and fusion are rarely employed in the treatment of AVN and/or PTA. Due to satisfactory patient outcomes, reverse total shoulder replacement (rTSA) has increased in popularity for the elderly population, while hemiarthroplasty (HA) may be appropriate for some young, active patients. With careful patient selection and meticulous surgical technique, AVN and PTA can be mitigated. Careful indications for ORIF may decrease the frequency of these complications. For most patients, rTSA is the optimal treatment option. Given the frequent utilization of ORIF and the higher than acceptable complication and failure rates, AVN and PTA warrant our attention.

Talar Allograft Preparation for Treatment of Reverse Hill-Sachs Defect in Recurrent Posterior Shoulder Instability

Reverse Hill-Sachs lesions (rHSLs) after chronic posterior shoulder instability are important to recognize and treat appropriately. Treatment options for posterior instability with rHSL in the current literature are primarily based on percentage of humeral bone loss. In cases of moderate (25% to 50%) anterolateral humeral head bone loss, fresh osteochondral allografts are preferred. Recent literature has indicated that the talus serves as a robust grafting alternative site for the humeral head, as the talar dome shows high congruency and offers variable sizes. The purpose of this Technical Note is, therefore, to describe our technique for talus allograft preparation for the treatment of a large rHSL that highlights precise cutting anatomy, sizing options, and use of orthobiologics to ensure excellent talus union to the native humeral head surface.

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

BACKGROUND

We aimed to characterize the long-term clinical and radiographic outcomes of total shoulder arthroplasty (TSA) in patients aged < 60 years. We hypothesized meaningful improvements in shoulder functionality and pain with TSA and an acceptably low rate of prosthesis complications and revisions.

METHODS

This was a retrospective cohort study of 29 patients (34 shoulders) undergoing TSA before age 60 years with a minimum follow-up period of 10 years. Shoulder range of motion, functionality (American Shoulder and Elbow Surgeons and Simple Shoulder Test scores), and pain (visual analog scale score) were evaluated. Radiographs were assessed for lateral humeral offset, the acromiohumeral interval, and glenoid loosening.

RESULTS

The mean age of the patients was 54.4 ± 5.5 years (range, 35.5-59.8 years), with a mean follow-up period of 16.1 ± 4.5 years (range, 10.0-26.1 years). In patients aged < 60 years, TSA significantly improved forward elevation (from 119° ± 26° to 146° ± 21°, P = .0002), external rotation (from 21° ± 25° to 52° ± 15°, P = .0001), and internal rotation (from L5 to L1, P = .002). Additionally, TSA significantly increased American Shoulder and Elbow Surgeons scores (from 32 ± 20 to 64 ± 27, P = .0008) and Simple Shoulder Test scores (from 3 ± 2 to 7 ± 4, P = .0004) and reduced visual analog scale pain scores (from 7 ± 3 to 3 ± 3, P = .0001). Radiographically, there was no significant difference in mean lateral humeral offset (13 ± 6 mm vs. 10 ± 12 mm, P = .472) or the mean acromiohumeral interval (20 ± 4.2 mm vs. 16 ± 6 mm, P = .061) between immediate postoperative and final follow-up radiographs. Radiographic evidence of glenoid loosening was noted in 2 patients. Complications occurred in 6 patients (17.6%), all of which were cases of aseptic glenoid loosening. Ultimately, 4 patients underwent conversion to a reverse TSA and 2 underwent arthroscopic glenoid removal. The rate of prosthesis survivorship was 97.1% (95% confidence interval [CI], 91.4%-100%) at 10 years, 85.4% (95% CI, 73.7%-97.2%) at 15 years, and 80.1% (95% CI, 65.1%-98.4%) at 20 years.

DISCUSSION

TSA consistently improved shoulder functionality and reduced pain while limiting the need for further revisions. These findings suggest that TSA is a viable treatment option for glenohumeral arthritis in younger patients.

Humeral stem lucencies correlate with clinical outcomes in anatomic total shoulder arthroplasty

Background

Humeral stem lucencies are uncommon after uncemented anatomic total shoulder arthroplasty (aTSA), and their clinical significance is unknown. This study compares clinical outcomes of aTSA with and without humeral stem lucencies.

Methods

Two-hundred eighty aTSAs using an uncemented grit-blasted metaphyseal-fit humeral stem between 2005 and 2013 were retrospectively evaluated for radiographic humeral stem lucencies. All shoulders were evaluated at a minimum 5-year follow-up from a multicenter database. Clinical outcomes included range of motion (ROM) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Constant score, University of California-Los Angeles Shoulder Score (UCLA), Simple Shoulder Test (SST), and Shoulder Pain and Disability Index (SPADI) scores. Postoperative radiographs were evaluated and complications were recorded.

Results

Two-hundred forty-three humeral stems showed no radiolucent lines. Among the 37 humeral stems with lucent lines, lines were most common in zones 8, 4, 7, and 3. Preoperative ROM and functional outcomes were similar between groups. Postoperative change in outcomes exceeded the minimal clinically important difference (MCID) for all ROM and outcomes in both groups. Postoperative change between groups showed no significant difference in ROM or outcome scores, but improved mean abduction exceeded the MCID in the patients without humeral lines. The complication rate after omitting patients with humeral loosening was higher in patients with humeral lucencies, as was the revision rate. There was also a higher glenoid-loosening rate in patients with humeral lucencies.

Conclusion

Humeral lucent lines after uncemented stemmed aTSA have a small negative effect on ROM and functional outcomes compared with patients without lucent humeral lines, which may not be clinically significant. The complication and revision rates were significantly higher in patients with humeral lucencies.

Outcomes and Survivorship After Arthroscopic Treatment of Glenohumeral Arthritis: A Systematic Review

PURPOSE

To perform a systematic review of the literature describing outcomes, surgical procedures, and rates of conversion to arthroplasty after arthroscopic debridement of symptomatic primary glenohumeral osteoarthritis.

METHODS

The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and Ovid MEDLINE were queried. Articles without sufficiently detailed descriptions of the debridement procedure, those primarily describing cartilage resurfacing procedures, or those that did not report any postoperative outcomes were excluded. Study design, patient demographic characteristics, operative details, imaging findings, patient-reported outcomes, and rates of conversion to arthroplasty were compiled and reported. Assessment of bias was performed using the Methodological Index for Non-randomized Studies (MINORS) criteria.

RESULTS

A total of 371 patients (382 shoulders) in 8 studies were included. Patient sample sizes ranged from 8 patients (9 shoulders) to 98 patients (107 shoulders), and the samples were predominantly comprised of male patients (range, 57.1%-100%). The mean age and follow-up period ranged from 38 to 59 years and from 13.7 to 46.8 months, respectively. In studies reporting both preoperative and postoperative outcomes, improvements were found in American Shoulder and Elbow Surgeons scores (range, 8.6-22) and visual analog scale scores for pain (range, 0.4-3.8). There was significant heterogeneity (I² = 75%) in the rates of conversion to shoulder arthroplasty, which ranged from 4% to 42.4%, with the mean time to conversion ranging from 9 to 56 months. Study heterogeneity improved with subgroup analyses based on minimum duration of follow-up (>2 years) and preoperative radiographic inclusion criteria.

CONCLUSIONS

Arthroscopic treatment of glenohumeral osteoarthritis provides improvements in ROM and patient-reported outcomes with minimal complications. Despite variability in procedures and rates of subsequent conversion to arthroplasty, arthroscopic treatment appears to provide symptom relief and functional improvements in carefully selected patients. However, the longevity of improvement remains unclear, with studies including a longer duration of follow-up showing potential regression of symptom relief and increased rates of conversion to arthroplasty.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Pyrocarbon interposition shoulder arthroplasty in young arthritic patients: a prospective observational study

BACKGROUND

We evaluated survival and midterm results of pyrocarbon interposition shoulder arthroplasty (PISA) in arthritic patients younger than 65 years.

METHODS

Fifty-eight PISAs (InSpyre; Tornier-Wright, Bloomington, MN, USA), implanted in 56 patients between 2010 and 2015, were prospectively observed. The mean age at surgery was 52 ± 13 years. The cause was primary osteoarthritis (18), fracture sequelae (16), post-instability arthritis (15), aseptic necrosis (3), inflammatory disease (2), and failed hemiarthroplasty (4); 34 shoulders (61%) had previously undergone surgery. Glenoid erosion was assessed in 4 grades according to the Sperling classification. Humeral erosion was also assessed in 4 grades. Multivariate analysis was used to determine predisposing risk factors for both humeral and glenoid erosion.

RESULTS

At a mean follow-up of 47 ± 15 months, survival rate was 90%. Six patients (10%) required conversion to reverse total shoulder prosthesis for painful glenoid erosion (n = 2) and humeral erosion with greater tuberosity stress fractures (n = 4). The mean Constant score and subjective shoulder value significantly increased from 36 ± 14 points to 70 ± 15 points and 32% ± 14% to 75% ± 19%, respectively (P < .001). Humeral medialization was observed in 78% of the cases with increased pain score. Uncorrected anteroposterior implant subluxation (12 cases) was associated with lower Constant score (50 points vs. 72 points; P = .02) and lower subjective shoulder value (53% vs. 78%; P = .002). On multivariate analysis, no risk factors for glenoid or humeral erosion were found.

CONCLUSION

At midterm follow-up, PISA does not protect from progressive glenoid erosion and can lead to greater tuberosity erosion and stress fractures. Longer follow-up is required to see whether PISA survival will be superior to that of hemiarthroplasty.

Short-term outcomes after anatomic total shoulder arthroplasty in patients with osteoarthritis versus osteonecrosis

Background

The outcomes of anatomic total shoulder arthroplasty (TSA) for glenohumeral osteoarthritis (OA) have been extensively reported in the literature. However, there is a paucity of short-term outcomes data on perioperative and post-operative outcomes in patients receiving TSA for either glenoid or humeral head osteonecrosis (ON). We compared the short-term outcomes of TSA performed on patients who had glenohumeral OA and those who had ON. Specifically, we compared: (I) demographics; (II) length-of-stay (LOS); and (III) 30-day postoperative complication rates.

Methods

Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to select 7,066 patients with a diagnosis of glenohumeral OA or ON who underwent TSA between January 1^st, 2008 and December 31^st, 2015. Propensity score matching was performed based on age, sex, race, and body mass index (BMI) with a 3:1 ratio of OA to ON patients. As a result, 387 patients who had a primary diagnosis of OA were compared with 129 patients who had ON. Analyses addressed perioperative complications and hospital disposition factors-including LOS and 30-day post-operative complications-using bivariate and logistic regression models.

Results

Overall complication rates were low in both groups, at 6.1% and 5.4% for the ON and OA cohorts respectively. The ON cohort had more comorbidities, including higher Charlson/Devo and American Society of Anesthesiologists (ASA) scores (P<0.05). Hospital disposition factors were not statistically different between the 2 groups. While not statistically significant, the ON cohort had a longer average (21.1% longer, P>0.05), an increased risk for developing any complication [odds ratio (OR) =2.07; 95% confidence interval (CI), 0.94 to 4.57; P=0.07], and a 134% higher risk for developing a minor complication compared to the OA (OR =2.34; 95% CI, 1.01 to 5.42; P=0.047).

Conclusions

Although the patient populations who develop ON or shoulder OA have differences, there are not statistically or clinically meaningful differences in the short-term outcomes after anatomic TSA. Future studies are required to examine if differences exist in the long-term follow-up between the two groups.

Evaluating Glenohumeral Osteoarthritis: The Relative Impact of Patient Age, Activity Level, Symptoms, and Kellgren-Lawrence Grade on Treatment

BACKGROUND

It is not always clear how to treat glenohumeral osteoarthritis, particularly in young patients. The goals of this study were to 1) quantify how patient age, activity level, symptoms, and radiographic findings impact the decision-making of shoulder specialists and 2) evaluate the observer reliability of the Kellgren-Lawrence (KL) grading system for primary osteoarthritis of the shoulder.

METHODS

Twenty-six shoulder surgeons were each sent 54 simulated patient cases. Each patient had a different combination of age, symptoms, activity level, and radiographs. Responders graded the radiographs and chose a treatment (non-operative, arthroscopy, hemiarthroplasty, or total shoulder arthroplasty). Spearman correlations and chi square tests were used to assess the relationship between factors and treatments. Sub-analysis was performed on surgical cases. An intra-class correlation (ICC) was used to assess observer agreement.

RESULTS

The significant correlations (P<0.01) were: symptoms [0.46], KL grade [0.44], and age [0.11]. In the sub-analysis of operative cases, the significant correlations were: KL grade [0.64], age [0.39], and activity level [-0.10]. The chi square analysis was significant (P<0.01) for all factors, but the practical significance of activity level was minimal. The ICCs were [inter](intra): KL [0.79] (0.84), patient management [0.54].

CONCLUSION

When evaluating glenohumeral osteoarthritis, patient symptoms and KL grade are the factors most strongly associated with treatment. In operative cases, the factors most strongly associated with the choice of operation were the patient's KL grade and age. Additionally, the KL classification demonstrated excellent observer reliability. However, there was only moderate agreement among shoulder specialists regarding treatment, indicating that this remains a controversial topic.

Revision of failed hemiarthroplasty for painful glenoid arthrosis to anatomic total shoulder arthroplasty

BACKGROUND

The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Painful glenoid arthrosis following hemiarthroplasty is a common cause of reoperation, and conversion to anatomic total shoulder arthroplasty is one option.

METHODS

We identified patients who underwent revision of painful hemiarthroplasty to total shoulder arthroplasty over a 15-year period in a single tertiary-care health system. Presurgical and operative data were analyzed for 28 patients who met the inclusion and exclusion criteria. Patients were contacted at a minimum of 2 years' follow-up after revision surgery for functional outcome scores, reoperations, and implant survival.

RESULTS

The 2- and 5-year implant survival rates were 93% and 86%, respectively. Functional outcomes were obtained from 21 patients with surviving implants. The mean American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Single Assessment Numerical Evaluation score were 78 ± 20, 2.3 ± 2.6, and 71 ± 24, respectively. The mean Short Form 12 mental and physical scores were 49 ± 10 and 43 ± 9, respectively. Of the patients, 17 (81%) were either satisfied or very satisfied with their outcome. Complications were seen in 10 patients (36%), and 6 patients (21%) required reoperation.

CONCLUSIONS

Anatomic total shoulder arthroplasty following hemiarthroplasty can achieve successful outcomes and implant survival rates. Given our poor understanding of reverse shoulder arthroplasty longevity, this procedure should remain an option for patients with glenoid arthrosis and an intact rotator cuff.

Return to Recreational Sporting Activities Following Total Shoulder Arthroplasty

Background:

Patients are staying active longer and expect to return to sports or continue participating in recreational activities after total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis.

Purpose/Hypothesis:

The purpose of this study was to assess the ability of patients to return to recreational sports following TSA. We hypothesized that TSA would allow a high rate of return to recreational sports.

Study Design:

Case series; Level of evidence, 4.

Methods:

All patients who underwent primary TSA by a single surgeon and were at least 2 years out from surgery were included and were studied for their ability to return to recreational activity following surgery between December 2005 and January 2015. Patient-reported outcomes were obtained, including the 12-Item Short Form Health Survey–Physical Component Summary (SF-12 PCS); Single Assessment Numeric Evaluation (SANE); Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire; American Shoulder and Elbow Surgeons (ASES) score; and satisfaction scores (10-point scale), preoperatively and at a minimum of 2 years postoperatively. Return-to-sport rates were assessed using a standardized patient-reported outcome questionnaire.

Results:

A total of 165 patients (186 shoulders) that received TSA met the inclusion criteria for the study. Preoperatively, 139 patients (157 shoulders) were involved in recreational sports; 16 (8.6%) shoulders required additional surgical intervention after the index TSA procedure. A significant postoperative increase was noted in the mean ASES (from 48.3 to 87.0; P < .001), QuickDASH (from 41.0 to 15.8; P < .001), SANE (from 49.1 to 81.2; P < .001), and SF-12 PCS scores (from 38.6 to 48.9; P = .004). Of the 157 shoulders in the recreational sports cohort, responses to the survey examining recreational sporting activities after surgery were available for 112 shoulders. The overall rate of return to sport or recreational activity following TSA was 93.7% (105/112 shoulders). The rate of return to recreational sporting activity equal to or better than the preinjury level was 69.7% (78/112 shoulders), while 6.3% (7/112 shoulders) of our cohort reported that they were unable to compete in recreational sports following TSA. Of the patients who participated in predominantly upper extremity sporting activities after TSA, 49% had to modify their postoperative recreational sporting activity because of lifestyle change, pain, weakness, or decreased range of motion.

Conclusion:

Patients undergoing TSA showed excellent postoperative improvement in their outcome scores, satisfaction, and return to athletic activities. Despite the expected decrease in activity levels with the slow progression of osteoarthritis over time until TSA was performed, almost 94% of patients successfully returned to various recreational sporting activities postoperatively. This study showed that return to recreational sports can be achieved at participation levels that are comparable with preoperative levels, but athletes in some sports such as tennis or swimming, which require more intense levels of exercise, are less likely to return to the same participation levels.

Survivorship of Hemiarthroplasty With Concentric Glenoid Reaming for Glenohumeral Arthritis in Young, Active Patients With a Biconcave Glenoid

INTRODUCTION

Hemiarthroplasty with concentric glenoid reaming (known as "ream and run") may be an option for treating glenohumeral arthritis in younger patients with a biconcave glenoid. The goal of this study was to evaluate early results of this technique.

METHODS

Two senior, fellowship-trained shoulder surgeons (G.R.W. and M.D.L.) performed a retrospective review of 23 patients (24 shoulders) with a biconcave glenoid and end-stage degenerative glenohumeral arthritis treated with hemiarthroplasty with concentric glenoid reaming. The mean patient age at the time of surgery was 50 years. We evaluated the Penn Shoulder Score (PSS), Single Assessment Numeric Evaluation (SANE) score, and Simple Shoulder Test (SST) score or the time to revision surgery.

RESULTS

Twenty-four humeral hemiarthroplasties with concentric glenoid reaming were performed in 23 patients. Twenty patients (21 shoulders) reached the end point of 2-year follow-up or revision surgery. Six shoulders (25%) required revision surgery at an average of 2.7 years (range, 0.7 to 7.2 years), and three were lost to follow-up. The remaining 14 patients (15 shoulders) were followed up for an average of 3.7 years (range, 2.3 to 4.9 years). At 2-year follow-up, these 15 shoulders did not require revision surgery and had an average SANE score, PSS, and SST score of 74.5%, 82.9, and 10.4, respectively. Increasing age correlated positively with the SANE score (r = 0.62; P = 0.015), PSS (r = 0.52; P = 0.047), and SST score (r = 0.63; P = 0.012). Early postoperative forward elevation correlated weakly with the PSS (r = 0.24; P = 0.395), and early postoperative external rotation correlated moderately with the PSS (r = 0.53; P = 0.044). Final external rotation correlated moderately with the PSS (r = 0.69; P = 0.005).

DISCUSSION

Modest results were achieved with a hemiarthroplasty and concentric glenoid reaming in young patients with end-stage glenohumeral arthritis and a biconcave glenoid. Younger age and stiffness were associated with worse outcomes. Given the high revision rate and the percentage of patients who had unsatisfactory results, this procedure should be performed only after careful patient selection. Patients who are willing and able to undergo aggressive physical therapy focused on achieving early range of motion are more likely to have a satisfactory outcome after humeral hemiarthroplasty with concentric glenoid reaming.

Comparative outcomes of outpatient and inpatient total shoulder arthroplasty: an analysis of the Medicare dataset

AIMS

The aim of the present study was to compare the 30- and 90-day re-admission rates and complication rates of outpatient and inpatient total shoulder arthroplasty (TSA).

PATIENTS AND METHODS

The United States Medicare Standard Analytical Files database was questioned to identify patients who had undergone outpatient or inpatient TSA between 2005 and 2012. Patient characteristics were compared between the two groups using chi-squared analysis. Multivariate logistic regression analysis was used to control for differences in baseline patient characteristics and to compare the two groups in terms of post-operative complications within 90 days and re-admission within 30 days and 90 days.

RESULTS

A total of 123 347 Medicare subscribers underwent TSA between 2005 and 2012; 3493 (2.8%) had the procedure performed as an outpatient. A significantly greater proportion of patients who underwent TSA as inpatients were women, had a history of smoking, and had a greater incidence of medical comorbidity including diabetes, coronary artery disease, congestive heart failure, and chronic kidney disease (p < 0.05 for all). Re-admission rates were significantly higher for inpatients at both 30 days (0.83% versus 0.60%, p = 0.016, odds ratio 1.8) and 90 days (2.87% versus 2.04%, p < 0.001, odds ratio 1.8). Complications, including thromboembolic events (p < 0.001) and surgical site infection (p = 0.002), were significantly higher in inpatients.

CONCLUSION

Patients who underwent TSA on an outpatient basis were overall younger and healthier than those who had inpatient surgery, which suggests that patient selection was taking place. After controlling for age, gender, and medical conditions, patients who underwent TSA as outpatients had lower rates of 30- and 90-day re-admission and a lower rate of complications than inpatients. Cite this article: Bone Joint J 2017;99-B:934-8.

A comparative analysis of work-related outcomes after humeral hemiarthroplasty and reverse total shoulder arthroplasty

BACKGROUND

The return to work of young patients undergoing shoulder arthroplasty is increasingly important. Whereas studies have shown superior outcomes of reverse total shoulder arthroplasty (RTSA) compared with humeral hemiarthroplasty (HHA), no prior literature has compared RTSA with HHA in regard to return to work.

METHODS

A retrospective review of a prospectively collected shoulder arthroplasty registry was performed to analyze all patients who underwent RTSA or HHA at a single institution. A validated questionnaire evaluating return to work postoperatively was administered at baseline and at follow-up in addition to the American Shoulder and Elbow Surgeons and visual analog scale (VAS) pain surveys.

RESULTS

The study included 40 RTSA and 41 HHA patients. The average age at surgery was 68.6 years in the RTSA group and 60.8 years in the HHA group (P < .001). Postoperatively, 65% of RTSA patients returned to work compared with 70.7% of HHA patients (P = .64). There was no significant difference in the time to return to work between the RTSA (2.3 months) and HHA (3.1 months) groups (P = .46). Both groups had statistically significant improvements in both the American Shoulder and Elbow Surgeons and VAS scores. The improvement in pain on the VAS for patients undergoing RTSA (-5.6) trended toward significance compared with HHA (-4.2) (P = .056).

CONCLUSION

Roughly two-thirds of patients undergoing either HHA or RTSA were able to return to work postoperatively, with no significant difference found between the 2 groups in terms of time to return to work, despite that patients undergoing RTSA were significantly older.

High Satisfaction and Return to Sports After Total Shoulder Arthroplasty in Patients Aged 55 Years and Younger

BACKGROUND

Young, active candidates for total shoulder arthroplasty (TSA) are a unique group of patients. Not only do they demand longevity and improved function, but they also desire a return to physical activities.

PURPOSE

To determine the rate of return to sports in patients aged ≤55 years undergoing TSA.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This was a retrospective review of consecutive patients who underwent anatomic TSA at a single institution. Exclusion criteria included age at the time of surgery >55 years and <2 years of follow-up. All patients had end-stage osteoarthritis with significant glenohumeral joint space narrowing. The final follow-up consisted of a patient-reported sports questionnaire, American Shoulder and Elbow Surgeons (ASES) score, and visual analog scale (VAS) score.

RESULTS

From 70 eligible patients, 59 patients (61 shoulders) were included with an average follow-up of 61.0 months (range, 25-103 months) and average age at the time of surgery of 48.9 years (range, 25-55 years). The average VAS score improved from 5.6 to 0.9 ( P < .001), and the average ASES score improved from 39.3 to 88.4 ( P < .001). Forty-nine procedures (80.3%) were performed for a primary diagnosis of osteoarthritis. Four shoulders returned to the operating room; none were for glenoid loosening. There was a 93.2% satisfaction rate, and 67.7% of patients (n = 40) stated that they underwent their surgery to return to sports. Moreover, patients in 96.4% of shoulders (55/57) restarted at least 1 sport at an average of 6.7 months. Direct rates of return were as follows: fitness sports (97.2%), golf (93.3%), singles tennis (87.5%), swimming (77.7%), basketball (75.0%), and flag football (66.7%). Patients in 47 shoulders (82.4%) returned to a similar or higher level of sports; 90.3% returned to high-demand sports, and 83.8% returned to high upper extremity sports. There was no significant difference in rates of return to sports by body mass index, sex, age, preoperative diagnosis, revision status, and dominant extremity.

CONCLUSION

In patients aged ≤55 years undergoing TSA, there was a 96.4% rate of return to ≥1 previous sports at an average of 6.7 months. Furthermore, at an average follow-up of 61.0 months, no patients needed revision of their glenoid component, despite an 83.8% rate of return to high upper extremity sports. While caution should still be advised in young, active patients undergoing TSA, these results demonstrate a high satisfaction rate and improved ability to return to most sports after surgery.

Anatomic Humeral Head Reconstruction With Fresh Osteochondral Talus Allograft for Recurrent Glenohumeral Instability With Reverse Hill-Sachs Lesion

The treatment of recurrent glenohumeral instability, especially with a concomitant bony lesion, remains challenging. This is especially true in the case of posterior instability given its less common incidence. Moreover, the presence of an engaging reverse Hill-Sachs lesion in combination with posterior instability will result in the need for a more aggressive treatment option. In comparison with a Hill-Sachs lesion, a reverse Hill-Sachs lesion features greater chondral deficiency that must be addressed during treatment. We propose the talus allograft as a potential allograft for treatment of an engaging reverse Hill-Sachs lesion. The superior articular surface of the talus may be used to reconstruct the articular surface of the humeral head. In this technical note, we describe our preferred primary technique for treatment of an engaging reverse Hill-Sachs lesion with recurrent glenohumeral instability through use of a fresh osteochondral talus allograft, as well as discuss the advantages and disadvantages of this allograft option.