Patient reported outcome measures of bilateral reverse total shoulder arthroplasty compared to bilateral anatomic total shoulder arthroplasty

How common is nerve injury after reverse shoulder arthroplasty? A systematic review

BACKGROUND

Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature.

METHODS

A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms "reverse shoulder," "reverse total shoulder," "inverted shoulder," and "inverted total shoulder" with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected.

RESULTS

After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases.

CONCLUSION

Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.

Outcomes after bilateral shoulder arthroplasty: a systematic review

The purpose of this systematic review was to report outcomes after bilateral shoulder arthroplasty including bilateral total shoulder arthroplasty (TSA), bilateral reverse shoulder arthroplasty (RSA), and ipsilateral TSA with contralateral RSA (TSA/RSA). Two reviewers independently performed a PRISMA-guided systematic search using MEDLINE/PubMed, Embase, and Cochrane Database of Systematic Reviews up to May 11, 2021. The databases were queried using the following search terms: (["bilateral" OR "contralateral"] AND "shoulder" AND ["arthroplast∗" OR "replacement"]). A total of 486 titles/abstracts were screened for eligibility and 19 studies were included in the final analysis. Risk of bias was assessed using Methodological Index for Nonrandomized Studies and Modified Coleman Methodology scores. Analysis compared overall results for bilateral shoulder arthroplasty and sub-group analyses compared TSA (all shoulders from bilateral TSA patients and the TSA shoulder in TSA/RSA patients) to RSA (all shoulders from bilateral RSA patients and the RSA shoulder in TSA/RSA patients), first shoulder arthroplasty to second contralateral shoulder arthroplasty, and interval between arthroplasty (IBA) <20 months to IBA ≥20 months. Nineteen studies analyzed bilateral TSA (n = 3), bilateral RSA (n = 7), and TSA/RSA (n = 8). The mean Methodological Index for Nonrandomized Studies was 18 and mean Modified Coleman Methodology Score was 74, with 63.2% of studies demonstrating level III evidence. A total of 2729 patients (30.4% male; mean age 72.2 years, mean follow-up 47.3 months, mean IBA 20 months) were analyzed. Postoperative forward flexion (142.0° vs. 129.6°), external rotation (ER) (42.5° vs. 25.6°), and internal rotation (60% reaching T12-T8 vs 85.7% reaching L3-L1) were higher for TSA when compared to RSA. Patient reported outcome measures such as Constant-Murley (73.2 vs. 59.2), American Shoulder and Elbow Surgeons (87.9 vs. 77.7), and Single Assessment Numeric Evaluation (SANE) (86.9 vs. 67.8) were higher for TSA when compared to RSA. Patients with IBA ≥20 months demonstrated greater ER and patient satisfaction than patients with IBA <20 months. Postoperative complication rates were 15.1% for TSA and 10.6% for RSA, while reoperation and revision rates were 13.7% for TSA and 7.1% for RSA. Bilateral shoulder arthroplasty results in improvements in motion, strength, pain, function, and high satisfaction. Bilateral TSA is associated with greater improvement in motion and function than bilateral RSA but higher complication, reoperation, and revision rates. IBA ≥20 months is associated with greater ER and satisfaction than IBA <20 months.

The relationship of bilateral shoulder arthroplasty timing and postoperative complications

BACKGROUND

Though several case series have described bilateral shoulder arthroplasty results with range of motion, patient-reported outcomes, and complications, little guidance exists regarding the optimal interval timing between surgeries.

METHODS

All patients from 2 insurance databases who underwent staged bilateral shoulder arthroplasty between 2005 and 2016 were identified. These patients were then stratified by elapsed time between surgeries into 4 study groups: (1) less than 3 months, (2) 3-6 months, (3) 6-9 months, and (4) 9-12 months. Surgical and perioperative medical complications of these patient cohorts were compared to a control group that underwent bilateral shoulder arthroplasty with a greater than 1-year interval between surgeries.

RESULTS

From 2005-2016, a total of 1764 patients (6.3%) underwent bilateral shoulder arthroplasty out of 27,962 shoulder arthroplasties performed in the 2 databases. Of the bilateral patients, 49.1% waited more than 1 year before their second shoulder arthroplasty. Patients waiting less than 3 months between surgeries comprised 4.9% of the total number of staged bilateral surgeries. Demographics and comorbidities were similar between the study groups. Overall, implant complications were higher in patients with surgeries less than 3 months apart compared to controls, including revision arthroplasty (11.6% vs. 5.4%, odds ratio [OR] 2.29, P = .037), loosening/lysis (8.1% vs. 3.5%, OR 2.46, P = .032), and periprosthetic fracture (4.7% vs. 1.2%, OR 4.18, P = .010). There were no significant increases in any implant-related complications when surgeries were staged by 3 months or more compared to controls. Venous thromboembolism (VTE; 8.1% vs. 2.2%, OR 3.95, P = .001) and blood transfusion (9.3% vs. 1.7%, OR 5.82, P < .001) occurred at a significantly higher rate in patients with less than 3 months between surgeries compared with controls. There were no differences in any medical complications when surgeries were staged by 3 months or more compared with controls.

CONCLUSIONS

Patients with staged bilateral shoulder arthroplasty who have the second arthroplasty within 3 months have significantly higher rates of revision surgery, loosening/lysis, periprosthetic fracture, VTE, and blood transfusions. Based on these lower complication rates, surgeons should consider waiting a minimum of 3 months before performing the second portion of a staged bilateral shoulder arthroplasty.