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Abstract

Shoulder arthroplasty outcomes have been reported in many case series. Typically, these series have followed either a single prosthesis used to treat a variety of arthritic disorders of the shoulder or experience in a single institution. In contrast, this report of a prospective study summarizes the experience of several surgeons with a single prosthetic design for treatment of primary osteoarthritis of the shoulder. A prospective, multicenter clinical outcome study evaluated 176 shoulders in 160 patients with primary osteoarthritis. This study evaluated a single prosthetic design (Global Shoulder) used by 19 contributing surgeons. Enrollment included 133 total shoulder replacements and 43 humeral head replacements (hemiarthroplasty) in 98 men and 62 women. Neither age nor sex affected whether hemiarthroplasty or total shoulder arthroplasty was performed. Patients with full-thickness cuff tears preferentially had hemiarthroplasty. The decision to perform total shoulder arthroplasty or hemiarthroplasty was based on the surgeon's preference. There were significant improvements (P <.001) in all evaluated and self-assessed outcome parameters from the preoperative baseline for both total shoulder arthroplasty and hemiarthroplasty. The results confirm that prosthetic arthroplasty leads to dramatic improvement in pain, function, and patient satisfaction. Intraoperative complications occurred in 5.4% of cases, and postoperative complications occurred in 7.8%. The most common intraoperative complications were intraoperative fractures, occurring in 9 cases. The most common postoperative complications were glenoid component loosening and humeral head subluxation. Almost all cases of humeral head instability were associated with rotator cuff tears or glenoid component loosening (or both). Seven shoulders underwent 9 additional surgeries during the 5-year study period. Thirteen shoulders in 11 patients were lost as a result of death unrelated to the procedure; 2 shoulders in 1 patient were lost within 3 days/3 months after the bilateral replacements as a result of death from pulmonary embolism. Nine percent of the shoulders (16/176) had full-thickness rotator cuff tears. Eight of the 16 shoulders with full-thickness supraspinatus cuff tears had hemiarthroplasty. All of these tears were isolated to the supraspinatus tendon, and all were repairable. There were no differences in postoperative pain, function, American Shoulder and Elbow Surgeons scores, or range of motion. There were no differences between total shoulder arthroplasty and hemiarthroplasty in those patients with a reparable rotator cuff tear. Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis result in good or excellent pain relief, improvement in function, and patient satisfaction in 95% of cases. Avoiding intraoperative humeral shaft fractures through use of an uncemented, canal-filling prosthetic stem requires careful attention to reaming and component sizing. Postoperative humeral head subluxation is often associated with other factors including rotator cuff tears or glenoid component loosening.

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... 4 Treatment options for this demographic have been pursued with varying outcomes. 2 The best treatment management remains controversial, 6,7 and despite the benefits of arthroplasty on pain and functional improvement, [8][9][10][11][12][13] concerns about implant longevity and the need for revision remain a dilemma. 3,8,[14][15][16][17][18][19][20] Numerous surgical options have been proposed including arthroscopic management, 2,21-23 hemiarthroplasty (HA), 2,3,8,[17][18][19][24][25][26][27][28][29][30][31][32][33] hemiarthroplasty with glenoid biological resurfacing (HABR), 2,20,31,[34][35][36][37][38][39][40][41][42][43][44][45] anatomical total shoulder arthroplasty (TSA) [2][3][4]14,18,26,27,33,[46][47][48][49][50] and reverse total shoulder arthroplasty (RSA). ...
... 3,8,[14][15][16][17][18][19][20] Numerous surgical options have been proposed including arthroscopic management, 2,21-23 hemiarthroplasty (HA), 2,3,8,[17][18][19][24][25][26][27][28][29][30][31][32][33] hemiarthroplasty with glenoid biological resurfacing (HABR), 2,20,31,[34][35][36][37][38][39][40][41][42][43][44][45] anatomical total shoulder arthroplasty (TSA) [2][3][4]14,18,26,27,33,[46][47][48][49][50] and reverse total shoulder arthroplasty (RSA). [51][52][53][54][55][56] Generally, TSA consistently improves symptoms and shoulder function, 11,[57][58][59][60] although, glenoid component loosening and need for revisions remain a concern. 34,61 HA may be an attractive solution, however, this technique provides significantly less pain relief and functional improvement than does TSA. ...
... For appropriately selected patients, TSA decreases pain and improves shoulder function. 11,73 In patients mainly with secondary and complex forms of osteoarthritis, as severe rotator cuff deficiency, which is uncommon in young patients (<60 years old), TSA may not be a viable treatment option. These patients represent a rare and special population that needs to be prudently addressed. ...
Article
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Aim This study aims to describe the shoulder arthroplasty options for young and active patients (<60 years old) with glenohumeral osteoarthritis. Methods A systematic review of the literature was conducted by searching on Pubmed database. Studies that reported outcomes of patients with glenohumeral arthritis, younger than 60 years, that underwent shoulder arthroplasty [(Hemiarthroplasty (HA), Hemiarthroplasty with biological resurfacing (HABR), Total shoulder arthroplasty (TSA), Reversed total shoulder arthroplasty (RSA)] were included. Data include patient characteristics, surgical technique, range of motion, pain relief, outcome scores, functional improvement, complications, need for and time to revision. Results A total of 1591 shoulders met the inclusion criteria. Shoulder arthroplasty provided improvements in terms of ROM on the 3 plains, forward flexion (FF), abduction (Abd) and external rotation (ER), in different proportions for each type of implant. Patients submitted to RSA had lower preoperative FF (p = 0.011), and the highest improvement (Δ) in Abd, but the worst in terms of ER (vsTSA, p = 0.05). HA had better ER postoperative values (vsRSA p = 0.049). Pain scores improved in all groups but no difference between them (p = 0.642). TSA and RSA groups had the best CS Δ (p = 0.012). HA group had higher complication rates (21.7%), RSA (19.4%, p = 0.034) and TSA (19.4%, p = 0.629) groups the lowest, and HABR had the highest rate of revisions (34.5%). Conclusions HA had the highest rate of complications and HABR unacceptable rates of revision. These implants have been replaced by modern TSAs, with RSA reserved for complex cases. Surgeons should be aware of the common pitfalls of each option.
... Two operative techniques may be used for total shoulder replacement: anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). Historically, TSA has been the gold-standard of care and has high rates of successful restoration of functional range of motion [5,15,18]. However, since this technique necessitates the presence of an intact and functional rotator cuff for normal glenohumeral range of motion [29], patients with rotator cuff deficiencies have experienced poor clinical outcomes following TSA [8,18,22,30]. ...
... Historically, TSA has been the gold-standard of care and has high rates of successful restoration of functional range of motion [5,15,18]. However, since this technique necessitates the presence of an intact and functional rotator cuff for normal glenohumeral range of motion [29], patients with rotator cuff deficiencies have experienced poor clinical outcomes following TSA [8,18,22,30]. In contrast, RSA does not rely on an intact rotator cuff, and consequently has proved to be a successful and reliable technique in managing these patients [2,7,16,17,27]. ...
Article
BACKGROUND Historically, anatomic total shoulder arthroplasty (TSA) has been the gold-standard of care for patients with glenohumeral osteoarthritis refractory to nonoperative treatment. With expanding indications, utilization of reverse total shoulder arthroplasty (RSA) has been rapidly increasing. The purpose of this study was to use a nationwide patient database with contemporary data to identify and compare joint and systemic complication rates following primary TSA and RSA. METHODS Patients records of patients receiving TSA or RSA were queried from PearlDiver (Fort Wayne, IN), a commercially available administrative claims database, using International Classification of Diseases, Ninth Revision and Tenth Revision (ICD-9/ICD-10) and Current Procedural Technology (CPT) codes. Incidences of postoperative joint complications were measured at 90-days and 1-year post-discharge. Incidences of systemic complications were measured at 90-days post-discharge. Complication rates were compared using logistic regression. Demographic data was also compared using chi-square analysis. RESULTS From 2007-2017, a total of 17,681 patients received primary total shoulder arthroplasty: 8,846 (50%) received TSA and 8,835 (50%) received RSA. A greater proportion of patients that underwent RSA were female (p < 0.001), over the age of 80 (p < 0.001), and had a higher average Charlson comorbidity index (2.49 vs. 1.99, p < 0.001). At 90-days post-discharge, patients that received RSA were more likely to have prosthetic joint infection (OR 1.66; 95% CI 1.30-2.70), periprosthetic fracture (OR 4.01; 95% CI 3.32-4.87), prosthetic dislocation (OR 2.10; 95% CI 1.57-2.85), and adjacent local scapular/acromion fractures (OR 3.58; 95% CI 2.05-6.71). At 1-year, these patients still had a higher association with periprosthetic fracture (OR 3.66; 95% CI 3.08-4.38), prosthetic dislocation (OR 1.40; 95% CI 1.12-1.75), and local fractures (OR 3.10; 95% CI 2.10-4.73). Patients that underwent TSA were more likely to have prosthetic loosening (OR 0.64; 95% CI 0.45-0.90) and prosthetic stiffness (OR 0.91; 95% CI 0.84-0.99). Additionally, patients that underwent RSA exhibited higher rates of DVT (OR 1.29; 95% CI 1.03-1.62), anemia (OR 1.42; 95% CI 1.25-1.62), acute renal failure (ARF) (OR 1.35; 95% CI 1.13-1.61), pneumonia (OR 1.23; 95% CI 1.02-1.48), and respiratory failure (OR 1.81; 95% CI 1.46-2.26). CONCLUSION Patients undergoing RSA exhibited higher rates of joint complications at both 90-days and 1-year post-discharge. These patients also experienced higher rates of systemic complications in the 90-day postoperative period, likely due to overall poorer health status. LEVEL OF EVIDENCE Level III; Treatment Study
... Primary shoulder arthroplasty (SA) is an expanding field in treating proximal humeral fractures and degenerative shoulder disorders, including osteoarthritis and cuff tear arthropathy (CTA) [1]. In 2012, 34 glenohumeral joint replacements per 10 5 inhabitants were performed in Germany, which means a tripling of the annual incidence in the past decade [2]. ...
Article
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Background: Periprosthetic shoulder infections are devastating complications after shoulder arthroplasty. A potential treatment concept is a two-stage prosthesis exchange. Data are sparse in terms of clinical outcome, including infection-free survival and patient satisfaction after this procedure. In the present study, we investigated recurrence of infection, revision-free survivorship and clinical outcome following two-stage revision due to periprosthetic shoulder infection. Furthermore, reasons for poor outcome were analyzed. Methods: Sixteen patients undergoing two-stage revision after shoulder joint infection were retrospectively identified. Recurrence of infection was analyzed by Kaplan-Meier survival curve. Clinical outcome was quantified with subjective shoulder value (SSV), "quick" Disabilities of the Arm, Shoulder and Hand (qDASH) and Rowe score. Range of motion (ROM) was measured pre- and postoperatively. Postoperative scores and ROM were compared in a subgroup analysis according to different reimplanted prosthesis types. Results: The reinfection-free implant survival was 81% after one year and at final follow-up (FU; mean of 33.2 months). The overall revision-free survival amounted to 56% after one year and at final FU. Patients who received reverse shoulder arthroplasty (RSA) as part of reimplantation had less disability and long-term complications. This group demonstrated better subjective stability and function compared to patients revised to megaprostheses or large-head hemiarthroplasties. Conclusions: Two-stage revision following periprosthetic joint infection of the shoulder allows appropriate infection control in the majority of patients. However, the overall complications and revision rates due to mechanical failure or reinfection are high. Reimplantation of RSA seem superior to alternative prosthesis models in terms of function and patient satisfaction. Therefore, bone-saving surgery and reconstruction of the glenoid may increase the likelihood of reimplantation of RSA and potentially improve outcome in the case of infection-related two-stage revision of the shoulder.
... Anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) are orthopedic procedures found to improve satisfaction and quality of life in patients with shoulder arthritis [35]. Annual TSA and RTSA procedures performed in the United States are steadily increasing in recent years with one study reporting an increase in utilization from 6.1 to 13.4 per 100,000 patients from 2005 to 2013 [9]. ...
Article
Introduction : With the heightened focus on lowering adverse postoperative events through preoperative patient optimization, malnutrition may be a modifiable risk factor that could be addressed and lead to improved postoperative outcomes. However, an understanding of the association between malnutrition status and adverse postoperative events following shoulder arthroplasty is lacking. We sought to evaluate the association between preoperative malnutrition status, identified via the total serum lymphocyte count, and adverse postoperative events following shoulder arthroplasty. Methods : We conducted a cohort study using data from an integrated healthcare system's shoulder arthroplasty registry. Patients who underwent elective primary shoulder arthroplasty were identified (2005-2016). Patients with a preoperative total lymphocyte count <1500 cells/mm³ were defined as malnourished. A competing risk Cox multi-state model was used to evaluate the association between malnutrition and revision or death with stratification by age. Multiple logistic regression was used to evaluate 5-year deep infection, 90-day ED visit, 90-day readmission, and 90-day VTE. Receiver operating characteristic (ROC) curves were generated for discrete total lymphocyte counts to determine whether a threshold exists to identify patients at higher risk of adverse postoperative events. Results : The final study cohort comprised 6956 shoulder arthroplasty patients, with 2133 (30.7%) identified as malnourished. No difference in septic or aseptic revision risks was observed when comparing patients with and without malnutrition; however, malnourished patients had a higher risk for death, regardless of age (<60 years: hazard ratio [HR]=2.25, 95% confidence interval [CI]=1.07-4.73; ≥60 years: HR=1.47, 95% CI=1.28-1.70). We did not observe a difference in likelihood of deep infection, ED visit, readmission, or VTE. ROC curve analysis suggested preoperative total lymphocyte count performed poorly at differentiating adverse events. Conclusions : Only a higher mortality risk was observed to be associated with total lymphocyte count-defined malnutrition in patients undergoing elective shoulder arthroplasty. When instead looking at total lymphocyte count continuously, an optimal threshold for discriminating risk of adverse postoperative events could not be identified. Further study is needed to identify an appropriate indicator of malnutrition in shoulder arthroplasty patients and if this indicator can be modified to improve patient status and quality of care. Level of evidence : Level III
... Traditional onlay glenoid prostheses exhibit signs of loosening at relatively high rates, even when optimally placed [44][45][46]. Metal-backed glenoids have fallen out of favor due to the unacceptably high failure rates [47], so all-polyethylene designs are the gold standard. Though somewhat controversial, pegged onlay glenoids appear to have superior survivorship to keeled glenoids [45,48]. ...
Article
Full-text available
Innovations currently available with anatomic total shoulder arthroplasty include shorter stem designs and augmented/inset/inlay glenoid components. Regarding reverse shoulder arthroplasty (RSA), metal augmentation, including custom augments, on both the glenoid and humeral side have expanded indications in cases of bone loss. In the setting of revision arthroplasty, humeral options include convertible stems and newer tools to improve humeral implant removal. New strategies for treatment and surgical techniques have been developed for recalcitrant shoulder instability, acromial fractures, and infections after RSA. Finally, computer planning, navigation, PSI, and augmented reality are imaging options now available that have redefined preoperative planning and indications as well intraoperative component placement. This review covers many of the innovations in the realm of shoulder arthroplasty.
... 37 However, intraoperative and postoperative complications remain a common challenge, reportedly occurring in 5.4% and 7.8% of cases, respectively. 27 The most frequently reported long-term complication of TSA is glenoid loosening, accounting for approximately 24% of all TSA complications. 15 The cause of glenoid loosening is likely multifactorial and may be related to surgical technique, implant design, patient characteristics, rotator cuff integrity, or the presence of indolent infections. ...
Article
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Background Surgeon- and patient-specific characteristics as they pertain to total shoulder arthroplasty (TSA) are limited in the literature. The influence of surgeon upper extremity dominance in TSA and whether outcomes vary among patients undergoing right or left TSA with respect to surgeon handedness have yet to be investigated. Purpose To determine whether surgeon or patient upper extremity dominance has an effect on clinical outcomes after primary TSA at short-term follow-up. Study Design Case series; Level of evidence, 4. Methods A retrospective chart review was performed on prospectively collected data from an institutional shoulder registry. Patients who underwent primary TSA for glenohumeral osteoarthritis from June 2008 to August 2012 were included in the study. Preoperative and postoperative American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), and visual analog scale (VAS) pain scores were evaluated. To determine the clinical relevance of ASES scores, the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), and the patient acceptable symptom state (PASS) were used. Active forward elevation, abduction, and external rotation were recorded for each patient. Glenoid version was also evaluated preoperatively on standard radiographs. Results Included in this study were 40 patients (n = 44 shoulders; mean age, 69.0 ± 7.3 years) with a mean follow-up of 36.5 ± 16.2 months. Final active range of motion between patients who underwent dominant versus nondominant and left versus right TSA by a right-handed surgeon was not significantly different. Clinical outcomes including the ASES, SST, and VAS pain scores were compared, and no statistical significance was identified between groups. With regard to the ASES score, 89% of patients achieved the MCID, 64% achieved the SCB, and 60% reached or exceeded the PASS. No significant difference in preoperative glenoid version between groups could be found. Conclusion With the numbers available, neither patient nor surgeon upper extremity dominance had a significant influence on clinical outcomes after primary TSA at short-term follow-up. Clinical Relevance The influence of surgeon and patient upper extremity dominance on TSA outcomes is an important consideration, given the preferential use of the dominant extremity exhibited by most patients during activities of daily living. To this, operating on a right shoulder might be technically more demanding for a right-handed surgeon and vice versa, as it is considered in other subspecialties.
... While not the primary driver of the golf swing, shoulder motion is an essential aspect of the swing and limitations in shoulder abduction and external rotation inhibit performance (13). Outcomes following TSA offer reliable pain relief and return to function for patients suffering from advanced shoulder osteoarthritis (14,15). A meta-analysis of patients undergoing any )310( type of shoulder replacement (anatomic, reverse or hemiarthroplasty) found an overall return to sport rate of 80.7% (16). ...
Article
Object: The object of this study was to examine return to golf and changes in golf performance after shoulder arthroplasty. Additionally, we set out to determine if there were differences in return to play and performance between total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). We also examined pain during the golf swing to determine if there is a change in pain level after surgery. Methods: Patients were identified using a Current Procedural Terminology code 23472 search for TSA. A 19-question online survey was sent out to each patient with questions detailing golfing performance and pain during the swing before and after surgery. Comparisons were made to determine differences in pain, performance and enjoyment between TSA and RTSA groups before and after surgery. Results: A total of 586 patients who underwent shoulder arthroplasty were sent the online survey via email. Of those patients, 33 identified themselves as golfers and who responded to the survey, resulting in an overall response rate of 5.6%. Twenty-three of 31 (74%) patients were able to return to golf following their procedure. Overall, the respondents who reported pain associated with golfing activity had significantly decreased pain after undergoing either TSA or RTSA. The RTSA group had a significant drop in driving distance following the procedure and this was significantly lower than the postoperative driving distance in the TSA group, despite an insignificant preoperative difference. Conclusions: Overall, TSA offers a safe and effective means for reducing pain during the golf swing in patients suffering from advanced shoulder osteoarthritis. While there were no significant changes in performance following TSA, individuals undergoing RTSA can be counseled that they are at risk for lower driving distances due to altered mechanics. Overall, patients were satisfied with their procedure and their ability to return to the golf course.
... The prevalence of shoulder arthroplasty is increasing, likely because of consistently favorable outcomes, an aging population, and expanding surgical indications [1][2][3][4] . Researchers project a ninefold increase in arthroplasty within the general population (to 184.8 cases per 100,000 people) and a threefold increase among patients who are <55 years old (to 10.1 cases per 100,000 people) in the United States from 2011 to 2030 5 . ...
... The humeral shaft is then sized, and the humeral implant is placed and cemented. (Wierks et al. 2009) Among the most critical aspects for the success of TSA procedures is achieving accurate positioning and orientation of the glenoid component of the implant to reduce the likelihood of loosening, one of the most common post-operative complications of this procedure (Levy et al. 2014;Norris and Iannotti 2002;Nyffeler et al. 2006;Mansat et al. 2007). In order to minimize mechanical failures, implants should be as centrally aligned as possible (Hopkins et al. 2004). ...
Article
Full-text available
Total Shoulder Arthroplasty (TSA) is a shoulder replacement procedure to treat severe rotator cuff deficiency, primarily caused by osteoarthritis in elderly patients. One of the critical factors in reducing postoperative complications is accurate drilling of a centring hole on the glenoid surface at a precise position and orientation. While the drilling path is planned pre-operatively on 3D diagnostic images, the absence of visual guidance during surgery can lead to low reproducibility. In this paper, we present the design and feasibility analysis of a marker-less image-based registration pipeline using the Microsoft HoloLens 1 and its built-in sensors to guide glenoid drilling during TSA. Our solution intra-operatively registers the pre-operative 3D scan to the exposed glenoid surface both with and without occlusion. Our results provide a breakdown of the sources contributing to registration error. In addition to the commonly discussed errors (SLAM-based head tracking, partial overlap etc.), we find that the poor performance of the depth sensing camera becomes a major source of error. We further find that partial overlap between the source and target remains a large concern for registration in high occlusion scenarios. This work begins to characterise the depth sensor error and suggests future work towards image-based augmented reality guidance.
... 25 Historically, anatomic total shoulder arthroplasty (TSA) has been the standard surgical indication for patients with primary glenohumeral osteoarthritis (GHOA) and an intact and functioning rotator cuff. 7,18 Conversely, the more highly constrained reverse shoulder arthroplasty (RSA) has been reserved for those patients without a functioning rotator cuff. 5,32 Because of the overall success of RSA in patients with defective rotator cuffs, however, the surgical indications for RSA have expanded to include other conditions, such as primary GHOA with severe bone loss or soft-tissue imbalance, complex fractures, tumor, and avascular necrosis, regardless of the presence of a functioning rotator cuff. ...
Article
Background The relative indications of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) continue to evolve. Some surgeons favor RSA over TSA for elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff due to fear of a postoperative (secondary) rotator cuff tear in this age group. However, RSA is associated with unique complications and a worse functional arc of motion compared to TSA. Therefore, it is important to understand the clinical outcomes and rates of revision surgery and secondary rotator cuff tears in elderly patients undergoing TSA. Methods Between January 1st, 2010 and December 31st, 2017, 377 consecutive TSAs were performed for primary GHOA in 340 patients seventy years of age or older. The mean age at surgery was 76.2 years (SD 4.9). Clinical evaluation included pain, motion, and ASES score. Radiographs were reviewed for preoperative morphology and postoperative complications. All complications and reoperations were recorded. The average clinical follow-up time was 3.3 years (SD 2.0). Statistical analyses were performed, and Kaplan-Meier implant survival estimates were calculated. For all analyses, a p value < .05 was considered statistically significant. Results The mean pain VAS and ASES score at final follow-up were 1.6 (SD 2.2) and 78.0 (SD 17.8), respectively. Forward elevation and external rotation increased from 96o (SD 30o) and 26o (SD 20o) preoperatively to 160o (SD 32o) and 64o (SD 26o) postoperatively (p < .001 for each). The percentage of patients who had internal rotation to L5 or greater increased from 24.8% preoperatively to 71.8% postoperatively (p < .001). Revision surgery was performed in three shoulders (0.8%) and the five-year implant survival estimate 98.9% (95% CI 97.3-100%). There were three medical (0.8%), ten minor surgical (2.7%), and five major surgical (1.3%) complications. No shoulder had radiographic evidence of humeral component loosening while seven (2%) had evidence of some degree of glenoid component loosening. In total, there were five secondary rotator cuff tears (1.3%), of which two (0.5%) required revision surgery. Conclusion Elderly patients with primary GHOA and an intact rotator cuff have excellent clinical and radiographic outcomes following anatomic TSA, with high implant survival rates and a low incidence of secondary rotator cuff tears in the first five postoperative years. Age greater than seventy by itself should not be considered an indication for RSA over TSA. Level of Evidence Level IV; Case Series; Treatment Study
... Osteoarthritis (OA) of the glenohumeral joint often result in painful shoulders [13,25]. In cases when surgical intervention is warranted, joint replacement has been recommended by the American Academy of Orthopedic Surgeons (AAOS) as it has been shown to result in signi cant improvement of pain, quality of life, function, and overall patient health [9,16,18,24,33,34,37,44,45]. Moreover, total shoulder arthroplasty (TSA) has been recommended by AAOS over hemiarthroplasty (HA) due to better outcomes and less chance of revision [30]. ...
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Background Osteoarthritis (OA) is a common shoulder disorder that impacts shoulder functions. Shoulder arthroplasty is often required to restore function and quality of life. Reverse total shoulder arthroplasty (RSA), which was originally designed mainly for irreparable rotator cuff damage, has gained popularity in recent years for the treatment of advanced shoulder OA instead of the clinically standard total shoulder arthroplasty (TSA). However, this RSA has some nonnegligible flaws such as higher complications rate and economic cost, not mention the following problems caused by irreversible physical structural damage. Therefore, the employment of RSA needs to be carefully considered.PurposeThis study aimed to compare TSA and RSA in OA patients with or without rotator cuff damage to better guide clinical decision making. We believe the radical use of RSA in patients without rotator cuff deficiency may cause more harm than good.Study designCross-sectional studyMethods We queried the Nationwide Inpatient Sample (NIS) database from 2011 to 2014 to collect information on OA patients who received TSA and RSA. Patients were divided into 2 groups of comparison according to the presence of rotator cuff deficiency and matched with propensity score analysis.Results A total of 57,156 shoulder arthroplasties were identified. RSA patients in the rotator cuff deficiency group had significant higher transfusion rates and longer hospital stays. RSA patients without rotator cuff deficiency had a statistically significantly higher number of implant-related mechanical complications, acute upper respiratory infections and postoperative pain. Overall, RSA incurred higher costs in both groups.Conclusion For OA patients with rotator cuff deficiencies, RSA has its benefits as complication rates were comparable to TSA. For those patients without rotator cuff deficiencies, the use of RSA should be reconsidered as there were more complications with higher severity.
Article
This article provides a review of the various options for the treatment of osteoarticular pathology of the shoulder. This can range from focal osteochondral defects to diffuse arthritis and can occur at any age. Although total shoulder arthroplasty and hemiarthroplasty are the most frequently used methods, they not generally suitable for younger patients under 60 years old due to the lack of long-term stability and deterioration. If conservative treatment is unsuccessful or not an option, resurfacing is an alternative procedure with good long-term results. The various methods that have been reported for resurfacing and partial resurfacing of the humeral head are described as well as the results of studies on these procedures. In this article the indications, biomechanics, outcomes and complications are outlined for the two resurfacing options preferred by the authors.
Article
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Background Stem-free shoulder arthroplasty has recently been shown to have comparable results to stemmed arthroplasty, though stemless designs are typically used in a younger patient population. Additionally, although the native humeral head is elliptical in shape, clinical results with ellipsoid implants in shoulder arthroplasty have not been reported on previously. This case series reports on the outcomes of a recently introduced anatomic total shoulder arthroplasty with an ellipsoid-shaped articular surface and unique multiplanar platform type of stemless fixation. Methods This retrospective case series examines the initial cohort of patients that received an anatomic total shoulder arthroplasty using an ellipsoid stem-free humeral prosthesis and an all-polyethylene glenoid component from the Catalyst CSR Total Shoulder System (Catalyst OrthoScience, Naples, FL, USA) over a one-year period. Inclusion criteria were patients with a diagnosis of advanced glenohumeral joint arthritis with an intact rotator cuff, regardless of patient age. Clinical outcomes including shoulder range of motion and patient reported outcome measures, as well as radiographs, were evaluated at multiple time points postoperatively, with minimum 2-year follow-up. Results Sixty-three shoulders in 57 patients with a mean age of 73.0 years (range 60-85 years) were included in the study with a mean follow-up period of 30.5 months (range 24-41 months). Forward elevation improved from 121° to 150° (p<0.0001), external rotation improved from 28° to 48° (p<0.0001) and internal rotation improved from L3 to L1 (p<0.001). There were statistically significant improvements exceeding the minimal clinically important difference (MCID) in the American Shoulder and Elbow Surgeons score (37 to 94, p<0.001), Single Assessment Numeric Evaluation (40 to 93, p<0.001), Visual Analog Scale (6.3 to 0.4, p<0.001), and PROMIS physical domain T-score (44 to 57, p<0.001). The improvement in the ASES score also exceeded the threshold for the substantial clinical benefit (SCB). Age, sex, and preoperative glenoid morphology did not appear to have effect on clinical outcome scores. There were no implant failures or evidence of radiographic loosening of the humerus component in any patients. Conclusion At two-year minimum follow-up, this stem-free ellipsoid humerus total shoulder arthroplasty provides very good results with high patient satisfaction, clinical improvement in all outcome measures studied, and no signs of loosening.
Article
Introduction Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, published literature is sparse, as is the quantity and quality of research evidence. Objective To outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and 3 weeks. Material and methods Between July 2005 and October 2017, 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 weeks or 3 weeks postoperative immobilization respectively for group 1, 2 and no-immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, 12 months and yearly thereafter postoperatively. Constant Score (CS), Subjective Shoulder Value (SSV), patient satisfaction and pain scores were used at each appointment and patients assessed both clinically and radiographically. Results Mean age at surgery was 76 years (range 40 - 93). At 1-year follow-up, Constant Score (CS) improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n=114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n=125) and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n=118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2 and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10 and 8.1/10 for groups 1, 2 and 3 respectively. Mean range of movement (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2 and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain and ROM between the three groups. Less postoperative complications were observed in group 3 (No immobilization). Conclusion Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms non-inferiority of the accelerated rehabilitation regime with less postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.
Article
Background Posterior shoulder arthroplasty is an approach to shoulder replacement. The goal of this cadaveric study was to determine anatomic feasibility for posterior approach shoulder arthroplasty by evaluating access to the glenoid, humerus and canal. Methods Twelve fresh frozen shoulders (10 males; 2 females) (mean age 76 (range, 55 to 92 years); weight 79 kg (range, 34-125 kg)) were utilized. Traditional exposure techniques and retractors were used to evaluate direct access. Exposure to the glenoid and humerus was evaluated utilizing digital imaging software. Successful placement from stemmed arthroplasty was evaluated utilizing digital radiographs and imaging software. Results The posterior approach permitted direct access to 88.8% ± 8.1 % of the glenoid. There was access to the center of the humeral head cut surface in 12/12 specimens. In ten specimens, there was 100% access to the entire cut surface of the humerus and peripheral edges. The average access to the humerus was 95.3% ± 13.4%. Average angulation with stem placement was 0.73 degrees of varus (range, 4.4 degrees of varus - 3.5 degrees of valgus). Regarding lateral plane angulation, there was an average of 0.33 degrees of posterior angulation (range, 3.3 degrees of posterior angulation - 2.5 degrees of anterior angulation). Conclusion Access to the center of the glenoid and humerus was achieved in all cases. More research is needed to evaluate the clinical efficacy of posterior shoulder arthroplasty, including mid and long-term outcome and safety studies. Level of Evidence Anatomy Study; Cadaver Dissection
Article
Background Surgical site infections (SSI) are relatively uncommon, but can be debilitating complications following shoulder arthroplasty. Infections can result in further complications including sepsis and revision surgery. Methods The National Surgical Quality Improvement Program (NSQIP) database was queried for all total and reverse total shoulder arthroplasty cases (Current Procedural Terminology [CPT] code 23472) between 2012 and 2015 yielding 8,438 total cases. The outcome of interest was 30-day surgical site infection (SSI) incidence, defined as a superficial and/or deep wound infection. The infection incidence for each year was calculated. Results The total number of primary shoulder arthroplasties increased from 2012 to 2015 (1,191 to 3,227; 271% increase). Over the 4-year study period, the incidence of SSIs following TSA was 0.40%. A downward trend in SSI rates was observed over time. An inverse relationship between SSI rates and year of surgery (R² -0.17) was observed; however, this was not statistically significant (p>0.05). Infection rates in 2015 decreased by 48% when compared to 2012 (0.31 vs. 0.50%, p>0.05). A larger decrease in SSI rate (76%) was noted between 2015 and 2013 (0.31 vs. 0.69%, p>0.05). Conclusion SSI rates following shoulder arthroplasty declined from 2012 to 2015 by 48%. There was an inverse relationship between SSI rate and year of surgery, with the lowest infection rate found to be in the most recent year studied. It is hoped that continued measures will further promulgate these downward trends of these devastating complications. Level of Evidence Level IV; Retrospective Case Series
Article
Background With increasing emphasis on value-based care and the heavy demands on the nation’s health care budget, surgeons must be cognizant of factors that drive cost and quality of patient care. Our objective was to determine patient-level drivers of lower costs and improved health-related quality of life (HRQoL) in two anatomic shoulder arthroplasty procedures – total shoulder arthroplasty (TSA) and ream-and-run arthroplasty. Methods 222 TSAs and 211 ream-and-run arthroplasties were included. Simple Shoulder Test (SST) scores, Single Assessment Numeric Evaluation (SANE), and Short-Form 36 (SF-36) scores were collected preoperatively and 2 years postoperatively. Quality adjusted life years (QALYs) were calculated as a measure of HRQoL. Univariate and multivariate analyses determined factors significantly associated with decreased hospitalization costs and improved HRQoL. Results In the TSA group, female sex, lower ASA score, diagnoses other than capsulorrhaphy arthropathy, lower pain scores, and higher SANE scores were associated with decreased total hospitalization costs, and female sex was an independent predictor of lower total costs. Insurance other than worker’s compensation, diagnosis of chondrolysis, and higher optimism led to greater QALY gains, but diagnosis of capsulorrhaphy arthropathy was the only independent predictor of greater QALY gains. In the ream-and-run group, older age, lower BMI, lower ASA score, insurance other than Medicaid, diagnoses other than capsulorrhaphy arthropathy, no history of previous surgery, higher preoperative SST scores, and higher preoperative SF-36 physical component summary scores were associated with lower total costs, and lower BMI was an independent predictor of lower costs. Higher preoperative optimism was an independent predictor of greater QALY gains. Conclusions Identifying factors associated with decreased costs and increased quality are becoming increasingly important in value-based care. This study identified fixed (sex, diagnosis) and modifiable (BMI) factors that drive decreased hospitalization costs and increased HRQoL improvements in shoulder arthroplasty patients. Higher preoperative patient optimism is a consistent predictor of improved HRQoL for both TSA and ream-and-run patients, and further study on optimizing the influence of patient expectations and optimism may be warranted.
Article
Background : Golf is a common sporting activity that patients continue to participate into older age, including after joint replacement surgery. The influence of shoulder replacement on golf performance remains unclear. We hypothesized that patients undergoing anatomic total shoulder arthroplasty (TSA) would have significantly better return to play rates and better performance metrics, including handicap, driving distance, and 7-iron distance, after shoulder replacement relative to those treated with reverse total shoulder arthroplasty (RTSA). Methods : Patients were retrospectively surveyed after anatomic TSA and RTSA with regards to return to golf and golf performance before and after shoulder replacement. Patients reported if they were able to return to golf after shoulder replacement, timing of return to golf, and driving distance, 7-iron distance, handicap, and difficulty with specific shot types upon returning to golf. Significance was defined as p<0.05. Results : The survey was completed by 31 patients with a total of 37 replaced shoulders (68.0 ± 8.1 years; 87% male) out of 44 patients who indicated they played golf. The overall return to golf rate was 74%. Patients undergoing anatomic TSA returned at a significantly higher rate relative to patients treated with RTSA (93% [14 of 15] vs 56% [9 of 16], p = 0.037). There was no difference between groups with regards to drive distance, 7-iron distance, and handicap. There were also no difference between preoperative and postoperative values for patients who were able to return to golf. Overall, patients played golf less frequently afterwards than they did prior to shoulder replacement (p = 0.013). Conclusion : Patients are able to return to golf after shoulder replacement, at an overall rate of 74%, including a rate of 93% for patients with anatomic TSA and 56% for patients with RTSA. Golf performance was similar before and after shoulder replacement surgery for both groups amongst those who were able to return to play, though overall frequency was decreased after shoulder replacement. Level of Evidence : Level III; Retrospective Comparative Study
Article
Background:. This study evaluated the ability of shoulder arthroplasty using a standard glenoid component to improve patient self-assessed comfort and function and to correct preoperative humeral-head decentering on the face of the glenoid in patients with primary glenohumeral arthritis and type-B2 or B3 glenoids. Methods:. We identified 66 shoulders with type-B2 glenoids (n = 40) or type-B3 glenoids (n = 26) undergoing total shoulder arthroplasties with a non-augmented glenoid component inserted without attempting to normalize glenoid version and with clinical and radiographic follow-up that was a minimum of 2 years. The Simple Shoulder Test (SST), the percentage of humeral-head decentering on the glenoid face, and bone ingrowth into the central peg were the main outcome variables of interest. Similar analyses were made for concurrent patients with type-A1, A2, B1, and D glenoid pathoanatomy to determine if the outcomes for type-B2 and B3 glenoids were inferior to those for the other types. Results:. The SST score (and standard deviation) improved from 3.2 ± 2.1 points preoperatively to 9.9 ± 2.4 points postoperatively (p < 0.001) at a mean time of 2.8 ± 1.2 years for type-B2 glenoids and from 3.0 ± 2.5 points preoperatively to 9.4 ± 2.1 points postoperatively (p < 0.001) at a mean time of 2.9 ± 1.5 years for type-B3 glenoids; these results were not inferior to those for shoulders with other glenoid types. Postoperative glenoid version was not significantly different (p > 0.05) from preoperative glenoid version. The mean humeral-head decentering on the glenoid face was reduced for type-B2 glenoids from −14% ± 7% preoperatively to −1% ± 2% postoperatively (p < 0.001) and for type-B3 glenoids from −4% ± 6% preoperatively to −1% ± 3% postoperatively (p = 0.027). The rates of bone integration into the central peg for type-B2 glenoids (83%) and type-B3 glenoids (81%) were not inferior to those for other glenoid types. Conclusions:. Shoulder arthroplasty with a standard glenoid inserted without changing version can significantly improve patient comfort and function and consistently center the humeral head on the glenoid face in shoulders with type-B2 and B3 glenoids, achieving >80% osseous integration into the central peg. These clinical and radiographic outcomes for type-B2 and B3 glenoids were not inferior to those outcomes for other glenoid types. Level of Evidence:. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Article
The key management of glenohumeral osteoarthritis is shoulder arthroplasty which aims to reduce pain and restore full shoulder function: it has increased in recent years. A detailed understanding of the anatomy of the glenoid and humeral head, as well as morphological changes of the glenoid in osteoarthritis, are important factors to consider when deciding on replacement components. This review begins with a brief introduction of the glenohumeral joint itself, and then considers the detailed anatomy of the glenoid fossa and humeral head, both of which are reported to have variable morphology. Several studies have been undertaken to assess various parameters, especially of the glenoid fossa including its shape, height, width, and articular surface area, version and inclination, in an attempt to define a standard classification that can be applied to surgical intervention. Nevertheless, no definitive consensus concerning the classification of these morphologies has been forthcoming, hence the need for this review. Following a consideration of these morphologies, the current state of knowledge regarding glenoid deformity in osteoarthritis, as well as its surgical management, is considered.
Article
Shoulder arthroplasty is an effective treatment option for patients with symptomatic shoulder arthritis and rotator cuff arthropathy. Although there have been reports of variations in complication rates according to insurance type, few studies have examined the effect of payer status on functional outcomes. Patients who underwent elective shoulder arthroplasty performed by a single fellowship-trained surgeon and had a minimum of 1 year of follow-up were queried. Patient characteristics were compared across insurance types. Each patient completed the American Shoulder and Elbow Surgeons (ASES) questionnaire preoperatively and postoperatively. A generalized linear mixed model was specified to predict ASES score at 1 year and included preoperative ASES score as an adjustment variable. A total of 84 patients underwent 91 procedures. Before surgery, ASES score differed by insurance type (P=.014), with lower scores in the Medicaid cohort compared with the private insurance cohort (20.4 vs 38.8, P=.009). After controlling for baseline ASES score, postoperative ASES score at 1-year follow-up differed by insurance type (P<.001). Patients with private insurance had better ASES scores (85.6) than patients with Medicaid (55.2) (P<.001) and workers' compensation (57.1) (P=.028). Patients with Medicare (80.6) had better ASES scores at follow-up compared with those with Medicaid (P<.001). Patients with Medicaid are at risk for significantly lower postoperative functional outcome scores after shoulder arthroplasty compared with patients with private insurance and Medicare. In this study, patients with Medicaid had lower preoperative ASES scores compared with other groups. These observed differences are likely multifactorial and should be acknowledged when counseling patients. [Orthopedics. 2020;43(6):e523-e528.].
Article
Background The purpose of this biomechanical simulator study was primarily to compare latissimus dorsi to lower trapezius tendon transfers for active external rotation and the pectoralis major transfer for internal rotation after reverse shoulder arthroplasty. Secondarily, the role of humeral component lateralization on transfer function was assessed. Methods Eight rotator cuff deficient cadavers underwent reverse shoulder arthroplasty with an adjustable lateralization humeral component. Latissimus dorsi and lower trapezius transfers were compared for active external rotation restoration and pectoralis major transfer for internal rotation restoration. Internal rotation/external rotation torques were measured for each lateralization at varying abduction and internal rotation/external rotation ranges-of-motion. Results The lower trapezius transfer generated, on average, 1.6 ± 0.2 nm more torque than the latissimus dorsi transfer (p < 0.001). The internal rotation/external rotation torques of all tendon transfers decreased as abduction increased (p < 0.01). At 0° elevation, reverse shoulder arthroplasty humeral component lateralization had a significant positive effect on tendon transfer torque at 60° internal rotation and external rotation (p < 0.01). Discussion Both the lower trapezius and the latissimus dorsi tendon transfers were effective in restoring active external rotation after reverse shoulder arthroplasty; however, the lower trapezius generated significantly more torque. Additionally, the pectoralis major transfer was effective in restoring active internal rotation. All tendon transfers were optimized with greater humeral component lateralization.
Article
Background The number of golfers aged ≥65 years has increased in recent years, and shoulder arthritis is prevalent in this age group. Guidelines for return to golf (RTG) after shoulder arthroplasty have not been fully established. Purpose To review the data available in the current literature on RTG after shoulder arthroplasty. Study Design Systematic review. Methods A systematic review based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Two independent reviewers searched PubMed, Embase, and the Cochrane Library using the terms “shoulder,”“arthroplasty,”“replacement,” and “golf.” The authors sought to include all studies investigating RTG after total shoulder arthroplasty (TSA), shoulder hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA). Outcomes of interest included indications for shoulder arthroplasty, surgical technique, rehabilitation protocol, amount of time between surgery and resumption of golf activity, and patient-reported outcome measures. Results A total of 10 studies were included, 2 of which reported on golf performance after shoulder arthroplasty. The other 8 studies described return to sports after shoulder arthroplasty with golf-specific data for our analysis. Three studies that included patients who underwent TSA reported RTG rates ranging from 89% to 100% after mean follow-up periods of 5.1 to 8.4 months. Two studies included patients who underwent TSA and HA and reported RTG rates of 77% and 100% after mean intervals of 5.8 and 4.5 months, respectively. Two studies included patients who underwent RSA, with RTG rates of 50% and 79% after mean postoperative intervals of 5.3 and 6 months, respectively. One study included only patients undergoing HA, with an RTG rate of 54% and a mean RTG time of 6.5 months. Varying surgical procedures and baseline patient characteristics precluded our ability to draw conclusions regarding surgical technique, rehabilitation protocol, or patient-reported outcome measures among studies reporting these data. Conclusion Most patients who undergo a shoulder arthroplasty procedure can expect to resume playing golf approximately 6 months after the index procedure. The rate of return may be lower after RSA and HA as compared with anatomic TSA. The data presented in our review can help physicians counsel patients who wish to continue golf participation after a shoulder arthroplasty procedure.
Article
Background: Glenoid implant positioning is an important and challenging step in total shoulder arthroplasty. Accurate glenoid positioning is considered essential to prosthesis longevity and functional outcomes. This paper presents Bullseye, a novel system to ensure accurate glenoid guide pin placement using a hand-held structured light scanner and computer vision algorithms. Methods: Preclinical evaluation of the intra-operative structured light-based Bullseye system was conducted for 10 sawbone and 18 cadaveric procedures. Each scapula was instrumented with a 3.2mm glenoid guide pin. The Bullseye system was used to determine the position of the guide pin within the scapulae. The accuracy of Bullseye for assessing guide pin start-point and trajectory was validated using CT as a gold standard. Results: All procedures were carried out successfully, requiring less than 1 minute of intra-operative imaging time. Guide pin start-point was measured to within 0.37±0.28 mm and 0.38±0.32 mm and trajectory to within 0.92±0.40 degrees and 1.27±0.80 degrees, respectively for the sawbone and cadaveric procedures. There was no significant difference in accuracy between the sawbone and cadaveric procedures. No relationships were found between system accuracy and glenoid version or arthritic grade. Conclusion: Intra-operative structured light imaging can be used to efficiently and accurately evaluate the 3D position of the glenoid guide pin for total shoulder arthroplasty in-vitro and ex-vivo. Clinical validation is required to determine if use of the Bullseye system improves component positioning outcomes and patient clinical outcomes in the context of a randomized controlled trial. Level of Evidence: Level IV; Case Series
Article
A better understanding of how the shape and density of the shoulder vary among members of a population can help design more effective population-based orthopedic implants. The main objective of this study was to develop statistical shape models (SSMs) and statistical density models (SDMs) of the shoulder to describe the main modes of variability in the shape and density distributions of shoulder bones within a population in term of principal components (PCs). These PC scores were analyzed, and significant correlations were observed between the shape and density distributions of the shoulder and demographics of the population, such as sex and age. Our results demonstrated that when the overall body sizes of male and female donors were matched, males still had, on average, larger scapulae and thicker humeral cortical bones. Moreover, we concluded that age has a weak but significant inverse effect on the density within the entire shoulder. Weak and moderate, but significant, correlations were also found between many modes of shape and density variations in the shoulder. Our results suggested that donors with bigger humeri have bigger scapulae and higher bone density of humeri corresponds with higher bone density in the scapulae. Finally, asymmetry, to some extent, was noted in the shape and density distributions of the contralateral bones of the shoulder. These results can be used to help guide the designs of population-based prosthesis components and preoperative surgical planning.
Article
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Background The biomechanical effects of joint line medialization during shoulder surgery are poorly understood. It was therefore the purpose of this study was to investigate whether medialization of the joint line especially associated with total shoulder arthroplasty (TSA) leads to changes in the rotator cuff muscle forces required to stabilize the arm in space. Method A validated computational 3-D rigid body simulation model was used to calculate generated muscle forces, instability ratios, muscle-tendon-lengths and moment arms during scapular plane elevation. Measurements took place with the anatomical and a 2mm and 6 mm lateralized or medialized joint line. Results When the joint line was medialized, increased deltoid muscle activity was recorded throughout glenohumeral joint elevation. The rotator cuff muscle forces increased with medialization of the joint line in the early phases of elevation. Lateralization of the joint line led to higher rotator cuff muscle forces after 52°of glenohumeral elevation and to higher absolute values in muscle activity. A maximum instability ratio of >0.6 was recorded with 6mm of joint line medialization. Conclusion In this biomechanical study, medialization and lateralization of the normal joint line during TSA led to substantial load changes on the shoulder muscles used for stabilizing the arm in space. Specifically, medialization does not only lead to muscular shortening but also to increased load on the supraspinatus tendon during early arm elevation, the position which is already most loaded in the native joint. Level of evidence: Basic Science Study; Computer Modeling
Article
Massive tears of the rotator cuff can result in severe functional deficits due to loss of the axial force couple and effective fulcrum that the intact cuff normally provides. For massive, irreparable rotator cuff tears, especially in the setting of early to moderate degenerative changes, reverse total shoulder arthroplasty functions to modify the center of joint rotation, allowing the deltoid and intact components of the cuff to carry out shoulder function more effectively. Our preferred technique uses a standard open deltopectoral shoulder approach with a 3-dimensional glenoid baseplate model and a 135° prosthesis in an onlay configuration to reduce the risk of scapular notching and increase lateralization of the humerus.
Article
Introduction : Despite increasing utilization, little guidance is offered regarding appropriate indications for posterior augmented glenoid implants. The purpose of this study is to virtually assess the effect of implant selection on glenoid resurfacing and joint line restoration in osteoarthritic shoulders with posterior glenoid wear. Methods : Thirty-three CT scans were randomly selected from a cohort of osteoarthritic shoulders with Walch B2 or B3 deformities. Imascap SAS (Wright Medical, Memphis, TN) was used to assess bony deformities and plan glenoid resurfacing. Implants simulated included: standard Pegged Cortiloc, and 15° and 25° half-wedge augments. Each component was planned for a version correction to neutral and 10° retroversion, inclination was maintained within 5° of neutral and the component was medialized until bony support reached 80%. Implantation failure was defined as: greater than 20% cancellous bone support, central peg perforation, or joint line medialization relative to the pathologic joint (accounting for polyethylene thickness). Excessive lateralization was defined as creation of a joint-line >4mm lateral to the pathologic joint-line. Results : The mean retroversion deformity in this cohort was 23.7° (range: 13°-37°). When correcting to neutral, the corrective reaming alone failed in 72.7% (24/33) of cases compared to 15.2% (5/33) when correcting to 10° of implant retroversion. When correcting to neutral version failure was decreased with a 15° (27.3%; 9/33; p<0.001) and 25° augment (15.2%; 5/33; p<0.001). Receiver operating characteristic (ROC) analysis found that an augment is useful to resolve standard implant failure for retroversion deformities greater than 27° (area under the curve [AUC]=0.91) and 22° (AUC=0.77) for correcting version to neutral and 10° retroversion, respectively. When placing a 25° augment, there was high risk of overstuffing the joint for both correction to neutral (27.3%) and 10° retroversion (66.7%). Overstuffing was likely to occur when correcting deformities less than 19° (AUC=0.96) to neutral with a 25° augment. Likewise, implanting 15° or 25° augmented glenoids in 10° of retroversion is likely to overstuff the joint for pathologic retroversion deformities smaller than 18° (AUC=0.94) and 28° (AUC=0.69), respectively. Conclusion : This study helps to clarify the severity of glenoid deformities more appropriately addressed with the use of a half-wedged augmented glenoid. Both the severity of glenoid deformity and the desired implant version affect appropriate indications for the use of augmented glenoids. The risk of excessive joint-line lateralization in shoulders with less severe deformities should not be ignored. These considerations, in addition to individual soft tissue tension should be considered when planning and performing glenoid resurfacing. Level of Evidence : Level III; Treatment Study
Preprint
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Background The occurrence of prosthesis-related complications after total shoulder arthroplasty is devastating and costly. The purpose was to determine the incidence and risk of in-hospital prosthesis-related complications after total shoulder arthroplasty utilizing a large-scale sample database. Methods A retrospective database analysis was performed based on Nationwide Inpatient Sample from 2010 to 2014. Patients who underwent total shoulder arthroplasty were included. Patient demographics, hospital characteristics, length of stay, economic indicators, in-hospital mortality, comorbidities, and peri-operative complications were evaluated. Results A total of 34,198 cases were capture from the Nationwide Inpatient Sample database. There were 343 cases of in-hospital prosthesis-related complications after total shoulder arthroplasty and the overall incidence was 1%, with a more than 2.5-fold decrease from 2010 to 2014. Dislocation was the most common category among prosthesis-related complications (0.1%). The occurrence of in-hospital prosthesis-related complications was associated with significantly more total charges and slightly longer length of stay while less usage of Medicare. Risk factors of prosthesis-related complications were identified including younger age (<64 years), female, the native American, hospital in the South, alcohol abuse, depression, uncomplicated diabetes, diabetes with chronic complications, fluid and electrolyte disorders, metastatic cancer, neurological disorders, and renal failure. Interestingly, advanced age (≥65 years) and proprietary hospital were found as protective factors. Furthermore, prosthesis-related complications were associated with aseptic necrosis, rheumatoid arthritis, rotator cuff tear arthropathy, Parkinson’s disease, prior shoulder arthroscopy, and blood transfusion. Conclusions It is of benefit to study risk factors of prosthesis-related complications following total shoulder arthroplasty to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.
Article
Background The growing enthusiasm for the use of reverse shoulder arthroplasty (RSA) in the treatment of primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff is based on data derived from single-center studies with limited generalizability and follow-up. This study compared patient-reported outcomes (PROs) between RSA and TSA for the treatment of primary GHOA with up to 5-year follow-up and examined temporal trends in the treatment of GHOA between 2012-2021. Methods A retrospective review was performed on patients with primary GHOA undergoing primary arthroplasty surgery from the Surgical Outcomes System global registry between 2012-2021. Patient-reported outcomes including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and visual analog scale (VAS) for pain were compared between RSA and TSA at 1, 2, and 5 years postoperatively. Results A total of 4,451 patients were included, with 2,693 (60.5%) undergoing TSA and 1,758 (39.5%) RSA. Both RSA and TSA provided clinically excellent outcomes at 1 year postoperatively (ASES: 80.8 ± 17.9 vs 85.9 ± 15.2, respectively; SANE: 74.8 ± 24.7 vs 79.5 ± 22.9; VAS pain: 1.3 ± 2.0 vs 1.1 ± 1.7; all p<0.05) that were maintained at 2 years (ASES: 81.3 ± 19.3 vs 87.3 ± 14.9; SANE: 74.8 ± 26.2 vs 79.7 ± 24.7; VAS pain: 1.3 ± 2.1 vs 1.0 ± 1.6; all p <0.05) and 5 years (ASES: 81.7 ± 16.5 vs 86.9 ± 15.3; SANE: 71.6 ± 28.5 vs 78.2 ± 25.9; VAS pain: 1.0 ± 1.7 vs 1.0 ± 1.7; all p<0.05), with statistical significance favoring TSA. After controlling for age and sex, there was an adjusted difference of 4.5 units in the ASES score favoring TSA (p=0.005) at 5 years postoperatively, but no differences in adjusted SANE (p=0.745) and VAS pain (p=0.332) scores. The use of RSA for GHOA grew considerably over time, from representing only 17% of all replacements performed for GHOA in 2012 to nearly half (47%) in 2021 (p<0.001). Conclusions RSA as a treatment for GHOA with an intact rotator cuff seems to yield patient-reported outcomes that are largely clinically equivalent to TSA extending to 5 years postoperatively. The observed statistical significance favoring TSA appears to be of marginal clinical benefit based on established minimal clinically important differences and may be a result of the large sample size. Further research using more granular clinical data and examining differences in range of motion and complications is warranted as it may change the value analysis.
Article
Background/Purpose Shoulder osteoarthritis (OA) with eccentric (B) glenoids has generally been associated with poor patient reported outcomes and increased complications. The purpose of this study was to outline all the described treatment options and their outcomes and complications in order to better guide treatment. Methods This systematic review was performed according to the Preferred Reporting Items for Systematic review and Meta-analysis (PRISMA) guidelines. Searches were performed up to December 19, 2019 using Medline, EMBASE, Scopus, and Cochrane databases. Inclusion criteria included studies for glenohumeral OA reporting posterior humeral head subluxation and/or posterior glenoid erosion. Studies were excluded if they were review papers, abstracts, or conference papers, heterogeneity of included Walch types, or not written in English. Results 21 studies met inclusion criteria. Mean follow-up 47.5 months (range, 14-300) and mean patient age 62 years (38-88). Five different discernible techniques were identified. Asymmetric reaming with onlay glenoid (AROG) in 267 shoulders, posterior glenoid bone grafting(PGBG) with onlay glenoid in 79 shoulders, augmented glenoid (AG) in 160 shoulders, reverse shoulder arthroplasty (RSA) with or without bone grafting in 118 shoulders, hemiarthroplasty with concentric reaming (HACR) in 57 shoulders, and humeral head arthroplasty with inlay glenoid (HAIG) in 36 shoulders. All techniques reported improved patient outcomes and ROM. Short-term (<5yrs.) studies reported glenoid loosening leading to revisions in 3% AROG, 2.7% PGBG, 0.8% AG, 1.4% RSA, and 0% HAIG. HACR had a high revision rate (12.3%) due to persistent pain and stiffness. Mid-term (>5 years) studies demonstrated increased rates of glenoid loosening with AROG (14.5%), PGBG (21% loose, 23.8% “at risk”) and AG (18.9% “at risk”), as well as increased rates of subluxation or revision due to instability. HAIG did not demonstrate loosening, subluxation nor revision at 55.2 months Conclusion Various techniques exist to manage complex primary glenohumeral OA with posterior subluxation and posterior glenoid erosion. Glenoid component survival is a concern with ASOG, PGBG, and AG. HACR has the highest early revision rate. RSA offers promising short a mid-term results likely due the advantage of more secure fixation as well as a constrained design to prevent posterior subluxation. HAIG has lowest complication and revision rate although further long-term studies are needed.
Article
Introduction Early discharge has been a target of cost control efforts given the growing demand for joint replacement surgery. Select patients are given the choice for same day discharge (SDD) or overnight stay following shoulder arthroplasty. The COVID-19 pandemic changed patient perspectives regarding hospital visitation and admission. The purpose of this study was to determine if the COVID-19 pandemic impacted the utilization of SDD following shoulder arthroplasty. We hypothesize that patients undergoing shoulder arthroplasty after the start of the COVID-19 pandemic will have higher rates of SDD. Methods A retrospective continuous review was performed on 370 patients who underwent a primary anatomic (TSA) or reverse shoulder arthroplasty (RSA) between August 2019 and December 2020 by a single surgeon. This group of patients represent the 185 arthroplasty cases completed before the COVID-19 pandemic, and the first 185 patients after the start of the pandemic. April 1, 2020 was chosen as the cutoff for pre-COVID patients, as this represents the date a statewide ban on elective surgery was declared. All patients were counseled preoperatively regarding SDD and given the choice to stay overnight, unless medically contraindicated. Demographics, medical history, length of stay, 30 and 90-day readmissions, and 90-day emergency room (ER) and urgent care visits were obtained from medical records and compared. Two-tailed student t-tests, chi-square tests, and Fischer’s Exact were performed where appropriate. Results The two groups were similar in age, BMI, gender distribution, and Outpatient Arthroplasty Risk Assessment (OARA) score. During the collection period, there were more anatomic shoulder arthroplasties performed after (54%) than before (44%) the COVID-19 pandemic (p=0.029). Patients treated after the start of the COVID-19 pandemic were almost 3 times more likely to have a SDD (p<0.001), with 85.4% (158/185) of patients being discharged the same day following COVID-19, compared to 34.6% (64/185) before COVID-19. Discharge Disposition (location of discharge) was significantly different, as 99% (183/185) of patients undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared to 94% (174/185) of patients before COVID-19. There was no difference in 30-day readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the two groups. Conclusion Our study suggests that the COVID-19 pandemic has dramatically impacted patient choices for SDD within a single surgeon’s practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe alternative for patients following TSA and RSA.
Article
Introduction Readmissions following orthopaedic surgery are associated with worse outcomes and increased healthcare costs. Studies investigating trends, causes, and costs of readmissions following primary total shoulder arthroplasty (TSA) for the indication of glenohumeral osteoarthritis (OA) are limited. The objective was to compare: 1) patient-demographics of those readmitted and not readmitted within 90-days following primary TSA for OA; 2) causes of readmissions and 3) associated costs. Methods A retrospective query from 2005 to 2014 was performed using a nationwide administrative claims database. The study group consisted of patients readmitted within 90-days following primary TSA for glenohumeral OA, whereas patients not readmitted served as controls. Causes of readmission were stratified into the following groups: cardiovascular, hematological, endocrine, gastrointestinal (GI), musculoskeletal (MSK), neoplastic, neurological, pulmonary, infectious, renal, and miscellaneous causes. Patient demographics were compared, in addition to the frequency of the causes of readmissions, and their associated costs. Chi-square analyses compared demographics between groups. Analysis of variance was utilized to determine differences in 90-day costs for the causes of readmission. A p-value less than 0.001 was significant. Results The overall 90-day readmission rate was 2.4% (3432/143,878). Patients readmitted following primary TSA were more likely to be over the age of 75, female, and higher prevalence of comorbid conditions, including psychiatric and medical conditions. Readmitted patients had a higher overall comorbidity burden per mean Elixhauser-Comorbidity Index (ECI) scores (10 vs. 7,p < 0.0001). The leading cause of readmissions were due to MSK (17.34%), cardiac (16.28%), infectious (16.26%), and gastrointestinal (11.64%) etiologies. There were differences in the mean 90-day costs of care for the various causes of readmissions, with the leading cost of readmissions being cardiac causes ($10,913.70) and MSK ($10,590.50) etiologies. Conclusion Patients with greater comorbidities experienced increased incidence of readmission following TSA for glenohumeral OA. Cardiac and MSK etiologies were the primary cause of readmissions. Level of evidence III.
Article
Hypothesis Both clinical outcomes and early rates of failure will not be associated with glenoid retroversion. Methods All patients who underwent an anatomic TSA with minimal, non-corrective reaming between 2006 and 2016 with minimum 2-year follow-up were reviewed. Measurements for retroversion, inclination, and posterior subluxation were obtained from MRI or CT. A regression analysis was performed to assess the association between retroversion, inclination and subluxation, and their effect on PROs. Clinical failures and complications were reported. Results 151 anatomic TSAs (90% follow-up) with a mean follow-up of 4.6 years (range, 2-12 years) were assessed. Mean preoperative retroversion was 15.6° (range, 0.2-42.1), mean posterior subluxation was 15.1% (range, -3.6 to 44.1%), and mean glenoid inclination was 13.9° (range, -11.3 to 44.3). All median outcome scores improved significantly from pre- to postoperatively (p<.001). Median satisfaction was 10/10 (1st quartile=7, 3rd quartile=10). Linear regression analysis found no significant association between retroversion and any postoperative PRO. A total of 5 (3.3%) failures occurred due to glenoid implant loosening (3 patients) and Cutibacterium acnes infection (2 patients) with no association between failure causation and increased retroversion or inclination. No correlation could be found between the Walch classification and postoperative PROs. Conclusion Anatomic total shoulder replacement with minimal and non-corrective glenoid reaming demonstrates reliable increases in patient satisfaction and clinical outcomes at a mean of 4.6 years follow-up in patients with up to 40° of native retroversion. Higher values of retroversion were not associated with early deterioration of clinical outcomes, revisions, or failures. Long-term studies are needed to see if survivorship and outcomes hold up over time.
Article
Objective: to evaluate the effectiveness of performing exercises on an innovative mechanotherapy apparatus and the PIR technique for the recovery of patients with damage to the rotator cuff of the shoulder at the postoperative stage. Materials and Methods. The study involved 46 patients after arthroscopic intervention due to damage to the structures of the shoulder joint. The reasons for arthroscopic intervention were: adhesive capsulitis (3 patients), damage to the rotator cuff of the shoulder (39 patients), and impingement syndrome (4 patients). The average age of patients was 44.7±8.3 years. All patients were divided into 2 groups: the control group (CG, n=21) and the main group (MG, n=25). The beginning of rehabilitation among patients averaged 4.9±2.4 weeks after the surgery. The duration of treatment was 4.5±3.2 weeks. The study was carried out on the basis of the Department of Rehabilitation of the SI “Institute of Traumatology and Orthopedics of NAMS of Ukraine” during 2020-2021. Results and Discussion. According to the VAS results, the pain level after the rehabilitation program significantly decreased in both groups (p<0.05). In the MG, the dynamics of pain syndrome according to the VAS ranged from 6.2±1.2 cm to 0.9±0.7 cm 6 weeks after the surgery. In the CG, the majority of patients also noted an improvement in the level of pain after surgery (from 6.5±1.1 cm to 1.1±1.2 cm); no significant differences after treatment in terms of the level of pain between the patients in the MG and the CG (p>0.05) were observed. Also, patients who were included in the main group and did exercises with a simulator and elements of PIR according to the rehabilitation program showed generally better indicators of recovery of the function of the shoulder joint, namely there was a higher dynamics in increasing the amplitude of movements in the shoulder joint (112.5±10.60 flexion before physical rehabilitation (PR), 173.2±5.50 after РR). In the CG, the positive dynamics was less pronounced (107.7±6.80 flexion before PR, 151.2±6.50 after PR). Similar results were found according to the data of manual muscle testing (MMT). Conclusions. Therefore, the method of post-isometric muscle relaxation using the proposed technique of training on a mechanotherapy apparatus for developing the shoulder joint is an effective method for treating postoperative contractures and can be recommended for the use in the complex rehabilitation of patients with contracture of the shoulder joint as a result of arthroscopic intervention in patients with injury of the rotator cuff of the shoulder.
Article
Background: Shoulder arthroplasty is increasingly performed for patients with symptoms of glenohumeral arthritis. Advanced imaging may be used to assess the integrity of the rotator cuff preoperatively because a deficient rotator cuff may be an indication for reverse shoulder arthroplasty (RSA) rather than anatomic total shoulder arthroplasty (TSA). However, the cost-effectiveness of advanced imaging in this setting has not been analyzed. Questions/purposes: In this cost-effectiveness modeling study of TSA, all patients underwent history and physical examination, radiography, and CT, and we compared (1) no further advanced imaging, (2) selective MRI, (3) MRI for all, (4) selective ultrasound, and (5) ultrasound for all. Methods: A simple chain decision model was constructed with a base-case 65-year-old patient with a 7% probability of a large-to-massive rotator cuff tear and a follow-up of 5 years. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness to pay of both USD 50,000 and 100,000 per quality-adjusted life year (QALY) used, in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. Diagnostic test sensitivity and specificity were extracted from published systematic reviews and meta-analyses, and patient utilities were obtained using the Cost-Effectiveness Analysis Registry from the Center for the Evaluation of Value and Risk in Health. Final patient states were categorized as either inappropriate or appropriate based on the actual rotator cuff integrity and type of arthroplasty performed. Additionally, to evaluate the real-world impact of intraoperative determination of rotator cuff status, a secondary analysis was performed where all patients indicated for TSA underwent intraoperative rotator cuff examination to determine appropriate implant selection. Results: Selective MRI (ICER of USD 40,964) and MRI for all (ICER of USD 79,182/QALY) were the most cost-effective advanced imaging strategies at a willingness to pay (WTP) of USD 50,000/QALY gained and 100,000/QALY gained, respectively. Overall, quality-adjusted life years gained by advanced soft tissue imaging were minimal: 0.04 quality-adjusted life years gained for MRI for all. Secondary analysis accounting for the ability of the surgeon to alter the treatment plan based on intraoperative rotator cuff evaluation resulted in the no further advanced imaging strategy as the dominant strategy as it was the least costly (USD 23,038 ± 2259) and achieved the greatest health utility (0.99 ± 0.05). The sensitivity analysis found the original model was the most sensitive to the probability of a rotator cuff tear in the population, with the value of advanced imaging increasing as the prevalence increased (rotator cuff tear prevalence greater than 12% makes MRI for all cost-effective at a WTP of USD 50,000/QALY). Conclusion: In the case of diagnostic ambiguity based on physical exam, radiographs, and CT alone, having both TSA and RSA available in the operating room appears more cost-effective than obtaining advanced soft tissue imaging preoperatively. However, performing selective MRI to assess rotator cuff integrity to indicate RSA or TSA is cost-effective if surgical preparedness, patient expectations, and implant availability preclude the ability to switch implants intraoperatively. Level of evidence: Level III, economic and decision analysis.
Article
Accurate pin placement to guide renaming of the glenoid surface in total shoulder arthroplasty (TSA) is a critical step to restore range of motion in the glenohumeral joint. Achieving proper pin position with free-hand is complicated due to inadequate intra-operative availability of pre-operative planning data. Mixed reality provides a new modality of surgical navigation for arthroplasty without distracting surgeon from the patient anatomy. However, achieving accurate alignment between the pre-operative plan and the intra-operative anatomy is challenging, especially if workflow-compliant solutions are desired. In this paper, we present a calibration-free mixed reality navigation workflow for glenoid pin placement in TSA that contributes to solving some open challenges. We use a visible light stereo camera on a surgical support arm combined with a transformer-based disparity estimation algorithm to accurately reconstruct the 3D anatomy despite surgical lighting. Besides, we introduce a slide-on marker calibrated by design to overcome perceptual difficulties that arise when trying to align real to virtual objects. In a user study on a semi-anthropomorphic phantom, we assess the end-to-end pin placement accuracy using both our system and a clinical reference standard solution that relies on patient-specific drill guides. Averaging over 15 drilled trajectories, our mixed reality system achieved a pin placement accuracy of (3.80±1.28 mm, 4.66± 2.85°).
Article
Hypothesis In patients with symptomatic osteoarthritis of the shoulder, arthroscopic débridement and capsular release will provide relief of symptoms and improvement in function for a minimum of two years. Methods Prospective outcome data was collected from patients who underwent arthroscopic débridement and capsular release for painful idiopathic glenohumeral arthritis from 2005 to 2013 by one surgeon. The primary outcome was conversion to shoulder arthroplasty. UCLA and Simple Shoulder Test (SST) scores were also collected by phone or mailing. Preoperative radiographs were evaluated for Samilson and Prieto classification and Walch glenoid classification. Results Thirty-three of 40 patients (82.5%) who met inclusion criteria with an average time since surgery of 6.4 years (range, 2-10 years) were reached for final follow-up. Eight of 33 respondents (24.2%) had conversion to arthroplasty within the study period at an average 1.75 ± 2.37 years (range, 0.5-7 years) postoperatively. Nine patients (36%) reported no pain at the time of survey. Of patients who reported current pain (16/25, 64%), seven (43.7%) had improved pain since surgery. For patients with preoperative UCLA scores, scores were significantly higher at mid-term (p=0.003) and long-term (p=0.017) follow-up. Patients who were less than 8 years since surgery had significantly higher SST (2-4 years, p=0.004; 5-7 years, p=0.024) and UCLA (2-4 years, p=0.004; 5-7 years, p=0.011) scores than those who were 8-10 years since surgery. There were no significant differences in preoperative radiographic classifications and outcome. Conclusion Arthroscopic débridement with capsular release in certain patients with osteoarthritis of the shoulder can provide long-term pain reduction, increased function, and can delay shoulder arthroplasty. Level of Evidence Level IV; Prognostic Study; Case Series
Article
INTRODUCTION Renal disease including chronic renal disease and end-stage renal disease has been associated with the development of primary glenohumeral osteoarthritis. However, little is known about how renal disease affects outcomes following shoulder arthroplasty. Thus, the purpose of this study was to evaluate the impact of renal disease on outcomes of shoulder arthroplasty for glenohumeral osteoarthritis. METHODS This was a retrospective review utilizing the Nationwide Readmissions Database. Using ICD-9 codes, patients who underwent shoulder arthroplasty (including total shoulder arthroplasty and reverse total shoulder arthroplasty) for primary glenohumeral osteoarthritis were identified. These patients were divided into 3 groups: no renal disease, pre-dialysis chronic renal disease (including Stages 1-5), and end-stage renal disease. Primary outcomes of interest included the risk of complications during index hospitalization as well as within 90 days of index surgery. Secondary outcomes included index hospitalization length of stay, cost, and discharge location. RESULTS From 2010-2014, 29,336 patients underwent shoulder arthroplasty for glenohumeral osteoarthritis. 27,928 (95.2%) patients had no renal disease; 1,355 (4.6%) had pre-dialysis chronic renal disease, and 53 (0.2%) patients had end-stage renal disease. Compared to patients with no renal disease, both pre-dialysis chronic renal disease and end-stage renal disease patients had an increased risk of receiving blood transfusions (odds ratio [OR]= 2.04, p<0.0001 and 5.37, p=0.04, respectively) and experiencing any postoperative complication during the index hospitalization (OR= 2.31, p<0.0001 and 3.94, p=0.003, respectively). Specifically, pre-dialysis chronic renal disease patients were at an increased risk for cardiac (OR=1.96, p<0.0001) and respiratory (OR=1.55, p<0.0001) complications as well as acute renal failure (OR=14.70, p<0.0001) postoperatively. End-stage renal disease patients were at an increased risk for cardiac (OR=3.87, p=0.003) complications as well as acute renal failure (OR=10.35, p=0.002) postoperatively. Within 90 days, end-stage renal disease patients had an increased risk of hospital readmission (OR=8.01, p<0.0001), dislocation (OR=8.70, p=0.039), and surgical site infection (OR=19.06, p=0.001). Finally, compared to patients with no renal disease, pre-dialysis chronic renal disease and end-stage renal disease patients both had increased hospital length of stay and cost; pre-dialysis chronic renal disease patients had an increased risk of discharge to a skilled nursing facility (OR=1.39, p=0.039). DISCUSSION and CONCLUSION This retrospective cohort study demonstrates that even pre-dialysis chronic renal disease patients have worse outcomes compared to patients with no renal disease after shoulder arthroplasty for glenohumeral osteoarthritis. These findings serve to highlight the importance of close perioperative monitoring to prevent complications in a potentially overlooked patient population.
Article
Background For patients with end-stage glenohumeral osteoarthritis, anatomic total shoulder arthroplasty (TSA) serves as a reliable option for pain relief and improving function. It is not well understood if patients with pain due to osteoarthritis but preserved preoperative active range of motion (ROM) experience a similar postoperative benefit compared to those with more pronounced preoperative ROM deficits. Methods A multicenter shoulder arthroplasty registry was queried to identify all patients who underwent TSA with minimum 2-year clinical follow-up. These patients were separated into two cohorts: 1) preserved preoperative active motion, defined as both forward flexion (FF) and external rotation (ER) at the side a minimum of one standard deviation greater than the mean (>140° FF and >45° ER) and 2) a control group with restrictions in preoperative motion, defined by both preoperative FF < 140° and ER < 45°. Controls were matched 2:1 to study patients by preoperative visual analog pain score (VAS) ± 1.5 points, sex, and age ± 2 years. Outcome measures were patient-reported outcomes (PROs), active range of motion (ROM), strength and satisfaction at a minimum of 2 years postoperative. Results 30 patients were identified in preserved preoperative motion group (mean baseline 154±10° FF and 57±11° ER). 60 control patients with restricted motion were matched (mean baseline 97±24° FF and 23±16° ER). There were no significant differences in other baseline patient characteristics other than the Constant-Murley score and strength. At 2 year follow-up, there were no significant differences in VAS pain (0.8 vs 1.1, p = 0.446), all PROs, or any ROM measures other than FF which was higher in the preserved group (158±15° vs 146±19°, p = 0.003). The change in ROM was significantly higher for all ROM measurements in the restricted motion cohort with restricted preoperative motion compared to study patients. Patients with restricted motion had a significantly greater increase in Constant scores compared to those with preserved motion (32.6 vs 19.0, p < 0.001). There were no significant differences in rates of patients who were satisfied with their surgical result for all domains assessed between groups. Conclusion Patients undergoing TSA with preserved preoperative active ROM can expect similar final pain levels and improvement in pain compared to patients with greater limitations in preoperative ROM. As expected, patients with more restricted preoperative ROM have substantially greater improvement in ROM after TSA. However, there are no differences in satisfaction at 2 years after TSA regardless of preoperative active ROM.
Article
Background Patients undergoing revision total shoulder arthroplasty (TSA) typically achieve smaller improvements in outcome measurements than those undergoing primary TSA. The minimum clinically important difference (MCID) in the American Shoulder and Elbow Surgeons (ASES) questionnaire for primary shoulder arthroplasty ranges from 13.6-20.9, but the MCID for revision shoulder arthroplasty remains unclear. This study aims to define the MCID in ASES score for revision TSA and ascertain patient factors that affect achieving the MCID threshold. Methods Patients were identified from an institutional shoulder arthroplasty database. Prospective data collected included demographic variables, prior shoulder surgeries, primary and revision implants, indication for revision, and pre- and post- operative ASES scores. All patients provided informed consent to participate. An anchor-based method was used with a binary answer choice. The MCID was calculated using the receiver-operator curve (ROC) method, and the sensitivity, specificity, and area under the curve were obtained from the ROC. MCID values were compared between groups using Student's t-test. Multivariate logistic regression modeling was used to determine significant predictors for reaching MCID. Significance was defined as p < 0.05. Results A total of 46 patients underwent revision TSA with minimum two-year follow-up. The MCID using ROC method was 16.7 with 71% sensitivity and 62% specificity. There was a trend towards males being more likely to reach MCID after revision arthroplasty (p=0.058). There were also trends towards increased forward flexion and abduction range of motion in patients who met MCID (p=0.08, p=0.07). Multivariate logistic regression modeling demonstrated male sex to be associated with achieving MCID (p=0.03), while younger age and fewer prior shoulder surgeries demonstrated a trend to association with achieving MCID (p=0.06, p=0.10). Conclusion The MCID for ASES score in patients undergoing revision shoulder arthroplasty is similar to previously reported MCID values for patients undergoing primary shoulder arthroplasty. Younger, male patients with fewer prior shoulder surgeries were more likely to achieve MCID after revision TSA. Level of Evidence Level III
Article
Background/Purpose Modifiable risk factors can impact the surgical outcome after total shoulder arthroplasty (TSA), yet this topic has not been adequately explored. We sought to quantify the effects of common modifiable patient risk factors on the postoperative outcomes and complications in patients who underwent total shoulder arthroplasty (TSA). Methods Data was collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2006-2016 database for patients undergoing a principle procedure of total shoulder arthroplasty using current procedural terminology (CPT) code 23472. Modifiable risk factors were defined as patients’ smoking status, use of alcohol, diabetes, hypertension, obesity, recent loss of >10% body weight, malnutrition, and anemia. Outcomes of interest included discharge destination, surgical site infection, wound complications, and hematologic complications. Results There were 14,478 adult patients undergoing total shoulder arthroplasty in the NSQIP database. The majority of patients were Caucasian (83.9%), female (56.2%), and between the ages of 61 and 80 (70.1%). Malnutrition was the only preoperative modifiable variable found to be significantly associated with outcomes. Patients with malnutrition had an increased risk of non-routine discharge status (OR=3.12) and hematologic complications (OR=4.58). Other modifiable risk factors (smoking status, use of alcohol, diabetes, hypertension, obesity, recent loss of >10% body weight, and anemia) analyzed were not significantly associated with outcomes. Conclusions Malnutrition is associated with an approximately 3-time increased likelihood of non-routine discharge and 5-time increased likelihood of hematologic complications after TSA. Surgeons should have heightened awareness for potential complications in these patients. While surgeons should continue to counsel their patients on all modifiable risk factors, they may not expect to see differences in the clinical outcomes following TSA.
Article
Background: Total shoulder arthroplasty (TSA) is the gold standard treatment of end-stage glenohumeral osteoarthritis. TSA with stemless humeral implants have shown comparable rates of success to stemmed components. Prolonged operative time is associated with increased cost, surgical, and medical complications, and higher rates of infection. Therefore, the goal of this study was to evaluate operative time with stemless TSA compared to stemmed TSA. We hypothesize that stemless TSA will be associated with less operative than stemmed TSA. Methods: In this retrospective case-control study of 80 consecutive patients, 40 patients underwent stemless TSA and 40 patients underwent stemmed TSA. To eliminate potential bias due to individual surgeons surgical techniques, the cohorts were matched by surgeon in a 1:1 ratio. Only primary TSA, without augmented glenoid implants, were included. We evaluated the difference in operative time between groups. Operative time was defined as time from incision to commencement of wound closure. Results: Our sample included 62.5% and 55% females in the stemmed and stemless cohorts respectively. Patients in the stemless group were noted to be younger with a mean age of 61 compared to 68 in the stemmed group (p<0.01). The BMI between both cohorts were comparable at 29.72 and 30.04 in the stem and stemless cohorts, respectively (P=0.84). Operative time was noted to be significantly less in the stemless TSA cohort. Specifically, a 13.53 minutes difference was noted with a mean time of 100.35 vs 86.82 minutes (p=0.04). Conclusion: In this case-control study, matched by surgeon to avoid technique bias, evaluating stemmed and stemless humeral components for anatomic TSA, we noted a significantly shorter operative time in favor of stemless TSA. The clinical and economic impact of this difference remains unclear.
Article
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Introduction: Pain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery. Methods: The Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months. Results: Of the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group (P < .001). On multivariate analysis, younger age, female gender, and tobacco use, along with the comorbidities of coronary artery disease, clinical depression, diabetes, and rheumatic disease were all found to be predictive factors of prolonged opioid use. Discussion: The dose-dependent relationship observed between original opioid prescription data and number of additional refills needed, suggests that initially overprescribing opioids may lead to prolonged dependency. This study also identified several independent risk factors for prolonged opioid use, including younger age, depression, and tobacco use. This study will hopefully help recognize high-risk patient populations and serve as the foundation for future studies into opioid prescription standardization and preoperative opioid education.
Article
The incidence of patients undergoing total shoulder arthroplasty (TSA) for glenohumeral osteoarthritis has been steadily increasing in the United States. TSA with humeral head resurfacing with an inlay glenoid using OVO®/OVO® Motion (Arthrosurface, Inc., Franklin, Massachusetts) is an anatomic implant solution to shoulder arthritis. Anatomic resurfacing has demonstrated promising clinical- and patient-reported outcomes in the literature in both active and low-demand patients. Furthermore, patients are capable of returning to high-demand activities, such as weightlifting, which are restricted with conventional total shoulder replacement designs. Resurfacing designs offer a simple solution to a complex problem.
Article
Background Patients undergoing total shoulder arthroplasty (TSA) can have varying levels of improvement after surgery. As patients typically demonstrate a non-linear recovery trajectory, advanced analysis investigating the degrees of variation in outcomes is needed. Latent class analysis (LCA) is a mixed/multilevel model that estimates random slope variance to evaluate heterogeneity in outcome patterns among patient sub-groups and can be used to outline differing recovery trajectories. The purpose of this study was to determine recovery trajectory patterns after TSA and to identify factors that predict a given trajectory. Methods Data from a prospectively-collected single institutional database of patients undergoing anatomic and reverse TSA were utilized. Patients were included if they had American Shoulder and Elbow Surgeons (ASES) scores preoperatively, as well as postoperative scores at 6 weeks, 6 months, 1 year, and 2 years. Patients were excluded if they underwent a revision procedure or hemiarthroplasty, or for prior infection. LCA was used to subdivide the patient cohort into subclasses based on postoperative recovery trajectory. This was performed for all patients, as well as anatomic TSA and reverse TSA as separate groups. Unpaired Student’s t-tests, analysis of variance (ANOVA), and Fisher’s exact test were used to compare classes based on factors including age, body mass index (BMI), sex, preoperative diagnosis, and type of arthroplasty. Results A total of 244 TSAs were included in the final analysis – 89 anatomic TSA and 155 reverse TSA. In the combined group, LCA modeling revealed three patterns for recovery – Resistant Responders had low baseline scores (ASES<30) and poor final results (ASES<50), Steady Progressors had moderate baseline scores (ASES 30-50) with moderate final results (ASES 50-75), High Performers had moderate baseline scores (ASES>50) with excellent final results (ASES > 75). For anatomic TSA, we identified Delayed Responders with moderate baseline scores and a delayed response before ultimately achieving moderate final results, Steady Progressors with moderate baseline scores and a steady progression to achieve moderate final results, and High Performers who had moderate baseline scores and excellent final results. For reverse TSA, we identified Late Regressors with low baseline scores and poor final results, Steady Progressors with moderate baseline scores and moderate final results, and High Performers with moderate baseline scores and excellent final results. Conclusions Patients recover in a heterogenous manner following TSA. Through LCA we identified different recovery trajectories for patients undergoing anatomic TSA and reverse TSA.
Article
Objective: To summarize factors that are associated with a better treatment outcome after post-operative physical therapy in patients with shoulder arthroplasty. Data sources: PubMed, Cochrane, and Web of Science. Review methods: Studies examining factors that are associated with a better outcome after post-operative physical therapy interventions in patients with shoulder arthroplasty were included. Two independent reviewers performed screening, extracted data, and assessed the risk of bias and level of evidence, using the Quality In Prognosis Studies tool and Evidence-Based Guideline Development checklist. PRISMA guidelines were followed. Results: In total, 460 articles were found and 14 studies were included. Two of the included articles had a moderate risk of bias, 12 high. The overall number of patients in the included studies varied from 20 to 2053. Patients had either a reverse (N = 1863), an anatomic total shoulder arthroplasty (N = 1029) or, a hemiarthroplasty (N = 133). Anatomic total shoulder arthroplasty patients with a neutral rotation sling position showed less night pain and greater range of motion, which was awarded moderate evidence. Other modifiable and non-modifiable factors such as telemedicine, immediate range of motion exercises, and pre-operative function were only awarded preliminary or conflicting evidence. Conclusion: Mainly preliminary and conflicting evidence was found. The possible causes of the conflicting evidence were the different measurement methods, implant types, and follow-up times used. The methodological quality was low and physical therapy protocols differed greatly. More high-quality research with standardized protocols is needed to determine the association of various factors with treatment outcomes after post-operative physical therapy in patients with shoulder arthroplasty.
Article
Full-text available
Reverse total shoulder arthroplasty (RTSA) was originally developed because of unsatisfactory results with anatomic shoulder arthroplasty options for the majority of degenerative shoulder conditions and fractures. After initial concerns about RTSA longevity, indications were extended to primary osteoarthritis with glenoid deficiency, massive cuff tears in younger patients, fracture, tumour and failed anatomic total shoulder replacement. Traditional RTSA by Grammont has undergone a number of iterations such as glenoid lateralization, reduced neck-shaft angle, modular, stemless components and onlay systems. The incidence of complications such as dislocation, notching and acromial fractures has also evolved. Computer navigation, 3D planning and patient-specific implantation have been in use for several years and mixed-reality guided implantation is currently being trialled. Controversies in RTSA include lateralization, stemless humeral components, subscapularis repair and treatment of acromial fractures. Cite this article: EFORT Open Rev 2021;6:189-201. DOI: 10.1302/2058-5241.6.200085
Article
We determined the outcome of 113 total shoulder replacement arthroplasties performed with a Neer prosthesis between 1975 and 1981. The operations were performed for the treatment of osteoarthritis, rheumatoid arthritis, and old fractures or dislocations with traumatic arthritis. The probability of implant survival was 93% after 10 years and 87% after 15 years. Complications requiring reoperation developed in 14 shoulders. Seventy-nine patients with 89 replacements were available for follow-up a minimum of 5 years after the operation (mean 12.2 years, range 5 to 17 years). Relief from moderate or severe pain was achieved in 83% of shoulders. Active abduction improved by an average of 40 degrees to an average of 117 degrees. The amount of elevation that was regained was related to the amount of rotator cuff disease. Seventy-five glenoid components developed bone-cement radiolucencies, and 39 (44%) glenoid components had radiographic evidence of definite loosening. Glenoid loosening was associated with pain. A shift in position of the humeral component occurred in 49% of the press-fit stems and in none of the cemented stems. Humeral component loosening was not associated with pain.
Article
The American Shoulder and Elbow Surgeons have adopted a standardized form for assessment of the shoulder. The form has a patient self-evaluation section and a physician assessment section. The patient self-evaluation section of the form contains visual analog scales for pain and instability and an activities of daily living questionnaire. The activities of daily living questionnaire is marked on a four-point ordinal scale that can be converted to a cumulative activities of daily living index. The patient can complete the self-evaluation portion of the questionnaire in the absence of a physician. The physician assessment section includes an area to collect demographic information and assesses range of motion, specific physical signs, strength, and stability. A shoulder score can be derived from the visual analogue scale score for pain (50%) and the cumulative activities of daily living score (50%). It is hoped that adoption of this instrument to measure shoulder function will facilitate communication between investigators, stimulate multicenter studies, and encourage validity testing of this and other available instruments to measure shoulder function and outcome.
Article
Shoulder arthroplasty is in a stage of development that is ahead of replacement of other joints, if one considers not only movement and function but also durability. It is a difficult and demanding procedure requiring a meticulous cement and rotator cuff technique. Stability of a nonconstrained implant depends on its height and the length of the head version. Active motion depends on the rotator cuff and deltoid. Neither loss of bone nor tears of the rotator cuff contraindicate a nonconstrained replacement; however, massive defects of the muscles or bone are treated with a "limited goals rehabilitation" program to achieve stability with less motion. Shoulder replacement seems to enjoy unique durability; however, glenoid component follow-up is limited to 11 years. Up to now the incidence of reoperation for loosening of a glenoid component in 455 patients reported in four recent series combined was under 1%, and most radiolucent lines at the glenoid are believed to be attributable to errors in technique rather than loosening. Because of recent breakage of two polyethylene glenoid components, a standard-sized metal-backed glenoid component has been made available for general use and is preferred especially in active patients and those with sloping glenoids. The 600% glenoid component is no longer used; however, it is expected that the 200% component will be made available for general use after adequate clinical trial of the new holding device.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
We reviewed a consecutive series of 273 shoulders that were treated with metal-to-plastic total glenohumeral units. Nine sizes of humeral components and five different glenoid components, two of which were larger and more constrained, were used. The procedure is difficult and the technique varies according to the problems presented by each diagnostic category. Neither loss of bone nor a deficient rotator cuff is considered a contraindication to total glenohumeral replacement. Stability depends on the height as well as the version of the components. Function depends on the meticulous reconstruction and rehabilitation of the rotator-cuff and deltoid muscles. One hundred and ninety-four shoulders, which were followed for from twenty-four to ninety-nine months, were evaluated. Only four patients thought that they had not benefited from the procedure. Radiolucent lines were seen at some part of the bone-cement interface of the glenoid component in 30 per cent of those who were followed; the lines were thought to be due to faulty cementing technique in most patients. There was no instance of clinical loosening. There were twenty-four complications, of which twelve required further surgery. Of the 150 patients in the full exercise program, 129 (86%) achieved an excellent or satisfactory rating, and those with good muscles often had essentially normal motion and function. A so-called limited-goals rehabilitation category was delineated for the 20% of the patients in this series who had a massive deficiency of bone or muscle, and their results were graded separately. An investigation protocol has been established to determine the value of a deep-socket semi-constrained glenoid component for use in the rare shoulder with a non-functioning rotator cuff. Although special soft-tissue surgical technique and individualized postoperative care are mandatory for optimum results, we think that an unconstrained implant of this type, which approaches normal anatomy, will permit better function and endure longer in the shoulder joint than an implant with a fixed fulcrum.
Article
We determined the outcome of 113 total shoulder replacement arthroplasties performed with a Neer prosthesis between 1975 and 1981. The operations were performed for the treatment of osteoarthritis, rheumatoid arthritis, and old fractures or dislocations with traumatic arthritis. The probability of implant survival was 93% after 10 years and 87% after 15 years. Complications requiring reoperation developed in 14 shoulders. Seventy-nine patients with 89 replacements were available for follow-up a minimum of 5 years after the operation (mean 12.2 years, range 5 to 17 years). Relief from moderate or severe pain was achieved in 83% of shoulders. Active abduction improved by an average of 40 degrees to an average of 117 degrees. The amount of elevation that was regained was related to the amount of rotator cuff disease. Seventy-five glenoid components developed bone-cement radiolucencies, and 39 (44%) glenoid components had radiographic evidence of definite loosening. Glenoid loosening was associated with pain. A shift in position of the humeral component occurred in 49% of the press-fit stems and in none of the cemented stems. Humeral component loosening was not associated with pain.
Article
Seventy-eight Neer hemiarthroplasties and thirty-six Neer total shoulder arthroplasties were performed at our institution, between January 1, 1976, and December 31, 1985, in ninety-eight patients who were fifty years old or less. Two patients (two shoulders) died, and four patients (four shoulders) were lost to follow-up. The remaining seventy-four hemiarthroplasties (95 per cent) in sixty-four patients and thirty-four total shoulder arthroplasties (94 per cent) in thirty-one patients were included in the clinical analysis as the preoperative and operative records were complete and the patients had been followed for at least five years (mean, 12.3 years) or until revision. All 114 shoulders were included in the survivorship analysis. Both total shoulder arthroplasty and hemiarthroplasty resulted in significant long-term relief of pain (p < 0.0001) as well as improvement in active abduction (p < 0.0001) and external rotation (p < 0.0001). However, with the numbers available, we could not detect a significant difference between the two procedures with respect to these variables. A complete set of radiographs was available for sixty-eight (92 per cent) of the seventy-four shoulders that had a hemiarthroplasty and for thirty-two (94 per cent) of the thirty-four shoulders that had a total shoulder arthroplasty. A radiolucent line around the humeral component was noted after sixteen (24 per cent) of the hemiarthroplasties and after seventeen (53 per cent) of the total shoulder arthroplasties. A radiolucent line around the glenoid component was seen after nineteen (59 per cent) of the total shoulder arthroplasties. Erosion of the glenoid was found after forty-six (68 per cent) of the hemiarthroplasties. The results were graded according to a modification of the system of Neer et al. and of Cofield. Fifteen hemiarthroplasties led to an excellent result; twenty-four, a satisfactory result; and thirty-five, an unsatisfactory or unsuccessful result. Four total shoulder arthroplasties were followed by an excellent result; thirteen, a satisfactory result; and seventeen, an unsatisfactory or unsuccessful result. The estimated survival of the hemiarthroplasty prostheses (with 95 per cent confidence intervals) was 92 per cent (86 to 98 per cent) at five years, 83 per cent (75 to 93 per cent) at ten years, and 73 per cent (59 to 88 per cent) at fifteen years. Analysis of the results in association with the two major diagnoses revealed that the risk of revision was higher for the thirty shoulders that had the hemiarthroplasty for the treatment of the sequelae of trauma than for the twenty-eight that had the procedure for the treatment of rheumatoid arthritis (p = 0.017). The estimated survival of the total shoulder prostheses (with 95 per cent confidence intervals) was 97 per cent (92 to 100 per cent) at five years, 97 per cent (91 to 100 per cent) at ten years, and 84 per cent (70 to 100 per cent) at fifteen years. The risk of revision was higher for the seven shoulders that had had a tear of the rotator cuff at the time of the operation than for the twenty-seven that had not had one (p = 0.029). The data from the present study indicate that a shoulder arthroplasty provides marked long-term relief of pain and improvement in motion; however, nearly half of all young patients who have a shoulder arthroplasty have an unsatisfactory result according to a rating system. Care should be exercised when either a hemiarthroplasty or a total shoulder arthroplasty is offered to patients who are fifty years old or less.
Article
In 20 patients, 21 periprosthetic humeral fractures were reviewed retrospectively. The mean follow-up time was 27.1 months. Mild osteopenia was present in 45% of the patients, whereas 30% had severe osteopenia. Five mechanisms of fracture were identified, including 3 intraoperative causes that are avoidable. Treatment with stable intramedullary fixation utilizing the humeral stem and cerclage wiring provided superior results in terms of time to union, adverse effect on rehabilitation, and occurrence and severity of surgical complications. Diaphyseal fractures that were treated with standard stem arthroplasty with or without supplemental fixation had a longer time to fracture union, a higher complication rate, and prolonged rehabilitation. Fractures of the proximal humeral metaphysis can be treated with standard stem arthroplasty and cerclage wiring if the stem extends distal to the fracture site by at least 3 cortical diameters. Anatomic reduction of fractures treated by surgical means results in shorter healing times. Cast or brace immobilization can be used for management of postoperative fractures that occur distal to a well-fixed and stable prosthetic stem. Cast or brace immobilization results in fracture union but rehabilitation may be greatly impaired, and there is an increased risk of complications associated with immobilization of the extremity. Long-stem intramedullary fixation with cerclage wiring is the preferred surgical option for treatment of unstable humeral shaft fractures.
Article
From July 1977 through March of 1983, humeral head replacement was performed on 35 shoulders with osteoarthritis and 32 shoulders with rheumatoid arthritis and followed-up for an average of 9.3 years. Satisfactory pain relief was achieved in 44 (66%) and 52 of the shoulders (78%) were described by patients as being much better or better. Active elevation was improved from an average of 84 degrees to an average of 110 degrees with external rotation improving from 20 degrees to 44 degrees. Strength improvement also occurred. Only three complications developed, and these did not affect the final outcome. Because of moderate or severe pain, 12 shoulders (18%) required revision to total shoulder arthroplasty, and all patients were relieved of their pain. The result ratings were excellent in 10 shoulders, satisfactory in 23, and unsatisfactory in 34 (51%). With longer follow-up, a satisfactory level of pain relief may not continue for those patients with osteoarthritis and rheumatoid arthritis who have had humeral head replacement alone. Whereas this form of treatment should certainly be considered in those patients who have inadequate glenoid bone to support a glenoid implant and probably be considered in younger patients or patients who wish to remain more active, these latter patients must be fully appraised that the probability of continuing pain relief is less than has often been appreciated.
Article
The early symptomatic and functional results following removal of the humeral head have been improved by replacement of the articular surface and preservation of the bony attachments of the rotator-cuff. The appliance should be used only in cases in which established surgical principles indicate the need for head excision. The literature is reviewed and limitations discussed.
Shoulder reconstruction. Philadelphia: Saunders
  • C S Neer
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Neer CS II. Shoulder reconstruction. Philadelphia: Saunders; 1990.
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