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Is there evidence that the outcomes of primary anatomic and reverse shoulder arthroplasty are getting better?
Abstract
PurposeHave the results of shoulder arthroplasty got better over the last two decades? To answer this question, we sought published evidence that the patient-reported outcomes and re-operation rates have improved in reports of more recently performed anatomic (TSA) and reverse (RSA) total shoulder arthroplasties. Methods
We analyzed the arthroplasty results among studies published from 1990 to 2015, adjusting for the fact that the different publications presented patient groups with different combinations of diagnoses, used various outcome scales, and had different lengths of follow-up. ResultsThe adjusted clinical outcomes (p = 0.048), but not the revision rates (p = 0.3), were significantly better for articles reporting more recent TSA procedures. Neither the clinical outcomes (p = 0.9) nor the revision rates (p = 0.4) were significantly better in articles reporting more recent RSA surgeries. Conclusions
Better evidence from reports with greater detail will be necessary to show that patients are realizing progressively better outcomes from shoulder arthroplasty. Level of evidenceLevel IV
... In an attempt to address the high rate of glenoid failure, new glenoid components are being submitted and cleared by the U.S. Food and Drug Administration's 510 (k) process each year (Fig. 1). However, in spite of the introduction of these new designs, a recent analysis failed to show evidence of substantially improving outcomes for total shoulders over the last two decades [12]. It is difficult to know whether the new designs of glenoid components are yielding results that exceed the results of components that have been in widespread international usage for many years. ...
... Second, the maximal possible improvement for each patient was determined as the difference between the maximal possible value for the outcome scale and the patient's preoperative score. The amount of improvement achieved by each patient was then divided by the maximal possible improvement to obtain the percent of maximal possible improvement (%MPI)-clinically significant improvement has been defined as improvement of at least 30% of the maximal possible improvement [12,27,[38][39][40][41][42]. ...
... This report provides a broad-based and wellcharacterized data set against which the 1-and 2-year clinical outcomes for different glenoid components can be compared using universally available assessment scales (SST, ASES, Constant, Penn). Such comparisons are becoming increasing necessary and timely: new shoulder arthroplasty systems are being introduced annually without evidence that their clinical outcomes are superior to or even equal to those in current use [12]. Thus, a strong case exists for establishing a reference of 1-and 2-year clinical outcomes for standard glenoid components-such as that presented in this report-against which the early performance of new components can be compared. ...
... In an attempt to address the high rate of glenoid failure, new glenoid components are being submitted and cleared by the U.S. Food and Drug Administration's 510 (k) process each year (Fig. 1). However, in spite of the introduction of these new designs, a recent analysis failed to show evidence of substantially improving outcomes for total shoulders over the last two decades [12]. It is difficult to know whether the new designs of glenoid components are yielding results that exceed the results of components that have been in widespread international usage for many years. ...
... Second, the maximal possible improvement for each patient was determined as the difference between the maximal possible value for the outcome scale and the patient's preoperative score. The amount of improvement achieved by each patient was then divided by the maximal possible improvement to obtain the percent of maximal possible improvement (%MPI)-clinically significant improvement has been defined as improvement of at least 30% of the maximal possible improvement [12,27,[38][39][40][41][42]. ...
... This report provides a broad-based and wellcharacterized data set against which the 1-and 2-year clinical outcomes for different glenoid components can be compared using universally available assessment scales (SST, ASES, Constant, Penn). Such comparisons are becoming increasing necessary and timely: new shoulder arthroplasty systems are being introduced annually without evidence that their clinical outcomes are superior to or even equal to those in current use [12]. Thus, a strong case exists for establishing a reference of 1-and 2-year clinical outcomes for standard glenoid components-such as that presented in this report-against which the early performance of new components can be compared. ...
... In an attempt to address the high rate of glenoid failure, new glenoid components are being submitted and cleared by the U.S. Food and Drug Administration's 510 (k) process each year (Fig. 1). However, in spite of the introduction of these new designs, a recent analysis failed to show evidence of substantially improving outcomes for total shoulders over the last two decades [12]. It is difficult to know whether the new designs of glenoid components are yielding results that exceed the results of components that have been in widespread international usage for many years. ...
... Second, the maximal possible improvement for each patient was determined as the difference between the maximal possible value for the outcome scale and the patient's preoperative score. The amount of improvement achieved by each patient was then divided by the maximal possible improvement to obtain the percent of maximal possible improvement (%MPI)-clinically significant improvement has been defined as improvement of at least 30% of the maximal possible improvement [12,27,[38][39][40][41][42]. ...
... This report provides a broad-based and wellcharacterized data set against which the 1-and 2-year clinical outcomes for different glenoid components can be compared using universally available assessment scales (SST, ASES, Constant, Penn). Such comparisons are becoming increasing necessary and timely: new shoulder arthroplasty systems are being introduced annually without evidence that their clinical outcomes are superior to or even equal to those in current use [12]. Thus, a strong case exists for establishing a reference of 1-and 2-year clinical outcomes for standard glenoid components-such as that presented in this report-against which the early performance of new components can be compared. ...
Purpose
Clinical shoulder science lacks a benchmark against which the early clinical value of new glenoid components can be compared; such a benchmark may be derived from a multicenter study of patients receiving an established, internationally used design of glenoid component.
Methods
We obtained data from 11 centers on 1270 patients having total shoulder arthroplasty using an all-polyethylene component with a fluted central peg. We analyzed individual patient outcomes at 1 and 2 years after surgery. We compared the improvement for each patient to the minimal clinically important difference (MCID) and calculated each patient’s improvement as a percent of maximal possible improvement (MPI).
Results
The preoperative scores improved from SST 3 ± 2, ASES 37 ± 15, Constant score 36 ± 16, and Penn score 30 ± 19 to SST 10 ± 2, ASES 90 ± 12, Constant 76 ± 13, and Penn 80 ± 24 (p < 0.001 for each). A high percentage of patients improved by more than the MCID (SST 96%, ASES 98%, Constant 94%, Penn 93%) and obtained improvement of at least 30% of the MPI (SST 95%, ASES 98%, Constant 91%, Penn 87%). The clinical outcomes realized with this glenoid design were not worse for the 41% of shoulders with preoperative type B glenoids or for the 30% of shoulders with more than 15 degrees of glenoid retroversion.
Conclusions
Individual patients from 11 international practices having total shoulder arthroplasty using a basic glenoid component design obtained highly significant clinical outcomes, providing a benchmark against which the early outcomes of new designs can be compared to determine whether they provide increased clinical value.
... Of various indications of RTSA, the 10-year survival rate has been reported to be the most excellent in the CTA and massive rotator cuff tears. 6) Various authors have reported excellent results after RTSA in patients with CTA or massive rotator cuff tears. [7][8][9][10] Al-Hadithy et al. 7) reported that the mean age-adjusted Constant and Oxford scores improved from 34.2 to 71.0 points and 15 to 33 points, respectively, and the mean abduction and forward flexion improved from 64° to 100° and 55° to 110°, respectively. ...
... The results of RTSA appear to be comparable or even better in patients with osteoarthritis compared with CTA. Somerson et al. 6) reported that the increase of postoperative scores compared with preoperative scores were higher in CTA than osteoarthritis in their meta-analysis. ...
Indications of reverse total shoulder arthroplasty (RTSA) have been consistently extended by technical advancements in reverse arthroplasty prosthesis, continuous development of the implants, accumulated experiences and its successful treatment outcomes; accordingly, its use has rapidly increased. RTSA has been performed for a variety of indications, with variable outcomes depending on the initial diagnosis. However, controversial opinions still exist regarding the design of reverse arthroplasty prosthesis (medialized or lateralized design and the neck-shaft angle of the humeral prosthesis), suture of the subscapularis tendon, use of cement during placement of the humeral prosthesis, and surgical procedures; therefore, these should be investigated so that they can be better understood.
... Shoulder arthroplasty is a widely used approach for the management of glenohumeral pathology; each year an expanding range of diagnoses in an increasing number of patients are being treated with a growing variety of implants [1]. Assessing the broad-based effectiveness and value of the different forms of shoulder arthroplasty is an important challenge in the field of shoulder surgery. ...
... The value of national registries is that they have the potential for capturing the data from each arthroplasty, independent of the hospital or surgeon performing it. In that new implants are introduced to the marketplace each year [1], joint replacement registries provide a means for evaluating the overall effectiveness and failure rates of the new implants in comparison to those already in use, enabling the identification of implants with higher than expected rates of costly revision [6]. Population-based registries also allow for comparing and contrasting the patients and the shoulder arthroplasty procedures performed in different geographical regions [7][8][9][10]. ...
PurposeNational registries are valuable tools for understanding the results of shoulder arthroplasty across populations. These databases provide an unselected view of shoulder joint replacement within geographical areas that cannot be obtained from case series or prospective studies. They can be particularly helpful in determining which diagnoses, patients, procedures, and prostheses have higher than expected rates of revision. In an attempt to determine the generalizability of registry data, we asked, ‘how similar are the patients and procedures among the different national registries?’ Methods
We analyzed national shoulder arthroplasty registries and databases accessed via Internet portals and through a PubMed literature search. ResultsSeven national/regional registries and five publications regarding national shoulder arthroplasty data were identified; these sources contained a combined total of 261,484 shoulder arthroplasty cases. The percentages of hemiarthroplasty, anatomic (aTSA) and reverse total shoulders (rTSA), the diagnoses leading to arthroplasty, the mean patient age, and the distribution of patient gender varied significantly among these different databases. Conclusion
This study indicates that the indications for and application of shoulder arthroplasty have important geographical variations and that these variations must be considered when comparing outcomes of shoulder arthroplasty from different locations. Without controlling for age, gender, diagnosis and procedure type, the results from one national registry may not be applicable to patients from a different location. In that national data provide the opportunity to reduce costs by identifying implants and procedures with higher failure rates, the funding of registries needs to be free of conflicts of interest.
... A recent analysis indicates the incidence of periprosthetic joint infection (PJI) is 3% to 4%, although documented rates vary from 0.5% to 6.7% (Contreras et al, 2020). Notably, in a study scrutinising 4063 post-operative complications following shoulder arthroplasty, Somerson et al (2017) found that infections following RSA accounted for 13.8% of all reported RSA-related complications. ...
Reverse shoulder arthroplasty (RSA) was initially developed to manage cuff tear arthropathy in elderly patients. It has since become increasingly popular due to its ability to provide pain relief, enhance stability, and improve function in various complex shoulder pathologies. This review examines the evolution of RSA, including its expanded indications for use, complications, and the rising concern of potential overuse. While RSA has shown significant benefits in selected cases, its growing application in younger and more active patients raises questions about long-term outcomes and durability. Complications such as instability, infection, baseplate failure, and scapular notching remain substantial challenges, particularly in revision cases. The article emphasises the need for cautious patient selection and evidence-based practice to avoid overuse and ensure optimal patient outcomes. Future high-quality research with extended follow-up is essential to better understand RSA's long-term efficacy and safety, particularly in diverse and younger patient populations.
... проанализировали результаты артропластики, опубликованные в период с 1990 по 2015 г., с учетом того, что в исследованиях были представлены группы пациентов с различными диагнозами, использованы разные шкалы и сроки наблюдения. Скорректированные клинические результаты (p = 0,048) оказались значительно лучше в группах АЭ, а по частоте ревизионных вмешательств статистически значимой разницы (p = 0,4) отмечено не было [44]. ...
The article presents current trends in surgical treatment for oncological endoprosthesis of the shoulder joint. The main benefits and disadvantages of the 2 main techniques used in shoulder joint endoprosthesis are analyzed. Possibilities of their use in certain groups of patients are considered. Aim. To systemize and analyze the results of using anatomical and reverse endoprosthesis, consider possibilities of optimization of selection of treatment tactics.
... 26,29,33 Although the rates of reoperation and revision associated with RSA have decreased, implant-related complications are still significantly more common in RSA designs compared with anatomic shoulder arthroplasty designs. [2][3][4][5][6]28,31,32,[35][36][37][38][39]42 Glenoid baseplate loosening is one implant-related complication that can result from a number of potential factors including poor bone quality, inadequate initial biomechanical stability, and lack of bone ingrowth onto the prosthesis. 7,[16][17][18]27,28 The prosthetic design of a glenoid baseplate can affect both initial fixation and long-term survivorshipdseveral biomechanical studies have explored options to improve initial fixation and minimize micromotion [16][17][18]20,24 with use of various types and configurations of peripheral screws, 16,21,22,30 various baseplate positions and orientations, 1,30,40,41 and multiple baseplate designs. ...
Background
A linear relationship between baseplate insertion torque and compression force in reverse shoulder arthroplasty (RSA) baseplates with central screw design has been recently established. In this study, we evaluated 3 different baseplate designs and their influence on the torque-compression relationship.
Methods
Three different RSA baseplate designs were evaluated through biomechanical testing using a glenoid vault, bone surrogate model. A digital torque gauge was used to measure insertion torque applied to the baseplate, whereas compression data were collected continuously from a load cell. Additionally, 2 predictive models were developed to predict the compression forces of each baseplate design at varying levels of torque.
Results
A linear relationship was found between baseplate compression and insertion torque for all 3 baseplate designs. Both the monoblock and 2-piece locking designs achieved the goal torque of 6.8 Nm, whereas the 2-piece nonlocking design did not due to material strip-out. No significant difference in maximum compression was found between the monoblock and 2-piece locking designs. However, the 2-piece nonlocking design achieved significantly higher compression. Both predictive models were shown to adequately predict compressive forces at different torque inputs for the monoblock and 2-piece locking designs but not the 2-piece nonlocking design.
Conclusion
The torque-compression relationship of a central screw baseplate is significantly affected by baseplate design. A 2-piece nonlocking baseplate reaches higher compression levels and risks material strip-out at lower insertional torques compared with a monoblock and 2-piece locking design. This has implications both on component design and on surgeon tactile feedback during surgery.
... Frequency estimates in systematic reviews and large case series range from 1.8% to 10%, with most authors reporting rates of 5-9% for primary arthroplasty with higher rates for revision RSA. 1,[7][8][9][10][11][12][13][14][15] Initial fixation of non-cemented implants is critical to achieve a stable bone-to-implant interface during the first few months after surgery to potentiate bone ingrowth and avoid aseptic loosening. 3,[16][17][18] Minimization of micromotion to less than 150 µm between an implant and bone has been shown to be optimal in achieving a biological environment for bone growth onto metal arthroplasty surfaces. ...
Reverse shoulder arthroplasty is a well‐established procedure, however there is limited data in the literature regarding adequate insertion torque and the resulting compression for glenoid baseplate fixation. In this biomechanical study, we evaluated the relationship between insertion torque and baseplate compression by simultaneously measuring the insertion torque and axial compressive forces generated by two reverse shoulder arthroplasty baseplates with central screw design. Three different bone surrogates were chosen to mimic clinical scenarios where differences in compression achieved during baseplate insertion may exist due to varying bone quality. Epoxy resin sheet were combined with the bone surrogates to simulate the glenoid vault. A digital torque gauge was used to measure insertion torque applied to the baseplate, while compression data was collected continuously from a load cell. A strong positive correlation was found between baseplate compression and insertion torque. Among the lower density bone surrogates, neither baseplate design reached maximum insertion torque (6.8 Nm) due to material strip‐out. This phenomenon did not occur in denser bone surrogates. Both baseplate designs experienced a significant increase in mean baseplate compression as insertion torque increased and were found to behave similar in the denser bone surrogates. The results presented here suggest that larger compressive forces can be achieved with an increase in insertion torque in denser bone surrogates, but caution must be used when trying to achieve fixation in poor quality bone. Clinically, this could be useful preoperatively to minimize baseplate failure, and in further studies regarding baseplate design for improved initial fixation and stability. This article is protected by copyright. All rights reserved.
Introduction
The Ascend Flex short stem implant has been reported to have good early clinical outcomes and low revision rates. This retrospective study aimed to evaluate the early to mid-term radiographic and clinical outcomes of patients who underwent primary shoulder arthroplasty with this implant.
Methods
All consecutive patients who underwent primary shoulder arthroplasty with short uncemented Ascend Flex stems with a minimum of 24-month follow-up were included. The primary outcomes were revision and reoperation rate. The secondary outcomes included stress shielding and Oxford Shoulder Score (OSS).
Results
Totally, 151 shoulders were eligible for inclusion. Out of which 73 were anatomic total shoulder arthroplasty, 77 were reverse geometry, and 1 was a hemiarthroplasty. Mean follow-up duration was 52 ± 17.2 months. The revision and reoperation rates were 0.6% and 2.6%, respectively. 1.3% anatomic total shoulder arthroplasty (aTSA) cases and 6.5% RSA cases demonstrated stress shielding. OSS improved from 16.1 ± 8.5 to 34.1 ± 12.3 in aTSA cases ( Z = −3.98, p < 0.001) and from 15.6 ± 8.4 to 30.0 ± 13.5 in RSA cases ( Z = −3.41, p < 0.001).
Conclusion
These findings demonstrate reassuring outcomes for this implant at a mean of 52 months. Further reports are required to document the long-term outcomes for this component.
This study aims at answering the following questions (1) How high is the revision rate after osteoarthritis-, and rotator cuff-related compared to proximal humerus fracture (PHF)-related shoulder arthroplasty? (2) What are the associated risk factors for a revision after shoulder arthroplasty? Shoulder arthroplasty procedures occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare database. First, revision rates for PHF patients and age- and sex-matched non-fracture patients, grouped into osteoarthritis-related and rotator cuff-related arthroplasty, were compared. Second, revision rates between total shoulder arthroplasty and hemiarthroplasty after PHF were compared. Semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to investigate risk factors for revision surgery. Between the considered time period from 2009 through 2019, a total number of 47,979 PHFs was identified. A shoulder arthroplasty procedure was performed in n = 2639 (5.5%, 95%CI: 4.8–6.1) of the cases. The five-year survivorship of the implant was 96.3 (95%CI: 93.8–97.9) after hemiarthroplasty and 96.1% (05%CI: 94.2–97.3) after total shoulder arthroplasty. To compare the revision rates, n = 14,775 patients with osteoarthritis and n = 4268 patients with rotator cuff arthropathy, who received a shoulder arthroplasty, served as a non-fracture control group. Patients receiving a rotator cuff-related arthroplasty were more likely to require a revision compared to patients treated for osteoarthritis (HR: 1.27, 95%CI: 1.04–1.44, p = 0.018). Identified significant risk factors for revision surgery after shoulder arthroplasty included age ≤ 75 years, male sex, and osteoporosis. High implant survival was found for hemiarthroplasty and total shoulder arthroplasty for the treatment of PHF in elderly patients. The risk of revision surgery was elevated in patients receiving a rotator cuff-related arthroplasty as well as in patients with osteoporosis, male patients and patients older than 75 years.
Background
The purpose of this study was to determine if postoperative patient-reported outcomes improved over time following anatomic (TSA) and reverse (RTSA) total shoulder arthroplasty.
Methods
A retrospective analysis was performed on prospectively collected, patient-reported outcomes from our institution’s registry between 2008 and 2018 (n = 1,899). A minimum of 2-year postoperative ASES scores were required. Univariable linear models were used to test the association between year of surgery and improvement in ASES scores at 2- and 5-year follow-up, as well as any association with age, sex, primary or revision surgery, hand dominance, ASA classification, rotator cuff status, primary diagnosis, and Walch classification. Multivariable models were created to analyze ASES score improvement by index year while controlling for significant factors.
Results
In the univariable analysis, 5-year ASES difference scores increased each year by a mean of 1.65 (p < 0.001, CI 0.75-2.55) for TSA, 2.50 (p = 0.014, CI 0.52-4.49) for RTSA, and 1.64 (p < 0.001, CI 0.81-2.47) for the overall population. Patient sex, ASA classification, rotator cuff status, primary diagnosis, Walch classification, and revision procedures were also significant factors affecting ASES score. On multivariable analysis controlling for these factors, 5-year ASES difference scores were still significantly associated with year of surgery, increasing each year by a mean of 2.20 (p < 0.001, CI 0.91-3.50) for TSA, 4.83 (p < 0.001, CI 1.17-8.49) for RTSA, and 1.66 (p < 0.001, CI 0.81-2.51) for the entire population.
Conclusion
Both anatomic and reverse total shoulder arthroplasty patients reported increasing ASES difference scores at 5-year follow-up as time passed. These findings may indicate that advances in shoulder arthroplasties have resulted in better patient outcomes over time. Further research is needed to clarify which factors influence improvement in outcomes, particularly for revision procedures.
For practicing shoulder arthroplasty surgeons, it is advisable to consider a breadth of data sources concerning complications and outcomes. Although published series from high-volume centers are the primary source of data, these results may not be generalizable to a wide range of practice settings. National or health system-specific registry and medical device databases are useful adjuncts to assess the changing complication profile of shoulder arthroplasty, as well as to understand the complications specific to certain implants or implant types. To reduce the risk of postoperative complications, surgeons must have a clear understanding of the most common modes of failure.
Background:
As the utilization of reverse total shoulder arthroplasty (RSA) grows, it is increasingly important to examine the relationship between hospital volume and RSA outcomes. We hypothesized that hospitals that perform a higher volume of RSAs would have improved outcomes. We also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA.
Methods:
The Nationwide Readmissions Database was queried for patients who had undergone elective RSA from 2011 to 2015. Annual hospital volume and 90-day outcome data were collected, including readmission, revision, complications, hospital length of stay (LOS), supramedian cost, and discharge disposition. SSLR analysis was performed to determine hospital volume cutoffs associated with increased risks for adverse events. Cutoffs generated through SSLR analysis were confirmed via binomial logistic regression.
Results:
The proportion of patients receiving care at high-volume centers increased from 2011 to 2015. SSLR analysis produced hospital volume cutoffs for each outcome, with higher-volume centers showing improved outcomes. The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year, whereas cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year. SSLR analysis of 90-day readmission produced 3 hospital volume categories (1 to 16, 17 to 69, and ≥70 RSAs/year), each significantly different from each other. These were similar to the strata for 90-day revision (1 to 16, 17 to 53, and ≥54 RSAs/year) and 90-day complications (1 to 9, 10 to 68, and ≥69 RSAs/year). SSLR analysis produced 6 hospital volume categories for cost of care over the median value (1 to 5, 6 to 25, 26 to 47, 48 to 71, 72 to 105, and ≥106 RSAs/year), 5 categories for an extended LOS (1 to 10, 11 to 25, 26 to 59, 60 to 105, and ≥106 RSAs/year), and 4 categories for non-home discharge (1 to 31, 32 to 71, 72 to 105, and ≥106 RSAs/year).
Conclusions:
We have defined hospital surgical volumes that maximize outcomes after RSA, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways. This information may be used in future policy decisions to consolidate complex procedures, such as RSA, at high-volume destinations, or to encourage lower-volume institutions to strategize an approach to function as a higher-volume center.
Level of evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
The purpose of this study was to evaluate humeral stress shielding in shoulder arthroplasties performed with a smooth, standard-length humeral stem fixed with impaction autografting.
Methods:
Two-year outcomes were evaluated for 48 ream-and-run arthroplasties and 78 total shoulder arthroplasties (TSAs) performed at a single institution. Postoperative radiographs were analyzed for adaptive changes, calcar osteolysis, and component shift or subsidence. Radiographic outcomes were analyzed for associations with patient demographic characteristics, humeral stem filling ratios, and glenoid loosening; clinical outcomes were assessed using the Simple Shoulder Test.
Results:
At 2 years after surgery, the ream-and-run procedures showed partial calcar osteolysis in 9 cases (19%). The TSAs showed partial calcar osteolysis in 19 cases (24%) and complete calcar osteolysis in 2 (3%). Humeral component subsidence or component shift was observed in 3 ream-and-run procedures (6%) and in 8 TSAs (10%). These radiographic findings were not significantly associated with patient demographic characteristics, canal-filling ratios, or clinical outcomes.
Conclusion:
When inserted with impaction autografting, a smooth, standard-length humeral stem offers a secure bone-preserving approach for humeral component fixation in shoulder arthroplasty. These results with a conventional prosthesis can serve as a basis for comparison for new component designs and fixation methods.
Purpose
Total shoulder (TSA) is commonly used to treat arthritic shoulders with intact rotator cuffs; however, some patients choose a ream and run (RnR) to avoid the potential risks and limitations of a prosthetic glenoid component. Little is known about how patients selecting each of these two procedures compare and contrast.
Methods
We analyzed the patient characteristics, shoulder characteristics, and two year clinical outcomes of 544 patients having RnR or TSA at the same institution during the same six year period.
Results
Patients selecting the RnR were more likely to be male (92.0% vs. 47.0%), younger (58 ± 9 vs. 67 ± 10 years), married (83.2% vs. 66.8%), from outside of our state (51.7% vs. 21.7%), commercially insured (59.1% vs. 25.2%), and to have type B2 glenoids (46.0% vs. 27.8%) as well as greater glenoid retroversion (19 ± 11 vs. 15 ± 11 degrees) (p < .001). The average two year SST score for the RnRs was 10.0 ± 2.6 vs. 9.5 ± 2.7 for the TSAs. The percent of maximum possible improvement (%MPI) for the RnRs averaged 72 ± 39% vs. 73 ± 29% for the TSAs. Patients with work-related shoulder problems had lower two year SSTs and lower %MPIs. Younger patients having TSAs did less well than older patients. Female patients having RnRs did less well than those having TSAs (p < 0.001).
Conclusions
This investigation highlights important characteristics of patients selecting the RnR and the TSA for glenohumeral arthritis. Excellent outcomes can be achieved for appropriately selected patients having either procedure.
Objective
Reconstruction of proximal humeral bone defects in the setting of shoulder revision arthroplasty by implantation of a modular humeral component.
Indications
Severe segmental humeral bone defects in revision total shoulder arthroplasty, after tumor resection, trauma, pathological fractures, post-infectious or after failed osteosynthesis.
Contraindications
Acute or chronic local infections, large diaphyseal bone defects preventing adequate anchorage of the prosthesis, very short life expectancy (<3 months).
Surgical technique
Removal of the implant using an extended deltopectoral approach. Periarticular arthrolysis with preservation of neurovascular structures. Resection of the meta-diaphyseal bone and reconstruction of the humeral length with the help of different extension sleeves and a modular humeral component. Soft tissue management is crucial, especially with reverse shoulder arthroplasty.
Postoperative management
Three weeks postoperatively immobilization in a shoulder sling, active assisted movement therapy by gradual pain-adapted increase of movement, muscle coordination, and strength.
Results
The results of 11 consecutive patients treated with a modular humeral component due to a failed shoulder arthroplasty between 2008 and 2016 were evaluated retrospectively. Mean length of reconstruction was 100 mm. Due to recurrent dislocations one patient required revision and conversion to a reverse component. No cases of aseptic loosening or periprosthetic infection were observed.
Background
Cuff tear arthropathy is commonly managed with a reverse total shoulder arthroplasty (RTSA). A humeral hemiarthroplasty with an extended humeral head may provide a less invasive alternative for selected patients with cuff tear arthropathy if the shoulder has preserved active elevation. Because evidence regarding this procedure is limited, we investigated its safety and efficacy in treating selected patients with cuff tear arthropathy.
Methods
We analyzed the preoperative characteristics, surgical findings, and clinical outcomes for patients selected for extended head hemiarthroplasty.
Results
For 42 patients with 2-year follow-up, there were no complications or revisions. The Simple Shoulder Test score improved from a median of 3.0 to 8.0 (P < .001). The median percentage of maximal possible improvement was 50% (P < .001). The percentage of patients able to perform each of the functions of the Simple Shoulder Test was significantly improved; for example, the ability to sleep comfortably increased from 19% to 71%, and the ability to place a coin on the shelf at shoulder level increased from 38% to 86% (P < .001).
Conclusions
There are circumstances in which RTSA is clearly the preferred procedure for cuff tear arthropathy, including pseudoparalysis, anterosuperior escape, and glenohumeral instability; however, in shoulders with preserved active motion and stability of the humeral head provided by an intact coracoacromial arch, the extended head humeral arthroplasty can enable selected patients to realize improved comfort and function without the potential risks of RTSA. Extended humeral head hemiarthroplasty can provide a safe and effective alternative for the management of selected patients with rotator cuff tear arthropathy and preserved active motion.
Background:
Most of the literature on shoulder arthroplasty failure comes from high-volume centers. These reports tend to exclude the experience of community orthopedic surgeons, who perform most of the shoulder joint replacements.
Methods:
We analyzed the failure reports mandated by the US Food and Drug Administration for all hospitals. Each reported event from 2012 to 2016 was characterized by implant, failure mode, and year of surgery.
Results:
For the 1673 anatomic arthroplasties, the most common failure modes were glenoid component failure (20.4%), rotator cuff/subscapularis tear (15.4%), pain/stiffness (12.9%), dislocation/instability (11.8%), infection (9%), and humeral component loosening (5.1%). For the 2390 reverse arthroplasties, the most common failure modes were dislocation/instability (32%), infection (13.8%), glenosphere-baseplate dissociation (12.2%), failed/loosened baseplate (10.4%), humeral component dissociation/tray fracture (5.5%), difficulty inserting the baseplate (4.8%), and difficulty inserting the glenosphere (4.2%). Although the percentage distribution among the different failure modes was relatively consistent over the years of this study, the percentage distribution of these failure modes differed substantially among different implant manufacturers.
Conclusions:
The Food and Drug Administration database reveals modes of shoulder arthroplasty failure that are not emphasized in the published literature, such as rotator cuff tear, infection, and postoperative pain/stiffness for anatomic total shoulder arthroplasty and implant dissociation and baseplate failure for reverse shoulder arthroplasty. Knowledge of these failure modes may help inform surgical technique and implant design in ways that will lower the risk of implant failure in the future.
Background:
Evidence is limited regarding the complications and outcomes after medial ulnar collateral ligament (UCL) reconstruction. The published data regarding this procedure are composed predominantly of small Level-III and IV retrospective studies for which meta-analysis is not generally useful. Meta-regression is an alternative technique to identify variables across multiple publications that have an effect on published outcomes and complication rates.
Methods:
We performed a systematic search of published literature for outcomes after UCL reconstruction. A random effects meta-regression model was constructed to identify the association of study characteristics with outcome proportions. Sensitivity analyses were performed to assess the impact of influential studies on the results.
Results:
Fourteen studies (median sample size, 26 patients; range, 10 to 743 patients) were included in the systematic review and meta-regression. These studies included a total of 1,177 patients with a reported Conway outcome rating (a measure of a patient's return to play). The majority of patients (mean, 83.2%) achieved an excellent Conway rating. Studies involving the docking technique were more likely to have a higher percentage of patients with an excellent outcome (14% risk difference compared with the figure-of-8 technique, p = 0.002) and lower reported rates of ulnar neurapraxia (Spearman correlation = -0.83). A lower reported rate of ulnar neurapraxia was strongly associated with the likelihood of an excellent (p = 0.01) or good or excellent (p = 0.001) Conway outcome rating.
Conclusions:
Despite substantial heterogeneity among study outcomes, studies that involved a docking technique and that had lower reported rates of ulnar neurapraxia were associated with greater percentages of excellent or good-to-excellent reported Conway outcome ratings.
Level of evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
Although shoulder arthroplasties generally are effective in improving patients' comfort and function, the results are variable for reasons that are not well understood.
Questions/purposes:
We posed two questions: (1) What factors are associated with better 2-year outcomes after shoulder arthroplasty? (2) What are the sensitivities, specificities, and positive and negative predictive values of a multivariate predictive model for better outcome?
Methods:
Three hundred thirty-nine patients having a shoulder arthroplasty (hemiarthroplasty, arthroplasty for cuff tear arthropathy, ream and run arthroplasty, total shoulder or reverse total shoulder arthroplasty) between August 24, 2010 and December 31, 2012 consented to participate in this prospective study. Two patients were excluded because they were missing baseline variables. Forty-three patients were missing 2-year data. Univariate and multivariate analyses determined the relationship of baseline patient, shoulder, and surgical characteristics to a "better" outcome, defined as an improvement of at least 30% of the maximal possible improvement in the Simple Shoulder Test. The results were used to develop a predictive model, the accuracy of which was tested using a 10-fold cross-validation.
Results:
After controlling for potentially relevant confounding variables, the multivariate analysis showed that the factors significantly associated with better outcomes were American Society of Anesthesiologists Class I (odds ratio [OR], 1.94; 95% CI, 1.03-3.65; p = 0.041), shoulder problem not related to work (OR, 5.36; 95% CI, 2.15-13.37; p < 0.001), lower baseline Simple Shoulder Test score (OR, 1.32; 95% CI, 1.23-1.42; p < 0.001), no prior shoulder surgery (OR, 1.79; 95% CI, 1.18-2.70; p = 0.006), humeral head not superiorly displaced on the AP radiograph (OR, 2.14; 95% CI, 1.15-4.02; p = 0.017), and glenoid type other than A1 (OR, 4.47; 95% CI, 2.24-8.94; p < 0.001). Neither preoperative glenoid version nor posterior decentering of the humeral head on the glenoid were associated with the outcomes. The model predictive of a better result was driven mainly by the six factors listed above. The area under the receiver operating characteristic curve generated from the cross-validated enhanced predictive model was 0.79 (generally values of 0.7 to 0.8 are considered fair and values of 0.8 to 0.9 are considered good). The false-positive fraction and the true-positive fraction depended on the cutoff probability selected (ie, the selected probability above which the prediction would be classified as a better outcome). A cutoff probability of 0.68 yielded the best performance of the model with cross-validation predictions of better outcomes for 236 patients (80%) and worse outcomes for 58 patients (20%); sensitivity of 91% (95% CI, 88%-95%); specificity of 65% (95% CI, 53%-77%); positive predictive value of 92% (95% CI, 88%-95%); and negative predictive value of 64% (95% CI, 51%-76%).
Conclusions:
We found six easy-to-determine preoperative patient and shoulder factors that were significantly associated with better outcomes of shoulder arthroplasty. A model based on these characteristics had good predictive properties for identifying patients likely to have a better outcome from shoulder arthroplasty. Future research could refine this model with larger patient populations from multiple practices.
Level of evidence:
Level II, therapeutic study.
Each generation of total shoulder arthroplasy has improved on the previous. The newest humeral component innovation is shortening the humeral component or eliminating the stem entirely to rely on stemless fixation in the humeral metaphysis. This offers theoretical advantages of preserved bone stock, less stress shielding, eliminating the diaphyseal stress riser, ease of stem removal at revision, and humeral head placement independent from the humeral shaft axis. There are a number of short term cohorts that have shown low complication rates and outcomes similar to previous generations of stemmed humeral components. Longer term and better designed studies are needed in order for short stems and stemless components to become the standard of care.
Modularity in total shoulder arthroplasty (TSA) has increased over the past 30 years. Our institution previously showed shoulders treated with modular humeral head/stem arthroplasties had similar outcomes to monoblock designs. Presently, we aim to update clinical follow-up of 2nd generation TSAs and assess how increased modularity affects early outcomes and survivorship across three generations of implants.
Between 1997 and 2001, 75 second generation modular TSA's were performed for primary osteoarthritis. Shoulders were followed for a minimum of 2 years or until reoperation, mean 7.4 years. Results were compared with first generation monoblock TSAs and third generation TSAs which offered multiple humeral head shape options to more precisely replicate patient anatomy.
Second generation TSAs continue to show significant improvements in pain, elevation and external rotation: 90 % of shoulders were subjectively better at follow-up. Survivorship was estimated to be 89.0 % at 10 years. All generations showed similar pain relief, and improved range of motion and Neer ratings. Survivorship among the 3 groups was similar at 5 years but was estimated to be higher in the 1st generation group at 7 years. More glenoids were radiographically at risk in the 2nd and 3rd generation groups than in the 1st; however, this did not reach significance.
With extended mid-term follow-up, second generation anatomic TSA continues to provide improvements in pain and range of motion for primary OA. Implant modularity can facilitate surgery, but similar clinical outcomes can be expected regardless of modularity.
Level IV, Treatment study.
Background and purpose Previous studies on shoulder arthroplasty have usually described small patient populations, and few articles have addressed the survival of shoulder implants. We describe the results of shoulder replacement in the Norwegian population (of 4.7 million) during a 12-year period. Trends in the use of shoulder arthroplasty during the study period were also investigated.
Patients and methods 1,531 hemiprostheses (HPs), 69 total shoulder replacements (Neer type TSR), and 225 reversed total shoulder replacement (reversed TSR) operations were reported to the Norwegian Arthroplasty Register between 1994 and 2005. Kaplan-Meier failure curves were drawn up for particular subgroups of patients, and revision rates were calculated using Cox regression analysis.
Results The 5- and 10-year failure rates of hemiprostheses were 6% (95% CI: 5–7) and 8% (95% CI: 6–10), and for reversed total shoulder replacements they were 10% (95% CI: 5–15) and 22% (95% CI: 10–33), respectively. For hemiprostheses, the risk of revision for patients who were 70 years or older was half that of those who were younger (RR = 0.47, CI: 0.28–0.77), while the risk of revision was highest for patients with sequelae after fracture compared to those with acute fractures (RR = 3.3, CI: 1.5–7.2). No differences in prosthesis survival were found between the different hemiprosthesis brands. The main reasons for revision of hemiprostheses were pain and luxation. For reversed total prostheses, the risk of revision was less for women than for men (RR = 0.26, CI: 0.11–0.63), and the main cause of revision was aseptic loosening of the glenoid component. During the study period, the incidence of shoulder arthroplasty increased for all diagnostic groups except inflammatory arthritis, for which a decrease was seen.
Interpretation We found good results in terms of 5-year prosthesis failure rate, with the use of hemiarthroplasty for patients with inflammatory arthritis, osteoarthritis, and acute fractures. Reversed total shoulder replacement was associated with a rather poor prognosis.
Reverse shoulder arthroplasty provides satisfactory outcomes, but its cost-effectiveness is unproven. We prospectively analyzed outcomes and costs for primary reverse shoulder arthroplasty.
Thirty serial patients (16 women and 14 men; mean age, 74.1 years [range, 61.1-87.3 years]) with rotator cuff arthropathy had active motion recorded and completed function tests (visual pain analog scale; Simple Shoulder Test; American Shoulder and Elbow Surgeons Shoulder Outcome score; EuroQol; and Short Form-36 Health Survey) preoperatively and postoperatively at 1 and 2 years. Costs included professional fees, operating room and supply costs, and hospital care. Changes were compared by the Wilcoxon signed rank test, and quality-adjusted life-years were calculated preoperatively and postoperatively.
Twenty-seven patients completed the study. Clinical and functional outcomes demonstrated significant improvement (P < .05). Significantly improved (P < .05) Short Form-36 subgroups included physical functioning, role limitations due to physical health, bodily pain, vitality, and physical composite score. EuroQol dimensions of usual activities and pain/discomfort improved significantly (P < .05). Calculations with the SF-6D showed that median QALYs improved from 6.56 preoperatively to 7.43 at 1-year follow-up (P <.09) and from 6.56 preoperatively to 7.58 at 2-year follow-up (P <.003). The increase in QALYs calculated from the EQ-5D was somewhat greater, changing from 6.21 preoperatively to 7.69 at 1-year follow-up (P <.0001) and from 6.13 to 8.10 at 2-year follow-up (P <.04). Mean cost was 26,920/quality-adjusted life-year by the Short Form 6 Dimensions and 50,000/quality-adjusted life-year) improvement for cuff tear arthropathy patients after primary reverse shoulder arthroplasty.
Background
The role of evidence-based medicine in sports medicine and orthopaedic surgery is rapidly growing. Systematic reviews and meta-analyses are also proliferating in the medical literature.
Purpose
To provide the outline necessary for a practitioner to properly understand and/or conduct a systematic review for publication in a sports medicine journal.
Study Design
Review.
Methods
The steps of a successful systematic review include the following: identification of an unanswered answerable question; explicit definitions of the investigation’s participant(s), intervention(s), comparison(s), and outcome(s); utilization of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and PROSPERO registration; thorough systematic data extraction; and appropriate grading of the evidence and strength of the recommendations.
Results
An outline to understand and conduct a systematic review is provided, and the difference between meta-analyses and systematic reviews is described. The steps necessary to perform a systematic review are fully explained, including the study purpose, search methodology, data extraction, reporting of results, identification of bias, and reporting of the study’s main findings.
Conclusion
Systematic reviews or meta-analyses critically appraise and formally synthesize the best existing evidence to provide a statement of conclusion that answers specific clinical questions. Readers and reviewers, however, must recognize that the quality and strength of recommendations in a review are only as strong as the quality of studies that it analyzes. Thus, great care must be used in the interpretation of bias and extrapolation of the review’s findings to translation to clinical practice. Without advanced education on the topic, the reader may follow the steps discussed herein to perform a systematic review.
Cost in shoulder surgery has taken on a new focus with passage of the Patient Protection and Affordable Care Act. As part of this law, there is a provision for Accountable Care Organizations (ACOs) and the bundled payment initiative. In this model, one entity would receive a single payment for an episode of care and distribute funds to all other parties involved. Given its reproducible nature, shoulder arthroplasty is ideally situated to become a model for an episode of care. Currently, there is little research into cost in shoulder arthroplasty surgery. The current analyses do not provide surgeons with a method for determining the cost and outcomes of their interventions, which is necessary to the success of bundled payment. Surgeons are ideally positioned to become leaders in ACOs, but in order for them to do so a methodology must be developed where accurate costs and outcomes can be determined for the episode of care.
Previous studies on shoulder arthroplasty have usually described small patient populations, and few articles have addressed the survival of shoulder implants. We describe the results of shoulder replacement in the Norwegian population (of 4.7 million) during a 12-year period. Trends in the use of shoulder arthroplasty during the study period were also investigated.
1,531 hemiprostheses (HPs), 69 total shoulder replacements (Neer type TSR), and 225 reversed total shoulder replacement (reversed TSR) operations were reported to the Norwegian Arthroplasty Register between 1994 and 2005. Kaplan-Meier failure curves were drawn up for particular subgroups of patients, and revision rates were calculated using Cox regression analysis.
The 5- and 10-year failure rates of hemiprostheses were 6% (95% CI: 5-7) and 8% (95% CI: 6-10), and for reversed total shoulder replacements they were 10% (95% CI: 5-15) and 22% (95% CI: 10-33), respectively. For hemiprostheses, the risk of revision for patients who were 70 years or older was half that of those who were younger (RR = 0.47, CI: 0.28-0.77), while the risk of revision was highest for patients with sequelae after fracture compared to those with acute fractures (RR = 3.3, CI: 1.5-7.2). No differences in prosthesis survival were found between the different hemiprosthesis brands. The main reasons for revision of hemiprostheses were pain and luxation. For reversed total prostheses, the risk of revision was less for women than for men (RR = 0.26, CI: 0.11-0.63), and the main cause of revision was aseptic loosening of the glenoid component. During the study period, the incidence of shoulder arthroplasty increased for all diagnostic groups except inflammatory arthritis, for which a decrease was seen.
We found good results in terms of 5-year prosthesis failure rate, with the use of hemiarthroplasty for patients with inflammatory arthritis, osteoarthritis, and acute fractures. Reversed total shoulder replacement was associated with a rather poor prognosis.
We examined the outcomes of using 3 types of humeral prostheses in total shoulder arthroplasty for osteoarthritis: a modular prosthesis with variable head diameters (MV), a nonmodular prosthesis with variable head diameters (NV), and a nonmodular prosthesis with a fixed head diameter (NF). Patients (N=101) completed self-assessments of shoulder function and health status before surgery and at follow-up between 30 and 60 months after surgery. Outcomes for the MV and NV prostheses did not differ statistically. The NF prosthesis trended toward poorer functional scores. Two Short Form-36 dimensions were statistically significantly lower (P<.05) in the NF group than in the MV and NV groups. These results fail to confirm that humeral component modularity is an important factor in the outcome of shoulder arthroplasty.
Background
In selected patients with a desire to maintain activity levels greater than those recommended after reverse total shoulder arthroplasty, hemiarthroplasty remains an option for treatment of cuff tear arthropathy (CTA). However, given the relatively small case series that have been reported to date, little is known regarding which patients will show functional improvement after this surgery. Questions/purposesWe asked: What factors are associated with achieving the minimum clinically important difference in the simple shoulder test (SST) after hemiarthroplasty for cuff tear arthropathy? Patients and Methods
Between 1991 and 2007, two surgeons at one academic center performed 48 shoulder hemiarthroplasties for CTA. No patients were known to have died before data collection, and of those not known to have died, 42 (88%) were available for followup at a mean of 48 months (range, 24–132 months). During that time, the general indications for this approach were glenohumeral arthritis with superior decentering of the humeral head. The majority of the patients with CTA were treated nonoperatively with patient-directed physical therapy and other modalities. A total of 42 patients (42 shoulders; 24 males and 18 females) with CTA were treated with hemiarthroplasty and followed for a mean of 48 months (range, 24–132 months). This is a retrospective study that made use of a longitudinally maintained database, which included physical examination of ROM, the SST, VAS, and standardized radiographs. At latest followup, 33 of 42 patients achieved a clinically important percentage of maximum possible improvement (%MPI) in SST score, defined as an improvement of 30% of the total possible improvement on the 12-point scale (with higher scores representing better results). ResultsIntraoperative findings of a rotator cuff tear limited to the supraspinatus and infraspinatus (odds ratio [OR], ∞; 95% CI, 2.01 to ∞; p = 0.020) and limited preoperative external rotation (15° [range, −40° to 45°] vs 35° [range, 20°–45°], OR, 0.71; 95% CI, 0.38–0.90; p < 0.001) were associated with achieving the defined minimum functional improvement (30% of MPI) on multivariate analysis. Preoperative active elevation (p = 0.679) and use of a CTA-specific implant (p = 0.707) were not significantly associated with achievement of 30% of MPI. Conclusion
Patients with intact teres minor and subscapularis tendons and patients with lower preoperative external rotation had a better prognosis for achieving a clinically important percentage of MPI at short-term followup. Although some patients were followed for more than 10 years, the majority were followed for fewer than 5 years; future studies will need to determine whether these early functional results are maintained for longer periods. Level of EvidenceLevel III, therapeutic study.
Background:
Young patients with severe glenohumeral arthritis pose a challenging management problem for shoulder surgeons. Two controversial treatment options are total shoulder arthroplasty (TSA) and hemiarthroplasty. This study aims to characterize costs, as expressed by reimbursements for episodes of acute care, and outcomes associated with each treatment.
Questions/purposes:
We asked: for patients 30 to 50 years old with severe end-stage glenohumeral arthritis refractory to conservative management, (1) are more years of patient-derived satisfactory outcome by the Neer criteria and quality-adjusted life-years (QALYs) achieved using a TSA or a hemiarthroplasty; (2) does a TSA or a hemiarthroplasty result in a greater number of revision procedures; and (3) does a TSA or a hemiarthroplasty result in greater associated costs to society?
Methods:
The incidence of glenohumeral arthritis among 30- to 50-year-old patients, outcomes, reoperation probabilities, and associated costs from TSA and hemiarthroplasty were derived from the literature. A Markov chain decision tree model was developed from these estimates with number of revisions, cost of management for patients to 70 years old as defined by reimbursement for acute-care episodes, years with "satisfactory" or "excellent" outcome by the modified Neer criteria, and QALYs gained as principle outcome measures. A Monte Carlo simulation was conducted with a cohort representing the at-risk population for shoulder arthritis between 30 and 50 years old in the United States.
Results:
During the lifetime of a cohort of 5279 patients, hemiarthroplasty as the initial treatment resulted in 59,574 patient years of satisfactory or excellent results (11.29 per patient) and average QALYs gained of 6.55, whereas TSA as the initial treatment resulted in 85,969 patient years of satisfactory or excellent results (16.29 per patient) and average QALYs gained of 7.96. During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as the initial treatment led to 2090 lifetime revisions (0.4 per patient), whereas a TSA as the initial treatment led to 1605 lifetime revisions (0.3 per patient). During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as initial treatment resulted in USD 132,500,000 associated direct reimbursements (USD 25,000 per patient), whereas a TSA as initial treatment resulted in USD 125,500,000 associated direct reimbursements (USD 23,700 per patient).
Conclusions:
Treatment of end-stage glenohumeral arthritis refractory to conservative treatment in patients 30 to 50 years old in the United States with TSA, instead of hemiarthroplasty, would result in greater cost savings, avoid a substantial number of revision procedures, and result in greater years of satisfactory or excellent patient outcomes and greater QALYs gained. On a population level, TSA is the cost-effective treatment for glenohumeral arthritis in patients 30 to 50 years old.
Level of evidence:
Level II, economic and decision analysis study.
Purpose:
To compare the cost-effectiveness within the United States health care system of arthroscopic rotator cuff repair versus reverse total shoulder arthroplasty in patients with symptomatic large and massive rotator cuff tears without cuff-tear arthropathy.
Methods:
An expected-value decision analysis was constructed comparing the costs and outcomes of patients undergoing arthroscopic rotator cuff repair and reverse total shoulder arthroplasty for large and massive rotator cuff tears (and excluding cases of cuff-tear arthropathy). Comprehensive literature search provided input data to extrapolate costs and health utility states for these outcomes. The primary outcome assessed was that of incremental cost-effectiveness ratio (ICER) of reverse total shoulder arthroplasty versus rotator cuff repair.
Results:
For the base case, both arthroscopic rotator cuff repair and reverse total shoulder were superior to nonoperative care, with an ICER of 37,400/QALY, respectively. Arthroscopic rotator cuff repair was dominant over primary reverse total shoulder arthroplasty, with lower costs and slightly improved clinical outcomes. Arthroscopic rotator cuff repair was the preferred strategy as long as the lifetime progression rate from retear to end-stage cuff-tear arthropathy was less than 89%. However, when the model was modified to account for worse outcomes when reverse shoulder arthroplasty was performed after a failed attempted rotator cuff repair, primary reverse total shoulder had superior outcomes with an ICER of $90,000/QALY.
Conclusions:
Arthroscopic rotator cuff repair-despite high rates of tendon retearing-for patients with large and massive rotator cuff tears may be a more cost-effective initial treatment strategy when compared with primary reverse total shoulder arthroplasty and when assuming no detrimental impact of previous surgery on outcomes after arthroplasty. Clinical judgment should still be prioritized when formulating treatment plans for these patients. LEVEL OF EVIDENCE: Level II, economic decision analysis.
Background:
The Nordic Arthroplasty Register Association was initiated in 2007, and several papers about hip and knee arthroplasty have been published. Inspired by this, we aimed to examine the feasibility of merging data from the Nordic national shoulder arthroplasty registries by defining a common minimal data set.
Methods:
A group of surgeons met in 2014 to discuss the feasibility of merging data from the national shoulder registries in Denmark, Norway, and Sweden. Differences in organization, definitions, variables, and outcome measures were discussed. A common minimal data set was defined as a set of variables containing only data that all registries could deliver and where consensus according to definition of the variables could be made.
Results:
We agreed on a data set containing patient-related data (age, gender, and diagnosis), operative data (date, arthroplasty type and brand), and data in case of revision (date, reason for revision, and new arthroplasty brand). From 2004 to 2013, there were 19,857 primary arthroplasties reported. The most common indications were osteoarthritis (35%) and acute fracture (34%). The number of arthroplasties and especially the number of arthroplasties for osteoarthritis have increased in the study period. The most common arthroplasty type was total shoulder arthroplasty (34%) for osteoarthritis and stemmed hemiarthroplasty (90%) for acute fractures.
Conclusion:
We were able to merge data from the Nordic national registries into 1 common data set; however, the set of details was reduced. We found considerable differences between the 3 countries regarding incidence of shoulder arthroplasty, age, diagnoses, and choice of arthroplasty type and brand.
Background:
Increased length of hospital stay, hospital readmission, and revision surgery are adverse outcomes that increase the cost of elective orthopaedic procedures, such as shoulder arthroplasty. Awareness of the factors related to these adverse outcomes will help surgeons and medical centers design strategies for minimizing their occurrence and for managing their associated costs.
Methods:
We analyzed data from the New York Statewide Planning and Research Cooperative System on 17,311 primary shoulder arthroplasties performed from 1998 to 2011 to identify factors associated with extended lengths of hospitalization after surgery, readmission within ninety days, and surgical revision.
Results:
The factors associated with each of these three adverse outcomes were different. Longer lengths of hospital stay were associated with female sex, advanced patient age, Medicaid insurance, comorbidities, fracture as the diagnosis for arthroplasty, higher hospital case volumes, and lower surgeon case volumes. Readmission was associated with advanced patient age and medical comorbidities. The most common diagnoses for readmission within ninety days were fluid and electrolyte imbalance (28%), acute pulmonary problems (21%), cardiac arrhythmia (20%), heart failure (15%), acute myocardial infarction (10%), and urinary tract infection (10%). Revision was associated with younger patient age and osteoarthritis or traumatic arthritis. The most common diagnoses at the time of revision surgery were unspecified mechanical complications of the implant (60%), shoulder pain (18%), dislocation of the prosthetic joint (12%), component loosening (10%), a broken prosthesis (8%), a cuff tear (7%), and infection (7%).
Conclusions:
A small number of easily identified characteristics (sex, age, race, insurance type, comorbidities, diagnosis, and provider case volumes) were significantly associated with longer lengths of stay, readmission, and revision surgery. Consideration of these factors and their effects may guide efforts to improve patient safety and to manage the costs associated with these adverse outcomes.
The objective of this study is to investigate the patient factors associated with early revision within 1 year after shoulder arthroplasty, including total shoulder arthroplasty (TSA), hemiarthroplasty, and reverse TSA, and the cause of failure leading to early revision.
Patients who underwent shoulder arthroplasty from 2005 to 2012 were identified using International Classification of Diseases, Ninth Revision procedure codes. Those who underwent revision shoulder arthroplasty were then divided into early (<1 year) and late (>1 year) groups. Patients in each of the cohorts were queried for demographic data and etiologic factors for revision arthroplasty.
A total of 221,381 patients who underwent shoulder arthroplasty were identified, including 115,956 TSAs, 75,208 hemiarthroplasties, and 30,217 reverse TSAs. The patient factors significantly associated with early revision after shoulder arthroplasty regardless of type were age younger than 65 years, smoking, obesity, and morbid obesity. Dislocation was the most common reason for early revision after all types of arthroplasties. Loosening was a more common reason for early revision after TSA compared with both hemiarthroplasty and reverse TSA.
Several patient factors appear to be associated with early revision after shoulder arthroplasty, including younger age, smoking, obesity, and male sex. The cause of failure leading to early revision varies between late and early revision cases. These findings are important to identify patients preoperatively who may be at risk of early revision after shoulder arthroplasty to allow appropriate patient counseling and risk stratification.
Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Total shoulder arthroplasty (TSA) is commonly used to treat glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Recently, reverse shoulder arthroplasty (RSA) has been used for GHOA patients who are elderly or have eccentric glenoid wear. We evaluated patients with GHOA scheduled to have TSA but who were changed to RSA because of intraoperative difficulties with the glenoid component or instability and compared them with a cohort that underwent TSA to determine if the groups had similar outcomes.
We identified 24 consecutive GHOA patients who underwent RSA and matched them to 96 patients who underwent TSA. Glenoid wear and rotator cuff musculature were assessed with preoperative computed tomography scans. Direct hospital costs of the procedure were collected.
Postoperative American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and range of motion were similar between the 2 groups. Five TSA patients had radiographic glenoid loosening, whereas no RSA patients did. Neither group required a revision. One RSA patient required surgery for treatment of a periprosthetic fracture. RSA was $7274 more costly than TSA, related mainly to implant cost.
Patients with GHOA who were converted intraoperatively to RSA because of improper seating of the glenoid trial or persistent posterior subluxation had outcomes comparable to those of a similar group of patients in whom TSA was performed. At midterm follow-up, TSA is associated with lower cost than RSA. The higher rate of radiographic loosening in the TSA group warrants longer follow-up to assess revision costs. In cases in which a TSA cannot be performed with confidence, RSA is a reasonable alternative.
Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Background:
Rotator cuff tears are common, and rotator cuff repair represents a major health care expense. While patients often benefit from rotator cuff repair, anatomic failure of the repair is not unusual.
Purpose:
To identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs.
Study design:
Systematic review and meta-analysis of articles with evidence levels 1-4.
Methods:
A total of 2383 articles on rotator cuff repairs published between 1980 and 2012 were identified. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. Factors related to the patients, their shoulders, the procedures, and the results were systematically categorized and submitted for meta-analysis.
Results:
While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic results did not show improvement over this period. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, advanced age, and double-row repairs. Clinical improvement averaged 72% of the maximum possible improvement. Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff. The inconsistent and incomplete data in the published articles limited the meta-analysis of factors affecting the outcome of rotator cuff repair.
Conclusion:
In spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. The information needed to guide the management of this commonly treated and costly condition is seriously deficient. To accumulate the evidence necessary to inform practice, future clinical studies on the outcome of rotator cuff repair must report important data relating to each patient's condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function.
There is little information about the long-term longitudinal outcomes of total shoulder arthroplasty. Moreover, long-term data on a single shoulder replacement system are lacking. The aim of this study was to analyze, at different time points during a follow-up period of fifteen to twenty years, the clinical and radiographic outcomes of patients treated with a third-generation total shoulder arthroplasty.
Sixty-three total shoulder arthroplasties were performed in fifty-eight patients. Two patients were lost to follow-up, and sixteen patients died during the follow-up period, leaving a cohort of forty-five total shoulder arthroplasties in forty patients with a mean age of sixty-four years. Follow-up examinations were carried out at six months, one year, two years, three to four years, five to eight years, nine to fourteen years, and fifteen years or more. Preoperatively and at each follow-up visit, the Constant score as well as shoulder flexion and external rotation were assessed. Radiographs were analyzed for loosening and migration of the components at all time points.
There was a substantial improvement of all clinical parameters from baseline to the latest follow-up evaluation. Clinical results reached a plateau at one year, remained stable without substantial worsening for eight years, and then remained as good as the six-month results until fifteen years postoperatively. Compared with the outcomes at the six-month follow-up examination, the results were worse beyond fifteen years. The clinical outcome was not influenced by sex, age, hand dominance, glenoid morphology, glenoid loosening, or upward migration of the humeral head. Thirty-three (73%) of the forty-five shoulders had radiographic evidence of glenoid loosening at the time of final follow-up. Fourteen shoulders (31%) were revised: a soft-tissue revision was performed in one of them, and implant revision was necessary in thirteen.
Although there is a significant and longitudinal improvement in shoulder function and pain relief after total shoulder replacement, long-term follow-up of fifteen to twenty years demonstrated a high revision rate in this cohort.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. PEER REVIEW This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Background:
The purpose of this study is to report on cost, outcomes, reliability, and safety of reverse shoulder arthroplasty (RSA) in patients with symptomatic advanced rotator cuff deficiency.
Methods:
Fifty-five primary RSA patients operated on at a single institution by a single surgeon were prospectively studied for a mean of 48 months (range, 31-71 months). For each patient, validated subjective and independently evaluated objective outcome data were collected to determine clinical reliability. In addition, safety, defined as major complications, as well as direct costs specific to each patient, were collected and analyzed.
Results:
There were significant improvements (P < .05) in all clinical measures with the exception of the general health and vitality components as well as the mental component summary scores of the Short Form 36 version 2 (SF-36v2). In addition, the majority of the patients met the criteria set forth for clinical reliability (53 of 55 [96%]) and safety (49 of 55 [89%]). The mean total 4-year cost was 24,661 allowed the purchase of treatment with RSA, leading to a greater than 5-fold reduction in pain and a 70% improvement in shoulder function with a small risk of harm.
Background:
Modern semiconstrained reverse shoulder arthroplasty (RSA) has shown a great improvement in function and range of motion (ROM) in different etiologies, including revision surgery, sequelae of fractures, or tumors. Few studies have evaluated RSA for primary glenohumeral osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy excluding any other shoulder disease, and data on patients' quality of life after this surgery are lacking.
Methods:
In this prospective cohort study, 80 patients were evaluated after an RSA for either primary osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy with the Constant-Murley score (CMS), ROM, and Short Form Health Survey (SF-36). A radiologic assessment was performed preoperatively and postoperatively in 62 of these patients.
Results:
At a mean 5-year follow-up, the cumulative survival rate was 97.3% and significant improvements in the CMS and ROM were observed when compared with the baseline values. The CMS was 93.2% of the sex- and age-matched normal values. The postoperative SF-36 scores showed no significant differences compared with normative data. Younger patients and subjects with worse preoperative conditions achieved the greatest benefit after RSA. The length of follow-up was found to be associated with the severity of scapular notching.
Conclusions:
This study introduces new predictors for surgical outcomes, and it shows that patients who had undergone RSA a mean of 5 years earlier exhibit similar functionality and health-related quality of life with respect to healthy controls. Physicians should consider these results when discussing the outcomes of this surgery with patients.
Level of evidence:
Level IV, Case series, treatment study.
Background:
The purpose of this study is to report on cost, outcomes, reliability, and safety of total shoulder arthroplasty (TSA) in patients with symptomatic glenohumeral joint arthritis.
Materials and methods:
Eighty-three primary TSA patients operated on at a single institution by a single surgeon were prospectively studied for a mean of 48 months (range, 32-69 months). For each patient, validated subjective and independently evaluated objective outcome measures were collected to determine clinical reliability of TSA. In addition, safety-defined as the lack of major complications-and direct costs specific to each patient were collected and analyzed.
Results:
There were significant improvements (P < .01) in all clinical measures with the exception of the general health component of the Short Form 36 version 2. In addition, the majority of the patients met the criteria set forth for clinical reliability (76 of 83 [92%]) and safety (80 of 83 [96%]). The mean 4-year cost was 17,587 allowed the purchase of treatment with TSA, leading to a greater than 5-fold reduction in pain and a nearly double improvement in shoulder function with a small risk of harm.
Knowledge of the factors affecting the prognosis for improvement in function and comfort with time after shoulder arthroplasty is important to clinical decision-making. This study sought to identify some of these factors in 176 consecutive patients undergoing the ream-and-run procedure.
The time course for improvement in patient function and comfort was determined for the entire group as well as for subsets by sex, age, diagnosis, preoperative function, and surgery date. Patients having repeat surgery were analyzed in detail.
Shoulder comfort and function increased progressively after the ream-and-run procedure, reaching a steady state by approximately twenty months. The shoulders in 124 patients with at least two years of follow-up were improved by a minimal clinically important difference. The shoulders in sixteen patients with at least two years of follow-up were not improved by the minimal clinically important difference. Twenty-two patients had repeat procedures, but only seven had revision to a total shoulder arthroplasty. Fourteen patients did not have either a known revision arthroplasty or two years of follow-up. The best prognosis was for male patients over the age of sixty years, with primary osteoarthritis, no prior surgical procedures, a preoperative score on the simple shoulder test of ≥5 points, and surgery after 2004. Repeat surgical procedures were more common in patients who had a greater number of surgical procedures before the ream-and-run surgery.
This study is unique in that it characterizes the factors affecting the time course for improvement in shoulder comfort and function after a ream-and-run procedure. Improvement occurs after this procedure for at least 1.5 years. This procedure appears to be best suited for an older male patient with reasonable preoperative shoulder function without prior shoulder surgery.
Prognostic Level II. See Instructions for authors for a complete description of levels of evidence.
Hemiarthroplasty (humeral head replacement [HHR]) and reverse shoulder arthroplasty (RSA) are surgical options for cuff tear arthropathy (CTA). RSA may provide better pain relief and functional outcomes, but it costs more and may have a higher complication rate. The goal of this study was to compare the cost-effectiveness of these two treatments and to use sensitivity analysis to determine the drivers of the model.
A Markov decision model was used. Outcome and complication probabilities were obtained from existing literature. Costs were based on average Medicare reimbursement and implant prices. Utilities were derived from responses to health state surveys (Short Form 6D) from 31 patients at one institution who underwent RSA or HHR for CTA. Incremental cost-effectiveness ratios were used to compare treatments.
Our model showed RSA could be a cost-effective strategy for treatment of CTA, using 13,000 making RSA cost-effective.
Currently available cost and outcome data show that RSA could be a cost-effective alternative to HHR for CTA. The cost-effectiveness of RSA depends most on the health utility gained from the operation, the utility lost due to complications from the operation, and the cost of the implant. Dropping the implant price to <50,000 per quality-adjusted life-year gained. Further head-to-head studies evaluating the clinical and quality of life outcomes of these two treatments are warranted.
The aim of this study was to radiographically analyze the long-term glenoid migration patterns following total shoulder arthroplasty to better understand the factors responsible for loosening.
Complete radiographic follow-up of more than five years was available for 518 total shoulder arthroplasties performed for primary glenohumeral osteoarthritis with use of an anatomically designed prosthesis with a cemented, all-polyethylene, keeled glenoid component. Radiographs were assessed for humeral head subluxation, periprosthetic radiolucent lines, and shifting of the position of the glenoid component. The type of migration of the glenoid was defined according to the direction of tilt, or as subsidence in the case of medial migration.
Definite radiographic evidence of glenoid loosening was observed in 166 shoulders (32%) and was characterized by radiolucency of ≥2 mm over the entire bone-cement interface in thirty shoulders and by a migration of the glenoid component (shift or subsidence) in 136 shoulders. Three predominant patterns of migration of the glenoid component were observed: superior tilting in fifty-two shoulders (10%), subsidence in forty-one shoulders (7.9%), and posterior tilting in thirty-three shoulders (6.4%). Superior tilting of the glenoid was associated with three risk factors: low positioning of the glenoid component, superior tilt of the glenoid component on the immediate postoperative coronal plane radiographs, and superior subluxation of the humeral head (p < 0.05 for all). Subsidence of the glenoid component was associated with the use of reaming to optimize the seating and positioning of the glenoid component (p < 0.001). Posterior tilting of the glenoid component was associated with preoperative posterior subluxation (i.e., a Walch type-B glenoid) and with excessive reaming (p < 0.01 for both).
The three patterns of migration observed in this study underscore the potential importance of the supporting bone beneath the glenoid component. In some shoulders, use of a keel or pegs to provide fixation of a polyethylene component in the absence of good support from subchondral bone may not be sufficient to resist compressive and eccentric forces, resulting in loosening. Preserving subchondral bone may be important for long-term longevity of the glenoid component.
Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are two viable surgical treatment options for glenohumeral osteoarthritis. Recent systematic reviews and randomized trials suggest that TSA, while more costly initially, may have superior outcomes with regard to pain, function and quality of life with lower revision rates. This study compared the cost-effectiveness of TSA with HA.
A Markov decision model was constructed for a cost-utility analysis of TSA compared to HA in a cohort of 64-year-old patients. Outcome probabilities and effectiveness were derived from the literature. Costs were estimated from the societal perspective using the national average Medicare reimbursement for the procedures in 2008 US dollars. Effectiveness was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, incremental effectiveness, incremental QALYs, and net health benefits.
In the base case, HA resulted in a lower number of average QALYs gained at a higher average cost to society and was, therefore, dominated by the TSA strategy for the treatment of glenohumeral osteoarthritis. The cost effectiveness ratio for TSA and HA were 1,194/QALY respectively. Sensitivity analysis revealed that if the utility of TSA is equal to, or revision rate lower than HA, TSA continues to be a dominant strategy.
Total shoulder arthroplasty with a cemented glenoid is a cost-effective procedure, resulting in greater utility for the patient at a lower overall cost to the payer. These findings suggest that TSA is the preferred treatment for certain populations from both a patient and payer perspective.
The purpose of this study was to assess the impact of total shoulder arthroplasty on the self-assessed health status of a large series of patients with glenohumeral osteoarthritis. In 91 patients we were able to compare the 8 quantitative domains of Short Form-36 (SF-36) before surgery and at 30 to 60 months after surgery. These preoperative and postoperative scores were compared with data from an age- and gender-matched control population. These results were also compared with those reported for patients who underwent other common, effective surgical procedures. Preoperative SF-36 values were significantly lower than population controls for 6 of 8 SF-36 domains (physical function, social function, physical role function, emotional role function, vitality, and comfort). Patients improved significantly in 4 of 8 SF-36 domains at 30 to 60 months after total shoulder arthroplasty: physical role function (P <.01), comfort (P <.01), social function (P <.01), and mental health (P <.05). Although the improvements were significant and similar to the postoperative scores reported for total hip arthroplasty and coronary bypass procedures, the scores did not reach those of the general population.
Prosthetic replacement of the glenohumeral joint can relieve pain and improve shoulder function for patients with end-stage inflammatory arthritis. The purpose of this study was to prospectively analyze the clinical, functional, and radiographic outcomes of shoulder reconstruction with hemiarthroplasty or total shoulder arthroplasty.
In this multicenter prospective study, clinical history, physical examination, and self-assessment tools including a visual analogue scale, the Simple Shoulder Test, and an activities questionnaire were used to measure comfort, quality of life, and function. Radiographic outcome was determined by assessing the severity of the disease, the adaptation of the prosthesis to the anatomy, the implant position and relationships, and the restoration of glenohumeral alignment.
At the time of follow-up, at a minimum of twenty-four months (mean, thirty-nine months), the thirty-six shoulders treated with a hemiarthroplasty and the twenty-five treated with a total shoulder arthroplasty showed significant improvement (p < 0.0001) as demonstrated by the visual analogue scale and the Simple Shoulder Test as well as improvements in the components of the activities questionnaire. Active forward elevation was significantly better (p < 0.004) after the total shoulder arthroplasties than after the hemiarthroplasties. The presence of extremely severe disease did not affect the clinical outcome. Prosthetic adaptation to the anatomy and restoration of glenohumeral alignment resulted in significant improvement in certain motion parameters and were associated with one another (p < 0.001). Restoration of glenohumeral alignment resulted in significant improvements in overall quality of life (p = 0.038), use of the arm for work and play (p = 0.014), and range of motion (p = 0.0004) compared with those parameters when alignment had not been restored. Glenoid erosion occurred in four of the shoulders treated with hemiarthroplasty. Two of the glenoid components used in the total shoulder arthroplasties loosened.
Patients with inflammatory arthritis treated with hemiarthroplasty or total shoulder arthroplasty can be expected to have improved comfort, range of motion, and function. Restoration of glenohumeral alignment appears to lead to even greater improvement in these clinical parameters.
There are theoretical and practical advantages to modular rather than monoblock designs of prostheses for shoulder arthroplasty, but there are no reported studies which specifically compare the clinical and radiological results of their use. We have compared the results of unconstrained total shoulder arthroplasty for osteoarthritis using both types of implant. The monoblock design was used between 1992 and 1995 and the modular design after 1995. Both had cemented all-polyethylene glenoids, the monoblock with matched and the modular with mismatched radii of curvature. There were 34 consecutive shoulders in each group with a mean follow-up of 6.1 years in the first and 5.2 years in the second.
There were no significant differences in improvement of pain scores, active elevation, external rotation, internal rotation, patient satisfaction, or the Neer ratings between the two groups. Two of 28 glenoid components in the first group and six of 30 in the second met the criteria for being radiologically at risk for loosening (p = 0.25). There were no significant differences in clinical outcome or radiological changes between the first- and second-generation designs of implant for shoulder arthroplasty.
Failure of the glenoid component is the most common indication for late revision of a total shoulder arthroplasty (TSA). This is the first study to characterize the deterioration in patient self-assessment of shoulder function occurring with glenoid component failure at times remote from the index surgery. Of 115 total shoulders, 11 had revision by the original surgeon for isolated glenoid loosening. Simple Shoulder Test scores averaged 4.4 before TSA, rose to a mean of 11.3 after surgery, and fell to a mean of 4.6 before revision for glenoid loosening performed at a mean of 7 years after TSA. All shoulders showed a drop of at least 3 points between the peak Simple Shoulder Test score and the prerevision Simple Shoulder Test score. Periodic self-assessment of shoulder function may offer a method of screening patients for the possibility of late glenoid component failure.
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