Anatomic Shoulder Arthroplasty Research Articles

Surgical treatment of fracture sequelae of the proximal humerus according to a pathology-based modification of the Boileau classification results in improved clinical outcome after shoulder arthroplasty

BackgroundFracture sequelae of the proximal humerus were classified by Boileau into four types. Since there are pathomorphological differences and specific characteristics within the four types, we have developed a subclassification. For elderly patients, shoulder arthroplasty is mostly recommended. Based on the available literature and clinical trial results, a subclassification could be created that suggests a specific therapy for each subgroup. The aim of this study was to evaluate the endoprosthetic therapy according to the proposed subclassification and to provide an overview of the clinical and radiological results after endoprosthetic treatment of proximal humerus fracture sequelae.MethodsPatients with fracture sequelae of the proximal humerus who underwent arthroplasty according to the suggestion of the subclassification were included. Minimum time to follow-up was twelve months. General condition and several specific shoulder scores as the Constant–Murley Score (CS) were recorded at the follow-up examination. Complication and revision rates were analyzed.ResultsIn total, 59 patients (72.6 ± 10.0 years, 47 females, 12 males) were included. Mean follow-up time was 31.3 ± 17.0 months. Reverse shoulder arthroplasty was performed in 49 patients and anatomic shoulder arthroplasty was performed in ten patients. The CS increased by 47.3 points from preoperative (15.0) to postoperative (62.3). Good or very good clinical results were seen in 61% of the patients. Complications were observed in twelve (20%) patients and revision surgery was performed in nine (15%) patients.ConclusionDue to of the variety of fracture sequelae of the proximal humerus, a modification of the Boileau classification seems necessary. This study shows that endoprosthetic treatment for fracture sequelae can significantly improve the shoulder function in elderly patients. Good clinical results can be achieved with a comparatively low revision rate following the treatment suggestions of the proposed subclassification of the Boileau classification.Level of evidence IVCase series.

Revision reverse shoulder arthroplasty for the management of baseplate failure: an analysis of 676 revision reverse shoulder arthroplasty procedures

Baseplate failure in reverse shoulder arthroplasty (RSA) is a rare but potentially catastrophic complication owing to poor patient outcomes and significant glenoid bone loss. The purpose of this study was to report on the prevalence, causes, and outcomes of revision RSA (rRSA) for baseplate failure or loosening. A retrospective review of our institutional database was performed to identify all patients treated for a failed RSA from 2006 to 2021 who required revision to another RSA (rRSA) performed by a single surgeon. A total of 676 failed RSA procedures were identified, and further analysis identified 46 patients (6.8%) who underwent rRSA for baseplate failure with a confirmed loose baseplate at the time of rRSA. The primary outcome was repeated failure of the reimplanted baseplate following rRSA. The mode of failure associated with baseplate failure was stratified into 1 of 3 groups: aseptic, septic, or traumatic. Twenty-four patients underwent primary revision, and 22 had undergone >1 previous arthroplasty prior to undergoing re-revision. Five patients underwent previous rRSA for baseplate failure performed by an outside surgeon. The criteria for secondary outcome analysis of final American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and range of motion were met by 32 patients and 23 patients at 1- and 2-year follow-up, respectively. Three patients (6.5%) had repeated baseplate failure requiring re-revision; 2 had baseplate failure at <1year with associated periprosthetic infections and underwent conversion to hemiarthroplasty. The third patient experienced traumatic failure at 10 years and underwent successful rRSA. The mean American Shoulder and Elbow Surgeons scores at 1 and 2 years were 62.3 and 61.7, respectively. There was no significant difference in outcomes based on mode of baseplate failure (P=.232) or total arthroplasty burden (P=.305) at 1 year. There were 13 total complications in 11 patients, 5 of which required reoperation for reasons other than baseplate failure. In this study, rRSA for baseplate failure constituted 6.8% of all revisions performed over a period of 15 years. Re-revision for recurrent baseplate failure was required in 3 of 46 patients (6.5%). Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty.

A comparison of revision rates for stemmed and stemless primary anatomic shoulder arthroplasty with all-polyethylene glenoid components: analysis from the Australian Orthopaedic Association National Joint Replacement Registry

We compared the rate of all-cause revision of 2 classes of primary anatomic shoulder arthroplasty, stemmed (stTSA) and stemless (slTSA), undertaken with cemented all-polyethylene glenoid components. A large national arthroplasty registry identified 2 cohort groups for comparison, stTSA and l undertaken for all diagnoses between January 1, 2011, and December 31, 2021. A subanalysis from January 1, 2017, allowed capturing of additional patient demographics including American Society of Anesthesiologists score, body mass index, and glenoid morphology. The cumulative percent revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age and gender. Of the 7995 stTSA procedures, the CPR at 9 years was 5.6% (95% confidence interval [CI]: 5.0, 6.4), and for 3156 slTSA procedures, the CPR was 4.4% (95% CI: 3.6, 5.5). There was no significant difference in the rate of revision between the study groups (HR=0.76 [95% CI: 0.51, 1.14], P=.189, adjusted for age, gender, humeral head size, humeral fixation, bearing surface, glenoid design, and mean surgeon volume [MSV]). There was an increased rate of revision for stTSA and slTSA undertaken with humeral head sizes <44 mm (stTSA <44 mm vs. 44-50 mm, HR=1.56 [CI: 1.18, 2.08], P=.001; slTSA <44 mm vs. 44-50 mm, HR=2.08 [CI: 1.32, 3.33], P=.001). MSV as a continuous predictor was not a revision risk to stTSA vs. slTSA, but categorically, a low MSV (<10 stTSA+slTSA cases per annum) was associated with a higher revision rate for stTSA (10-20 cases/yr vs.<10 cases/yr, HR=0.72 [CI: 0.55, 0.95], P=.019) but was not in slTSA. Revision rates were increased for stTSA with non-crosslinked polyethylene (XLPE) glenoids vs. XPLE after 2 years (HR=2.20 [CI: 1.57, 3.08], P<.001) but did not significantly differ for slTSA. Metal/XPLE (humeral/glenoid) bearing surface of stTSA rate of revision was not different from each combination of slTSA bearing surface. Instability/dislocation was a revision risk for slTSA vs. stTSA (HR=1.93 [CI: 1.28, 2.91], P=.001), but from 2017, neither of American Society of Anesthesiologists score, body mass index, and glenoid morphology changed the rate of revision. Revision rates of stTSA and slTSA did not significantly differ and were associated with humeral head size but not patient characteristics. Surgeon inexperience of anatomic shoulder arthroplasty and non-XLPE glenoids were risk factors for stTSA revision but not slTSA. The metal/XLPE stTSA rate of revision was not found to differ significantly from slTSA regardless of polyethylene or humeral head bearing type. Revision for instability/dislocation was more common for slTSA.

Approach to glenoid bone loss and deformity in B3 and C glenoids: primary anatomic shoulder arthroplasty

Anatomic total shoulder arthroplasty in the setting of posterior glenoid bone loss creates a reconstructive challenge for shoulder surgeons. Glenoid retroversion and posterior humeral head subluxation can lead to eccentric wear and poor outcomes. The purpose of this article is to discuss strategies for the surgical treatment of Walch Type B3 and C glenoids in anatomic total shoulder arthroplasty, including eccentric reaming, bone grafting, the use of inlay glenoid components, and the use of augmented glenoid components. Additionally, we review the classification of glenoid morphology, techniques for measuring glenoid retroversion and humeral head subluxation, and risk factors for failure of anatomic total shoulder arthroplasty in the patient with posterior glenoid bone loss.

Paper 50: Biceps Autograft Patch Augmentation for Rotator Cuff Repair: The Effect of Point of Care Compression on Tenocyte Viability.

Objectives: Augmentation of rotator cuff repair in patients at risk for retear has gained popularity. These techniques have generally consisted of allograft and xenograft patches. Recently, use of an autograft biceps from the normally discarded portion after biceps tenodesis was described as a potential patch for rotator cuff repair augmentation. As an autograft, it is free and readily available. The original description prepared the patch by placing it through a commercial skin graft preparation station. This technique results in a significant decrease in tenocyte viability, however, and results in a patch that is difficult to work with. Recently, an autograft compression plate has been employed to use as a point of care processor for adapting the discarded long head of the biceps after tenodesis into an autograft patch. The purpose of this study was to evaluate the feasibility of this point of care graft preparation method, and to specifically evaluate its effect on tenocyte viability in patients undergoing patch augmentation for rotator cuff repair. Methods: We reviewed the medical records of consecutive patients who underwent biceps tenodesis for either rotator cuff repair or anatomic shoulder arthroplasty. After tenodesis, and after 27 mm of the long head of the biceps was secured for compression into the patch, the remaining length of normally discarded tendon was longitudinally split, resulting in 2 equal lengths of remnant tendon from the same zone of the tendon. One sample was sent to pathology with no preparation, and the other was prepared as a biceps autograft patch using the autograft compression plate according to the manufacturer’s recommendations. Once prepared, this second biceps sample was sent to pathology along with the first. The request was to evaluate for tenocyte viability. Pathologists were not told which sample was compressed. Records were reviewed to determine if biceps tendon samples were viable at the time of harvest, and whether the compression process affected a change between the first and second specimen. Results: 20 consecutive patients were reviewed. All 20 biceps produced usable patches. The remnant biceps samples that were sent to pathology revealed the following: Sixteen of the 20 patients had biceps tenocyte viability that were read out as completely normal in both the compressed and non compressed samples. Of the 4 patients that did show some degree of tenocyte necrosis or death, 3 of the patients had identical findings between the compressed and non-compressed samples. Only 1/20 (5%) of the patients showed a difference between the compressed sample and the non-compressed sample, with the compressed sample demonstrating small areas of “patchy necrosis” while the non compressed sample showed normal tendon in that specimen. Conclusions: Compression of the long head of the biceps results in an autograft patch that is a promising option in rotator cuff augmentation. The method of compression plating to process the long head of the biceps remnant into an augmentation patch appears to have no significant effect on tenocyte viability, suggesting that the patch has live tenocytes at the time of point of care augmentation.

Anatomic shoulder arthroplasty in Walch type C glenoid deformity: mid- to long-term outcomes.

Hypoplastic glenoid morphology in the setting of glenohumeral osteoarthritis is a rare yet complex surgical problem. Treatment of this patient population with anatomic total shoulder arthroplasty (aTSA) remains controversial. Furthermore, there is no gold-standard approach, with limited guidance for surgeons on the need for glenoid version correction in the setting of a dysplastic glenoid. The purpose of this study was to evaluate mid- to long-term outcomes and reoperation rates of aTSA for the treatment of primary glenohumeral osteoarthritis with Walch type C glenoid deformity. This observational, retrospective cohort study identified patients with a Walch type C glenoid who underwent aTSA at 2 institutions between 2007 and 2016. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 5.5 years postoperatively. The outcome measures collected included the American Shoulder and Elbow Surgeons (ASES) score and Single Assessment Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgical procedures on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. In total, 30 patients met the inclusion criteria, of whom 26 (86.7%) were able to be contacted to undergo final outcome evaluations. The mean age at the time of surgery was 61.3 years (range, 40.9-75.5 years), and 20 patients (76.9%) were men. The mean follow-up period was 8.5 years (range, 5.5-11.3 years) after surgery. Treatment was performed with an augmented component in 9 patients and with a standard component in 17. Of the 17 patients with non-augmented components, 9 underwent partial correction with asymmetrical reaming, 3 received a mini-inset glenoid component, and 2 had an anteriorly offset humeral component. At final follow-up, patients had a mean ASES score of 83.6 ± 16.7, ASES pain score of 24.7 ± 20.8, SANE score of 80.4 ± 20.9, and patient satisfaction rate of 84.1%. No statistically significant differences in any outcome measure were observed between patients with augmented glenoid components and those with non-augmented glenoid components. One revision to reverse shoulder arthroplasty was performed for instability at 7 years postoperatively after a traumatic dislocation. All patients reported that they would be willing to undergo the same surgical procedure again. Despite variance in glenoid reconstructive approach, aTSA provides satisfactory and sustained improvements in patient-reported outcomes in patients with glenoid dysplasia and primary glenohumeral osteoarthritis with a low revision rate at a mean of 8.5 years. Anatomic shoulder arthroplasty should remain a surgical option in patients with Walch type C glenoid deformity.

Assessment of a novel computed tomography ratio to characterize B2 glenoid morphology with total shoulder arthroplasty

BackgroundThe B2 glenoid poses significant challenges for reconstruction with shoulder arthroplasty. A variety of techniques has been used to quantify the B2 glenoid and is often used for surgical decision-making. The critical B2 glenoid ratio is a novel measure and is defined as the ratio between the paleoglenoid length (original glenoid surface) and the total glenoid length. This study aims to define inter and intrarater reliability of the critical B2 ratio and to compare it to conventional methods of measurement. MethodsA convenience sample of patients with Walch B2 glenoid morphology was generated from a prospectively collected multicenter shoulder arthroplasty registry. The axes of preoperative computed tomography (CT) images were reoriented in the scapular plane. Three sports medicine surgeons experienced in arthroplasty measured the critical B2 glenoid ratio in addition to posterior humeral subluxation, version, and glenoid bone loss at 2 timepoints greater than 1 week apart. Inter-rater and intra-rater reliability were calculated for all readers and CT measures with the intraclass correlation coefficient (ICC). The critical B2 glenoid ratio was compared to conventional measurements using Spearman’s rank correlation coefficients and receiver operating characteristic (ROC) curves. ResultsThe critical B2 glenoid ratio demonstrated good inter-rater reliability among the 3 measurers with ICCs of 0.89 and 0.799 for the 1st and 2nd measurement sessions, respectively. The critical B2 glenoid ratio showed excellent intrarater reliability for 2 of the measurers (ICC 0.933 and 0.98) and good intrarater reliability for 1 of the measurers (ICC 0.820). A significant correlation was observed between glenoid bone loss along Friedman’s line and the critical B2 ratio (P < .001). ROC curves found a B2 ratio = 0.4 was found to be an inflection point for 15° of neoglenoid (posterior erosion surface) retroversion. ROC curves to assess if humeral head subluxation >70% correlated to a threshold B2 ratio value revealed no significant threshold. ConclusionsThe critical B2 glenoid ratio is a novel and reproducible CT-based measure that is defined as the ratio between the paleoglenoid length and the total glenoid length. It has high reproducibility based on inter and intra-rater reliability among a group of shoulder surgeons. A critical B2 ratio of less than or equal to 0.4 correlates with significant neoglenoid retroversion and may be a threshold beyond which to avoid corrective eccentric reaming for anatomic shoulder arthroplasty.

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

Eccentric glenoid bone loss patterns (B- and C-type glenoid) pose a difficult challenge when performing shoulder arthroplasty. Anatomic total shoulder arthroplasty with preferential high-side reaming (ATSA+HSR) has been an accepted method to treat this problem. Reverse shoulder arthroplasty (RSA) has become an alternative method to manage these cases with eccentric glenoid wear. The purpose of this study was to compare the early 2-year outcomes with the midterm outcomes for patients who underwent ATSA+HSR vs. RSA for eccentric glenoid wear patterns with an intact rotator cuff. From 2008 to 2014 there were 242 shoulder arthroplasties performed in the setting of eccentric glenoid wear patterns. Of that initial cohort 101 ATSA+HSR and 93 RSA had both 2-year and final follow-up with a minimum of 7 years from surgery. American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST), range of motion, patient satisfaction, and radiographs were evaluated for each cohort and contrasted at the 2-year follow-up point and last follow-up time point. The average follow-up in the ATSA+HSR cohort was 8.3 years compared with 7.8 years in the RSA cohort. At the 2-year follow-up point, the ATSA+HSR group had better average ASES scores (85 vs. 80 [P<.001]), SST scores (10 vs. 9.6 [P<.001]), forward elevation (162° vs. 151° [P<.001]), external rotation (47° vs. 42° [P<.001]), and internal rotation (IR) (80% full IR vs. 55% full IR [P<.001]). At the 2-year follow-up, 95% of the ATSA+HSR cohort were satisfied compared with 93% in the RSA cohort. At the final follow-up, the RSA group had better average ASES scores (80 vs. 77 [P<.001]) and SST scores (9.4 vs. 8 [P<.001]) and a similar forward elevation (152° vs. 149° [P=.025]). The ATSA+HSR had better external rotation (45° vs. 41° [P<.001]) and IR (74% full IR vs. 54% full IR [P=.005]). Patient satisfaction at the final follow-up had decreased to 82% in the ATSA+HSR group, compared with 95% satisfied in the RSA group. Of the initial ATSA+HSR cohort, 8% of patients had undergone revision compared with 2% in the RSA cohort. ATSA with HSR had better outcome scores and range of motion with a similar patient satisfaction rating to RSA at the 2-year point. Over time, the ATSA+HSR results deteriorated, and at the final midterm follow-up, the RSA group had more durable results with better outcome scores, a higher patient satisfaction rating, and a lower revision rate.

A narrative review of non-infected painful total shoulder arthroplasty: evaluation and treatment.

The prevalence of shoulder arthroplasty has increased significantly over the past two decades outpacing both total hip and total knee arthroplasty. Total shoulder arthroplasty (TSA) has been shown to significantly improve function and pain in most patients, however, complications after shoulder arthroplasty have been reported to be greater than 10% in anatomic shoulder arthroplasty and 10-47% in reverse shoulder arthroplasty leading to a painful shoulder. As the number of performedprimary shoulder arthroplasty increases, the incidence of painful total shoulders and the need for revision shoulder arthroplasty will see a similar trend. Management of post-operative shoulder arthroplasty pain and complications will be even more essential for the orthopedic surgeon in this growing population. Potential sources of pain after shoulder arthroplasty are variable and include infection, implant related complications, hematoma, nerve injury, rotator cuff failure, instability, fracture, among other less prevalent complications. Treatment options for the painful shoulder arthroplasty differ depending on the source of pain, thus early identification of the cause will lead to expedited and appropriate definitive management. The objectives of this narrative review are to highlight the common causes of pain after TSA, provide surgeons an algorithmic approach for working up the painful total shoulder, and discuss treatment options for each source of pain. A database search of PubMed and Google Scholar was conducted including studies relating to painful shoulder arthroplasty evaluation, management, and treatment. This review presents an in-depth evaluation to the non-infected, painful shoulder arthroplasty, providing treatment options for each source with the goal of assisting practicing physicians in the management of painful post-operative shoulder arthroplasty. With increasing numbers of TSA being performed, a thorough understanding of the potential complications and their treatments is essential. A systematic approach to working up the painful TSA can help identify the source of symptoms more readily. Knowledge of the common complications and their specific causes can help surgeons avoid the painful TSA. This knowledge will also help to successfully treat the painful TSA when it is inevitably encountered.

Patterns of glenoid bone loss in revision of anatomic shoulder arthroplasty: the impact of prior glenoid resurfacing

BackgroundHistorically, glenoid resurfacing has been avoided in the young patient due to a perceived risk of early glenoid loosening and destructive bone loss. As a result, many young patients with end-stage arthritis undergo humeral-based hemiarthroplasty with subsequent incomplete pain relief. The aim of this study was to determine the status of glenoid bone stock in patients undergoing revision of a painful hemiarthroplasty versus anatomic total shoulder arthroplasty (aTSA). MethodsUsing an institutional shoulder arthroplasty revision database, all patients undergoing revision for aseptic glenoid-based pain after hemiarthroplasty or glenoid loosening of aTSA were identified. Patient demographics, implant longevity prior to revision, and implanted construct at revision were collected for each patient. Based upon preoperative plain films, computed tomography when available, and intraoperative documentation, the status of the glenoid bone stock was described. ResultsA total of 39 patients (14 aTSA and 25 hemiarthroplasty) met the inclusion criteria. No statistically significant difference in age at the time of index arthroplasty (56.4 vs. 52.4 years; P = .18), age at time of revision (64.5 vs. 59.0 years; P = .07), proportion of males (64.2% vs. 56.0%; P = .74), or longevity of the revised implant (110.9 vs. 79.2 months; P = .08) were identified between the aTSA and hemiarthroplasty cohorts, respectively. Patients undergoing revision of aTSA were more likely to receive a reverse total shoulder arthroplasty at revision (85.7% vs. 48%; P = .04). Peripheral wear alone was noted in 40% (10/25) of hemiarthroplasty revisions and central defect alone was noted in 79% (11/14) of aTSA revisions. Combined defects (central and peripheral bone loss) were noted in three patients undergoing revision of an aTSA (21.4%) and five undergoing revision of a hemiarthroplasty (20%; P = 1.0). The number of cases with medialization at or beyond the coracoid (Kocsis Grade 2; 42.9% vs. 40%) and at or beyond the spinoglenoid notch (Kocsis Grade 3; 14% vs. 12%) was not different between groups (P = 1.0). Structural bone graft or augmented glenoid components were used at the time of revision in 29% (4/14) and 32% (8/25) of failed aTSA and hemiarthroplasty, respectively (P = 1.0). ConclusionDespite variability in the cohorts, this study demonstrates no significant improvement in residual glenoid bone stock by deferring glenoid resurfacing at the time of shoulder arthroplasty. At the time of glenoid-based failure, glenoid resurfacing results in central bone loss while hemiarthroplasty results in peripheral/eccentric bone loss.

Complications and revisions in anatomic and reverse short stem shoulder arthroplasty

IntroductionOne current trend in the field of shoulder arthroplasty is a design shift to shorter and metaphyseal fixed humeral stem components. The aim of this investigation is to analyze complications resulting in revision surgery after anatomic (ASA) and reverse (RSA) short stem arthroplasty. We hypothesize that complications are influenced by the type of prosthesis and indication for arthroplasty.Materials and methodsA total of 279 short stem shoulder prostheses were implanted by the same surgeon (162 ASA; 117 RSA), and 223 of these prostheses were implanted as primary procedures; in 54 cases, arthroplasty was performed secondary to prior open surgery. Main indications were osteoarthritis (OA) (n = 134), cuff tear arthropathy (CTA) (n = 74) and posttraumatic deformities (PTr) (n = 59). Patients were evaluated at 6 weeks (follow-up 1; FU1), 2 years (FU2) and the time span of the last follow-up defined as FU3 with a minimum FU of 2 years. Complications were categorized into early complications (within FU1), intermediate complications (within FU2) and late complications (> 2 years; FU3).ResultsIn total, 268 prostheses (96.1%) were available for FU1; 267 prostheses (95.7%) were available for FU2 and 218 prostheses (77.8%) were available for FU3. The average time for FU3 was 53.0 months (range 24–95). A complication leading to revision occurred in 21 prostheses (7.8%), 6 (3.7%) in the ASA group and 15 (12.7%) in the RSA group (p < 0.005). The most frequent cause for revision was infection (n = 9; 42.9%). After primary implantation, 3 complications (2.2%) occurred in the ASA and 10 complications (11.0%) in the RSA group (p < 0.005). The complication rate was 2.2% in patients with OA, 13.5% in CTA and 11.9% in PTr.ConclusionsPrimary reverse shoulder arthroplasty had a significantly higher rate of complications and revisions than primary and secondary anatomic shoulder arthroplasty, respectively. Therefore, indications for reverse shoulder arthroplasty should be critically questioned in each individual case.

Preoperative metaphyseal cancellous bone density is associated with intraoperative conversion to stemmed total shoulder arthroplasty

Methods to determine whether a stemless humeral component is appropriate for anatomic total shoulder arthroplasty are varied and often subjective. Objective preoperative data regarding metaphyseal bone quality may help guide surgical decision-making. This study sought to evaluate preoperative proximal humeral bone quality and determine whether it is predictive of intraoperative conversion to a stemmed humeral component. Consecutive patients who underwent primary anatomic total shoulder arthroplasty from a single-surgeon practice were enrolled. All patients received a preoperative computed tomography (CT) scan for surgical templating purposes. The exclusion criteria were lack of a preoperative CT scan, preoperative plan for a stemmed component, and intraoperative conversion to a stem for a reason other than bone quality (ie, fracture). Preoperative CT scans were analyzed with an automated templating software. Cortical index and thickness were calculated, and bone density of the proximal diaphysis, cancellous metaphysis, and cortical metaphysis was obtained by averaging Hounsfield units (HU) across anatomically defined regions using a previously validated technique. The decision to convert to a stemmed humeral component was made intraoperatively based on a lack of stability of the trial stemless component. Bone quality measurements were compared between stemless and stemmed groups. An exact logistic regression was used incorporating gender and age. A total of 79 patients who underwent primary anatomic total shoulder arthroplasty were included in this study. Of these patients, 6 underwent intraoperative conversion to a stemmed humeral component (7.6%). There was no significant difference between cohorts in terms of cortical index and bone density within the proximal diaphysis and cortical metaphysis. On univariate analysis, cortical thickness, metaphyseal cancellous bone density, and gender were significantly different between groups. Patients receiving a stem had significantly lower metaphyseal cancellous bone density than those receiving stemless components (5.5 ± 11.2 HU vs. 47.6 ± 29.4 HU, P<.001). All patients converted to stems were female individuals (P= .01) and had metaphyseal cancellous bone density less than 20 HU (P<.001). Metaphyseal cancellous bone density can be calculated on preoperative CT scans and is associated with intraoperative conversion to a stemmed humeral component in anatomic shoulder arthroplasty. A threshold of 20 HU can be used to predict which patients are more likely to require stemmed components.

Shoulder &amp; Elbow

The February 2023 Shoulder &amp; Elbow Roundup360 looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty.

A COMPARISON OF REVISION RATES FOR STEMMED AND STEMLESS PRIMARY ANATOMIC SHOULDER ARTHROPLASTY WITH ALL-POLYETHYLENE GLENOID COMPONENTS: ANALYSIS FROM THE AUSTRALIAN ORTHOPAEDIC ASSOCIATION NATIONAL JOINT REPLACEMENT REGISTRY

We compared the rate of revision of two classes of primary anatomic shoulder arthroplasty, stemmed (aTSA) and stemless (sTSA) undertaken with cemented all polyethylene glenoid components.A large national arthroplasty registry identified two cohort groups for comparison, aTSA and sTSA between 1st January 2011 and 31st December 2020. A sub-analysis from 1 January 2017 captured additional patient demographics. The cumulative percentage revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age and gender.Of the 7,533 aTSA procedures, the CPR at 8 years was 5.3% and for 2,567 sTSA procedures was 4.0%. There was no difference in the risk of revision between study groups (p=0.128).There was an increased risk of revision for aTSA and sTSA undertaken with humeral head sizes &lt;44mm (p=0.006 and p=0.002 respectively). Low mean surgeon volume (MSV) (&lt;10 cases per annum) was a revision risk for aTSA (p=0.033) but not sTSA (p=0.926).For primary diagnosis osteoarthritis since 2017, low MSV was associated with an increased revision risk for aTSA vs sTSA in the first year (p=0.048). Conversely, low MSV was associated with a decreased revision risk for sTSA in the first 6 months (p&lt;0.001). Predominantly aTSA was revised for loosening (28.8%) and sTSA for instability/dislocation (40.6%).Revision risk of aTSA and sTSA was associated with humeral head size and mean surgeon volume but not patient characteristics. Inexperienced shoulder arthroplasty surgeons experience lower early revision rates with sTSA in the setting of osteoarthritis. Revision of aTSA and sTSA occurred for differing reasons.

Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use.

This study compared the healing rates of lesser tuberosity osteotomy (LTO) for anatomic total shoulder arthroplasty (TSA), repaired with either standard knot tying or a tensionable construct. Second, we evaluated LTO healing in stemmed and stemless prostheses and identified the patient characteristics associated with healing. An analysis of consecutive primary TSAs approached with an LTO performed by a single surgeon between 2016 and 2020 was conducted. In the first two years of the study period, the LTOs were repaired with four #2 polyblend sutures passed through drill tunnels and around a short press-fit stem, followed by manual knot tying. Subsequently, a tensionable construct with suture tapes (TCB) was universally adopted. The radiographic appearance of the LTO was evaluated at a minimum of six months postoperatively. A total of 340 patients met the study criteria, including 168 with manual knot tying, 84 TCB repairs with a stemmed implant, and 88 TCB repairs with a stemless implant. There was no difference in the baseline demographics between the groups. The LTO healing rate of the manual knot tying group (85%) was lower than that of the stemmed (95%) and stemless (98%) TCB groups (p < 0.001). When directly comparing the LTO healing between the stemmed and stemless TCB groups, the differences were not significant (p = 0.44). Across all constructs, the body mass index (BMI) was higher in the displaced nonunion group (p = 0.04), with a failure rate of 9.4% for a BMI between 30 and 40, 12.5% for a BMI between 40 and 50, and 28.6% for a BMI > 50. The rate of tobacco use was higher in the displaced nonunion group (p = 0.037). A tensionable construct improves LTO healing compared to manual knot tying, irrespective of the implant type. In addition to the surgical technique, the patient factors that influence tuberosity healing include a greater BMI and tobacco use. Level III, retrospective comparative study.

Ultrasound-determined healing rates with subscapularis tenotomy versus peel after anatomic shoulder arthroplasty.

Several techniques have been described for mobilizing the subscapularis tendon in anatomic total shoulder arthroplasty (TSA). The purpose of this study was to compare subscapularis tendon healing rates, as determined by ultrasound, in patients following anatomic TSA with either a subscapularis tenotomy or subscapularis peel. This study was a secondary analysis of patients from a previous randomized controlled trial in which patients underwent anatomic TSA and were randomized to either a tenotomy or peel approach. The primary outcome was postoperative tendon healing rates determined on ultrasound at >12 months after surgery. Secondary outcomes included postoperative tendon thickness measured on ultrasound; elbow position (neutral alignment in the belly-press position vs. posterior); internal rotation function measured with the third and fourth questions of the American Shoulder and Elbow Surgeons questionnaire; and Western Ontario Osteoarthritis of the Shoulder index. Radiographs were analyzed in patients with torn tendons. One hundred patients were randomized to a tenotomy (n=47) or peel (n=53) approach. Postoperative ultrasound results were available in 88 patients. Tendon healing rates were 95% for tenotomy vs. 75% for peel (P=.011). The mean postoperative tendon thickness was 4 mm (standard deviation, 1.0 mm) and 4 mm (standard deviation, 1 mm) in the tenotomy and peel groups, respectively (P=.37). Internal rotation function was not associated with healing status (P=.77 and P=.22 for questions 3 and 4, respectively, of the American Shoulder and Elbow Surgeons questionnaire), nor was elbow position (P=.2) in the belly-press position. We observed that subscapularis tenotomy had a higher healing rate than peel as determined by ultrasound in TSA patients. There was no statistically significant difference in postoperative tendon thickness in intact tendons as measured on ultrasound when comparing subscapularis mobilization techniques, nor was there any association between healing status and internal rotation function or elbow position.

Does Morbid Obesity (BMI ≥40 kg/m2) Impact Operative Time, Blood Loss, Length of Stay, or Complications Following Anatomic Total Shoulder Arthroplasty?

There have been conflicting reports regarding the effects of obesity on both surgical time and blood loss following anatomic shoulder arthroplasty. Varying categories of obesity has made comparison amongst existing studies difficult. A retrospective review of consecutive anatomic shoulder arthroplasty cases (aTSA) was undertaken. Demographic data, including age, gender, body mass index (BMI), age-adjusted Charleson Comorbidity Index (ACCI), operative time, hospital length of stay (LOS), and both POD#1 and discharge visual analogue score (VAS) was collected. Intra-operative total blood volume loss (ITBVL) and need for transfusion was calculated. BMI was categorized as non-obese (<30 kg/m2), obese (30-40 kg/m2) and morbidly obese (≥40 kg/m2). Unadjusted associations of BMI with operative time, ITBVL and LOS were examined using Spearman correlation coefficients. Regression analysis was used to identify factors associated with hospital LOS. There were 130 aTSA cases performed, including 45 short stem and 85 stemless implants, of which 23 (17.7%) were morbidly obese, 60 (46.2%) were obese and 47 (36.1%) were non-obese. Median operative time for the morbidly obese cohort was 119.5 minutes (IQR 93.0, 142.0) versus 116.5 minutes (IQR 99.5, 134.5) for the obese cohort versus 125.0 minutes (IQR, 99.0, 146.0) for the non-obese cohort. (P=0.61) The median ITBVL for the morbidly obese cohort was 235.8 ml (IQR 144.3, 329.7) versus 220.1 ml (IQR 147.7, 262.7) for the obese cohort versus 216.3 ml (IQR 139.7, 315.5) for the non-obese cohort. (P=0.72). BMI ≥40kg/m2 (IRR 1.32, P=0.038), age (IRR 1.01, P=0.026), and female gender (IRR 1.54, P<0.001) were predictive of increased LOS. There was no difference with regards to in-hospital medical complications (P=0.13), surgical complications (P=1.0), need for re-operation (P=0.66) and 30-day return to the ER (P=0.06). Morbid obesity was not associated with increased surgical time, ITBVL and perioperative medical or surgical complications following aTSA, though it was predictive of increased hospital LOS.

Anatomic Shoulder Arthroplasty in the Setting of Concurrent or Prior Rotator Cuff Repair: A Systematic Review.

Reverse total shoulder arthroplasty (RSA) is the gold standard in management of osteoarthritis (OA) in the setting of rotator cuff pathology. However, there are significant complications associated with the procedure. An alternative option in the setting of a deficient rotator cuff may be to perform a repair prior to or concurrently with an anatomic total shoulder arthroplasty (aTSA). A systematic review was performed utilizing Preferred Reporting Items for Systematic Meta-Analyses (PRISMA) guidelines to evaluate outcomes in aTSA with concomitant or prior rotator cuff repair (RCR). Key outcomes were complication rate and subjective outcome scores. Seven studies were included in the review. One study found a higher rate of total adverse events in the prior repair group (17% vs 7%, P = .01) while others found no significant difference. There was a nonstatistically significant increase in revision rates among patients with larger tears at time of repair. Prior repair groups were associated with a higher rate of re-tear in one study (13% vs 1%, P = .014). Concomitant repair was associated with a higher rate of loosening. In patients with prior repair, there was no statistical difference in strength, range of motion (ROM), simple shoulder test (SST), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and visual analogue scale (VAS). In patients with concurrent repair, one study demonstrated a less drastic improvement in Hospital for Special Surgery (HSS) in "moderate" repairs as opposed to "good" repairs. Anatomic TSA is an appropriate treatment for glenohumeral OA in patients with a prior successful RCR and in younger patients with concurrent repair of small or medium tears. Level III.

Patients with limited health literacy have worse preoperative function and pain control and experience prolonged hospitalizations following shoulder arthroplasty.

Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption. We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables. Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P=.002), more self-reported allergies (P=.007), and worse American Shoulder and Elbow Surgeons scores (P=.001), visual analog scale pain scores (P=.020), forward elevation (P<.001), and external rotation (P=.022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P>.05). Patients with LHL had a significantly longer LOS (1.84±0.92 days vs. 1.57±0.58 days, P=.012) but did not differ in terms of total hospitalization costs (P=.65) or total inpatient opioid consumption (P=.721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P=.035). LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.

Best practice in shoulder arthroplasty-a reflective personal review

IntroductionShoulder arthroplasty is uncommon but increasing in number when compared to hip and knee arthroplasty. The average UK shoulder surgeon performs less than 10 a year and revision surgery is even more rare. The surgeon should be familiar with surgical approaches, implant designs and preferably be fellowship trained to produce good outcomes. MethodsNarrative review was undertaken and senior author's personal practice was discussed. ResultsThe need for a clear understanding of indications and contraindications for both anatomic shoulder arthroplasty and reverse total shoulder arthroplasty, good preoperative planning, protocol-based peri-operative management and good rehabilitation protocol in the post operative period cannot be overemphasized. ConclusionWe are still learning best practice and prosthesis designs have changed over the past years with extensive choices especially in Reverse arthroplasty. Each of these designs has unique biomechanical properties and require a deep understanding of indications. Good surgical training and the use of multi-disciplinary team meetings for complex cases should improve the safety and quality of surgery for patients and ultimately long-term outcome of shoulder arthroplasty.