Conventional Total Shoulder Arthroplasty Research Articles

Stemless versus stemmed anatomic total shoulder arthroplasty: a meta-analysis of randomized clinical studies at short term follow-up

BackgroundStemless total shoulder arthroplasty (TSA) implants were developed to counteract many of the complications and challenges associated with the stemmed humeral component. The purpose of this study was to evaluate the clinical efficacy, radiographic outcomes, and incidence of major complications of stemless implants relative to stemmed implants in the context of anatomic TSA using pooled data from randomized clinical studies. MethodsEight databases were queried in October 2021 for randomized clinical studies directly comparing the outcomes between patients treated with stemless anatomic TSA, and conventional anatomic TSA with a stemmed humeral component. Clinical outcomes between groups were compared using a random effects model and a pooled weighted mean difference, a pooled standardized mean difference, or a pooled odds ratio. ResultsFive randomized clinical studies were identified with a total of 584 patients at final follow-up (range: 24.0-32.7 months) and an average age of 64.9 years (range: 62.1-69.0 years) at the time of surgery. There was no significant difference between the 2 groups for adjusted Constant–Murley Scores (P = .20), pooled patient reported functional outcomes (P = .41), forward flexion range of motion (P = .92), external rotation range of motion (P = .05), radiographic migration/subluxation of the humeral component (P = .52), infection risk (P = .89), odds of a revision surgery (P = .86), or odds of a subsequent reverse TSA (P = .68). For odds of a periprosthetic fracture (P = .07) and odds of developing radiolucency related to the humeral component (P = .06), there was a potential clinical benefit for the stemless component; however, this difference was not statistically significant for the current data set. ConclusionThis meta-analysis directly compared stemless and stemmed anatomic TSA implants and demonstrated no significant difference in the pooled results for any of the included clinical outcomes, radiographic outcomes, major complication outcomes, or revision surgery related outcomes between the 2 groups at early follow-up, although the small sample size may preclude in finding significance. These findings suggest that there are equivalent clinical outcomes of stemless anatomic TSA components and that these implants are safe, efficacious, and non-inferior relative to the current gold standard stemmed humeral implant. The data suggest that this is true for relatively younger anatomic TSA patients sampled from a population that is similar to those included in this meta-analysis.

Surgical time and outcomes of stemmed versus stemless total shoulder arthroplasty.

Stemless total shoulder arthroplasty (TSA) was approved for use in the United States in 2015, and there remains a paucity of data on its performance in this market. Decreased operative time without compromise of clinical outcomes is a theoretical advantage of stemless TSA, but no studies have evaluated this in a comparative study to date. Herein, the operative times and clinical outcomes of stemless vs. conventional stemmed TSA are investigated. This is a retrospective cohort study, evaluating all consecutive TSAs performed by a single surgeon between 2015 and 2018. Data were collected from 59 patients who underwent TSA with conventional, stemmed humeral implants and 115 patients in whom a stemless humeral implant was used. Operative times and demographic data were collected retrospectively from the anesthesia record, and prospectively collected patient-reported outcome measures were collected from the Surgical Outcomes System database. For patient-reported outcome measure, visual analog scale, American Shoulder and Elbow Surgeons, and Single Assessment Numerical Evaluation scores were recorded serially until a minimum 2-year follow-up. The average operative time was 24 minutes less in the stemless cohort compared with the stemmed cohort (104 minutes vs. 128 minutes, P<.001). Cost analysis showed a decreased personnel cost of 15.9% that correlates to a 3.1% overall reduction in operating room-associated cost. Patient-reported outcome scores significantly improved postoperatively in both cohorts across all time points. There was no difference found in visual analog scale, American Shoulder and Elbow Surgeons, and Single Assessment Numerical Evaluation scores between the cohorts at the 2-year follow-up. Stemless TSA significantly reduces operative time with equivalent functional outcomes at a minimum 2-year follow-up.

Current concept of shoulder replacement arthroplasty

Since the development of the first anatomic shoulder replacement in 1950, the technology has undergone substantial evolution, making it a viable option to manage variable shoulder problems, including severe osteoarthritis, rheumatoid arthritis, and fracture of the proximal humerus. However, the design of conventional total shoulder arthroplasty prostheses does not account for concomitant musculotendinous pathologies, including larger rotator cuff tears, which are associated with fatty infiltration of the infraspinatus muscle and substantially compromise the outcome of total shoulder arthroplasty. For patients without a rotator cuff or with rotator cuff tear arthropathy, hemiarthroplasty was the conventional treatment. Unfortunately, for these indications, hemiarthroplasty may provide little improvement in range of motion or function. Recently, radical changes in prosthetic design were made that transformed poorly performing reverse ball-and-socket total shoulder prosthesis into a highly successful salvage implant for pseudoparalytic and severe rotator cuff–deficient shoulders. The annual number of reverse total shoulder arthroplasties is increasing dramatically, and the indications also have expanded to include several conditions. In this review, the current concept of variable shoulder arthroplasty is discussed for clinical physicians.

Long-Term Radiographic Changes in Stemless Press-Fit Total Shoulder Arthroplasty.

Stemmed humeral implants have represented the gold standard in total shoulder arthroplasty (TSA) for decades. Like many other joints, the latest trends in TSA designs aim at bone preservation. Current studies have demonstrated that native proximal humeral bone stresses are most closely mimicked by stemless implants. Nevertheless, there are concerns about the long-term performance of stemless designs. The aim of the present study was to evaluate the long-term radiographic changes at the proximal humerus in anatomical stemless press-fit TSA. Between 2008 and 2010, 48 shoulders in 43 patients were resurfaced using an anatomic stemless shoulder prosthesis (TESS, Biomet). Thirty shoulders in twenty-five patients who were aged 65.7 ± 9.9 (34 to 82) years were available for clinical and radiographic review at a mean follow-up of 94.0 ± 8.9 (78 to 110) months. Radiographic changes of the proximal humerus due to stress shielding were found in 38.4% of the stemless TESS implants. Mild stress shielding accounted for 80% of the observed radiographic changes. Radiographs exhibited stable fixation of the stemless humeral press-fit implant at early and late follow-up. In contrast, radiolucent lines at the glenoid implant were found in 96.1% of the cases. Irrespective of the degree of radiographic changes, clinical scores (VAS, Quick-DASH, Constant score) significantly improved at follow-up. The anatomic stemless press-fit implant seems to be favorable in terms of implant-related stress shielding. Clinical outcome was not affected by radiographic changes, demonstrating an 8-year clinical performance that seems to be comparable to conventional stemmed TSA.

Complications of reverse shoulder arthroplasty

Reverse shoulder arthroplasty is a common treatment for shoulder disorders. Complication rates after reverse shoulder arthroplasty are significantly higher than that of conventional total shoulder arthroplasty especially in high risk patient populations. Complications include instability, intra-operative glenoid fractures, intra-operative humeral fractures, acromial fractures, neurologic injury, infection, baseplate failure, humeral stem loosening, component dissociation, dislocation, and scapular notching. Recognition of risk factors, thorough understanding of the mechanics of the reverse arthroplasty and techniques for implantation, and pre-operative planning are essential in optimizing patient outcome and intra-operative success. Failure of reverse shoulder arthroplasty is a significant challenge requiring appropriate diagnosis of the failure mode.

Cementless versus cemented glenoid components in conventional total shoulder joint arthroplasty: analysis from the Australian Orthopaedic Association National Joint Replacement Registry

Glenoid loosening is a common mode of failure after total shoulder arthroplasty (TSA). Newer cementless glenoid components have been introduced to promote biological fixation with the aim to decrease glenoid loosening. Limited data are available comparing revision rates between cemented and cementless glenoid fixation in TSA. The study aim was to compare the revision rates of cemented and cementless design glenoid components used in conventional TSA performed for the diagnosis of osteoarthritis. The secondary aim was to compare various subclasses of glenoid components. Data were obtained between April 16, 2004, and December 31, 2016, from the Australian Orthopaedic Association National Joint Replacement Registry. Within the study period, 10,805 primary conventional TSAs were identified. The analysis was undertaken for the diagnosis of osteoarthritis, which represented 95.8% of all conventional TSA procedures. At 5 years, in patients with primary TSA procedures, those with cemented glenoids had a lower revision rate than those with cementless glenoids: 3.7% versus 17.9% (hazard ratio for entire period, 4.77). The most common revision diagnosis for primary conventional TSA with cementless glenoid fixation was rotator cuff insufficiency (4.4% for cementless vs 0.4% for cemented), instability and/or dislocation (3.8% for cementless vs 0.8% for cemented), and loosening and/or lysis (1.1% for cementless vs 1.1% for cemented). Cementless glenoid components in conventional TSA had a significantly higher revision rate than cemented glenoid components. The loosening rates between cemented and cementless glenoid components were similar. Glenoid design and fixation are important considerations when selecting a prosthesis for TSA.

Patient-specific instrumentation for total shoulder arthroplasty: not as accurate as it would seem

There is an increasing body of literature suggesting that the use of patient-specific instrumentation (PSI) in total shoulder arthroplasty (TSA) results in improved positioning of the glenoid component. The aim of this in vivo study was to assess the accuracy of PSI of the glenoid component in TSA in a consecutive series at a single center. Eleven consecutive TSAs (7 TSAs and 4 reverse TSAs) were performed using custom-made patient-specific positioning guides for the glenoid component. Each patient had preoperative computed tomography scans and guides produced to allow 0° of glenoid inclination and version in anatomic TSAs and 10° of inferior inclination for reverse TSAs. Postoperative computed tomography imaging was performed to determine accuracy of component implantation. Patients were observed to the 1-year mark. For the conventional TSA group, the mean version was measured at 8° ± 10° retroversion and 1° ± 4° inclination. For reverse TSAs, mean version was 10° ± 10° retroversion and -1° ± 5° inclination. There were 5 cases classified as outliers in terms of version (>10° anteversion or retroversion). We had a mean correction of version of 22° ± 9° and 17° ± 9° in inclination compared with preoperative measurements. Our results suggest that the in vivo accuracy of PSI-guided glenoid positioning is not as successful as suggested in the literature.

Early Outcomes Following Metal-on-Metal Reverse Total Shoulder Arthroplasty in Patients Younger Than 50 Years.

Reverse total shoulder arthroplasty (TSA) is a useful intervention for older patients with glenohumeral arthritis and a deficient rotator cuff. However, as a semiconstrained prosthesis, conventional reverse TSA implanted in a young patient could fail over time secondary to polyethylene wear and subsequent osteolysis. A metal-on-metal prosthesis may avoid this type of failure. The purpose of this study is to assess the outcomes in an initial cohort of young patients who underwent reverse TSA using a metal-on-metal prosthesis. Surgical indications included age younger than 50 years with a functioning deltoid and significant impairment of shoulder function with irreparable rotator cuff due to tumor resection, arthritis, or revision surgery. Nine patients with an average age of 37 years underwent implantation of a custom metal-on-metal reverse TSA prosthesis. All patients had a minimum 12-month follow-up or a failure of their procedure requiring revision surgery prior to 1 year. American Shoulder and Elbow Surgeons (ASES) scores, Constant scores, and range of motion were recorded and analyzed pre- and postoperatively to assess improvement, and all complications were noted. Average ASES score improved from 47 points preoperatively to 73.4 points postoperatively (P=.013). Average Constant and adjusted Constant scores improved from 20.8 points and 16% preoperatively to 61.8 points and 67.3% postoperatively, respectively (P=.019 and P=.068). Mean postoperative active forward flexion and active external rotation were 119.4° and 10°, respectively. Complications included the following: 3 patients sustained a postoperative dislocation, 1 patient had a glenoid fracture and complete loss of fixation of the baseplate, and 1 patient experienced dissociation of the glenosphere from the base-plate. Although metal-on-metal reverse TSA may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are disappointing, and the complication rate is high. [Orthopedics.2016; 39(5):e957-e961.].

Isolated Musculocutaneous Nerve Palsy after the Reverse Total Shoulder Arthroplasty

Reverse total shoulder arthroplasty has been performed with promising results in rotator cuff tear arthropathy. However, the global complication of the reverse total shoulder arthroplasty is relatively higher than that of the conventional total shoulder arthroplasty. Neurologic complications after reverse total shoulder arthroplasty are rare but there are sometimes remaining sequelae. The cause of the neurologic complication is multifactorial, including arm traction, position and the design of the implant. Most cases of neurologic palsy following reverse total shoulder arthroplasty occur in the axillary nerve and the radial nerve. The authors report on a case of a 71-year-old man with isolated musculocutaneous nerve palsy after reveres total shoulder arthroplasty with related literature.

Shoulder arthroplasty in patients with Parkinson's disease is associated with increased complications

Case series suggest a higher postoperative complication rate after shoulder arthroplasty in patients with Parkinson's disease (PD). The purpose of this study was to evaluate the perioperative complications in patients with PD undergoing conventional total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and shoulder hemiarthroplasty (HA). Patients with PD who underwent TSA, RSA, or HA were identified in a national insurance database and then matched to controls without a diagnosis of PD based on age, gender, obesity, diabetes, and tobacco use. Complications were assessed, including infection, dislocation, revision, stiffness, fracture, component loosening, and systemic complications. The final study cohorts included 3390 TSA patients with PD and 47,034 matched TSA controls; 809 RSA patients with PD and 14,262 matched controls; and 2833 HA patients with PD and 38,850 matched controls. PD was associated with significant higher rates of infection (odds ratio [OR], 1.5, 1.7, 1.5, respectively), dislocation (OR, 2.5, 2.0, 2.8, respectively), revision arthroplasty (OR, 1.7, 1.8, 1.4, respectively), and systemic complications (OR, 1.4, 1.7, 1.3, respectively) after all 3 types of shoulder arthroplasty and with higher rates of periprosthetic fracture after conventional TSA (OR, 1.5) and shoulder HA (OR, 1.5). Component loosening was also more commonly noted in patients with PD after conventional TSA (OR, 1.5) and HA (OR, 1.9). PD is associated with increased rates of infection, dislocation, revision shoulder arthroplasty, fracture, component loosening, and systemic complications after conventional TSA, RSA, and shoulder HA.

Management of complications after reverse shoulder arthroplasty.

Reverse total shoulder arthroplasty (RTSA) has become the treatment of choice for patients with rotator cuff arthropathy. Complication rate after RTSA has been reported to be three to five times that of conventional total shoulder arthroplasty. Intraoperative and postoperative complications include neurological injury, infection, dislocation or instability, acromial or scapular spine fracture, hematoma, and scapular notching. Knowledge of optimal component placement along with preoperative planning and recognition of risk factors are essential in optimizing patient outcome. The purpose of this review article is to identify the most common and serious complications associated with the RTSA and discuss the current methods of management. Complications after RTSA pose a significant challenge for healthcare providers and economic burden to society. Therefore, it is essential to make the proper diagnosis and develop and implement early management plans to improve patient outcome and satisfaction.

Comparison of Functional Outcomes of Reverse Shoulder Arthroplasty with Those of Hemiarthroplasty in the Treatment of Cuff-Tear Arthropathy

Rotator cuff-tear arthropathy has traditionally represented a challenge to the shoulder arthroplasty surgeon. The poor results of conventional total shoulder arthroplasty in rotator-cuff-deficient shoulders due to glenoid component loosening have led to hemiarthroplasty being the traditional preferred surgical option. Recently, reverse total shoulder arthroplasty has gained increasing popularity because of a clinical perception of an improved functional outcome, despite the lack of comparative data. The aim of this study was to compare the early functional results of hemiarthroplasty with those of reverse shoulder arthroplasty in the management of cuff-tear arthropathy. The results of 102 primary hemiarthroplasties for rotator cuff-tear arthropathy were compared with those of 102 reverse shoulder arthroplasties performed for the same diagnosis. Patients were identified from the New Zealand Joint Registry and matched for age, sex, and American Society of Anesthesiologists (ASA) scores. Oxford Shoulder Scores (OSS) collected at six months postoperatively as well as mortality and revision rates were compared between the two groups. There were fifty-one men and fifty-one women in each group, with a mean age of 71.6 years in the hemiarthroplasty group and 72.6 years in the reverse shoulder arthroplasty group. The mean OSS at six months was 31.1 in the hemiarthroplasty group and 37.5 in the reverse shoulder arthroplasty group. At the time of follow-up, there were nine revisions in the hemiarthroplasty group and five in the reverse shoulder arthroplasty group. No difference in mortality rate was seen between the two groups. In this unselected population with rotator cuff-tear arthropathy, controlled for age, sex, and ASA score, reverse shoulder arthroplasty resulted in a functional outcome that was superior to that of hemiarthroplasty. Longer-term follow-up is needed to confirm these findings.

Use of a custom alignment guide to improve glenoid component position in total shoulder arthroplasty

Total and reverse total shoulder arthroplasty (TSA) are used to treat patients with glenohumeral joint osteoarthritis. The revision rate remains high compared with hip and knee arthroplasty. Glenoid component loosening is an important complication and may be caused by poor positioning of the component. We aimed to evaluate the safety and accuracy of a custom glenoid jig created using preoperative computed tomography (CT) imaging with 3D modelling for glenoid component implantation. Preoperative CT scans of each shoulder (N = 7) were obtained. Implants were virtually aligned and custom templates were created for intraoperative use. A two-part custom jig was manufactured for alignment of the central peg and the peripheral screws. Three-dimensional orientation of the component and screws was evaluated in postoperative CT scans. The difference between the preoperative plan and the result was then calculated. No technical difficulties or complications occurred. The mean absolute difference between the planned alignment and the postoperative placement of the glenoid component in the three-dimensional space was 3.4 mm (SD = 1 mm). The total average difference for all screws (N = 10) was 6.3° (SD = 3.2°). A CT-based custom glenoid component alignment can reliably guide the placement of the glenoid component during conventional and reverse TSA. This custom jig may be useful for optimizing glenoid component position in the setting of reverse and TSA.

Reverse shoulder arthroplasty

The reverse shoulder arthroplasty emerged as a potential solution for those patients who could not be managed effectively with a conventional total shoulder arthroplasty. Grammont revolutionized the design by medializing and distalizing the center of rotation and utilizing a large convex glenoid surface and concave humeral component with a neck-shaft angle of 155°. This design has been highly successful in cuff deficient shoulders, and indications continue to broaden. Many mid-term studies have improved upon the early encouraging results. Long-term studies are starting to emerge, demonstrating good survivorship, but progressive functional and radiographic deterioration continue to be concerning. Careful patient selection and attention to appropriate technique are required to reduce the current high rate of complications. New prosthesis designs are continuing to develop to address some of these limitations.

Reverse total shoulder arthroplasty—from the most to the least common complication

Reverse total shoulder arthroplasty (RTSA) has been reported to be associated with a complication rate that is four times that of conventional total shoulder arthroplasty. It is the purpose of this article to identify and understand the most common and most serious complications of RTSA and to review current methods of prevention and treatment. The current literature was reviewed to identify type and prevalence of reported complications and to identify risk factors, preventive measures as well as technical details for management strategies for complications of RTSA. The variable accuracy of reporting and the heterogeneity of methodology in the literature limited our study, however, a definitive ranking of most to least common complication emerged. The currently identified most common complication is scapular notching. The clinically most relevant complications are infection, instability and acromial fractures. Haematoma formation used to be very frequent but can be controlled, glenoid component loosening, however, is rare when compared with conventional total shoulder replacement. In conclusion, RTSA is associated with a high rate of complications. Their incidence and the results of their treatment are inconsistently reported. To document and then prevent complications, a standardised monitoring tool including clear definitions and assessment instructions appears necessary.

In-vitro evaluation of a polyurethane compliant-layer glenoid for use in shoulder arthroplasty

A polyurethane glenoid component has been designed and manufactured as part of a total shoulder arthroplasty (TSA) system based on compliant-layer (CL) technology. Compared with conventional TSA designs, this biomimetic approach offers reduced friction and wear and potentially improved longevity. In-vitro evaluation of the glenoid system has included loosening and stability tests, and wear measurement using a specially constructed wear simulator. The results obtained support the hypothesis that a CL glenoid design may provide improved resistance to dynamic loosening and rim erosion, and demonstrate superior wear performance over a standard ultra-high molecular weight polyethylene design. This study not only confirms the feasibility of a CL glenoid component but also highlights the potential to increase implant longevity, thereby allowing earlier surgical intervention before poor glenoid bone stock and soft tissue compromise the outcome of TSA.

Die CUP-Prothese mit einer zementierten Schultergelenkpfanne im Vergleich zur konventionellen anatomischen Totalendoprothese – eine Matched-Pair-Analyse

The purpose of this clinical study (matched-pair design) was to compare the functional short-term results obtained in patients with surface replacement of the humeral head and cemented glenoid prosthesis with those obtained after total shoulder arthroplasty. 20 patients (average age 67.7 [43-85] years, 17 women, three men) who received surface replacement of the humeral head with cemented glenoid prosthesis were matched to a control group of 20 patients (average age 67.55 [42-85] years, 17 women, three men) with a conventional total shoulder arthroplasty. Six patients were treated for osteoarthritis, two for post-traumatic arthritis, 1 each for osteonecrosis and rheumatoid arthritis. Preoperative status, perioperative results and postoperative status (Constant score, subjective assessment, range of motion, radiographic evaluation) were compared in all patients and controls. The adjusted Constant score improved from a mean of 37.25% to a mean of 87.75% in the hybrid group and from a mean of 30.8% to a value of 87.1% in the TSA group. Regarding the relative improvement at 12 months compared to baseline, patients treated with hybrid prostheses showed a comparable benefit in the Constant score, pain reduction and range of motion. Only the criterion "strength" revealed a significantly better result in the TSA group (p = 0.025). There was one irreversible injury of the brachial plexus in one case and neural injuries with a full recovery in two cases of Hybrid prosthesis. The combination of humeral surface replacement with cemented glenoid component offers a relatively new option for the treatment of different pathologies at the shoulder joint which need a total joint substitute.The short-term results are comparable with those of conventional total shoulder arthroplasty. Surface replacement of the shoulder facilitates later revision because of less loss of bone stock. It must be considered that surface replacement with implantation of cemented glenoid prosthesis is a difficult procedure because of the exploration of the glenoid.

Influence of component positioning on impingement in conventional total shoulder arthroplasty

Background Clinical experience suggests that component impingement can lead to eccentric implant loading and thereby cause glenoid loosening in conventional total shoulder arthroplasty. This study tests the hypothesis that certain implant component positioning configurations may lead to impingement within the physiological range of motion. Methods A rigid-body model of the shoulder comprising the scapula and humerus was constructed. Within this 3D model, a commercially available total shoulder arthroplasty implant was positioned according to manufacturer guidelines. The configuration was modified around this default position to investigate the associated angle of inferior and superior impingement during glenohumeral elevation, as well as in lateral impingement during axial rotation at both 0° and 60° of glenohumeral elevation. Glenoid component size, version, inclination and inferior–superior offset as well as humeral component size, torsion, inclination, offset and height were examined. The influence of the humeral calcar anatomy was also investigated. Findings Certain implant configurations caused component impingement in the physiological range of motion. The most sensitive parameters affecting impingement were: (1) the inclination of the glenoid component, (2) the inferior–superior position of the humeral component along the resection line and (3) the prominence of the humeral calcar. Glenoid offset and inclination and humeral head offset and height directly affected subacromial impingement. Interpretation This study suggests that several intraoperatively adjustable implant positioning parameters can influence the likelihood of implant impingement in conventional total shoulder arthroplasty, and that the geometry of the humeral calcar should be taken into consideration when designing an operative strategy for shoulder joint replacement.

Rehabilitation Following Reverse Total Shoulder Arthroplasty

Reverse or inverse total shoulder arthroplasty (rTSA) is becoming a widely accepted surgical intervention. This procedure is specifically designed for the treatment of glenohumeral (GH) joint arthritis or complex fractures, when associated with irreparable rotator cuff (RC) damage or in the presence of RC arthropathy. Additionally, rTSA is an option for the revision of a previously failed conventional total shoulder arthroplasty (TSA) or hemiarthroplasty (HA) in the RC-deficient shoulder. The physical therapist, surgeon, and patient must take into consideration that the postoperative course for a patient following rTSA should be different than the rehabilitation following a traditional TSA. rTSA has only recently been approved by the Food and Drug Administration in the United States; however, nearly a 20-year history of its use exists in Europe. To date, we are aware of no peer-reviewed published descriptions of the postoperative rehabilitation for patients having undergone this procedure. The purpose of this paper is to review the indications for rTSA, focusing on underlying pathology, and to outline a rehabilitation protocol founded on basic science principles and our experience working with patients following rTSA.