Cuff Tear Arthropathy Research Articles

Lateralization and distalization shoulder angles do not predict outcomes in reverse shoulder arthroplasty for cuff tear arthropathy

In reverse shoulder arthroplasty (RSA), there is a plethora of measurements regarding implant lateralization and distalization to optimize the center of rotation. Two specific measurements known as the lateralization shoulder angle (LSA) and distalization shoulder angle (DSA) have been the recent focus of studies to assess their association with RSA and postoperative function. The aim of this study was to evaluate the prognostic clinical value of the LSA and DSA in a large cohort of patients with cuff tear arthropathy (CTA) who were treated with different RSA systems. Two local shoulder arthroplasty registries were reviewed for all RSA patients documented with a radiological assessment and complete 2-year follow-up examination. The main inclusion criterion was primary RSA for patients with CTA. Any patients with either a complete teres minor tear, os acromiale or acromial stress fractures reported between the time of surgery and the 24-month follow-up were excluded. Five different RSA implant systems with four different neck-shaft angles were assessed. The Constant Score (CS), Subjective Shoulder Value (SSV) and range of motion (ROM) at two years were correlated with both LSA and DSA assessed on 6-month anteroposterior radiographs. Linear and parabolic univariable regressions were calculated for both shoulder angles, for each prosthesis system and for the entire patient cohort. Between May 2006 and November 2019, there were a total of 630 CTA patients who had undergone primary RSA. Of this large cohort, 270 were treated with the Promos Reverse (neck-shaft angle [NSA], 155°), 44 with the Aequalis Reversed II (NSA, 155°), 62 with the Lima SMR Reverse (150°), 25 with the Aequalis Ascend Flex (145°) and 229 with the Univers Revers (135°) prosthesis systems. The mean (standard deviation [SD]) LSA was 78° (10; range, 6-107) and the mean DSA was 51° (10; range, 7-91). The average CS at 24 months follow-up was 68.1 (SD: 13; 13-96) points. Neither the linear nor parabolic regression calculations for LSA or DSA revealed significant associations with any of the clinical outcomes. Different patients may achieve different clinical outcomes despite having identical LSA and DSA values. There is no association between angular radiographic measurements and 2-year functional outcome.

The impact of coracoid morphometry on internal rotation outcome in patients with cuff tear arthropathy treated with reverse shoulder arthroplasty

BackgroundFunctional internal rotation (fIR) motion remains a concern after reverse shoulder arthroplasty (RSA). The extreme variability of the coracoid morphometry together with the gain in tension of the conjoint tendon could impact internal rotation (IR) after RSA. Our aim was to evaluate the relationship between postoperative IR outcome and coracoid morphometry, evaluated as anteroposterior (AP) and mediolateral (ML) glenocoracoid distances in a 3-dimensional preoperative computed tomography scans, in a consecutive series of patients undergoing the same RSA implant. Materials and methodsA retrospective analysis of a prospectively collected series of 40 patients (18 male, 22 female; mean age (standard deviation [SD]), 73.4 years [4.1]) submitted to RSA for cuff tear arthropathy was performed. fIR function was measured as the highest midline segment of the back that can be reached and converted into 5 range segments of motion. Participants were divided into 2 groups according to the fIR (group A, ≤6; group B, >6). Passive IR was also measured. The AP and ML glenocoracoid distances were measured, in millimeters, on the preoperative 3-dimensional computed tomography scans. Statistics were performed. ResultsThe mean follow-up was 29 months (range, 24-39). The mean score for fIR was 6.45 (SD: 1.81) while the mean score for passive IR was 6.84 (SD: 1.75). No difference was found between fIR and passive IR (P = .328). No statistical difference was found between fIR and glenosphere size (P = .562) and fIR and size of the liner (P = .429). Significant statistical correlations have been found between AP and ML coracoid distances and the two groups (AP in group A: 28.50 and B: 31.265, P = .034; ML in group A: 23.053 and B: 14.27, P < .001). ConclusionsOur study demonstrated that coracoid morphometry, evaluated as glenocoracoid distance, significantly impact IR outcomes in a 145° neck shaft angle RSA; in particular, a high ML glenocoracoid distance (>23 mm) was found to be determinant. This anatomical parameter should be considered in the preoperative planning of RSA and additional surgical strategies addressed in order to gain satisfactory fIR.

Comparison of Clinical Outcomes Using Inlay Versus Onlay Humeral Trays in Reverse Shoulder Arthroplasty for Patients with Cuff Tear Arthropathy

Comparison of Clinical Outcomes Using Inlay Versus Onlay Humeral Trays in Reverse Shoulder Arthroplasty for Patients with Cuff Tear Arthropathy

Outcomes of Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit

Background: Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied. Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed. Results: Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was −12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9). Conclusions: RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Do patients with poor early clinical outcomes after reverse total shoulder arthroplasty ultimately improve?

Although most patients undergoing reverse total shoulder arthroplasty (rTSA) have substantial improvement in pain and function at early follow-up, improvements in pain and range of motion progress more slowly during postoperative rehabilitation in a subset of patients. The purpose of this study was to define a patient's risk of persistent shoulder dysfunction beyond the early postoperative period and identify risk factors for persistent poor performance. We retrospectively reviewed 292 primary rTSAs with early poor performance and a preoperative diagnosis of osteoarthritis, cuff tear arthropathy, or rotator cuff tear from a multicenter database. Early poor performance was defined as a postoperative American Shoulder and Elbow Surgeons (ASES) score below the 20th percentile at 3 months (58 points) or 6 months (65 points) postoperatively. Persistent poor performance at 2 years was defined as failure to achieve the patient acceptable symptomatic state for rTSA (77.3 points for the ASES score). The primary outcome was the rate of persistent poor performance. Secondarily, we compared the clinical outcomes of persistent poor performers vs. shoulders that improved at 2-year follow-up and assessed risk factors for persistent poor performance. At 2-year follow-up, 61% of patients (n = 178) with poor performance at either 3- or 6-month follow-up had persistent poor performance. The rate increased to 85% if poor performance occurred at both 3- and 6-month follow-up. The minimal clinically important difference and substantial clinical benefit for range of motion and outcome scores were exceeded by early poor performers at rates of 83%-92% and 60%-77%, respectively, at 2-year follow-up. On multivariate logistic regression analysis, independent predictors of persistent poor performance after rTSA were lack of hypertension (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.13-0.57; P<.001), heart disease (OR, 2.89; 95% CI, 1.24-6.77; P=.011), uncemented humeral fixation (OR, 0.11; 95% CI, 0.01-1.18; P=.037), previous shoulder surgery (OR, 2.14; 95% CI, 1.06-4.30; P=.031), lower preoperative ASES score (OR, 0.92; 95% CI, 0.87-0.97; P=.002), and lower preoperative subjective rating of pain at its worst (OR, 0.73; 95% CI, 0.54-0.99; P=.038). Despite the fact that 85% of rTSA patients with an ASES score below the 20th percentile at early follow-up exceeded the minimal clinically important difference for improvement in the ASES score at 2-year clinical follow-up, 61% still had persistent poor performance, with failure to achieve the patient acceptable symptomatic state for the ASES score. Persistent poor performance after rTSA was best predicted by a history of shoulder surgery and a poorer preoperative ASES score. These findings can aid surgeons when counseling patients both preoperatively and postoperatively. In the setting of early poor performance, the risk of persistent poor performance must be balanced against the potential outcomes of revision surgery when considering early surgical intervention.

Higher rates of mortality and perioperative complications in patients undergoing primary shoulder arthroplasty and a history of previous stroke.

Cerebrovascular accidents (CVAs), or strokes, are the second most common cause of mortality and third most common cause of disability worldwide. Although advances in the treatment of strokes have improved survivorship following these events, there remains a limited understanding of the effect of a prior stroke and sequelae on patients undergoing shoulder arthroplasty (SA). This study aimed to determine the outcomes of patients with a history of stroke with sequela undergoing primary SA. Over a 30-year time period (1990-2020), 205 primary SAs (32 hemiarthroplasties [HAs], 56 anatomic total shoulder arthroplasties [aTSAs], and 117 reverse shoulder arthroplasties [RSAs]) were performed in patients who sustained a previous stroke with sequela and were followed for a minimum of 2 years. This cohort was matched (1:2) according to age, sex, body mass index, implant, and year of surgery with patients who had undergone HA or aTSA for osteoarthritis or RSA for cuff tear arthropathy. Mortality after primary SA was individually calculated through a cumulative incidence analysis. Implant survivorship was analyzed with a competing risk model selecting death as the competing risk. The stroke cohort sustained 38 (18.5%) surgical and 42 (20.5%) medical perioperative complications. Compared with the control group, the stroke cohort demonstrated higher rates of any surgical complication (18.5% vs 10.7%; P=.007), instability (6.3 % vs 1.7%; P=.002), venous thromboembolism (3.4% vs 0.5%; P=.004), pulmonary embolus (2.0% vs 0%; P=.005), postoperative stroke (2.4% vs 0%; P=.004), respiratory failure (1.0% vs 0%; P=.045), any medical complication (20.5% vs 7.3%; P<.001), and 90-day readmission (16.6% vs 4.9%; P<.001). Additionally, RSA in the stroke cohort was associated with higher reoperation (8.5% vs 2.6%; P=.011) and revision rates (6.8% vs 1.7%; P=.013) compared with the matched cohort. Subsequent cumulative incidences of death at 1, 2, 5, 10, 15, and 20 years were 4.4% vs 3.4%, 10.7% vs 5.1%, 25.6% vs 14.7%, 51.6% vs 39.3%, 74.3% vs 58.6%, and 92.6% vs 58.6% between the stroke and matched cohorts, respectively (P<.001). A preoperative diagnosis of a stroke in patients undergoing primary SA is associated with higher rates of perioperative complications and mortality when compared to a matched cohort. This information should be considered to counsel patients and surgeons to optimize care and help mitigate risks associated with the perioperative period.

Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients

Reverse total shoulder arthroplasty (RTSA), initially indicated for cuff tear arthropathy, is increasingly used for elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff. This is often done to avoid revision surgery in elderly patients for rotator cuff failure with anatomic total shoulder arthroplasty (TSA) despite traditionally good outcomes of TSA. We sought to determine whether there was a difference in outcomes for patients ≥70 years who receive RTSA compared to TSA for GHOA. A retrospective cohort study was conducted using data from a US integrated health care system's Shoulder Arthroplasty Registry. Patients ≥70 years who underwent primary shoulder arthroplasty for GHOA with an intact rotator cuff were included (2012-2021). RTSA was compared to TSA. Multivariable Cox proportional hazard regression was used to evaluate all-cause revision risk during follow-up, while multivariable logistic regression was used to evaluate 90-day emergency department (ED) visit, and 90-day readmission. The final study sample comprised 685 RTSA and 3,106 TSA. Mean age was 75.8 years (standard deviation 4.6) and 43.4% were male. After accounting for confounders, no significant difference in all-cause revision risk was observed for RTSA compared to TSA (hazard ratio=0.79, 95% confidence interval [CI]=0.39-1.58). The most common reason for revision following RTSA was glenoid component loosening (40.0%). Over half (54.0%) of revisions following TSA were for rotator cuff tear. No difference between procedure type was observed in likelihood for 90-day ED visits (odds ratio [OR]=0.94, 95% CI=0.71-1.26) and 90-day readmission (OR=1.32, 95% CI=0.83-2.09). RTSA and TSA for GHOA with an intact rotator cuff in patients ≥70 years had a similar revision risk, as well as likelihood for 90-day ED visits and readmissions. While revision risk was similar, the most common causes for revision were different with rotator cuff tears for TSA and glenoid component loosening for RTSA.

Reverse Total Shoulder Arthroplasty for Proximal Humeral Fractures and Sequalae Compared to Non-Fracture Indications: A Matched Cohort Analysis of Outcome and Complications

With the increase in utility and popularity of the reverse total shoulder arthroplasty (RTSA) within the last decades, indications for RTSA have expanded. As well as the established indications such as cuff tear arthropathy and massive irreparable rotator cuff tears, RTSA for complex proximal humeral fractures in elderly patients has been proven to be a reliable treatment option. A prospectively enrolled RTSA database of 1457 RTSAs implanted between September 2005 and November 2020 was reviewed. Patients treated with RTSA for a complex proximal humerus fracture and fracture sequalae (F-RTSA) were 1:1 matched with a group of patients who were treated electively with RTSA for indications other than a fracture (E-RTSA). Matching criteria included sex, age, length of follow-up and body mass index. Evaluation after a minimum of 2 years follow-up included evaluation of the absolute and relative Constant-Murley score (aCS; rCS), subjective shoulder value (SSV), range of motion (ROM) assessment and complications. Each of the matched cohorts comprised 134 patients with a mean follow-up of 58 ± 41 months for the fracture group and 58 ± 36 months for the elective group. The mean age for both groups was 69 ± 11 years in the F-RTSA and 70 ± 9 years for the E-RTSA group. There were no significant differences in clinical outcome measures including aCS, rCS and SSV (p > 0.05). There was a significant difference in mean active external rotation with 20° ± 18° in the F-RTSA group compared with 25° ± 19° in the E-RTSA group (p = 0.017). The complication rate was not significantly different, with 41 complications in 36 shoulders in the F-RTSA and 40 complications in 32 shoulders in the E-RTSA group (p = 0.73). The main complication for the F-RTSA group was dislocation of the greater tuberosity (6%), whereas acromial fractures (9%) were the leading complication in the E-RTSA group. There was also no significant difference in revision rate comparing F-RTSA with E-RTSA (10% vs. 14%; p = 0.25). RTSA for complex proximal humeral fractures and its sequalae leads to a comparable clinical outcome as that for patients treated electively with RTSA for indications other than fracture. There was, however, a significant difference in active external rotation, with inferior rotation in patients undergoing RTSA for fracture. This valuable information can help in requesting informed consent of patients with proximal humeral fractures.

Paper 18: Minimum 10-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears: Graft survival rate and progression of cuff tear arthropathy

Objectives: Superior capsule reconstruction (SCR) was developed as an alternative treatment for irreparable rotator cuff tears. Previous studies showed graft healing is key to improve shoulder function and pain relief after SCR. Graft healing rate after SCR have been reported for irreparable rotator cuff tears in short-term follow-up studies. The objective of this study was to assess graft survival rate and progression of cuff tear arthropathy in minimum 10-year follow-up of arthroscopic SCR. Methods: A total of 48 consecutive patients with 50 affected shoulders underwent SCR using fascia lata autograft for the treatment of irreparable rotator cuff tears by a single surgeon between 2007 to 2011. Of these 48 initially identified patients, 5 had died, 5 had moved and were unable to be contacted, 2 had severe health problems that were unrelated to SCR, 1 refused to participate, and 1 was unable to participate because she was caring for her child with terminal cancer, thus leaving 34 patients with 36 affected shoulders for review. Structural outcomes were evaluated for a minimum of 10 years of follow-up (range, 10–13 years). Acromiohumeral distance (AHD) and Hamada grade (stage of cuff tear arthropathy) were evaluated by using standard radiography. Fatty degeneration of the rotator cuff muscles was evaluated according to the Goutallier grading system. Graft healing and thickness were assessed by using T2-weighted MRI (1.5-T closed-type scanner). By using SYNAPSE software (accuracy, 0.05 mm; FUJIFILM Medical System, Loveland, CO), graft thickness at 1 cm posterior to the bicipital groove in the coronal plane of T2-weighted MRI was measured at the greater tuberosity side (medial aspect of the footprint on the greater tuberosity), at midgraft (top of the humeral head), and at the glenoid side (5 mm posterior to the articular surface on the glenoid). Results: Graft survival rate was 94% (34 of 36 shoulders) at 1 year after SCR, 92% (33 of 36 shoulders) at 2 to 4 years after SCR, and 89% (32 of 36 shoulders) at 5 to 10 years after SCR. Regarding the 30 patients (32 shoulders) whose grafts remained intact, graft thickness at 1 year after SCR was 8.1 ± 1.9 mm on the greater tuberosity, 6.8 ± 1.5 mm at midgraft, and 11.4 ± 2.0 mm on the glenoid. At 10 years after SCR, graft thickness (7.8 ± 1.6 mm on the greater tuberosity, 7.5 ± 1.8 mm at midgraft, 11.2 ± 2.2 mm on the glenoid) did not significantly differ from that at 1 year after SCR (P = 0.14 to 0.52). Although the rate of low intensity on T2 MRI of the grafts at 1 year after SCR was 53% (17 of 32 shoulders), all grafts had become low intensity on T2 MRI by 10 years after SCR (P &lt; 0.001). Compared with the preoperative measurement, AHD was increased significantly at 1, 5, and 10 years after SCR (P &lt; 0.001). Average AHD did not differ among 1, 5, and 10 years after SCR (P = 0.09 to 0.87). Because of the increase in AHD, the Hamada grade at 1, 5, and 10 years after SCR was significantly decreased (i.e., reduced cuff tear arthropathy) (P &lt; 0.001) compared with the preoperative grade. Before SCR, the AHD was significantly narrower and the Hamada grade was significantly higher in the affected shoulder compared with the unaffected shoulder. At 10 years after SCR, neither AHD nor Hamada grade differed significantly between the affected and unaffected shoulders (i.e., cuff tear arthropathy had not progressed during the 10 years or more after SCR) in patients with healed grafts, whereas all 4 of the remaining patients with postoperative graft tear showed increased cuff tear arthropathy to grade 4a or 4b. One patient with graft tear was converted to reverse shoulder arthroplasty. Conclusions: The graft survival rate at 10 years follow-up was 89%. Graft thickness was maintained at 10 years after SCR when graft was healed. Graft healing prevented progression of cuff tear arthropathy after arthroscopic SCR.

Shoulder arthroplasty after prior external beam radiation therapy: a matched cohort analysis.

External beam radiation therapy (XRT) is a commonly used therapeutic modality for the treatment of various chest wall and axillary malignancies. Despite the known risk of local soft tissue dysfunction, and possibly compromised bone ingrowth for cementless implants, there remains limited data on the impact of prior XRT in a shoulder arthroplasty (SA) cohort. This study evaluated the outcomes of primary SA in patients with prior XRT compared to a matched cohort (MC). Over a 27-year time period (1993-2020), 80 primary SAs (7 hemiarthroplasties [HAs], 29 anatomic total shoulder arthroplasties [aTSAs], and 44 reverse shoulder arthroplasties [rTSAs]) with previous XRT to the upper chest or axillary region and a minimum of 2-year follow-up were included. This cohort was matched (1:2) according to age, sex, body mass index (BMI), implant, and year of surgery with patients who had undergone HA or TSA for osteoarthritis or RSA for cuff tear arthropathy. Clinical outcomes including pain, active shoulder range of motion (ROM), strength, complications, and reoperations inclusive of revision surgery were assessed. The XRT cohort consisted of 71 (88.8%) women with a mean age of 70.9 (range, 43-87) years, BMI of 30.9±7.6, and follow-up period of 6.6 years (range, 2.0-28.2). In these patients, SA led to substantial improvements in pain, ROM, and strength across the entire cohort. When compared to the MC, the XRT group demonstrated a lower final postoperative forward elevation (FE) (111° vs. 126°; P=.013) and less improvements in pain (5.3 vs. 6.2; P=.002), FE (34° vs. 54°; P=.002), and external rotation (13° vs. 24°; P<.001). There were 14 (17.5%) complications and 7 reoperations in the XRT group, with rotator cuff failure after HA or TSA (n=4 of 36; 11.1%) as the most common complication and no instances of loose humeral components. The XRT group had a higher rate of complications (17.5% vs. 8.1%; P=.03) but not reoperations (8.8% vs. 3.1%; P=.059). When evaluated by implant, rTSA demonstrated the lowest rate of reoperations followed by aTSA and HA (2.3% vs. 10.3% vs. 42.9%; P=.002). Primary SA is an effective treatment modality for the improvement of pain, motion, and strength in patients with a history of prior XRT. However, when compared to patients without prior XRT, less clinical improvement and a higher rate of postoperative complications were observed.

Superior Capsular Reconstruction Partially Restores Native Glenohumeral Joint Loads in a Dynamic Biomechanical Shoulder Model

To evaluate the effect of an irreparable posterosuperior rotator cuff tear (PSRCT) on glenohumeral joint loads and to quantify improvement after superior capsular reconstruction (SCR) using an acellular dermal allograft. Ten fresh-frozen cadaveric shoulders were tested using a validated dynamic shoulder simulator. A pressure mapping sensor was placed between the humeral head and glenoid surface. Each specimen underwent the following conditions: (1) native, (2) irreparable PSRCT, and (3) SCR using a 3-mm-thick acellular dermal allograft. Glenohumeral abduction angle (gAA) and superior humeral head migration (SM) were measured using 3-dimensional motion-tracking software. Cumulative deltoid force (cDF) and glenohumeral contact mechanics, including glenohumeral contact area and glenohumeral contact pressure (gCP), were assessed at rest, 15°, 30°, 45°, and maximum angle of glenohumeral abduction. The PSRCT resulted in a significant decrease of gAA along with an increase in SM, cDF, and gCP (P < .001, respectively). SCR did not restore native gAA (P < .001); however, SM was significantly reduced (P < .001). Further, SCR significantly reduced deltoid forces at 30° (P= .007) and 45° of abduction (P= .007) when compared with the PSRCT. SCR did not restore native cDF at 30° (P= .015), 45° (P < .001), and maximum angle (P < .001) of glenohumeral abduction. Compared with the PSRCT, SCR resulted in a significant decrease of gCP at 15° (P= .008), 30° (P= .002), and 45° (P= .006). However, SCR did not completely restore native gCP at 45° (P= .038) and maximum abduction angle (P= .014). In this dynamic shoulder model, SCR only partially restored native glenohumeral joint loads. However, SCR significantly decreased glenohumeral contact pressure, cumulative deltoid forces, and superior migration, while increasing abduction motion, when compared with the posterosuperior rotator cuff tear. These observations raise concerns regarding the true joint-preserving potential of SCR for an irreparable posterosuperior rotator cuff tear, along with its ability to delay progression of cuff tear arthropathy and eventual conversion to reverse shoulder arthroplasty.

Patients With Mild Osteoarthritis Are Less Likely to Achieve a Clinically Important Improvement in Pain or Function After Anatomic Total Shoulder Arthroplasty.

The severity of glenohumeral osteoarthritis (OA) as demonstrated by preoperative radiographs and patient-reported pain plays an important role in the indication for anatomic total shoulder arthroplasty (aTSA). In hip and knee research, data about the effect of the severity of preoperative radiographic OA on the outcome of total joint arthroplasty have been mixed. For shoulder replacement, we are unsure of the effects of radiographic severity on outcomes. This study investigated whether the preoperative radiographic severity of glenohumeral OA is associated with improvement in pain and function after aTSA. We asked, (1) does the severity of glenohumeral OA correlate with improvement in patient-reported outcomes after TSA (delta American Shoulder and Elbow Surgeons score [postoperative-preoperative], delta Single Assessment Numeric Evaluation, delta Simple Shoulder Test, and delta VAS)? (2) Is having mild osteoarthritis associated with not meeting the minimum clinically important differences in preoperative and postoperative American Shoulder and Elbow Surgeons scores? An institutional query of patients who underwent aTSA for OA was performed between January 2015 and December 2018. A total of 1035 patients were eligible; however, only patients with adequate preoperative radiographs and patient-reported outcome measures collected preoperatively and at a minimum of 2 years postoperatively were included. Patients with proximal humerus fractures, inflammatory arthropathy, cuff tear arthropathy, prior ipsilateral rotator cuff repair, brachial plexus injury or neuromuscular disorder, workers compensation, periprosthetic joint infection, or revision surgery within 2 years were excluded. Patient characteristics, comorbidities, and prior shoulder surgery were recorded. The severity of OA was classified based on the modified Samilson-Prieto and Walch classification. The association between Samilson-Prieto grade and patient-reported outcome measures (American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and VAS score) was evaluated. Radiographic characteristics, patient demographics, comorbidities, and prior surgery were also evaluated for the potential risk of not achieving improvement in the minimum clinically important difference (16.1) with respect to the American Shoulder and Elbow Surgeons score. The American Shoulder and Elbow Surgeons score is scored 0 to 100, with higher scores representing less pain and better function. A total of 206 patients (20% of those eligible) with a mean follow-up of 2.3 years were included. Twenty-three patients had Samilson-Prieto Grade I, 38 had Grade II, 57 had Grade III, and 88 had Grade IV. There were no differences in improvements (delta) between the groups and between patient-reported outcome scores (American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and VAS). Compared with patients with more severe osteoarthritis (Samilson-Prieto Grades II, III, and IV), a higher proportion of patients with less severe osteoarthritis (Grade I) did not exceed the minimum clinical important difference for the American Shoulder and Elbow Surgeons score (22% [five of 23] versus 4% [seven of 183]; odds ratio 0.14 [95% confidence interval 0.04 to 0.520]; p = 0.006). The improvement in patient-reported outcome measure scores was similar regardless of radiographic severity after aTSA. Surgeons should use caution when recommending surgery to patients with less severe OA because a higher percentage did not improve, based on the minimum clinically important difference. Level III, therapeutic study.

Superior capsular reconstruction with a porcine xenograft

Short-term clinical and radiographical results after surgical treatment of irreparable rotator cuff rupture with superior capsular reconstruction. A prospective study to examine the functional outcome and radiographical shoulder findings after superior capsular reconstruction using a porcine extracellular matrix dermal graft. Clinical results were evaluated using the Constant Score and Western Ontario Rotator Cuff Index over a 2-year follow-up period. Twenty-seven of 29 operated shoulders had magnetic resonance imaging of the injured shoulder after one year with a qualitative radiographic evaluation of graft integrity. A total of 28 patients were operated with 29 superior capsular reconstructions. Over a 5-year period, 27 patients were included for a 2-year follow-up in which 24 patients completed. The mean age was 59 years at the time of surgery. At the final follow-up for 24 patients (mean 24 months) the mean Constant Score had improved from an average of 25.3 points to 56.5 points. The mean Western Ontario Rotator Cuff Index had increased from a percentage average of 30.2%-59.4%. Five out of 27 grafts were ruptured on follow-up magnetic resonance imaging. The clinical failure rate was 6 patients out of28. No certain correlation between functional outcome scores and graft durability was found. No certain correlation between functional outcome and single tendon vs. 2 tendon defects was proven. There was a positive correlation between an inferior functional outcome and advanced stages of glenohumeral arthropathy. This study suggests that a superior capsular reconstruction can yield results that are comparable to other known salvage treatment options in patients with large-to-massive, irreparable rotator cuff defects with no significant cuff tear arthropathy. With these results, selected patients can be considered for treatment with superior capsular reconstruction rather than reverse shoulder arthroplasty, débridement, or tendon transfer.

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.

Clinical outcomes after reverse shoulder arthroplasty in patients 60 years old and younger; medium-term results

Reverse total shoulder arthroplasty (RTSA) has been well-described as a surgical solution to manage rotator cuff tear arthropathy in elderly, low demand paitents. As experience has increased along with improvements in technique and implant design, RTSA has become increasingly used to manage more varied pathologic conditions of the shoulder in younger, more active patients. This study evaluates outcomes in a consecutive series of patients aged 60 years old and younger after undergoing RTSA. There were 94 shoulders in 89 patients enrolled. Mean age of the cohort was 54.8 (range 18-60 years). Surgical indications included rotator cuff tear arthropathy, irreparable rotator cuff tear without arthritis, glenohumeral arthritis with erosive glenoid deformity, inflammatory arthropathy, proximal humerus fracture nonunion/malunion and failed prior shoulder arthroplasty. Sixty-one shoulders (70%) had undergone at least one prior surgery. Of these, 6 shoulders (6% of total cohort) had a prior failed arthroplasty. Clinical outcomes (American Shoulder and Elbow Surgeons score, Western Ontario Osteoarthritis of the Shoulder index; visual analog scale pain), radiographic outcomes and complications were analyzed and assessed for correlation with patient demographic factors. The mean follow-up for this cohort was 4.9 years (range 2-12 years). Subjects experienced improvements in ASES score and pain (P<.001) and active forward elevation (88° preop to 135° postop, P<.001). Prior operation correlated with worse postoperative ASES and WOOS scores. Higher demand occupation correlated with less improvement in pain scores. The overall complication rate was 12%. Seven shoulders (7%) underwent an additional procedure. There was a 2% incidence of dislocation and a 4% incidence of acromial stress fracture. There was a 36% incidence of notching. With medium-term follow-up, RTSA is a reliable and predictable operation to manage various pathologic conditions in patients aged 60 years or less. Patients predictably experience significant improvements in pain and range of motion while assuming a modest complication risk. Long-term study is needed to understand potential for late complications or implant failure.

Age- and Gender-Related Differences in the Morphology of Cuff Tear Arthropathy: A Cross Sectional Analysis.

Rotator cuff tear arthropathy (CTA) is the most common reason for reverse total shoulder arthroplasty (RSA). There is minimal understanding of the natural progression of osteoarthritis of the shoulder and of the morphologic differences between men and women and between younger and older patients. This trial comprised 309 patients (342 shoulders) who underwent RSA due to CTA in the period between January 2009 and September 2019. The patients were divided into gender and age groups. Preoperative X-rays, computed tomography and magnetic resonance imaging were conducted using various classifications to describe the morphology of the CTA. Of all 342 analyzed shoulders, 209 were right and 133 were left shoulders. A total of 257 female shoulders and 85 male shoulders were assessed. Both mean age and age distribution were significantly different (74.37 years in female and 70.11 years in male patients, p = 0.001; 70.2% female patients in the age group <75.5 years and 80.1% in the age group >75.5 years, p = 0.045). A larger extent of progression of the fatty infiltration was detected both in the female cohort (p = 0.006) and in the older age group (p = 0.001). Additionally, older patients had significantly higher levels of muscle retraction (Patte; p = 0.003), a lower acromiohumeral distance (p = 0.042) and more advanced CTA (Seebauer; p = 0.006).

A Comparison of Complications and Survivorship after Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture compared with Cuff Tear Arthropathy.

Traditionally used to treat rotator cuff tear arthropathy (CTA), reverse total shoulder arthroplasty (RTSA) is becoming increasingly utilized for the treatment of proximal humeral fractures (PHF). The purpose of this study was to use a matched cohort analysis to assess differences in 90-day complications as well as 2-year and 5-year implant survival between patients undergoing RTSA for CTA and patients undergoing RTSA for PHF. Patients with at least a 5-year follow-up who underwent primary RTSA for either PHF or CTA were identified in a national database (PearlDiver Technologies) using current procedural terminology (CPT) and international classification of diseases (ICD) 9 and 10 codes. Patients with a surgical indication of PHF were matched with patients with a surgical indication of CTA based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index (BMI)>30). All-cause revision at the 2-year and 5-year postoperative time intervals were assessed. Reimbursements for the surgical care episode up to the 30-day, 90-day, and 1-year postoperative intervals were also assessed. Bivariate analysis was performed with a significance set at P<0.05. In total, 802 PHF patients were matched with 802 CTA patients. Compared to CTA patients, PHF patients undergoing RTSA were significantly at increased risk of atrial fibrillation, anemia, and heart failure within 90 days of surgery. Notably, there was no significant difference in all-cause revision surgery at 2-year and 5-year postoperative intervals or hospital reimbursements at the 30-day, 90-day, and 1-year postoperative intervals. Preoperative indication appears to be an important driver of healthcare utilization for RTSA, as PHF patients undergoing RTSA have a higher risk of short-term postoperative complications compared to CTA patients. However, there is no difference in hospital reimbursement for the two indications of RTSA, suggesting that current payment modalities may not appropriately adjust for risk based on the surgical indication.

Spontaneous Deltoid Tear in Cuff Tear Arthropathy and Its Effect on the Outcome of Reverse Total Shoulder Arthroplasty: A Comparison Using Propensity Score Matching.

Deltoid function critically influences the results of reverse total shoulder arthroplasty (RTSA), and spontaneous deltoid attrition tears are frequently detected in cuff tear arthropathy (CTA) patients; however, the clinical impacts of these tears on RTSA outcomes are undetermined. Our aim was to determine the effect of spontaneous deltoid attrition tears on postoperative outcomes after RTSA without an additional deltoid procedure. Seventy-two patients who underwent RTSA for CTA with preoperative magnetic resonance imaging (MRI) and a minimum clinical follow-up of 1 year (mean, 32 months) were retrospectively reviewed in the study. Patients with a history of previous shoulder surgery or injury were excluded. The presence and location of deltoid attrition tears were determined in preoperative MRI. Propensity score matching (1:1) was performed to construct tear and no-tear groups. Finally, 21 patients, matched with respect to age, sex, hand dominance, symptom duration, medical comorbidity (obesity, diabetes mellitus, and coronary artery disease), Hamada grade, and implant type, were assigned to each group. Clinical outcomes (functional scores, isometric power, and range of motion) in the two groups were compared. Deltoid attrition tears were detected in 21 of the 72 enrolled cases (29.1%). Anterolateral deltoid was the most frequent location and no tear was detected in the posterior deltoid. The tear rate increased with disease severity (Hamada G2, 4.8%; G3, 23.8%; > G4, 71.4%). No pre- or postoperative clinical variables differed significantly between the tear and no tear groups. Deltoid attrition tears were detected in 29% of CTA patients who underwent RTSA. The most common site was the anterolateral region and tear prevalence tended to increase with CTA progression. However, RTSA was found to provide satisfactory outcomes regardless of the presence of a deltoid attrition tear.

Reverse Shoulder Arthroplasty for Patients with Massive Rotator Cuff Tears or Cuff Tear Arthropathies at a Minimum Follow-up of 7 Years.

To evaluate indications and factors that influence long-term clinical outcomes and revision rates for reverse shoulder arthroplasty (RSA) in shoulders with irreparable massive rotator cuff tears (mRCTs) or cuff tear arthropathies (CTAs). The authors retrospectively evaluated a consecutive series of shoulders with no fracture sequelae that underwent primary RSA between 2011 and 2013. Independent observers collected demographic data, surgical techniques, and implant types, as well as primary outcome measures such as American Shoulder and Elbow Society (ASES) score and Constant score (CS). Case series, level IV. From the initial series of 123 patients that underwent RSA, 29 patients died (24%) for reasons unrelated to the shoulder arthroplasty, 11 were lost to follow-up (9%), and 4 required revision surgery (3%). The final cohort of 79 patients comprised 55 women (70%), and 24 men (30%), aged 72.7 ± 7.0. At a final follow-up of 8.9 ± 0.6 years (range: 7.4-10.3) the absolute CS was 59.0 ± 16.2, the age-/sex-adjusted CS was 76.6 ± 41.2, and ASES was 77.1 ± 20.3. Univariable analysis revealed no associations for absolute CS, but revealed that age-/sex-adjusted CS was significantly lower for patients with high blood pressure (β = -15.8, p = .025). At a minimum follow-up of 7.4 years, the absolute CS was 59.0 ± 16.2, the age-/sex-adjusted CS was 87.4 ± 24.1 and ASES was 77.1 ± 20.3. When stratifying the outcomes of RSA by indication, there were no significant differences in patients with mRCTs versus CTA in terms of absolute CS, age-/sex-adjusted CS, and ASES. Univariable analysis revealed no association with absolute and age-/sex-adjusted CS for type of indication or surgical approach.

Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty.

Previous studies have indicated an increased risk of periprosthetic joint infection (PJI) in patients treated with reverse shoulder arthroplasty (RSA) compared with patients treated with anatomic total shoulder arthroplasty. The reason for this is unclear but may be related to a high prevalence of previous rotator cuff repair in patients who are treated with RSA. The purpose of this study was to determine previous non-arthroplasty surgery as a risk factor for revision owing to PJI after RSA for cuff tear arthropathy, massive irreparable rotator cuff tears, or osteoarthritis. Data were retrieved from the Danish Shoulder Arthroplasty Registry and medical records. We included 2217 patients who underwent RSA for cuff tear arthropathy, massive irreparable rotator cuff tears, or osteoarthritis between 2006 and 2019. PJI was defined as ≥3 of 5 tissue samples positive for the same bacteria or as definite or probable PJI evaluated based on criteria from the International Consensus Meeting. The Kaplan-Meier method was used to illustrate the unadjusted 14-year cumulative rates of revision. A Cox regression model was used to report hazard for revision owing to PJI. Results were adjusted for previous non-arthroplasty surgery, sex, diagnosis, and age. Revision was performed in 88 shoulders (4.0%), of which 40 (1.8%) underwent revision owing to PJI. There were 272 patients (12.3%) who underwent previous rotator cuff repair, of whom 11 (4.0%) underwent revision owing to PJI. The 14-year cumulative rate of revision owing to PJI was 14.1% for patients with previous rotator cuff repair and 2.7% for patients without previous surgery. The adjusted hazard ratio for revision owing to PJI for patients with previous rotator cuff repair was 2.2 (95% confidence interval, 1.04-4.60) compared with patients without previous surgery. There is an increased risk of revision owing to PJI after RSA for patients with previous rotator cuff repair. We recommend that patients with previous rotator cuff repair be regarded as high-risk patients when considering RSA.