Elective Primary Shoulder Arthroplasty Research Articles

Does long-term follow-up and monitoring of primary shoulder arthroplasty identify failing implants requiring revision?

Published scoping review has identified evidence paucity related to long-term follow-up of shoulder arthroplasty. We aim to report effectiveness of elective primary shoulder arthroplasty surveillance in identifying failing implants requiring revision. A prospective database recording shoulder arthroplasty and subsequent follow-up surveillance in a shoulder unit was analyzed. Shoulder arthroplasty was performed by 4 fellowship-trained shoulder surgeons for accepted elective indications including the use of anatomic arthroplasty in arthritic shoulders with intact rotator cuff and a reverse prosthesis being used in rotator cuff-deficient shoulders and rotator cuff-competent arthritic shoulders when deemed preferable by the treating surgeon. All shoulder arthroplasty implants used had achieved a minimum 7A Orthopaedic Data Evaluation Panel (ODEP) rating. The included shoulder arthroplasties were performed between May 1, 2004, and December 31, 2021, with minimum 1-year follow-up. Surveillance program involves specialist physiotherapist review at 1, 2, 3, 5, 8, 10, and 15 years postoperatively, including clinical examination, outcome scoring, and radiographs. Patient-initiated review occurred between time points if a patient requested assessment because of symptoms. Outcome measures include ratio of failing implants identified by surveillance and patient-initiated review, with number of surveillance reviews offered and proportion that identified a failing implant requiring revision calculated. A total of 1002 elective primary shoulder arthroplasty with minimum 1-year follow-up were performed (547 reverse total shoulder arthroplasty [rTSA], 234 anatomic total shoulder arthroplasty [aTSA], and 221 hemiarthroplasty [HA]). A total of 238 patients died prior to December 31, 2022, resulting in 4019 surveillance appointments offered. Thirty-eight prostheses required revision ≥1 year postoperatively (6 rTSA, 9 aTSA, and 23 HA), with surveillance identifying requirement in 53% (33% rTSA, 56% aTSA, and 57% HA) and patient-initiated review in 47%. Mean years from implantation to revision was 5.2 (2.7 rTSA, 3.6 aTSA, and 6.6 HA). Revision indications included rotator cuff failure (56% aTSR and 43% HA) and glenoid erosion (57% HA). This is the first series reporting effectiveness of shoulder arthroplasty surveillance in identifying implants requiring revision. Surveillance identified more than half of implants requiring revision, although only 0.5% of appointments identified revision requirement. Surveillance enrolment may influence patient-initiated review utilization; therefore, similar studies using only patient-initiated follow-up would help inform recommendations.

Rationalizing routine postoperative blood testing following elective shoulder arthroplasty

BackgroundImprovements in perioperative care have decreased complication rates following arthroplasty surgery and enabled outpatient surgery. Although studies have suggested selective routine postoperative blood tests for lower limb arthroplasty, there is currently a paucity of research into its utility for shoulder arthroplasty. Our aim was to define an algorithm based on Charlson Comorbidity Index (CCI) value as part of a predictive algorithm to identify low-risk patients undergoing elective anatomic and reverse shoulder arthroplasty that can safely do without routine postoperative blood tests. MethodsElectronic medical records were retrospectively reviewed for patients who underwent elective primary shoulder arthroplasty at our institution, both anatomic and reverse, between January 2009 and October 2020. Inclusion criteria included patients who underwent reverse or anatomic shoulder arthroplasty for glenohumeral joint osteoarthritis or rotator cuff arthropathy and had documented preoperative and postoperative blood tests including full blood count and serum electrolytes. Exclusion criteria included patients who had revision and trauma indications for surgery because of the increased complication rates associated with these indications. Variables recorded included age, gender, body mass index, indication for surgery, comorbidities, American Society of Anesthesiologists score, CCI score, preoperative blood test values from preadmission assessment, postoperative day one blood test values, and interventions required based on blood results. ResultsA total of 140 patients were included in the study. Eighteen patients (12.85%) required intervention based on postoperative blood tests, the most common indications being anemia and hyponatremia. Patients that required intervention had higher CCI (P = .001) and lower preoperative hemoglobin (P = .014). With the application of cutoff values of hemoglobin of ≥106 g/L, and CCI score of less than 4, only one patient in our study required intervention. ConclusionRoutine postoperative blood test following primary elective shoulder arthroplasty is not required in low-risk patients, defined as those with a CCI score of <4 and a preoperative hemoglobin of >106 g/L.

Sociodemographic disparities in distance traveled to receive primary shoulder arthroplasty

BackgroundShoulder arthroplasty is a common procedure, but patterns in patient travel distance to undergo this operation are unknown. This study aims to describe the relationships between patient travel distance, patient demographics, and surgical outcomes after primary shoulder arthroplasty. We hypothesized that older age, higher Charlson comorbidity index, white race, and higher socioeconomic status would be associated with increased travel distance. MethodsData from the Healthcare Cost and Utilization Project, American Hospital Association database, and UnitedStatesZipCodes.org Enterprise database were used to collect patient data and geographic coordinates for patients’ home zip codes and the hospitals at which they underwent shoulder arthroplasty. The distances from population-weighted zip code centroid points and hospital coordinates were calculated. The relationships between the distance traveled to receive care and patient demographic data and postoperative adverse outcomes were then assessed using analysis of variance test and logistic regression analysis. ResultsA total of 49,567 patients who underwent elective primary shoulder arthroplasty in Florida and New York between 2005 and 2015 were included for analysis. Age and number of medical comorbidities were inversely related to travel distance (P < .0001). White race (P < .0001), private insurance coverage (P = .03), and anatomic shoulder arthroplasty were each associated with increased travel distance (P < .0001). Hemiarthroplasty patients traveled less distance than patients who underwent anatomic or reverse shoulder arthroplasty (P < .0001). No significant associations were observed between travel distance and postoperative adverse outcomes. ConclusionThis study provides robust evidence of differences in distance traveled to undergo primary shoulder arthroplasty based on patient age, medical comorbidities, race, socioeconomic status, insurance provider, and type of shoulder arthroplasty. Future work may elucidate whether disparities in travel distance are based on patient preference or necessity and may offer additional insights with respect to access to care for this specialized procedure.

Preoperative total lymphocyte count was not associated with adverse postoperative events following elective shoulder arthroplasty

BackgroundWith the heightened focus on lowering adverse postoperative events through preoperative patient optimization, malnutrition may be a modifiable risk factor that could be addressed and lead to improved postoperative outcomes. However, an understanding of the association between malnutrition status and adverse postoperative events following shoulder arthroplasty is lacking. We sought to evaluate the association between preoperative malnutrition status, identified via the total serum lymphocyte count, and adverse postoperative events following shoulder arthroplasty. MethodsWe conducted a cohort study using data from Kaiser Permanente's Shoulder Arthroplasty Registry. Patients who underwent elective primary shoulder arthroplasty were identified (2005-2016). Patients with a preoperative total lymphocyte count <1500 cells/mm3 were defined as malnourished. A competing risk Cox multistate model was used to evaluate the association between malnutrition and revision or death with stratification by age. Multiple logistic regression was used to evaluate 5-year deep infection, 90-day emergency department visit, 90-day readmission, and 90-day venous thromboembolism. Receiver operating characteristic curves were generated for discrete total lymphocyte counts to determine whether a threshold exists to identify patients at higher risk of adverse postoperative events. ResultsThe final study cohort comprised 6956 shoulder arthroplasty patients, with 2133 (30.7%) identified as malnourished. No difference in septic or aseptic revision risks was observed when comparing patients with and without malnutrition; however, malnourished patients had a higher risk for death, regardless of age (<60 years: hazard ratio = 2.25, 95% confidence interval = 1.07-4.73; ≥60 years: hazard ratio = 1.47, 95% confidence interval = 1.28-1.70). We did not observe a difference in likelihood of deep infection, emergency department visit, readmission, or venous thromboembolism. Receiver operating characteristic curve analysis suggested preoperative total lymphocyte count performed poorly at differentiating adverse events. ConclusionOnly a higher mortality risk was observed to be associated with total lymphocyte count-defined malnutrition in patients undergoing elective shoulder arthroplasty. When instead looking at total lymphocyte count continuously, an optimal threshold for discriminating risk of adverse postoperative events could not be identified. Further study is needed to identify an appropriate indicator of malnutrition in shoulder arthroplasty patients and if this indicator can be modified to improve patient status and quality of care. Level of EvidenceLevel III; Retrospective Cohort Comparative Study

A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial

Hematoma formation and the need for blood transfusions are commonly reported complications after shoulder arthroplasty. Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to decrease perioperative blood loss. The role of TXA is still being established in shoulder arthroplasty. We conducted a double-blind randomized controlled trial comparing intravenous TXA vs. placebo in 60 patients undergoing primary anatomic or reverse shoulder arthroplasty. Of these patients, 29 received a placebo whereas 31 received a single dose of 2 g of intravenous TXA. Patient demographic characteristics, as well as drain tube output, blood loss, hematoma formation, transfusion requirement, length of hospital stay, and pain score, were recorded. Patients were followed up for 12 weeks to assess for complications. Patients who received TXA had a lower drain tube output at all time points: 41 mL vs. 133 mL at 6 hours, 75 mL vs. 179 mL at 12 hours, and 94 mL vs. 226 mL at 24 hours (P < .001 for all). They also had a higher postoperative hemoglobin (Hb) level (12.3 g/dL vs. 11.4 g/dL, P = .009), lower change in Hb level (1.7 g/dL vs. 2.3 g/dL, P = .011), lower total Hb loss (0.078 g vs. 0.103 g, P = .042), lower blood volume loss (0.55 L vs. 0.74 L, P = .021), higher postoperative hematocrit level (36.7% vs. 34.6%, P = .020), and lower hematocrit change (5.4% vs. 7.6%, P = .022). There was no significant difference in pain score or length of hospital stay, and no patients required a transfusion. A single dose of 2 g of intravenous TXA decreases blood loss and drain tube output in primary anatomic and reverse arthroplasty of the shoulder. No differences were detected in the occurrence of complications, need for transfusion, pain score, or length of hospital stay. With the mounting evidence now available, patients undergoing elective primary shoulder arthroplasty should be given intravenous TXA to decrease perioperative blood loss.

Early postoperative pain relief after total shoulder arthroplasty

BackgroundPatients undergoing elective shoulder arthroplasty have highly variable pain experiences. We sought to characterize preoperative patient characteristics associated with fast and slow pain relief after elective total shoulder arthroplasty and evaluated whether differences in early pain recovery predicted longer term pain relief. MethodsWe identified 324 patients undergoing elective primary shoulder arthroplasty, reverse and anatomic, between 2015 and 2018 from our prospective registry. Postoperative pain relief was defined as the difference in preoperative and 2-week postoperative pain intensity. Three groups were then created: fast responders (top decile), slow responders (bottom decile), and normal responders. Multinomial regression was used to identify preoperative patient factors associated with either slow or fast pain responses. ResultsFactors associated with a fast pain response included older age and being married. A slow pain response was associated with being unmarried. Pain intensity was lower in the fast responders at 6 weeks (0.60 ± 0.80 vs. 3.4 ± 2.50, P < .05) and 3 months (0.60 ± 0.90 vs. 2.60 ± 2.30, P < .05), but there was no difference at 1 year (0.30 ± 0.60 vs. 1.00 ± 1.10, P = .068) and 2 years (0.50 ± 1.30 vs. 1.40 ± 2.10, P = .183) postoperatively. ConclusionThe postoperative pain experience after shoulder arthroplasty seems to be influenced by patient age and marital status. Patients with marginal improvement in pain relief should be counseled that their recovery may be more prolonged, but by the 1-year mark they are likely to achieve comparably low pain levels to other patients. Level of evidenceLevel III; Retrospective Design; Prognosis Study

Prevalence and predictors of persistent pain 2 years after total shoulder arthroplasty

BackgroundElective total shoulder arthroplasty is highly successful, but there is a subset of patients who continue to experience pain after this procedure. The purposes of this study were to elucidate the prevalence and patient characteristics predictive of persistent pain after shoulder arthroplasty. MethodsWe identified patients who had received an elective primary shoulder arthroplasty (anatomic or reverse) between 2016 and 2017 from our prospectively maintained, single-surgeon registry. Patients were stratified by the presence or absence of persistent pain at 2 years postoperatively, as defined by a Visual Analog Pain score of ≥2. This value was chosen in accordance with previously reported values for minimal clinically important differences. Multivariable logistic regression was used to identify factors associated with persistent pain. ResultsOf the 244 patients included for analysis, 46(18.9%) had persistent pain at 2 years postoperatively. The average pain score in this group was found to be significantly greater than the patients without pain (3.6 ± 1.6 vs 0.14 ± 0.35, P< .001). Patients with persistent pain had a higher incidence of preoperative opioid use (26.1% vs 13.6%, P= .038), diabetes (28.3% vs 11.6%, P= .004), number of self-reported allergies (3 ± 4.8 vs 1.9 ± 2.3,P= .03), peak postoperative inpatient pain (8.1 ± 1.9 vs 6.9 ± 2.1,P< .001), incidence of prior ipsilateral shoulder surgery (50% vs 30%, P= .011), and a higher percentage received a reverse shoulder arthroplasty (87% vs 70.7%, P= .024). The patient characteristics that were independently predictive of persistent pain were history of prior ipsilateral shoulder surgery (odds ratio 2.44; 95% confidence interval 1.21-4.91; P = .013) and greater postoperative inpatient pain intensity (odds ratio, 1.26 per 1 unit increase; 95% confidence interval 1.03-1.55; P = .024). ConclusionAbout 1 in 5 patients report persistent pain after elective primary shoulder arthroplasty. Prompt identification of at-risk patients (eg, those with severe postoperative inpatient pain and a history of prior shoulder surgery) may prove effective in optimizing the pain experience after shoulder arthroplasty. Level of evidenceLevel III; Cohort Study with Prospective Data and Retrospective Study Design.

Lower-extremity total joint arthroplasty in shoulder arthroplasty patients: does the order of the lower-extremity total joint arthroplasty matter?

As total joint arthroplasty (TJA) utilization increases, arthroplasties of multiple joints in a patient are more common. An understanding of the success of shoulder arthroplasty patients also requiring a lower-extremity (hip or knee) TJA is lacking. We evaluated the following questions: (1) Is there a difference in the revision risk following shoulder arthroplasty in patients who also undergo a lower-extremity TJA compared with those who do not? (2) Does the revision risk differ depending on the sequence of the procedures? Patients who underwent elective primary shoulder arthroplasty from 2009 through 2015 were identified using Kaiser Permanente's shoulder arthroplasty registry. Patients with a lower-extremity TJA were identified using the institution's total joint replacement registry. Revision related to the index shoulder was modeled via Cox regression stratified by procedure type and adjusted for confounders. Of the 4751 shoulder arthroplasties identified, 1285 (27.0%) underwent a prior hip and/or knee arthroplasty and 483 (10.2%) underwent a hip and/or knee arthroplasty following the index shoulder arthroplasty. No difference was found in all-cause shoulder revision risk with lower-extremity TJA before (hazard ratio, 1.38; 95% confidence interval, 0.97-1.96) or after (hazard ratio, 1.30; 95% confidence interval, 0.82-2.06) the index shoulder arthroplasty compared with patients who underwent a shoulder arthroplasty only. In our study sample, we did not observe shoulder revision surgery risk to be different in patients who also underwent a lower-extremity TJA, regardless of the sequence of the 2 procedures. Future prospective studies should investigate whether the timing of the lower-extremity TJA in relation to the shoulder procedure impacts the latter's success.

Postoperative Day 1 Discharge Following Elective Shoulder Arthroplasty

Background The number of shoulder arthroplasty procedures performed has greatly increased in recent years and this trend is expected to continue. However, accelerated recoveries by way of reduced postoperative hospital stays have not been studied for this patient population as extensively as in the hip and knee arthroplasty literature. The average length of stay for shoulder arthroplasty patients has consistently been found to be between 2 and 2.5 days. We conducted a study to determine whether postoperative day 1 (POD1) discharge would put patients at increased risk for complications and readmission following elective shoulder arthroplasty. Methods A retrospective review of patients who underwent shoulder arthroplasty (reverse or anatomic total shoulder arthroplasty) performed by one surgeon at one institution from 2008 to 2015 was conducted. All elective primary shoulder arthroplasty patients were included. Exclusion criteria included revision arthroplasty, humeral head replacement, humeral head resurfacing, and arthroplasty for fracture. Patient demographics, medical comorbidities, postoperative length of stay, hospital readmission within 30 days of discharge, and reason for readmission were collected. The 30-day readmission rate was the primary outcome used in determination of the safety of this practice. Results A total of 353 patients were found to meet our criteria, of which 205 (58.1%) were discharged on POD1. A total of 83 patients were discharged on postoperative day 2 or 3 (POD2-3) from 2008 to 2011. Of those discharged on POD1, 8 were found to have been readmitted to the hospital within 30 days of original discharge to give an overall readmission rate of 3.90%. The most common reason for readmission was dyspnea (3/8, 37.5%). No risk factors were found to be associated with increased likelihood of readmission in this patient group. There were 4 readmissions in the POD2-3 discharge group to give an overall readmission rate of 4.82% (4/83). No statistically significant difference was found between 30-day readmission rates of POD1 and POD2-3 discharge elective shoulder arthroplasty patients in this study or shoulder arthroplasty patients in general from other studies ( P &gt; .100). Conclusion POD1 discharge following elective shoulder arthroplasty does not increase the risk for postoperative complications requiring hospital readmission. With shorter hospital stays, POD1 discharge following elective shoulder arthroplasty could provide a method to reduce healthcare expenditures.