Outcomes Of Reverse Total Shoulder Arthroplasty Research Articles

How To Choose The Best Lateralization And Distalization Of The Reverse Shoulder Arthroplasty To Optimize The Clinical Outcome In Cuff Tear Arthropathy

PurposeLateralization shoulder angle (LSA) and distalization shoulder angle (DSA) are two parameters that had been described for a better planification of the arthroplasty, but the range of these angles are very wide. The purpose of this study was to investigate the best combination in terms of lateralization and distalization to optimize the outcome of Reverse total shoulder arthroplasty(RTSA) for cuff tear arthropathy (CTA) with a functional deltoid. MethodsThis retrospective cohort study, conducted between 2014 and 2018 at a specialized shoulder unit in Paris, focused on patients exclusively treated with RTSA for CTA, ensuring a minimum follow-up of 1 year. The primary outcome measure was the ASES score. Secondary outcome measures included range of motion and patient-reported outcomes at the final follow-up, such as the Constant score, SSV, SST, and VAS. Optimal RTSA outcomes were delineated by scores surpassing the patient's acceptable symptom state (PASS) for ASES, set in literature at 76. Patients were categorized into two groups based on ASES scores at the last follow-up: those below and those above 76. The capabilities of LSA and DSA to predict the outcome of interest were assessed and the corresponding optimal thresholds for having better outcome were calculated using the Receiver Operator Characteristic (ROC) curve. ResultsSixty-two patients were included in the study with a mean age of 74.51 ± 6.79. Correlation analysis revealed significant medium correlation between ASES and both LSA (r = -0.43, p = .001) and DSA (r = 0.39, p = .002). The DSA of patients with ASES > 76 was 48.55 ± 12.44 with an IQR of 39.5 – 57.5, as compared to lower values for patients with ASES < 76, which was 37.82 ± 9.8 (IQR 32 – 46.5) (p=0.009). Similarly, the LSA of patients with ASES > 76 was 86.43 ± 11.4 (IQR 79.5 – 93.5), as compared to higher values for patients with ASES < 76, which was 100.09 ± 7.63 (IQR 93 – 105.5) (p<0.001). The ROC curve confirmed LSA and DSA as good predictors for the ASES outcome, with AUCs of 0.851 and 0.741, respectively. The optimal LSA should be no more than 90.5° (Se=100%, Sp=67.7%). The optimal DSA should be no less than 37.5° (Se=78.4%, Sp=63.6%). ConclusionThe LSA and DSA angle could represent a helpful tool to optimize the clinical outcomes of an adaptable RTSA in CTA with a functional deltoid and a complete passive range of motion.

Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty

Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT). This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables. Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2±21.1 vs. 21.9±14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2±4.4 vs. 54.2±7.8 years, P<.001) and had more severe arthritis (1.8±0.9 vs. 1.2±0.5 Samilson-Prieto, P=.019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ±26° vs. 73°±30° change, P=.048), greater postoperative SSV (91±8% vs. 69±25%, P<.001), lower postoperative VAS pain scores (0.6±1.2 vs. 2.2±2.9, P=.020), and less postoperative internal rotation (IR; 4.6°±1.6° vs. 6.9°±1.8°, P=.004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (β=21.5, P=.021) and lower VAS scores (β=-1.4, P=.037), whereas SCR was predictive of greater IR ROM (β=3.0, P=.043). Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.

Anatomic versus reverse total shoulder arthroplasty outcomes after prior contralateral anatomic total shoulder arthroplasty in patients with bilateral primary osteoarthritis with an intact rotator cuff.

We aimed to compare outcomes in patients that underwent bilateral anatomic total shoulder arthroplasty (aTSA) vs. aTSA/ reverse total shoulder arthroplasty (rTSA) for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA) to further elucidate the role of rTSA in this patient population. A single-institution prospectively collected shoulder arthroplasty database was reviewed for patients undergoing bilateral total shoulder arthroplasty (TSA) for RCI-GHOA with a primary aTSA and subsequent contralateral aTSA or rTSA. Outcome scores (SPADI, SST, ASES, UCLA, Constant) and active range of motion (abduction, forward elevation [FE], external and internal rotation [ER and IR]) were evaluated. Clinically relevant benchmarks (minimal clinically important difference [MCID], substantial clinical benefit [SCB], and patient acceptable symptomatic state [PASS]) were evaluated against values in prior literature. Incidence of surgical complications and revision rates were examined in qualifying patients as well as those without <twoyear follow-up. Of the 55 bilateral TSA patients with an intact rotator cuff, 46 underwent aTSA/aTSA and 9 underwent aTSA/rTSA. At the time of the second TSA, patients undergoing aTSA/rTSA were older (71 ± 4 vs. 67 ± 7, P = .032) and more commonly had inflammatory arthritis (44% vs. 11%, P = .031). Mean time to the second TSA was shorter for aTSA/aTSA (2.3 ± 2.8 vs. 4.4 ± 3.6years, P < .001). Postoperative outcomes were similar after the first aTSAs between groups with similar proportions achieving the MCID, SCB, and PASS (all P > .05). The 2nd TSAs between groups were similar preoperatively, but aTSA/rTSA had superior outcome scores, overhead motion, and active abduction compared to patients that underwent aTSA/aTSA. There were no differences in active ER and IR scores or complication rates between groups. Patients with RCI-GHOA have excellent clinical outcomes after either aTSA/aTSA or aTSA/rTSA.

Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy.

Indications for reverse total shoulder arthroplasty (RSA) have expanded to include individuals with intact rotator cuffs such as patients with severe glenoid deformity or with concern of future rotator cuff insufficiency. The purpose of this study was to compare outcomes of RSA with an intact rotator cuff to RSA for cuff arthropathy and anatomic total shoulder arthroplasty (TSA). We hypothesized that outcomes of RSA with an intact rotator cuff would be comparable to RSA for cuff arthropathy and TSA but with diminished range of motion (ROM) compared with TSA. Patients at one institution who underwent RSA and TSA between 2015 and 2020 with minimum 12-month follow-up were identified. RSA with preservation of the rotator cuff (+rcRSA) was compared to RSA for cuff arthropathy (-rcRSA) and anatomic TSA (TSA). Demographics and glenoid version/inclination were obtained. Pre- and postoperative ROM; patient-reported outcomes including visual analog scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores; and complications were obtained. Twenty-four patients underwent+rcRSA, 69 underwent -rcRSA, and 93 underwent TSA. There were more women in the +rcRSA cohort (75.8%) than in the -rcRSA (37.7%, P=.001) and TSA (37.6%, P=.001) cohorts. Mean age of the +rcRSA cohort (71.1) was greater than that of TSA (66.0, P=.021) but similar to that of -rcRSA (72.4, P=.237). Glenoid retroversion was greater in +rcRSA (18.2°) compared with -rcRSA (10.5°, P=.011) but was similar to TSA (14.7°; P=.244). Postoperatively, there were no differences in VAS or ASES between+rcRSA vs. -rcRSA and +rcRSA vs. TSA. SSV was lower in +rcRSA (83.9) compared with -rcRSA (91.8, P=.021), but was similar to TSA (90.5, P=.073). Similar ROM was achieved in forward flexion, external rotation, and internal rotation at final follow-up between+rcRSA and -rcRSA, but TSA had greater external rotation (44° vs. 38°, P=.041) and internal rotation (6.5° vs. 5.0°, P=.001) compared with+rcRSA. There were no differences in complication rates. At short-term follow-up, preservation of the rotator cuff in RSA demonstrated similarly excellent outcomes and low complication rates compared with RSA with a deficient rotator cuff and TSA, except for slightly lower internal and external rotation compared with TSA. Although multiple factors deserve consideration when choosing between RSA and TSA, RSA with preservation of the posterosuperior cuff is a viable treatment option for glenohumeral osteoarthritis, particularly in patients with severe glenoid deformity or those at risk for future rotator cuff insufficiency.

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 total shoulder arthroplasty for complex proximal humerus fracture in the elderly: clinical and radiological results

The use of reverse total shoulder arthroplasty (RSA) for the treatment of proximal humeral fractures (PHFs) is steadily increasing. Better clinical outcomes of RSA have been correlated with tuberosity reattachment and healing. The purpose of this study was to evaluate both the clinical and radiological results of reverse shoulder arthroplasty in the management of a proximal humerus fracture in the elderly. Retrospective study including 400 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 12-month follow-up. In all the cases, the greater tuberosity was reattached with a standardized suture technique and a local bone graft. All the patients were assessed at the 12-month follow-up with Constant-Murley Score (CMS). Radiographic healing of the greater tuberosity was noted. Complications and revision rates were reported. Mean final CMS for this cohort was 82 points. The greater tuberosity healed in anatomic position in 85% of the cases (N= 340), obtaining an average CMS of 85 in these patients. Healing of the greater tuberosity did not occur in 13% of the cases (N= 52) and displacement more than 5 mm occurred in 2% (N= 8) of the patients for an average CMS of 60. All patients scored above 120° in forward elevation with a mean of 150°. Mean active external rotation was 35°. The lateralization shoulder angle had a mean of 91° and the distalization shoulder angle had a mean of 54°. Low-grade scapular notching was reported in <1% of the cases. A total of 60 patients presented failure of healing or displacement of the greater tuberosity. Major complications were reported in nine patients. Of these nine patients, two acquired superficial wound infections, while two had deep shoulder prosthetic infection. Two other patients developed hematomas, one sustained an acromial stress fracture, and two had a stem loosening. There were 4 reoperations. Reverse shoulder arthroplasty, with the use of a fracture-specific stem, allows an improved rate of greater tuberosity healing and short-term clinical outcomes in the elderly population.

Humeral and Glenoid Version in Reverse Total Shoulder Arthroplasty: A Systematic Review.

There is increasing interest in reverse total shoulder arthroplasty (RTSA) as a reliable treatment for arthritic, rotator cuff deficient shoulders. Humeral and glenoid version are controversial parameters that can influence internal and external rotation, muscular forces, and implant stability as outcomes of RTSA. The aim of this study was to obtain an overview of the current knowledge on the effect of both humeral component version and glenoid component version and give recommendations on their most optimal degree for RTSA. A comprehensive quantitative review of the published literature on the effect of humeral version and glenoid version in RTSA was performed, to identify its influence on the range of movement, muscle forces, and intrinsic stability of the reverse prosthesis. Eleven studies were included: nine were biomechanical studies, one was a clinical-radiographic study, and one was an implant design consideration. Anterior stability can be improved by implanting the humeral component in neutral or with some anteversion. Glenoid component retroversion has been proven to reduce the likelihood of subluxation, while increasing ER and ROM at the same time. The study was conducted considering 5° anteversion; neutral; and 5°, 10°, and 20° retroversion of the glenoid component. Although a final opinion has not been yet expressed on the matter, the general consensus tends to agree on restoring 0° to 20° of retroversion of the humeral and glenoid component to yield the best outcomes.

Three-dimensional analysis of baseplate screw penetration in reverse total shoulder arthroplasty: risk of iatrogenic suprascapular neuropathy by screw violation.

Baseplate screws have been suggested to be a possible cause of suprascapular neuropathy after reverse total shoulder arthroplasty (RTSA). Three-dimensional analyses of screw penetration and confirmation of its clinical impacts are relevant. The study aims to investigate the association between screw penetration and the clinical outcomes. Eighty-two patients who underwent RTSA for a massive rotator cuff tear, cuff tear arthropathy, or osteoarthritis with rotator cuff tear were retrospectively enrolled. They were followed up for a minimum of 12 months, and all underwent computed tomography at 1 year postoperatively. The lengths of the superior and posterior baseplate screws were documented. Postoperative computed tomography images were subjected to 3-dimensional analysis to determine whether superior or posterior screws penetrated the glenoid vault and the location to which they penetrated, and screw-to-nerve distances were measured to estimate risks of screw nerve violation and iatrogenic suprascapular neuropathy. Patients with any screw <5 mm from the suprascapular nerve were deemed to have a high risk. Clinical outcomes (functional scores, ranges of motion, and isometric strengths) of patients in the high- and lower-risk groups were compared. The mean lengths of the superior and posterior screws were 28 ± 4 mm and 18 ± 3 mm, respectively. Penetration was detected for 13% of superior screws and 64% of posterior screws. Sixty-three percent of penetrating superior screws and 5% of penetrating posterior screws were <5 mm from the suprascapular nerve, and therefore, 12% of patients who received RTSA were assessed to have a high risk of iatrogenic suprascapular neuropathy. However, no significant difference was detected in clinical outcomes between the high- and lower-risk patients after a mean follow-up period of 20 months. Twelve percent of patients who received RTSA were assessed to be at high risk of iatrogenic suprascapular neuropathy by baseplate screw penetration. However, the clinical outcomes of RTSA at a minimum follow-up of 1 year were similar in the high- and lower-risk groups.

Functional outcomes of reverse total shoulder arthroplasty in Boileau class 1 and class 2 proximal humeral fracture sequelae: A meta-analysis and systematic review.

Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae. A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed. Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%. Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.

Acute versus delayed reverse total shoulder arthroplasty for proximal humeral fractures: a consecutive cohort study.

The treatment of displaced proximal humeral fractures (PHFs) remains controversial. Open reduction-internal fixation (ORIF) can be challenging, especially in elderly patients with poor bone quality, whereas hemiarthroplasty has had unpredictable outcomes. Conservative treatment may result in severe fracture sequelae with poor outcomes, requiring late reverse total shoulder arthroplasty (RTSA) in many cases. The past few years have seen a shift toward the use of RTSA for the treatment of PHFs. The aim of this study was to compare the outcomes of RTSA between patients with acute fractures and patients who underwent delayed RTSA for fracture sequelae. Our hypothesis was that the outcomes of RTSA for acute PHFs would be better than those of delayed RTSA for fracture sequelae. We followed up 36 patients with a mean age of 79.1 years who underwent primary RTSA for acute PHFs and 56 patients with a mean age of 72.1 years who underwent RTSA in delayed fashion for fracture sequelae, including failed ORIF. The minimum follow-up period was 24 months. The mean follow-up period was 39.3 months in the acute RTSA group and 56.6 months in the delayed RTSA group. Demographic data, radiographs, and surgery data were prospectively collected and analyzed. At final follow-up, range of motion and radiographic analysis findings, as well as the Subjective Shoulder Value (SSV) and Constant score (CS), were recorded. The clinical results favored the group undergoing acute RTSA for acute PHFs, with a mean SSV of 8.3 of 10 and adjusted CS of 88.9% compared with a mean SSV of 8.0 of 10 and adjusted CS of 77.6% in the group undergoing late RTSA for fracture sequelae-but without statistically significant differences between the groups. Although the acute RTSA group showed slightly better range-of-motion values, no statistically significant differences were found between the groups. No intraoperative complications occurred. The time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. Although there were no statistically significant differences in outcomes between early RTSA for acute PHFs and late RTSA for fracture sequelae, the time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. Therefore, we advocate early RTSA for acute PHFs in elderly patients to provide a quicker recovery and an early return to good predictable outcomes with a much shorter period of pain and discomfort. In cases of failed conservative treatment, malunion, or failed ORIF, salvage RTSA has the potential to provide a good outcome.

Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction.

BackgroundHistory of prior rotator cuff repair (RCR) may adversely affect the outcomes of reverse total shoulder arthroplasty (RTSA), but there is no information regarding the influence of prior superior capsular reconstruction (SCR) surgery on the outcomes of RTSA. The purpose of this study is to evaluate the outcomes of RTSA following failed arthroscopic SCR.MethodsAll patients who underwent RTSA for failed SCR (SCR cohort) at our institution were identified from our institutional database. A comparative cohort of patients who had RTSA with a history of failed RCR (Control cohort) was also reviewed. Demographic information, 90-day complication rate, 90-day emergency department visits, length of stay, and outcome scores (patient-reported outcomes measurement information system [PROMIS] physical function upper extremity, Visual Analog Scale score, and range of motion) were compared.ResultsFrom 2015 to 2020, 87 arthroscopic SCRs were performed at our institution and of these, 13 patients underwent RTSA at a mean time of 14.6 months (5.8-32.4) after SCR and were followed up for an average of 17.9 months (1.6-44.6). The average number of shoulder surgeries prior to RTSA was 2.8 (1-7), with the last surgery being SCR. During the same period, we identified 15 patients who underwent an RTSA after a failed RCR (control cohort). The RTSA in the control cohort was performed on average at 12.8 months (1.5-39.5) following the last RCR, and patients were followed up for an average of 27.7 months (2.8-53.9). The average number of shoulder surgeries before the RTSA in the control cohort was 1.4 (1-3). Although the SCR cohort had significant improvements in pain scores and forward flexion (FF), there was only a modest functional improvement with PROMIS scores and no meaningful improvement with external rotation. Complications (23%) in the SCR cohort included 1 periprosthetic joint infection requiring 2-stage revision, 1 acromion stress fracture, and 1 ulnar neuritis. Overall, compared to the SCR cohort, patients in the control cohort had better function (PROMIS physical function upper extremity), lower Visual Analog Scale score, and greater range of motion (FF and external rotation) preoperatively and at last follow-up, but there were no differences in the length of stay and 90-day emergency department visits, infection, and complication rate between the 2 cohorts.ConclusionRTSA after failed SCR improves pain and FF but is associated with modest functional improvements and high complication rates. However, these findings will require confirmation in a larger cohort with longer follow-up.

Comparison of Clinical Performance of Inlay versus Onlay Humerus Implants in Reverse Total Shoulder Arthroplasty.

Reverse total shoulder arthroplasty (RTSA) has become the treatment of choice for the management of massive rotator cuff tears combined with cuff tear arthropathy, and many novel designs have been proposed to overcome the shortcomings of classic RTSA. This study sought to evaluate and compare RTSA outcomes among patients with cuff tear arthropathy treated by a medialized inlay humerus implant with a neck shaft angle of 155° or a lateralized onlay implant with a neck shaft angle of 145°. A retrospective review of 32 inlay implants and 32 onlay implants was performed. The active range of motion (ROM), visual analog scale (VAS) for pain, motor power for elevation and external rotation, and functional scores including the American Shoulder and Elbow Surgeons score, Constant score, and Korean Shoulder Scoring system were assessed before surgery, at 3, 6, and 12 months after surgery, and at the last follow-up at least 24 months after surgery. Scapular notching, lateral humeral offset, and deltoid wrapping offset were assessed for radiographic evaluation. The preoperative demographic data of both groups showed no significant differences (p > 0.05). The mean follow-up period was 24.9 months. Significant improvements in forward flexion, functional scores, and pain VAS score were observed in both groups at the last follow-up. No significant differences in ROM or functional scores were found between two groups at each time point, except that the onlay implant group exhibited a significantly greater range of external rotation at 3 and 12 months after surgery and at the last follow-up. The rate of scapular notching and the final power improvement did not show significant differences between the groups. Primary RTSA using inlay or onlay humerus implants was associated with recovery from pseudoparalysis and good clinical outcomes. However, RTSA with onlay humerus implantation led to clinically superior results in terms of external rotation.

Clinical outcomes of reverse total shoulder arthroplasty for elective indications versus acute 3- and 4-part proximal humeral fractures: a systematic review and meta-analysis.

Reverse total shoulder arthroplasty (RTSA) has continued to increase in clinical utility and popularity as an effective treatment for cuff tear arthropathy (CTA), irreparable rotator cuff tears (RCTs), osteoarthritis, and acute 3- and 4-part proximal humeral fractures. Performing RTSA for acute proximal humeral fractures presents the unique challenges of tuberosity management, bone loss, and instability compared with elective indications such as CTA or irreparable RCTs. The purpose of this study was to compare the clinical outcomes, active range of motion (ROM), radiographic outcomes, and complications between patients undergoing elective RTSA (RTSA-E) and those undergoing RTSA for fracture (RTSA-F). A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We queried 3 electronic databases (Embase, Cochrane, and PubMed) using the search term "reverse" AND "shoulder" AND "arthroplasty." Studies investigating the clinical outcomes of RTSA for traumatic and/or elective indications were included. Studies were excluded if they included RTSA performed for fracture sequelae, inflammatory arthritis, post-traumatic osteoarthritis, or avascular necrosis. Data collected included patient demographic characteristics, subjective outcome measurements, ROM, and complications. The pooled means and proportions along with their 95% confidence intervals were generated by a random-effects model that incorporated the between-study variations in weighting. A total of 134 studies (11,651 shoulders) investigating the clinical outcomes of RTSA-E patients and 66 studies (3117 shoulders) investigating RTSA-F patients were included in this systematic review. Analysis of patient-reported outcomes demonstrated that RTSA-F patients experienced significantly lower Constant scores than RTSA-E patients; however, relative Constant scores, Simple Shoulder Test scores, Disabilities of the Arm, Shoulder and Hand scores, American Shoulder and Elbow Surgeons scores, and visual analog scale pain scores were similar. RTSA-F patients also had significantly lower forward elevation, abduction, and external rotation. RTSA-F patients experienced tuberosity complications at a significantly higher rate than RTSA-E patients (25.9% vs. 4.1%). There was no significant difference between the 2 groups in terms of other complications such as heterotopic ossification, radiographic loosening, revision, nerve injury, postoperative stiffness, infection, dislocation, and component loosening. RTSA performed for acute 3- and 4-part proximal humeral fractures yields overall worse clinical outcomes and active ROM compared with RTSA performed for elective indications including CTA, massive irreparable RCTs, and osteoarthritis with deformity. Tuberosity healing may be a major contributing factor to the difference in clinical outcomes. In the setting of RTSA-F, patient and surgeon expectations may need to be tempered and appropriate measures undertaken to optimize tuberosity healing.

Influence of Thoracic Kyphosis on Reverse Total Shoulder Arthroplasty Outcomes.

Patient dissatisfaction after primary reverse total shoulder arthroplasty (rTSA) has been reported as high as 9%. In patients with excessive thoracic kyphosis, the scapula protracts and tilts anteriorly, which may lead to early impingement with the acromion and loss of forward elevation. The primary purpose of this study was to evaluate the effect of thoracic kyphosis on overhead ROM after rTSA. A prospectively collected shoulder registry was retrospectively reviewed for all patients undergoing primary rTSA with a minimum of 2-year follow-up. Preoperative and latest follow-up ROM (forward elevation, abduction, internal rotation, and external rotation), patient-reported outcome measures (SPADI, SST-12, ASES, UCLA, SF-12, and the visual analog scale), and the Constant score were collected. Postoperative radiographs were evaluated for implant loosening and notching. Patients were separated into three groups according to the thoracic kyphosis angle (<25°, 25 to 45°, and >45°) and also analyzed as a continuous variable. The groups were compared using analysis of variance and chi-square tests as indicated. Three hundred five shoulders in 279 patients were reviewed at a mean follow-up of 3.9 years (range 2 to 10 years). Female patients and patients with a history of heart disease were statistically more likely to have increased thoracic kyphosis (P < 0.05). After surgery, forward elevation and abduction were similar among all groups (<25: 133°, 25 to 45: 132°, >45: 127°; P = 0.199 and <25: 123°, 25 to 45: 122°, >45: 117°; P = 0.330). All other postoperative ROM measurements and all patient-reported outcome measures were also similar, regardless of measured kyphosis. In addition, no association was observed between the degree of thoracic kyphosis and scapular notching (P = 0.291). Despite thoracic kyphosis being a known risk factor for loss of overhead motion in the native shoulder, shoulders with excessive thoracic kyphosis demonstrated similar overhead ROM at early follow-up after primary rTSA. III.

Outcomes of acute but not delayed reverse total shoulder arthroplasty for proximal humerus fracture are equal to those for rotator cuff arthropathy

BackgroundThe utilization of reverse total shoulder arthroplasty (RTSA) for the treatment of proximal humerus fractures in the elderly is increasing. Recent results support the use of RTSA for this indication over hemiarthroplasty or open reduction internal fixation (ORIF). However, there are limited data on the outcomes of RTSA for fracture or fracture sequelae as compared to RTSA for cuff tear arthropathy (CTA). We hypothesized that patients undergoing RTSA for fracture or fracture sequelae would have worse outcomes compared to patients undergoing RTSA for CTA. MethodsThis was a retrospective analysis of a prospectively collected outcomes database of all patients undergoing shoulder arthroplasty at a single institution between 2008 and 2019. Patients were included if they underwent primary RTSA for a diagnosis of acute fracture, fracture nonunion or malunion, failed hemiarthroplasty or ORIF for proximal humerus fracture, or rotator cuff arthropathy. The primary outcome was American Shoulder and Elbow Surgeons (ASES) score at the most recent follow-up, with minimum 1-year follow-up. Secondary outcomes included range of motion (ROM) at most recent follow-up, patient satisfaction with surgery, and revision or reoperation rates. Analysis of variance was used to compare continuous variables between the groups, while chi-square or Fisher's exact test were used to compare categorical variables. Linear regression analysis was used to perform multivariable analysis. Prosthesis survival rates were calculated using Kaplan-Meier survival analysis. Significance was defined as P< .05. ResultsThere were 287 patients included in the final cohort, including 62 with fracture and 225 with CTA. Sex, diagnosis, increasing patient comorbidities, and diagnosis (malunion/nonunion and failed prior surgery) were associated with worse ASES scores on univariate analysis (P < .05). On multivariate analysis, there was no difference in outcomes (ASES and ROM) between the acute fracture and CTA cohorts (P > .05). Outcomes of delayed RTSA for malunion/nonunion and hemiarthroplasty/ORIF were significantly worse than those for acute fracture/CTA (P < .01). Three-year prosthesis survival was 95% for CTA, 97% for acute fracture, 97% for malunion/nonunion, and 78% for failed prior surgery. ConclusionTreatment of acute proximal humerus fractures with RTSA leads to similar improvements in patient outcomes compared to elective treatment for CTA, but outcomes of delayed RTSA for fracture are considerably worse. These findings provide further guidance to clinicians counselling patients on treatment options and outcomes for proximal humerus fractures. Level of evidenceLevel III; Retrospective comparative study

Long-term Reverse Total Shoulder Arthroplasty Outcomes: The Effect of the Inferior Shifting of Glenoid Component Fixation.

BackgroudThe 155° Grammont reverse shoulder replacement has a long track record of success, but also a high radiographic notching rate. The increased distance between the scapular pillar and the humeral component theoretically decreases postoperative notching. The glenoid component can be shifted inferiorly relative to the glenoid; however, there also is some concern that shifting the glenoid component too far inferiorly (inferior glenoid component overhang > 3.5 mm) may compromise long-term stability of the glenoid component. This study was conducted to determine if clinical outcomes, scapular notching, and complications vary with more inferior placement of the glenoid component.MethodsA retrospective analysis of prospectively collected data was performed in order to compare radiographic outcomes (notching rate and signs of glenoid loosening or component disassembly) and clinical outcomes (range of motion, Constant score, subjective shoulder value, and complication rate) of all patients who underwent reverse shoulder replacement with the glenosphere positioned either flush with the inferior rim of the glenoid (flush group) or with at least 3.5 mm of inferior overhang (overhang group) at a minimum follow-up of 60 months. Ninety-seven patients ultimately met the inclusion criteria, with 41 patients with flush glenoid component and 56 patients with at least 3.5 mm of inferior overhang.ResultsAverage follow-up was 97.8 months. The overhang group had a lower rate of radiographic notching (37% vs. 82.5%, p < 0.05), better clinical outcomes (improvement in Constant score: +40 vs. +32, p = 0.036), and higher subjective shoulder value (79 vs. 69, p = 0.026) than the flush group. No difference in complications between groups was found.ConclusionsIn this study, at least 3.5 mm of inferior glenosphere overhang relative to the inferior rim of the glenoid was associated with the lower notching rate without negative effect on the clinical outcomes in 155° Grammont-style reverse shoulder replacement. Therefore, no increase in complications should be expected when using this surgical technique.

Effect of scapular notching on clinical outcomes after reverse total shoulder arthroplasty.

AimsScapular notching is thought to have an adverse effect on the outcome of reverse total shoulder arthroplasty (RTSA). However, the matter is still controversial. The aim of this study was to determine the clinical impact of scapular notching on outcomes after RTSA.MethodsThree electronic databases (PubMed, Cochrane Database, and EMBASE) were searched for studies which evaluated the influence of scapular notching on clinical outcome after RTSA. The quality of each study was assessed. Functional outcome scores (the Constant-Murley scores (CMS), and the American Shoulder and Elbow Surgeons (ASES) scores), and postoperative range of movement (forward flexion (FF), abduction, and external rotation (ER)) were extracted and subjected to meta-analysis. Effect sizes were expressed as weighted mean differences (WMD).ResultsIn all, 11 studies (two level III and nine level IV) were included in the meta-analysis. All analyzed variables indicated that scapular notching has a negative effect on the outcome of RTSA . Statistical significance was found for the CMS (WMD –3.11; 95% confidence interval (CI) –4.98 to –1.23), the ASES score (WMD –6.50; 95% CI –10.80 to –2.19), FF (WMD –6.3°; 95% CI –9.9° to –2.6°), and abduction (WMD –9.4°; 95% CI –17.8° to –1.0°), but not for ER (WMD –0.6°; 95% CI –3.7° to 2.5°).ConclusionThe current literature suggests that patients with scapular notching after RTSA have significantly worse results when evaluated by the CMS, ASES score, and range of movement in flexion and abduction.Cite this article: Bone Joint J 2020;102-B(11):1438–1445.

Reverse total shoulder arthroplasty for patients with minimal preoperative pain: a matched-cohort analysis

Profound improvements in function have been described in patients following reverse total shoulder arthroplasty (RSA). Previous studies have demonstrated young age, high preoperative function, and neurologic dysfunction to be predictors of poor functional improvement. However, no study to date has focused on patients electing to undergo RSA for function more than pain. The purpose of this study was to compare the outcomes of RSA in patients with minimal preoperative pain with those in patients who have higher baseline pain. We performed a retrospective matched-cohort study of RSA patients treated by a single surgeon with a minimum of 2 years' follow-up. Patients with at least moderate baseline pain (function-pain group), predefined by existing literature as a visual analog scale pain score > 3, were matched 3:1 based on sex, indication, and age to patients with minimal pain (function group), defined as a visual analog scale score ≤ 3. Patient-reported outcome measures, active range of motion, and overall satisfaction were compared. The percentage of maximal improvement in outcomes and the proportion of patients exceeding the established threshold that predicts excellent satisfaction were also compared. A total of 260 patients (195 in function-pain group and 65 in function group) were selected for matched analysis with a similar sex distribution; the mean age was 73.1 years, and the mean follow-up period was 50 months. No differences in most recent postoperative function, overall improvement in functional scores, and active motion were found between patients in the 2 groups (P > .05). However, pain scores improved only in patients with at least moderate baseline pain (P < .0001). Patient satisfaction was significantly different (P = .035), as 10.8% of patients who elected to undergo RSA for function were unsatisfied. The function cohort also had worse percentage of maximal Simple Shoulder Test score (P = .034) and American Shoulder and Elbow Surgeons score (P < .0001) improvement, and a lower proportion of these patients exceeded the threshold for the percentage of maximal improvement that predicts an "excellent" outcome (P < .0001). RSA patients with minimal preoperative pain achieve significant improvements in function and motion similar to those who choose to undergo RSA for both pain and function, but they are less satisfied and are less likely to achieve an excellentoutcome. Patients electing to proceed with RSA with minimal pain should be counseled accordingly.

Reverse shoulder arthroplasty in patients younger than 65 years, minimum 5-year follow-up

Indications for reverse total shoulder arthroplasty (RTSA) are expanding, and more young patients are undergoing RTSA. Younger patients are expected to place increased functional demands on their shoulder, which may affect implant performance and longevity. Reports on longer-term outcomes in young patients remain limited. This study evaluates the minimum 5-year functional outcomes of RTSA in patients younger than 65 years. A retrospective review was performed using a multinational prospective shoulder arthroplasty database of a single implant system, Exactech Equinoxe (Gainesville, FL, USA). All RTSAs performed between 2007 and 2014 in patients younger than 65 years with minimum 5-year follow-up were included. Shoulder function was assessed preoperatively and at last follow-up via range-of-motion measurements and multiple patient-reported outcome measures. Fifty-two shoulders were evaluated at an average follow-up of 6.3 years. Abduction, forward flexion, internal rotation, and Simple Shoulder Test, Constant, American Shoulder and Elbow Surgeons, University of California-Los Angeles, Shoulder Pain and Disability Index, and visual analog scale scores all showed statistically significant improvements greater than the minimum clinically important difference at the time of last follow-up. Three patients (5.8%) required revision surgery after a mean of 7.5 years and 1 more suffered an acromial stress fracture, bringing the total complication rate to 7.7%. Five patients (9.6%) demonstrated scapular notching, one of whom required revision arthroplasty. RTSA provides clinically significant improvement in nearly all functional measures at a mean follow-up of 6.3 years in patients younger than 65 years. The implants appear to have good midterm survivorship; only 5.8% of patients required revision.

Effect of preoperative teres minor hypertrophy on reverse total shoulder arthroplasty

The preoperative status of the teres minor (Tm) can affect the outcome of reverse total shoulder arthroplasty (RTSA). The effect of preoperative Tm hypertrophy on the outcome of RTSA is unclear. A total of 86 shoulders that underwent RTSA were retrospectively enrolled. Of these, 48cases with a Tm occupation ratio (OR) of >0.288 in the preoperative magnetic resonance image were assigned to the hypertrophic group, and 38 cases to the control group. The two groups were compared with respect to preoperative rotator cuff tearinvolvement, fatty infiltration, pre- and postoperativerotator cuff ORs, pain scores, functional scores, range of motion, and muscle strength. Postoperative Tm ORs in 1-year follow-up multidetector computed tomography were compared with preoperative Tm ORs. Preoperatively, integrities of infraspinatus (ISP) and supraspinatus were significantly different between the 2 groups (P = .001, 0.009, each). Preoperative ISP ORs were significantly related to preoperative Tm ORs (r = -0.534, P < .001). The mean pre- to postoperative change of Tm ORs in the hypertrophic group decreased (-0.029 ± 0.068), whereas that of the control group increased (+0.047 ± 0.092). Postoperative pain scores, functional scores, range of motion, and muscle strength were not different between groups. In cases of advanced rotator cuff tear requiring RTSA, Tm hypertrophy is found to be related to tear and atrophy of the ISP, suggesting that Tm hypertrophy is a compensatory change for ISP dysfunction. However, Tm hypertrophy was observed to diminish after RTSA. Preoperative Tm hypertrophy appears to have no beneficial effect on the outcomes of RTSA.