Primary Reverse Total Shoulder Arthroplasty Research Articles

Influence of Lateralization and Distalization on Joint Function after Primary Reverse Total Shoulder Arthroplasty.

The purpose of this study was to investigate how lateralization shoulder angle (LSA) and distalization shoulder angle (DSA) are related to clinical and kinematic outcomes after reverse total shoulder arthroplasty. Thirty-three patients were evaluated at least six months postoperatively. The Single Assessment Numeric Evaluation (SANE), Constant Murley Score (CMS), Simple Shoulder Test (SST), and Visual Analogue Scale (VAS) were used. Shoulder kinematics was evaluated with a stereophotogrammetric system. LSA and DSA inter-rater reliability was analysed through the interclass correlation coefficient (ICC). Stepwise forward linear regression analysis was conducted between LSA and DSA with clinical scales and kinematic measures, between which a correlation analysis was conducted. The inter-rater reliability for LSA (mean ICC = 0.93) and DSA (mean ICC = 0.97) results were good to excellent. Greater LSA values were associated with higher peaks of internal rotation (p = 0.012, R2 = 0.188) and range of motion (ROM) (p = 0.037, R2 = 0.133). SANE (p = 0.009), CMS (p = 0.031), and SST (0.026) were positively correlated to external rotation, while VAS (p = 0.020) was negatively related. Abduction peaks were positively related to CMS (p = 0.011) and SANE (p = 0.037), as well as abduction ROM (SANE, p = 0.031; CMS, p = 0.014).

Primary reverse total shoulder arthroplasty for fractures requires more revisions than for degenerative conditions 1 year after surgery: an analysis from the Dutch Arthroplasty Register.

Although reverse total shoulder arthroplasty (RTSA) is considered a viable treatment strategy for proximal humeral fractures, there is an ongoing discussion of how its revision rate compares with indications performed in the elective setting. First, this study evaluated whether RTSA for fractures conveyed a higher revision rate than RTSA for degenerative conditions (osteoarthritis, rotator cuff arthropathy, rotator cuff tear, or rheumatoid arthritis). Second, this study assessed whether there was a difference in patient-reported outcomes between these 2 groups following primary replacement. Finally, the results of conventional stem designs were compared with those of fracture-specific designs within the fracture group. This was a retrospective comparative cohort study with registry data from the Netherlands, generated prospectively between 2014 and 2020. Patients (aged ≥ 18 years) were included if they underwent primary RTSA for a fracture (<4 weeks after trauma), osteoarthritis, rotator cuff arthropathy, rotator cuff tear, or rheumatoid arthritis, with follow-up until first revision, death, or the end of the study period. The primary outcome was the revision rate. The secondary outcomes were the Oxford Shoulder Score, EuroQol 5 Dimensions (EQ-5D) score, numerical rating scale score (pain at rest and during activity), recommendation score, and scores assessing change in daily functioning and change in pain. This study included 8753 patients in the degenerative condition group (mean age, 74.3±7.2 years) and 2104 patients in the fracture group (mean age, 74.3±7.8 years). RTSA performed for fractures showed an early steep decline in survivorship: Adjusted for time, age, sex, and arthroplasty brand, the revision risk after 1 year was significantly higher in these patients than in those with degenerative conditions (hazard ratio [HR], 2.50; 95% confidence interval, 1.66-3.77). Over time, the HR steadily decreased, with an HR of 0.98 at year 6. Apart from the recommendation score (which was slightly better within the fracture group), there were no clinically relevant differences in the patient-reported outcome measures after 12 months. Patients who received conventional stems (n=1137) did not have a higher likelihood of undergoing a revision procedure than those who received fracture-specific stems (n=675) (HR, 1.70; 95% confidence interval, 0.91-3.17). Patients undergoing primary RTSA for fractures have a substantially higher likelihood of undergoing revision within the first year following the procedure than patients with degenerative conditions preoperatively. Although RTSA is regarded as a reliable and safe treatment option for fractures, surgeons should inform patients accordingly and incorporate this information in decision making when opting for head replacement surgery. There were no differences in patient-reported outcomes between the 2 groups and no differences in revision rates between conventional and fracture-specific stem designs.

The effects of length and width of the stem on proximal humerus stress shielding in uncemented primary reverse total shoulder arthroplasty.

To preserve humeral bone during RTSA, stems have been made shorter and cement avoided whenever possible. However, with the increased use of uncemented RTSA, a phenomenon comparable to the stress shielding of the hip has been described for the proximal humerus. The aim of this study was to investigate the influence of stem length and width on proximal humeral bone resorption after primary uncemented RTSA. The prospective shoulder arthroplasty database of our institution was reviewed for all primary uncemented RTSAs from 2017 to 2020 in osteoarthritis and cuff tear arthropathy cases with > 2-year follow-up. We compared the clinical and the radiographic 2-year outcome of the short and standard length stems of the same prosthesis design. This allowed us to assess the effects of stem length and width with regard to stress shielding. Furthermore, we defined a cut-off value for the filling ratios to prevent stress shielding. Fifty patients were included in the analysis, nineteen were in the short stem group (SHORT) and thirty-one in the standard stem group (STANDARD). After 2years, SHORT showed a relative Constant Score of 91.8% and STANDARD of 98.3% (p = 0.256). Stress shielding was found in 4 patients (21%) in SHORT and in 16 patients (52%) in STANDARD (p = 0.03); it occurred more frequently in patients with higher humeral filling ratios (p < 0.05). The calculated cut-off to prevent stress shielding was 0.7 (± 0.03) for the metaphyseal and distal filling ratio. While short and standard stems for RTSA have good results after 2years, we found a significant negative effect of higher length and width of the stem with regard to stress shielding. Even though the clinical effects of stress shielding have to be assessed, short stems should be chosen with a filling ratio at the metaphyseal and distal position below 0.7. III.

Functional and radiographic outcomes of octogenarians undergoing primary reverse total shoulder arthroplasty: a retrospective study

BackgroundAs the demand for primary reverse total shoulder arthroplasty (RTSA) increases due to an aging population and expanding indications, it is crucial to understand the effects of the age on outcomes, particularly in patients 80 years or older. The purpose of this study was to determine postoperative patient-reported outcomes and evaluate postoperative imaging of octogenarian patients (≥80 year old) who underwent primary RTSA with a minimum 12-month follow-up. MethodsIn this retrospective case series, all consecutive patients aged 80 years or older who underwent primary RTSA at a tertiary health-care system were included from April 2012 to January 2022. Patient demographic and preoperative comorbidity data were collected, and the corresponding standard comorbidity indices were determined for each patient. Primary outcomes included postoperative patient-reported functional outcomes, while the secondary outcomes were adverse radiographic findings, mortality, and 90-day postoperative complications. Statistical analysis included descriptive analyses and a Wilcoxon Signed-Rank test for comparisons. A P < .05 was considered to be statistically significant. ResultsA total of 59 patients were included in the analysis, with a mean age of 84.21 ± 3.24 years and 39 (66.1%) female patients. All patient-reported outcome measures significantly improved postoperatively, including the Single Assessment Numeric Evaluation and American Shoulder and Elbow Surgeons scores, the Visual Analog Scale, and range of motion. The most common adverse radiographic outcome was scapular notching (27.1%), followed by acromial stress fractures (5.1%). Eight (13.6%) complications were observed, requiring four revision surgeries. ConclusionIn conclusion, RTSA leads to significant improvements in patient-reported outcomes with an acceptable rate of adverse radiographic outcomes in patients aged 80 years or older. Despite the potential for increased risk of adverse events in the elderly population, our study did not find an increase in complications within this age group when compared to rates previously reported in literature. Our findings suggest that RTSA is a safe and effective option in octogenarian patients.

Concomitant open distal clavicle excision is associated with greater improvement in range of motion without increased risk of acromial stress fracture after reverse total shoulder arthroplasty: a retrospective cohort study.

The purpose of this study was to evaluate the effect of concomitant open distal clavicle excision (DCE) on postoperative clinical outcomes and incidence of acromial and scapular stress fractures (ASFs) in patients with symptomatic acromioclavicular joint osteoarthritis (ACJ OA) undergoing reverse total shoulder arthroplasty (RTSA). A single-surgeon retrospective cohort study was conducted including patients who underwent primary elective RTSA with or without DCE from 2015 to 2019 with a minimum 6-month follow-up period. Shoulder active range of motion (AROM) and visual analog scale (VAS) pain were recorded preoperatively and postoperatively. ASFs and other adverse events were identified using postoperative notes and/or radiographs. Characteristics and outcomes were compared between the RTSA and RTSA-DCE groups. Forty-six RTSA patients (mean age, 67.9±8.7 years; 60.9% male; mean follow-up, 24.9±16.6 months) and 70 RTSA-DCE patients (mean age, 70.2±8.9 years; 20.0% male; mean follow-up, 22.7±12.9 months) were included. There were no significant intergroup differences in rates of ASF (RTSA, 0.0% vs. RTSA-DCE, 1.4%; P=1.00), stress reactions (RTSA, 8.7% vs. RTSA-DCE, 11.4%; P=0.76), reoperation, revision, or infection (all P>0.05), or in pre-to-postoperative reduction in VAS pain (P=0.17) at latest follow-up. However, the RTSA-DCE group had greater pre-to-postoperative improvement in flexion AROM (RTSA, 43.7°±38.5° vs. RTSA-DCE, 59.5°±33.4°; P=0.03) and internal rotation (IR) AROM (P=0.02) at latest follow-up. Concomitant DCE in RTSA improves shoulder flexion and IR AROM, alleviates shoulder pain, and does not increase the risk of ASFs. Level of evidence: III.

EPIDEMIOLOGICAL DATA REVIEW OF PRIMARY REVERSE TOTAL SHOULDER ARTHROPLASTY AT A SINGLE TERTIARY ACADEMIC HOSPITAL IN SOUTH AFRICA: A FOUR-YEAR RETROSPECTIVE REVIEW

Reverse Total shoulder arthroplasty (RTSA) was initially introduced to treat rotator cuff arthropathy. With proven successful long-term outcomes, it has gained a noteworthy surge in popularity with its indications consequently being extended to treating various traumatic glenohumeral diseases.Several countries holding national registries remain a guide to the use the prosthesis, however a notable lack of epidemiological data still exists. More so in South Africa where the spectrum of joint disease related to communicable diseases such as HIV and tuberculosis may influence indications and patient demographics. By analysing the epidemiology of patients who underwent RTSA at our institution, we aimed to outline the local disease spectrum, the patients afflicted and indications for surgery.A retrospective review of all patients operated within the sports unit between 1 January 2019 and 31 December 2022 was conducted. An analysis of the epidemiological data pertaining to patient demographics, diagnosis, indications for surgery and complications were recorded.Included in the review were 58 patients who underwent primary RTSA over the 4-year period. There were 41 females and 17 male patients, age &lt;55 years (n= 14) &gt;55 years (n=44). The indications included 23 rotator cuff arthropathy (40%), 12 primary glenohumeral osteoarthritis (OA) (20%), 10 avascular necrosis (AVN) humeral head (17%), 7 inflammatory OA (12%), 4 chronic shoulder dislocation (7%) and 2 sequalae of proximal humerus fractures (4%).The study revealed RTSA being performed in patients older than 55 years of age, the main pathologies included rotator cuff arthropathy and primary OA, however AVN and shoulder dislocations secondary to trauma contributed significantly to the total tally of surgeries undertaken. This highlights the disease burden of developing countries contributing to patients presenting for RTSA

Revision reverse shoulder arthroplasty has similar outcomes to primary reverse shoulder arthroplasty at 5 Year average follow-up

BackgroundShoulder arthroplasty is a successful procedure that provides pain relief and improvements in function and range of motion. Anatomic and reverse shoulder arthroplasty are both effective procedures, and their indications continue to expand. We look at the outcomes of revision reverse total shoulder arthroplasty and compare it to the outcomes of primary reverse and anatomic total shoulder arthroplasty. MethodsWe identified patients undergoing total shoulder arthroplasty at our institution between the years of 2010 and 2020. Data was prospectively collected and retrospectively reviewed for post-operative range of motion and strength in patients with revision surgery and compared to controls. Measurements were collected preoperatively and postoperatively including range of motion and strength in the affected and unaffected shoulder. We collected patient reported outcome measures in person and via phone to identify subjective outcomes of total shoulder arthroplasty. Average final follow-up was 5.27 years. ResultsOur total patient sample was split between three groups: those with primary anatomic arthroplasty those who underwent primary reverse arthroplasty, and those who were revised to a reverse shoulder arthroplasty. All three groups had significant improvements in abduction and forward elevation from their pre-operative baseline to two years follow-up. Primary reverse had a significant improvement over revision reverse in abduction at one year follow-up. For all other range of motion measurements, there was no statistically significant difference at 2 years between primary and revision reverse shoulder arthroplasty. Patient reported outcomes had a significant increase from pre-op to most recent follow-up in all three groups. ConclusionOverall, our data suggest there is an improvement in outcomes with both primary and revision surgeries, and that results after revision reverse total shoulder arthroplasty may be comparable to primary reverse total shoulder arthroplasty.

Quantifying success after reverse total shoulder arthroplasty: the minimal clinically important percentage of maximal possible improvement.

In high functioning patients, the ceiling effect associated with many patient-reported outcome measures (PROMs) limits the ability to appropriately stratify success. The percentage maximal possible improvement (%MPI) was introduced as another evaluation tool, with a proposed threshold of success at 30%. It remains unclear if this threshold correlates with perceived patient success following shoulder arthroplasty. The purpose of this study was to compare the proportion of patients that achieved the minimal clinically important difference (MCID) and %MPI for different outcome scores and to define the %MPI thresholds associated with patient satisfaction following primary reverse total shoulder arthroplasty (rTSA). A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary rTSAs performed using a single implant system with minimum 2-year follow-up were reviewed. Pre- and postoperative outcome scores were evaluated for all patients to determine the raw improvement and %MPI. The proportion of patients achieving the MCID and 30% MPI were determined for each outcome score. Thresholds for the minimal clinically important %MPI (MCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex. A total of 2573 shoulders with a mean follow-up of 47 months were included. Outcome scores with known ceiling effects (Simple Shoulder Test [SST], Shoulder Pain and Disability Index [SPADI], University of California-Los Angeles shoulder score [UCLA]) had higher rates of patients achieving the 30% MPI but not the previously reported MCID. Inversely, outcome scores without significant ceiling effects (Constant and Shoulder Arthroplasty Smart [SAS] scores) had higher rates of patients achieving the MCID, but not the 30% MPI. The MCI-%MPI differed among outcome scores and mean values were as follows: 33% for the SST, 27% for the Constant score, 35% for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, 43% for the UCLA score, 34% for the SPADI score, and 30% for the SAS score. The MCI-%MPI increased with greater age for SPADI (P<.04) and SAS (P<.01) scores, meaning that patients with higher thresholds required a greater fraction of the possible improvement for a given score to be satisfied but did not reach statistical significance for other scores. Females had a greater MCI-%MPI for the SAS and ASES scores and a lower MCI-MPI% for the SPADI score. The %MPI offers a simple method to quickly assess improvements across patient outcome scores. However, the %MPI that represents patient improvement after surgery is not uniformly the previously established 30% threshold. Surgeons should use score-specific estimates of the MCI-%MPI to gauge success when evaluating patients undergoing primary rTSA.

Why is female gender associated with poorer clinical outcomes after reverse total shoulder arthroplasty?

There is a lack of gender-specific research after reverse total shoulder arthroplasty (RTSA). Although previous studies have documented worse outcomes in women, a more thorough understanding of why outcomes may differ is needed. We therefore asked: (1) Are there gender-specific differences in preoperative and postoperative clinical scores, complications, surgery-related parameters, and demographics? (2) Is female gender an independent risk factor for poorer clinical outcomes after RTSA? (3) If so, why is female gender associated with poorer outcomes after RTSA? Between 2005 and 2019, 987 primary RTSAs were performed in our institution. After exclusion criteria were applied, data of 422 female and 271 male patients were analyzed. Clinical outcomes (absolute/relative Constant Score [a/rCS] and Subjective Shoulder Value [SSV]), complications (intra- and/or postoperative fracture, loosening), surgery-related parameters (indication, implant-related characteristics), and demographics (age, gender, body mass index, and number of previous surgeries) were evaluated. Preoperative and postoperative radiographs were analyzed (critical shoulder angle, deltoid-tuberosity index, reverse shoulder angle, lateralization shoulder angle, and distalization shoulder angle). Preoperative clinical scores (aCS, rCS, SSV, and pain level) and postoperative clinical outcomes (aCS and rCS) were significantly worse in women. However, the improvement between preoperative and postoperative outcomes was significantly higher in female patients for rCS (P=.037), internal rotation (P<.001), and regarding pain (P<.001). Female patients had a significantly higher number of intraoperative and postoperative fractures (24.9% vs. 11.4%, P<.001). The proportion of female patients with a deltoid-tuberosity index <1.4 was significantly higher than males (P=.01). Female gender was an independent negative predictor for postoperative rCS (P=.047, coefficient -0.084) and pain (P=.017, coefficient -0.574). In addition to female sex per se being a predictive factor of worse outcomes, females were significantly more likely to meet 2 of the 3 most significant predictive factors: (1) significantly worse preoperative clinical scores and (2) higher rate of intra- and/or postoperative fractures. Female sex is a very weak, but isolated, negative predictive factor that negatively affects the objective clinical outcome (rCS) after RTSA. However, differences did not reach the minimal clinically important difference, and it is not a predictor for the subjective outcome (SSV). The main reason for the worse outcome in female patients seems to be a combination of higher preoperative disability and higher incidence of fractures. To improve the outcome of women, all measures that contribute to the reduction of perioperative fracture risk should be used.

The efficacy of tranexamic acid in primary anatomic and reverse total shoulder arthroplasty: A systematic review and meta-analysis of level I randomized controlled trials.

The purpose of this study was to systematically review the available level I evidence regarding the impact of tranexamic acid (TXA) on early postoperative outcomes in patients undergoing anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). A systematic review of the literature through April 2023 was performed to identify level I RCTs examining the use of TXA at the time of primary TSA or RTSA. Among 5 included studies, a total of 435 patients (219 TXA, 216 control) were identified. Superior hematologic outcomes were observed among the TXA cohort, including lower 24-hour drain output (MD -112.70 mL: p < 0.001), lower pre- to postoperative change in hemoglobin (MD: -0.68 g/dL, p < 0.001), and less total perioperative blood loss (MD: -249.56 mL, p < 0.001). Postoperative Visual Analog Scale for pain (VAS-pain) scores were lower in the TXA group, but not significantly (MD: -0.46, p = 0.17). Postoperative blood transfusion was required in 3/219 TXA patients (1.4%) and 7/216 control patients (3.2%) (RR: 0.40, p = 0.16). Perioperative TXA reduces drain output and total blood loss without increasing the risk of adverse events. TXA was not shown to decrease postoperative transfusion rates when compared to placebo controls. Level I, meta-analysis.

Anterosuperior versus deltopectoral approach for primary reverse total shoulder arthroplasty.

The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years. All patients in the registry who underwent a primary rTSA between January 2014 and December 2016 using an anterosuperior or deltopectoral approach were included, with a minimum follow-up of five years. Cox and logistic regression models were used to assess the association between the approach and the implant survival, instability, and glenoid loosening, independent of confounders. In total, 3,902 rTSAs were included. A deltopectoral approach was used in 54% (2,099/3,902) and an anterosuperior approach in 46% (1,803/3,902). Overall, the mean age in the cohort was 75 years (50 to 96) and the most common indication for rTSA was cuff tear arthropathy (35%; n = 1,375), followed by osteoarthritis (29%; n = 1,126), acute fracture (13%; n = 517), post-traumatic sequelae (10%; n = 398), and an irreparable cuff rupture (5%; n = 199). The two high-volume centres performed the anterosuperior approach more often compared to the medium- and low-volume centres (p < 0.001). Of the 3,902 rTSAs, 187 were revised (5%), resulting in a five-year survival of 95.4% (95% confidence interval 94.7 to 96.0; 3,137 at risk). The most common reason for revision was a periprosthetic joint infection (35%; n = 65), followed by instability (25%; n = 46) and loosening (25%; n = 46). After correcting for relevant confounders, the revision rate for glenoid loosening, instability, and the overall implant survival did not differ significantly between the two approaches (p = 0.494, p = 0.826, and p = 0.101, respectively). The surgical approach used for rTSA did not influence the overall implant survival or the revision rate for instability or glenoid loosening.

Increased complication rates for salvage RTSA after failed locked plate fixation compared to primary RTSA in the treatment of proximal humeral fractures in elderly patients.

Common surgical treatment options for proximal humeral fractures in the elderly include locked plate fixation (LPF) and reverse total shoulder arthroplasty (RTSA). It was hypothesized that secondary RTSA after LPF was associated with higher complication rates and costs compared to primary RTSA. Health insurance data of patients ≥65 years of age that received a RTSA due to a proximal humeral fracture between 01/2013 and 09/2019 with a pre-study phase of five years were analyzed. Multivariable Cox, logistic and linear regression models were used to evaluate the association between treatment group, complications, length of hospital stay (LOS), charges and mortality during 34 months follow-up. 14,220 patients received a primary and 1.282 a secondary RTSA after prior surgery using LPF for treatment of a proximal humeral fracture. After adjustment to patient's characteristics, more surgical complications were observed after secondary RTSA during index hospitalization (OR 4.62, 95% CI 4.00 - 5.34, p<0.001) and long-term follow-up (HR 1.52, 95% CI 1.27 - 1.81, p<0.001). Moreover, secondary RTSA was associated with an increased cumulative total cost of 6638.1€ (95% CI 6229.9 - 7046.5€, p<0.001). If conversion from LPF to secondary RTSA occurred during index hospitalization more major adverse, thromboembolic events as well as a higher mortality was found during short and long-term (all p<0.05). Secondary RTSA is associated with higher total costs and more complications. Hence, if surgical treatment of a proximal humeral fracture in the elderly is needed, prognostic factors for LPF need to be evaluated carefully. In doubt, patients will profit from primary RTSA in long term.

Alcohol and opiate abuse are risk factors for dislocation after primary reverse total shoulder arthroplasty

BackgroundAs indications for reverse total shoulder arthroplasty (RTSA) expand and patients present with increasing comorbidities, complications have become more frequent. Dislocation and instability are devastating complications and have become one of the leading causes of revision surgery. Current literature suggests multifactorial causes for dislocation, but studies are limited to physiologic and mechanical risk factors. The purpose of this study was to investigate social risk factors, including alcohol and drug abuse, and their association with dislocation after RTSA. MethodsA retrospective cohort of all RTSA performed at a single center by the senior author between January 2012 and March 2021 was reviewed. All patients had minimum 1-year follow-up. Cases of revision arthroplasty were excluded. Patients were grouped into 2 cohorts based on the presence or absence of any postoperative dislocation events. Bivariate analysis was used to compare patient characteristics and identify risk factors for dislocation. ResultsFour hundred and thirty one patients were included, 423 (98.1%) experienced no dislocation events and 8 (1.9%) experienced at least 1 dislocation. The mean time to dislocation was 106 ± 159 days. Six (75%) of the 8 patients had dislocations within 3 months postoperatively. Chronic opioid use (odds ratio (OR) 23.17, 3.86-139.00; P < .001), alcohol abuse (OR 15.92, 3.76-67.44; P < .001), and history of falling (OR 10.22, 2.03-51.45; P = .005) were significant social risk factors for dislocation. In the multivariable model, alcohol abuse (OR 9.37, 1.70-51.67; P = .010) and history of falling (OR 8.22, 1.54-43.88; P = .014) were independent risk factors for dislocation following RTSA. ConclusionAlcohol abuse and history of falling are independent risk factors for dislocation following primary RTSA. Chronic opioid use is also a significant risk factor for dislocation following RTSA.

Outcomes of reverse total shoulder arthroplasty were not adversely affected by the COVID-19 pandemic

BackgroundThe objective was to investigate outcomes in reverse total shoulder arthroplasty (RTSA) in patients affected by the COVID-19 pandemic shutdown. We hypothesized that patients undergoing RTSA in early 2020 would have decreased access to physical therapy (PT) and worse postoperative outcomes compared to historical controls. Materials and methodsPatients who received primary RTSA between 1/1/2020, and 3/17/2020, were included and patients who received primary RTSA between 1/1/2019, and 3/17/2019, were used as a control group. Retrospective chart review was performed, and patient-reported outcomes were recorded at an average of 2.69 ± 0.06 years and a minimum of 1 year postoperatively. Patient data were collected and statistically analyzed using the 2-sample t-test and chi-square test. The Mann-Whitney U test and Fisher’s exact test were used when appropriate. ResultsThirty eight patients in 2020 were included in this study and compared to 31 patients in 2019. RTSA performed in 2019 had improvements in forward elevation (FE) (95.7° ± 47.2° to 144.7° ± 17.2°, P < .001), but not in external rotation (ER) (32.5° ± 20.3° to 41.0° ± 13.3°, P = .15), or internal rotation (IR) (S1 to L5, P = .76). RTSA 2020 cases had improvements in FE (111.5° ± 40.3 to 132.8° ± 30.6, P = .016), but not ER (31.9° ± 18.2 to 35.7° ± 15.9, P = .36) or IR (S1 to L5, P = .13). Patients in 2019 (FE: 4 to 5-, P < .001; ER: 4+ to 5-, P = .003; IR: 5- to 5, P < .001) and 2020 (FE: 4 to 5-, P < .001; ER: 4+ to 5, P < .001; IR: 5- to 5, P = .02) both experienced improvements in strength. Patients in 2020 initiated PT later (2019: 39.3 ± 27.3 days, 2020: 57.1 ± 35.5 days, P = .028) and completed less PT sessions (2019: 20.7 ± 11.1, 2020: 12.9 ± 6.6, P < .001) than patients in 2019. In the 2020 cohort, 10.5% (4/38) did not complete any PT, 34.2% (13/38) reported a delay in initiating PT, and 47.4% (18/38) reported that their recovery was negatively affected by the COVID-19 pandemic. At final follow-up, patients in 2020 reported a mean single assessment numeric evaluation score of 73.6 ± 17.5 on their affected shoulder and a mean visual analog scale score of 1.68 ± 1.23. DiscussionDespite a delay in initiating PT and completing less PT overall, patients who received RTSA in 2020 experienced significant improvements in range of motion and strength at final follow-up and were comparable to the 2019 patients.

Effect of primary diagnosis on return to sport after reverse total shoulder arthroplasty

BackgroundIncreasing evidence exists regarding the impact of primary diagnosis on clinical outcomes following reverse total shoulder arthroplasty (RTSA). Expanding indications coupled with emerging clinical evidence has resulted in increased use of RTSA for glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. The ability to return to sports after RTSA is a common concern for patients; however, most literature evaluating this does not stratify patients by diagnosis. The purpose of this investigation was to evaluate the effect of diagnosis on return to sports after RTSA. MethodsA single institution, retrospective study was performed on patients who underwent primary RTSA with a minimum 2-year follow-up. Patients answered a 7-question survey regarding sport participation within 3 years before surgery and the level to which they returned to their sports after surgery. Patient demographics, patient-reported outcome scores, and range of motion were accessed from the database. Descriptive statistics and univariate analysis were performed to assess differences between patients who did not return to sport or did so at lower level and those that returned at the same or higher level, as well as between patients with GHOA and those with rotator cuff disease. Binary logistic regression was performed to assess predictors of returning to sports. ResultsA total of 106 patients meeting inclusion criteria were identified with a mean age of 72 years (range, 55-88 years). Ninety-six patients (90.6%) returned to playing sports, of which 84 (87.5%) returned at the same or higher level. Patients with GHOA demonstrated a higher rate of return to sport compared to those with rotator cuff disease (95.6% vs. 81.6%; P = .033). Logistic regression controlling for sport intensity demonstrated that GHOA is a predictor of returning to sports (odds ratio = 6.3; P = .017). Patients who did not return to sports or did so at a lower level had higher preoperative pain (P = .007), lower postoperative SANE (Single Assessment Numerical Evaluation of the Shoulder) (P = .027), lower preoperative and postoperative ASES (American Shoulder and Elbow Surgeons) scores (P = .004 and P = .016, respectively), less preoperative and postoperative forward elevation (P = .037 and P = .019, respectively), lower postoperative external rotation (P = .004), and lower preoperative internal rotation (P = .027). ConclusionThe ability of patients to return to sports after RTSA is highly influenced by preoperative diagnosis. Patients with GHOA have higher rates of return to sport than previously recognized. These results are useful for establishing expectations with patients regarding their postoperative activity level.

Management of Glenoid Bone Loss in Primary Reverse Total Shoulder Arthroplasty.

Glenoid bone loss presents distinct challenges in reverse total shoulder arthroplasty (rTSA) which, if unaddressed, can cause complications including poor outcomes and early implant failure. The purpose of this review is to discuss the etiology, evaluation, and management strategies of glenoid bone loss in primary rTSA. Three-dimensional computed tomography (3D CT) imaging and preoperative planning software have revolutionized the understanding of complex glenoid deformity and wear patterns from bone loss. With this knowledge, a detailed preoperative plan can be created and implemented for a more optimal management strategy. When appropriately indicated, deformity correction techniques with biologic or metal augmentation are successful in addressing the glenoid bone deficiency, creating optimal implant position, and thus providing stable baseplate fixation and improving outcomes. Thorough evaluation and characterization of the degree of glenoid deformity with 3D CT imaging is necessary prior to treatment with rTSA. Eccentric reaming, bone grafting, and augmented glenoid components have shown promising results in correcting glenoid deformity due to bone loss, but long-term outcomes are currently unknown.

Reversed total shoulder arthroplasty after acromioclavicular joint resection yields equivalent clinical results compared to a matched control group.

Reverse total shoulder arthroplasty (RTSA) is a well-establish procedure with increasing incidence. Depending on the medical history, many patients undergo multiple soft-tissue procedures before RTSA. The role of acromioclavicular pathology as well as the consequences of a distal clavicle resection (DCR) before RTSA has not been evaluated yet. A retrospective single-center review was performed on all patients undergoing primary RTSA with or without DCR with a minimum follow-up of 2years. We compared patient-reported outcome measures (Constant score (CS), subjective shoulder values (SSV), and range of motion (ROM)) with a matched control group. The control group consisted of patients treated with a RTSA without DCR and matching was performed for age, sex, operating side, American Society of Anesthesiologists (ASA), body mass index (BMI), and indication. Surgical time and complication rate were recorded. Thirty-nine patients with a mean follow-up of 63months (SD 33) were enrolled in the study group. Mean age was 67years (SD 7) with 44% male patients for both groups. The mean relative CS improved from 43% (SD 17) to 73% (SD 20) in the study group, and from 43% (18) to 73% (22) in the control group. The SSV improved from 29% (SD 17) to 63% (SD 29) in the study group, and from 28% (SD 16) to 69% (SD 26) in the control group (both n.s.). The postoperative ROM did not significantly differ between the two groups. Five patients in the study group and six in the control group had reoperations. Patients who received a DCR before RTSA showed equivalent clinical outcomes compared to a match-control group with RTSA only. Surgical time was not different, and no complication related to the open DCR was observed in the study group. Therefore, we conclude that a prior DCR does not influence the postoperative outcome after RTSA. Level III: Retrospective comparative study.

Analysis of 90-day complications in outpatient total shoulder arthroplasty

BackgroundThere are limited data documenting the safety and clinical outcomes following outpatient total shoulder arthroplasty (TSA) and reverse TSA (RTSA) compared to inpatient shoulder arthroplasty. It was hypothesized that there would be no significant differences in complication and emergency room (ER) visit rate between outpatient TSA and RTSA. MethodsA prospectively maintained institutional registry was retrospectively queried for all patients undergoing primary TSA or RTSA between September 2016 and April 2019 and confirmed as having undergone outpatient surgery, defined as surgery performed at an ambulatory surgery center. Ninety-day complications, readmissions, and ER visits were analyzed for outpatient TSA and RTSA. The 90-day complications included infection, thromboembolic disease (pulmonary embolism, deep venous thrombosis), neurovascular injury, revision surgery, and inflammatory processes. ResultsA total of 140 patients were identified who underwent outpatient TSA or RTSA from 2016 to 2019. Four complications (3.7%) were reported in the TSA cohort, compared to 4 complications (12.9%) reported in the RTSA cohort (P = .060). Three ER visits occurred in the RTSA group compared to 0 in the TSA group (P = .001). Patients who experienced a complication had significantly higher body mass index (TSA: P = .049, RTSA: P = .035). In addition, there were no readmissions or reoperations in either TSA or RTSA patients. ConclusionOverall, the rate of complications, ER visits, and readmission rates in outpatient TSA and RTSA was found to be relatively low given the sample size of this study and minor complications reported. In addition, there were no readmissions or reoperations in either TSA or RTSA patients. Elevated body mass index may significantly increase the risk of complications after both a TSA and RTSA. This study suggests that outpatient TSA and RTSA are safe in selected patients.

Augmented baseplates yield optimum outcomes when compared with bone graft augmentation for managing glenoid deformity during reverse total shoulder arthroplasty: a retrospective comparative study.

The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using glenoid bone grafting (BG rTSA) with primary rTSA using augmented glenoid baseplates (Aug rTSA) with a minimum 2-year follow-up. A total of 520 primary rTSA patients treated with 8° posterior glenoid augments (n=246), 10° superior glenoid augments (n=97), or combined 10° superior/8° posterior glenoid augments (n=177) were compared with 47 patients undergoing glenoid bone grafting for glenoid bone insufficiency. The mean follow-up was 37.0(±16) and 53.0(±27) months, respectively. Outcomes were analyzed preoperatively and at the latest follow-up using conventional statistics and stratification by minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds where applicable. Radiographs were analyzed for baseplate failure, and the incidences of postoperative complications and revisions were recorded. The glenoid Aug rTSA cohort had greater improvements in patient-reported outcome measures (PROMs) and range of motion when compared with the BG rTSA group at a minimum of 2-year follow-up, including Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles score, Shoulder Pain and Disability Index score, shoulder function, Shoulder Arthroplasty Smart score, abduction, and external rotation (P<.05). Patient satisfaction was higher in the Aug rTSA group compared with the BG rTSA group (P=.006). The utilization of an augmented glenoid component instead of glenoid bone grafting resulted in approximately 50% less total intraoperative time (P<.001), nearly 33% less intraoperative blood loss volume (P<.001), approximately 3-fold less scapular notching (P<.01), and approximately 15-fold less adverse events requiring revision (P<.01) when compared with the BG rTSA cohort. Aside from SCB for abduction, the Aug rTSA cohort achieved higher rates of exceeding MCID and SCB for every PROM compared with BG rTSA. More specifically, 77.6% and 70.2% of the Aug rTSA achieved SCB for American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index vs. 55% and 48.6% in the BG rTSA, respectively (P=.003 and P=.013). The present midterm clinical and radiographic study demonstrates that the utilization of an augmented baseplate for insufficient glenoid bone stock is superior as judged by multiple PROMs and range of motion metrics when compared with bone graft augmentation at minimum 2-year follow-up. In addition, when analyzed according to MCID and SCB thresholds, the use of augmented baseplates outperforms the use of glenoid bone grafting. Complication and revision rates also favor the use of augmented glenoid baseplates over glenoid bone grafting. Long-term clinical and radiographic follow-up is necessary to confirm that these promising midterm results are durable.

Return to driving following anatomic and reverse shoulder arthroplasty: a comparative analysis.

The currently recommended time to return to driving following shoulder arthroplasty is controversial. The purpose of this study was to determine patient-specific factors associated with early return to driving after anatomic (aTSA) and reverse total shoulder arthroplasty (RTSA). All patients aged >18 years undergoing primary aTSA or RTSA at a single institution over a 3-year period were retrospectively identified. Patients were emailed a questionnaire to determine time to postoperative return to driving and frequency of driving prior to and following surgery. Patients who did not drive prior to surgery or did not complete the questionnaire were excluded from analysis. Multivariate analysis was used to determine patient-specific factors associated with early return to driving (within 2 weeks following surgery) and delayed return (>6 weeks following surgery). Four hundred six patients were included for analysis (aTSA=214, RTSA=192). Patients undergoing aTSA were significantly younger (68 vs. 74 years) and drove more frequently both pre- and postoperatively than the RTSA cohort. One hundred percent of patients returned to driving postoperatively. Patients undergoing aTSA more commonly demonstrated earlier return to driving than RTSA patients (34% vs. 20%). Factors associated with increased odds of early return to driving included male sex (aTSA) and compliance with surgeon instruction (aTSA). Decreased odds of early return was associated with waiting to drive until cessation of sling use (RTSA), older age (RTSA), and increased body mass index (RTSA). The presence of surgical complications (aTSA) and prolonged use of narcotics (RTSA) were associated with return to driving >6 weeks following surgery. No difference in the rate of motor vehicle accidents was found between patients returning to driving <2 vs. >2 weeks postoperatively. Patients undergoing aTSA return to driving sooner than those undergoing RTSA. Early return to driving appears to be influenced by patient sex, age, BMI, narcotic and sling use, and compliance with surgeon instruction, but does not appear to result in a high incidence of postoperative MVA.