Primary Shoulder Arthroplasty Research Articles

Reverse Shoulder Arthroplasty for Proximal Humerus Head-Split Fractures—A Retrospective Cohort Study

Head-split fractures are proximal humerus fractures (PHF) that result from fracture lines traversing the articular surface. While head-split fractures are rare, surgical treatment of these complex injuries can be extremely challenging and is associated with high rates of complications. Treatment using primary reverse shoulder arthroplasty (RSA) has been associated with moderate complication rates and reproducible clinical results. The aim of this study was to evaluate clinical and radiographic outcomes, and complication rates of RSA for head-split PHF. Twenty-six patients were evaluated based on Constant Score (CS) and range of motion of both shoulders and Subjective Shoulder Value (SSV). Radiographic analysis evaluated tuberosity healing, prosthetic loosening and scapular notching. Patients achieved good clinical results with a CS of 73.7 points and SSV of 82% after a mean follow-up of 50 months. The relative CS comparing operated versus the unaffected shoulder was 92%. Greater tuberosity healing was achieved in 61%. Patients who suffered a high-energy trauma reached a significantly greater functional outcome. Patients who suffered multifragmentation to the humeral head performed the worst. There were no cases of loosening; scapular notching was visible in two cases. The complication rate was 8%. RSA is an adequate treatment option with for head-split PHF in elderly patients.

Radiological changes in shoulder osteoarthritis and pain sensation correlate with patients’ age

PurposeOsteoarthritis (OA) is one of the most common musculoskeletal disorders in the aging population. The correlation of radiographic OA severity, disability and pain is variable and inconsistent for the different joints. This study aims to elucidate the relationship between histological and radiological signs of shoulder OA with pain sensation and functional impairment to potentially adapt the recommendation for surgical treatment for primary total shoulder arthroplasty (TSA).MethodsForty-four patients with shoulder OA undergoing TSA using an anatomic stemless implant were included in this study. The radiological OA severity was scored pre-operatively on true ap X-rays according to the Kellgren–Lawrence score (KL-Score). Acromial types according to Bigliani were defined by pre-operative radiological images. The histological OA severity was determined according to the OARSI-Score using bone–cartilage sections from loaded areas of the humeral head. Pain was quantified using the visual analog scale (VAS). The functional status was assessed by the items “mobility” and “strength” out of the Constant–Murley score (CS Score). Demographic data including BMI, age, gender, diabetes mellitus and smoking were recorded.ResultsThere was no correlation between radiographic and histological severity in shoulder OA. However, a correlation of age and the severity of radiological changes was observed. Further, pain did not correlate with histological or radiological scores, whereas it correlated with age and the presence of diabetes mellitus. The functional shoulder status (mobility, strength) correlated with the severity of radiological changes, but not with the histologic scoring, which correlated with nicotine abuse.ConclusionThis study shows that increased age is the main determinant of radiological changes in shoulder OA, as well as pain. Therefore, age and pain sensation should be considered as important parameters for the recommendation for TSA.

Risk factors for instability after reverse shoulder arthroplasty

BackgroundInstability after primary reverse total shoulder arthroplasty (rTSA) is a rare but serious complication, potentially resulting in revision surgery. The causes of instability after rTSA are multifactorial and sometimes unknown. The goal of this study is to analyze an international database of one-platform shoulder prosthesis and conduct a logistic multivariate regression analysis to identify the factors associated with instability after primary rTSA and quantify the 2-year minimum clinical outcomes of patients with and without instability. MethodsA total of 5631 primary rTSA patients were analyzed from the international database of single rTSA prosthesis to quantify clinical outcomes at 2-year minimum follow-up for patients with and without instability. rTSA patients were divided into 2 cohorts based on if they were stable or unstable, and a subanalysis was conducted for patients who were unstable early (<6 months) and also unstable late (>6 months). For both stable and unstable rTSA patients, univariate and multivariate analyses were performed to quantify the patient, implant, and operative risk factors associated with instability after rTSA. ResultsFifty-five of the 5631 primary rTSA shoulders were reported to be unstable, with an overall instability rate of 0.98%. Female patients had an instability rate of 0.60% (21/3496), which was significantly lower (P < .0001) than the 1.63% instability rate for male patients (34/2085). Patients with subscapularis repair had an instability rate of 0.45% (10/2222), which was significantly lower (P = .0052) than the 1.17% instability rate of patients without a subscapularis repair (37/3161). Multivariate analysis identified numerous risk factors for instability, including younger age at the time of surgery, the use of cemented humeral fixation, larger glenosphere diameters, expanded/lateralized center of rotation glenospheres, and not repairing the subscapularis. DiscussionOur study demonstrated that patients with instability had significantly worse clinical outcomes, more pain, and worse function and range of motion as compared to rTSA patients who were stable. The univariate and multivariate analyses identified numerous patient, implant, and operative risk factors associated with instability. A patient with 1 or more of these identified parameters has an increased risk for instability, and that recognition is useful for patient counseling and consideration of repair of the subscapularis, when possible.

Primary reverse total shoulder arthroplasty performed for glenohumeral arthritis: does glenoid morphology matter?

Indications for reverse total shoulder arthroplasty (RTSA) have expanded to include primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Limited evidence exists on RTSA in patients with primary GHOA and no posterior glenoid wear (Walch A1, A2, and B1 morphologies). The purpose of this retrospective cohort study was to determine if glenoid morphology is associated with clinical outcomes in patients undergoing RTSA for primary GHOA. A retrospective review of prospectively collected data was performed in patients undergoing primary RTSA for GHOA with a minimum of 2-year clinical follow-up. Preoperative computed tomography and magnetic resonance imaging were used to categorize glenoid morphology as described by the modified Walch classification. Pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) pain scores, and range of motion (ROM) measurements were compared across Walch glenoid subtypes. The percentage of patients that reached previously established clinically significant thresholds for minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also comparatively assessed. Multivariable analysis was used to evaluate the association between glenoid morphology and postoperative ASES score while controlling for potentially confounding variables. Of the 247 consecutive patients, 197 were available at a minimum 2-year follow-up (80%). Significant improvements were seen in ASES, VAS pain, SANE, and ROM from baseline to final postoperative follow-up in the combined patient cohort (all P < .001). Most (98.0%) patients reached MCID, and 90.9% of patients reached SCB for ASES threshold. No significant differences were found among Walch subtypes in terms of preoperative to postoperative improvement in ASES (P = .39), SANE (P = .4), VAS pain (P = .49), forward elevation (P = .77), external rotation (P = .45), or internal rotation (P= 0.1). The only significant difference in postoperative outcomes between Walch glenoid subtypes was higher postoperative ASES scores among type B3 glenoids compared with type A1 glenoids (P = .03) on univariate analysis. However, no individual Walch glenoid subtype was associated with lower postoperative ASES scores on multivariable analysis (P > .05). Primary RTSA provides excellent short-term outcomes in patients with glenohumeral arthritis with intact rotator cuff, regardless of the degree of preoperative glenoid deformity. Surgeons can use these data to support the use of RTSA for glenohumeral arthritis in a more standardized way.

Characterization of ASES score pain and functional improvement after anatomic total shoulder arthroplasty: a patient-centered perspective.

Interpretation of anchor-based clinical differences in the context of pain and functional change remains undefined. The purpose of this study was to characterize American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores for patients after anatomic total shoulder arthroplasty with minimum 1 year of follow-up in terms of pain and change in each functional element on the ASES. We performed a retrospective study of a prospective institutional patient database of primary anatomic total shoulder arthroplasties from 2017-2020 with baseline and 1-year postoperative ASES scores. Three clinical outcome groups were established using an anchor-based global rating of change assessment: minimal clinically important difference (MCID), moderate clinical benefit (MCB), and substantial clinical benefit (SCB). Pain and functional outcomes in each group where then characterized and compared. A total of 67 patients were analyzed in terms of demographics and clinical outcomes. Two-thirds (65%) of patients achieved the SCB, 24% achieved the MCB, and 10% achieved the MCID. Washing, reaching for a shelf, and throwing were the most common functional deficits experienced preoperatively and accounted for the largest improvement in function postoperatively. Patients in the MCID group had higher preoperative visual analog scale (VAS) pain scores (7.1 ± 3.0) than the MCB (5.8 ± 2.5) or SCB (5.8 ± 2.2) groups (P = .0612). The MCID group had the least amount of preoperative functional deficits when compared to the MCB and SCB groups (P = .041). Postoperative VAS pain scores improved by 5.1 in the SCB, 3.6 in the MCB, and 3.7 in the MCID groups. Functional change in each element of the ASES improved by 1.4/4 in the SCB, followed by 0.9/4 in the MCB group and 0.05/4 in the MCID group (P < .001). The MCID group had higher preoperative pain scores and the least amount of preoperative functional deficits when compared to the MCB and SCB groups. The MCID was realized through pain improvement only, whereas the MCB and SCB consisted of meaningful improvements in pain and function.

Is there a threshold of preoperative function that predicts failure to achieve clinically significant outcomes after total and reverse shoulder arthroplasty?

BackgroundThe purpose of this study was to determine if there is a threshold of preoperative function that is predictive of postoperative outcomes and the likelihood of achieving clinically significant outcomes following shoulder arthroplasty (SA). MethodsWe retrospectively identified patients who underwent a primary SA at our institution. Patients with preoperative and postoperative American Shoulder and Elbow Surgeons scores (ASES) were included in our analysis. A receiver operating characteristic (ROC) analysis was utilized to reach a preoperative ASES threshold correlated with achievement of the following clinically significant outcomes: minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state. This analysis was performed for our entire SA cohort and subanalyzed for total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). Fischer exact tests were used to analyze categorical data while continuous data were analyzed using t-tests. For the ROC, area under the curve (AUC) was calculated, along with bootstrap 95% confidence intervals and P values, with <0.05 as significant. ResultsA total of 516 patients were included (164 TSA and 352 RSA). ROC analysis yielded a preoperative ASES above 54 as predictive of failure to achieve MCID for all SAs (AUC, 0.77; P < .001), above 49 for TSA (AUC 0.74, P < .001), and above 56 for RSA (AUC 0.79, P < .001). Patients with preoperative ASES scores above 54 were significantly less likely to achieve MCID (odds ratio 5.1, P < .001) and SCB (odds ratio 7.2, P < .001); however, they had higher postoperative ASES scores (84 vs. 78, P < .001). A preoperative ASES score of 73 corresponded to a 50% chance of achieving MCID. ROC analysis also yielded a preoperative ASES score above 51 as predictive of failure to achieve SCB for all SA, TSA, and RSA (AUC: 0.79, 0.78, and 0.80, respectively, all P < .001). A preop ASES score of 52 corresponded to a 50% chance of achieving SCB. ConclusionPreoperative ASES scores above 49-56 are predictive of failure to achieve MCID and SCB following TSA and RSA. Although patients above these preoperative thresholds achieve higher absolute ASES scores at the final follow-up, they experienced less relative improvement from baseline. This will help surgeons counsel individual patients about appropriate expectations after arthroplasty.

Risk of 30-day readmission in patients aged 75 years and older following same-day discharge for primary total shoulder arthroplasty

BackgroundLittle is known about the safety and feasibility of same-day discharge following primary total shoulder arthroplasty (anatomic and reverse, SA) in geriatric patients, who may have more comorbidities and be at higher risk of surgical complications. The purpose of this study is to evaluate whether patients aged 75 years or older undergoing same-day discharge following primary SA are at an increased risk for certain complications, readmission, or mortality compared to their younger counterparts. MethodsThe 2007-2019 National Surgical Quality Improvement Program database was used to identify all primary SA patients who underwent same-day discharge. Patients were categorized into 2 cohorts, younger than 75 years and aged 75 years or older. Bivariate and multivariate analyses were performed to compare the 2 cohorts. ResultsOf 1637 SA patients who were discharged on the same day, 1246 (76.1%) patients were younger than 75 years, and 391 (23.9%) were aged 75 years or older. Bivariate analyses showed that patients aged 75 years or older were more likely to develop urinary tract infections (P = .003) and require hospital readmission (P = .002). After controlling for potential confounding variables on multivariate analysis, the cohort of patients aged 75 years or older had an increased risk of unplanned hospital readmission compared to patients younger than 75 years (odds ratio 3.99; P = .001). ConclusionPatients of age 75 years or older are at an increased risk for unplanned hospital readmission within 30 days of same-day discharge following primary SA. Surgeons and patients should be aware of this risk when evaluating SA candidates for same-day discharge.

The outcomes of shoulder arthroplasty in those aged ≥70 years with glenohumeral arthritis: a New Zealand Joint Registry study.

Reverse total shoulder arthroplasty (RTSA) was traditionally reserved for the patient with rotator cuff tear arthropathy. As the indications for RTSA continue to expand, the role of RTSA in patients aged >70 years with glenohumeral arthritis and an intact rotator cuff remains unclear. To study the New Zealand Joint Registry (NZJR) and compare the outcomes of a primary Total Shoulder Arthroplasty (TSA), a primary RSA and an RSA performed for revision of a failed TSA in patients aged >70 years, to determine if there is clear evidence to support a primary RSA in those aged >70 years instead of a primary TSA METHOD: This is a retrospective study of the NZJR from 2000 to 2018. We included all primary TSAs, primary RTSAs, and those RTSAs that were performed for the revision of a failed TSA. We excluded those RTSAs that were performed for the revision of an RTSA or hemiarthroplasty. The primary outcome was the Oxford Shoulder Score (OSS) at 6 months and 5 years, with a secondary outcome being the subsequent revision rate. A total of 3449 primary TSAs, 4681 primary RTSAs, and 104 revision RTSAs were identified. The mean OSSs at 6 months for a primary TSA, a primary RTSA, and a revision RTSA were 39.5 ± 9.0, 35.5 ± 9.4, and 32.5 ± 9.7, respectively (P < .001, primary TSA vs. primary RSTA; P <.001, primary TSA vs. revision RTSA; P = .0252 primary RTSA vs. revision RTSA). The mean OSSs at 5 years for a primary TSA and a primary RTSA were 42.1 ± 7.5 vs. 39.8 ± 8.4, respectively (P < .001), with no results available for revision RTSA. The secondary outcome was the revision rate for those aged >70 years with osteoarthritis as their primary indication for surgery. The revision rates for a primary TSA and a primary RTSA were 0.53/100 component-years (95% confidence interval [CI] 0.38-0.72) and 0.51/100 component-years (95% CI 0.31-0.79), respectively (P = .193), which was not statistically significant. The TSA remains the gold standard for primary shoulder arthroplasty. For those individuals aged >70 years with osteoarthritis as their primary diagnosis, a primary TSA is associated with a higher OSS than and similar revision rates to a primary RTSA's. However, these patients must be counseled regarding the risk of subsequent cuff failure, as the outcomes from a revision RTSA are significantly inferior than those from a primary RTSA.

A Prospective Observational Study on Short-term Functional Outcomes of Primary Reverse Shoulder Arthroplasty in the Indian Population

Background: Reverse shoulder arthroplasty (RSA) is becoming more popular for specific indications globally with good functional outcomes reported. There is no study, to the authors’ knowledge, on the outcomes of RSA in the Indian population. The present study aimed to fill the void. Methodology: A prospective observational study on the functional outcomes using University of California, Los Angeles (UCLA) and Constant scores in the first 27 consecutive patients who underwent RSA in a tertiary care hospital between 2019 and 2020 were assessed in periodic intervals up to a maximum of 1-year follow-up. Results: Twenty-seven patients underwent unilateral primary RSA and were included with a median age of 71 years (interquartile range [IQR]: 66–76). There was a statistically significant improvement in both the functional scores over the study duration. At a follow-up time of 6 months (n = 27 patients), the median improvement in UCLA score was 17 points (IQR: 12–19) and Constant shoulder score of 52 points (IQR: 47–60). Thirteen of these patients were followed up further up to 1 year, with a median improvement in UCLA score of 13 points (IQR: 21–25) and Constant shoulder score of 56 points (IQR: 49.50–66.50) from the preoperative scores. All 27 implants were radiographically stable. There was 7.4% complication rate; one scapular notching was noticed at the end of 1-year follow-up and one glenosphere dissociation in the immediate postoperative period. Conclusion: RSA provides consistent improvements in functional outcome measures in the Indian population with a low complication rate. Further studies with larger patient cohorts and longer follow-ups are needed to validate these findings.

Comparison of patient-demographics, causes, and costs of 90-day readmissions following primary total shoulder arthroplasty for glenohumeral osteoarthritis

IntroductionReadmissions following orthopaedic surgery are associated with worse outcomes and increased healthcare costs. Studies investigating trends, causes, and costs of readmissions following primary total shoulder arthroplasty (TSA) for the indication of glenohumeral osteoarthritis (OA) are limited. The objective was to compare: 1) patient-demographics of those readmitted and not readmitted within 90-days following primary TSA for OA; 2) causes of readmissions and 3) associated costs. MethodsA retrospective query from 2005 to 2014 was performed using a nationwide administrative claims database. The study group consisted of patients readmitted within 90-days following primary TSA for glenohumeral OA, whereas patients not readmitted served as controls. Causes of readmission were stratified into the following groups: cardiovascular, hematological, endocrine, gastrointestinal (GI), musculoskeletal (MSK), neoplastic, neurological, pulmonary, infectious, renal, and miscellaneous causes. Patient demographics were compared, in addition to the frequency of the causes of readmissions, and their associated costs. Chi-square analyses compared demographics between groups. Analysis of variance was utilized to determine differences in 90-day costs for the causes of readmission. A p-value less than 0.001 was significant. ResultsThe overall 90-day readmission rate was 2.4% (3432/143,878). Patients readmitted following primary TSA were more likely to be over the age of 75, female, and higher prevalence of comorbid conditions, including psychiatric and medical conditions. Readmitted patients had a higher overall comorbidity burden per mean Elixhauser-Comorbidity Index (ECI) scores (10 vs. 7,p < .0001). The leading cause of readmissions were due to MSK (17.34%), cardiac (16.28%), infectious (16.26%), and gastrointestinal (11.64%) etiologies. There were differences in the mean 90-day costs of care for the various causes of readmissions, with the leading cost of readmissions being cardiac causes ($10,913.70) and MSK ($10,590.50) etiologies. ConclusionPatients with greater comorbidities experienced increased incidence of readmission following TSA for glenohumeral OA. Cardiac and MSK etiologies were the primary cause of readmissions. Level of evidenceIII.

Humeral stem with low filling ratio reduces stress shielding in primary reverse shoulder arthroplasty.

Some patients show severe humeral bone stress shielding even oneyear after press-fit humeral stem, which can be a risk factor for implant durability. This study compared humeral stress shielding and clinical outcomes between high and low filling ratio (HFR and LFR) stems in primary reverse shoulder arthroplasty (RSA). From 2015 to 2020, 104 patients who underwent RSA with a non-cemented standard-length humeral stem were examined. The humeral stems included large press-fit stems (HFR group, 53 patients) or small non-press-fit stems with autogenous cancellous bone grafting (LFR group, 51 patients). The radiologic and clinical outcomes were compared between the groups oneyear post-operatively. One patient in the LFR group with early infectious dislocation was excluded from the 1-oneyear evaluation. No stress shielding was observed in 27/50 (54.0%) and 5/53 (9.4%) of patients in the LFR and HFR groups, while 3/50 (6%) and 19/53 (35.8%) patients showed high-stress shielding, respectively. However, the stem alignment change, subsidence, complications and evidence of loosening did not differ between the groups. The final range-of-motion and functional scores were significantly poorer in the LFR group than those in the HFR group, although the difference was minimal. Even at oneyear follow-up, patients receiving LFR stems with autogenous bone grafting had significantly less humeral stress shielding compared to patients with HFR stem with press-fit in primary RSA, without compromising stem stability.

The impact of sleep apnea on primary reverse shoulder arthroplasty for the treatment of glenohumeral osteoarthritis.

As the prevalence of sleep apnea (SA) increases nationwide, large sample sized studies following primary reverse shoulder arthroplasty (RSA) in SA patients are scarce. Therefore, this study evaluated whether SA is associated with 1) longer in-hospital lengths of stay (LOS) 2) readmissions 3) medical complications and 4) costs. A retrospective nationwide Medicare analysis from 2005 to 2014 was performed. Inclusion criteria were patients with SA undergoing RSA for the treatment of glenohumeral osteoarthritis. Study group patients were 1:5 ratio matched to controls yielding 6241 patients in the study and 31,179 in the comparison cohort. Logistic regression was used to calculate odds-ratios (OR) for readmissions and complications. A p-value less than 0.004 was significant. SA patients had significantly longer in-hospital LOS compared to their counterparts (3-days versus 2-days, p < 0.0001), but similar rates of 90-day readmissions (7.98% vs. 6.54%; OR: 1.00, p = 0.907). Patients with SA had significantly greater incidence and odds of 90-day medical complications (13.36% vs. 7.29%; OR: 1.42, p < 0.0001) and significantly higher 90-day costs ($16,529.16 vs. $14,789.15, p < 0.0001). Patients with SA undergoing primary RSA for the treatment of glenohumeral OA have longer in-hospital LOS, increased medical complications, and costs of care. Readmissions were not more common. III.

Risks of chronic steroid or immunosuppressive therapy on total shoulder arthroplasty patients.

Patients on chronic corticosteroids/immunosuppressants (SI) undergoing orthopaedic surgery are at an increased risk for surgical complications and worse outcomes. However, whether or not chronic preoperative SI use increases the risk for 30-day complications in patients undergoing primary total shoulder arthroplasty (SA) has yet to be explored. From 2006 to 2019, the National Surgical Quality Improvement Program (NSQIP) database was used to identify all patients who underwent primary SA (anatomic TSA and reverse TSA). Patients were stratified into two cohorts: chronic preoperative SI users and those without use. Bivariate and multivariate analyses were utilized in this study. Of the 26,979 patients who underwent primary SA, 25,656 (95.1%) patients did not have SI usage whereas 1323 (4.9%) patients had chronic preoperative SI usage. Following adjustment on multivariate analyses, compared to the non-SI usage cohort, patients who used SI had an increased risk of urinary tract infections (UTIs) (OR 1.87; p = 0.009) and septic shock (OR 7.14; p = 0.002). There were no differences in mortality between the two cohorts (p = 0.058). Chronic pre-operative SI use is an independent risk factor for septic shock and UTIs following primary SA. Surgeons and patients should be aware of these risks to better inform patient counseling and surgical decision making.

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.

Is There Synergistic Effect Between Obesity and Hypoalbuminemia on Postoperative Outcomes Among Primary Total Shoulder Arthroplasty Recipients?

Malnutrition and obesity are established predictors of complications following joint replacement surgery. However, the effect of obesity in the setting of albumin deficiency has not been explored in non-weight-bearing upper-extremity joint arthroplasty. We sought to determine whether there is a synergistic effect between obesity and hypoalbuminemia among patients undergoing primary total shoulder arthroplasty (TSA) with respect to postoperative outcomes, including (1) mortality rates, (2) composite surgical complications, (3) length of hospitalization, and (4) hospital readmission. We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database to find patients who underwent primary TSA from January 1, 2006, to December 31, 2019. We grouped these patients as obese (body mass index [BMI] ≥ 30 kg/m2) or nonobese (BMI = 18.5-29.9 kg/m2) and by serum albumin level (hypoalbuminemia < 3.5 mg/dL or normoalbuminemia ≥ 3.5 mg/dL). We gathered data on readmission and mortality rates, and NSQIP complications were organized into 3 composite variables: wound infection, systemic infection, and cardiac/pulmonary complication. For each outcome, multivariate logistic regression analysis evaluated its association with obesity and hypoalbuminemia, as well as with the interaction of BMI and albumin, while adjusting for covariates. Of 12,881 patients, 51.8% were obese and 7.0% had hypoalbuminemia; 7.6% of obese patients had hypoalbuminemia versus 6.3% of those who were not obese. Patients with hypoalbuminemia had the longest hospital stays and the highest rates of mortality and systemic infection of all subgroups. Multivariate logistic regression analysis did not show higher complication rates due to obesity or evidence of additive interaction between hypoalbuminemia and obesity. Unlike previous reports in weight-bearing arthroplasty, in this retrospective study of a cohort of patients who underwent TSA, we did not observe greater complications due to obesity alone, nor did we find evidence of additive interaction between obesity and hypoalbuminemia. This distinction may be due to the non-weight-bearing nature of TSA, in which excessive BMI may be less relevant for postoperative healing.

The deltoid tuberosity index predicts intraoperative fracture risk in shoulder arthroplasty

BackgroundWhen intraoperative fracture of the humerus during primary shoulder arthroplasty occurs, it can have significant clinical implications. To date, there are no described radiographic parameters to preoperatively assess risk of intraoperative fracture. The purpose of the current study was to determine if the deltoid tuberosity index (DTI), a validated tool for radiographic assessment of proximal humerus bone mineral density, correlates with risk of intraoperative humerus fracture during primary shoulder arthroplasty. MethodsA multicenter retrospective matched cohort study was performed utilizing patient data from two geographically diverse high-volume health systems. Intraoperative humerus fractures during primary shoulder arthroplasty were identified and matched 3:1 with a nonfracture cohort based on age, sex, body mass index, and type of arthroplasty surgery. DTIs were measured on preoperative anteroposterior radiographs in a blinded fashion. Additional data collected included American Society of Anesthesiologists score, preoperative diagnosis of osteoporosis, and various descriptive fracture variables. The chi-square test and independent samples t-test were used to analyze categorical and continuous variables, respectively. ResultsEighteen intraoperative humerus fractures were identified and matched with 54 nonfracture primary shoulder arthroplasty cases. The two cohorts did not significantly differ in age, sex, body mass index, type of arthroplasty surgery, mean American Society of Anesthesiologists score, or preoperative osteoporosis diagnosis. The mean DTI of the fracture cohort was significantly lower than that of the nonfracture cohort (1.34 vs. 1.46, P = .0018). A DTI value less than 1.44 was significantly associated with an increased risk of intraoperative humerus fracture (odds ratio = 19.6, 95% confidence interval = 2.4-155.6, P < .0001). Fractures most commonly occurred in female patients (83%), in reverse shoulder arthroplasty (89%), and with use of press-fit systems (72%). ConclusionThe DTI is a simple and broadly applicable tool for assessing a patient’s proximal humerus bone quality preoperatively. We found that a DTI less than 1.44 correlates with an increased risk of intraoperative humerus fracture during primary shoulder arthroplasty. This study provides radiographic parameters for preoperatively assessing a patient’s risk of intraoperative humeral fracture during primary shoulder arthroplasty.

Complications And Reinterventions In Reverse Total Shoulder Arthroplasty: Report Of 854 Primary Cases

The aim of this study was to report the incidence of implant-related complications, reintervention surgeries and clinical outcome in our prospectively followed cohort of primary reverse total shoulder arthroplasties.

Complications and further surgery after reverse total shoulder arthroplasty : report of 854 primary cases.

The aim of this study was to report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA). The prospectively collected clinical and radiological data of 797 patients who underwent 854 primary RTSAs between January 2005 and August 2018 were analyzed. The hypothesis was that the presence of complications would adversely affect the outcome. Further procedures were defined as all necessary operations, including reoperations without change of components, and partial or total revisions. The clinical outcome was evaluated using the absolute and relative Constant Scores (aCS, rCS), the Subjective Shoulder Value (SSV) scores, range of motion, and pain. The overall surgical site complication rate was 22% (188 complications) in 152 patients (156 RTSAs; 18%) at a mean follow-up of 46 months (0 to 169). The most common complications were acromial fracture (in 44 patients, 45 RTSAs; 5.3%), glenoid loosening (in 37 patients, 37 RTSAs; 4.3%), instability (in 23 patients, 23 RTSAs; 2.7%), humeral fracture or loosening of the humeral component (in 21 patients, 21 RTSAs; 2.5%), and periprosthetic infection (in 14 patients, 14 RTSAs; 1.6%). Further surgery was undertaken in 79 patients (82 RTSAs) requiring a total of 135 procedures (41% revision rate). The most common indications for further surgery were glenoid-related complications (in 23 patients, 23 RTSAs; 2.7%), instability (in 15 patients, 15 RTSAs; 1.8%), acromial fractures (in 11 patients, 11 RTSAs; 1.3%), pain and severe scarring (in 13 patients, 13 RTSAs; 1.5%), and infection (in 8 patients, 8 RTSAs; 0.9%). Patients who had a complication had significantly worse mean rCS scores (57% (SD 24%) vs 81% (SD 16%)) and SSV scores (53% (SD 27%) vs 80% (SD 20%)) compared with those without a complication. If revision surgery was necessary, the outcome was even further compromised (mean rCS score: 51% (SD 23%) vs 63% (SD 23%); SSV score: 4% (SD 25%) vs 61% (SD 27%). Although the indications for, and use of, a RTSA are increasing, it remains a demanding surgical procedure. We found that about one in five patients had a complication and one in ten required further surgery. Both adversely affected the outcome. Cite this article: Bone Joint J2022;104-B(3):401-407.

Are short press-fit stems comparable to standard-length cemented stems in reverse shoulder arthroplasty? A prospective, randomized clinical trial.

The literature comparing humeral implants in reverse shoulder arthroplasty is sparse. With minimal supporting literature, there has been a trend away from standard-length cemented humeral implants to press-fit stems and, recently, to shorter-stem implants. It is known that early implant migration, within the first 2 years postoperatively, is predictive of later implant loosening and possible revision surgery. Therefore, the purpose of this study was to compare clinical outcomes and implant migration between cemented standard-length humeral stems and press-fit short stems using model-based radiostereometric analysis. After a power analysis, 41 shoulders were prospectively randomized to receive either a cemented standard-length or press-fit short humeral stem for primary reverse shoulder arthroplasty between July 2017 and June 2019. Following surgery, participants were imaged with stereo radiographs acquired at 6 weeks (baseline), 3 months, 6 months, 1 year, and 2 years. Migration of the humeral stem at each time point was compared with baseline, with differences in migration between cohorts assessed using a mixed-effects model with the Bonferroni test for multiple comparisons. Patient-reported outcome measures (Subjective Shoulder Value; American Shoulder and Elbow Surgeons shoulder score; Simple Shoulder Test score; Disabilities of the Arm, Shoulder and Hand score; and Constant score) were also compared. At 6 months (P=.025), 1 year (P=.004), and 2 years (P=.001) postoperatively, press-fit short stems migrated significantly more than cemented stems along the superior-inferior translation axis; in addition, they showed greater total translation at 2 years (P=.003). Mean total translation (± standard deviation) at 2 years was 0.4±0.2 mm and 1.0±1.1 mm for the cemented and press-fit cohorts, respectively. Mean migration between the 1- and 2-year time points was minimal for both stem fixation groups along all axes (<0.1 mm and 0.6°). There was no difference in active range of motion, pain, or validated outcome measures between the cohorts at 2 years (P≥.170). This randomized clinical trial shows that press-fit short humeral stems subside substantially more than standard-length cemented stems but ultimately achieve stability from 1 year through 2 years. Conversely, no significant differences were observed in clinical outcomes between cohorts.

Shoulder arthroplasty after prior anterior shoulder instability surgery: a matched cohort analysis.

To evaluate the effect of prior anterior shoulder instability surgery (SIS) on the outcomes and complications of primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA). Between 2007 and 2018, 38 primary total shoulder arthroplasties (TSA) (22 aTSA and 16 rTSA) with a prior SIS and a minimum of 2years of follow-up were identified. This cohort was matched 1:3 based on age, sex, body mass index, year of surgery, and dominant shoulder. aTSA and rTSA were matched to patients with primary osteoarthritis (OA) and rotator cuff tear arthropathy (CTA), respectively. TSA produced similar postoperative pain, ROM, patient-reported outcome measures, complications, and revisions in those with prior SIS vs. controls. aTSA with prior SIS demonstrated worse final postoperative abduction (116° vs. 133°; P = 0.046) and abduction improvement (24° vs. 47°; P = 0.034) compared to OA controls. Both aTSA and rTSA with prior SIS demonstrated significant improvements from baseline across all metrics, with no significant differences between the groups. aTSA and rTSA with prior SIS demonstrated no differences to controls in complications (4.6% vs. 6.1%; P = .786 and 0% vs. 6.3%. P = .183) or revisions (4.6% vs. 4.6%; P = .999 and 0% vs. 4.2%; P = .279). TSA after prior SIS surgery can improve both pain and function without adversely increasing the rates of complications or revision surgery. When compared to patients without prior SIS, aTSA demonstrated worse abduction; however, all other functional differences remained statistically similar. III; Retrospective Cohort Comparison; Treatment Study.