Primary Shoulder Arthroplasty Research Articles

Prior shoulder surgery and rheumatoid arthritis increase early risk of infection after primary reverse total shoulder arthroplasty.

BackgroundReverse total shoulder arthroplasty (RTSA) has become an increasingly popular surgery for patients with rotator cuff arthropathy, unreconstructible proximal humeral fracture, and end-stage glenohumeral arthritis. The increased annual volume of RTSAs has resulted in more postoperative complications and revision rates between 3.3% and 10.1%. Postoperative infection is one of the most common complications requiring revision surgery after primary RTSA. This study assesses patient-specific risk factors for development of early infection after primary RTSA in a single high-volume shoulder arthroplasty institution.MethodsFrom 2014 to 2019, 902 consecutive primary RTSAs were performed for surgical treatment of rotator cuff arthropathy, glenohumeral arthritis, inflammatory arthropathy, and/or dislocation. Excluding proximal humeral or scapula fractures, 756 cases met the inclusion criteria and had a minimum of 3-month follow-up. All surgeries were performed using the same surgical technique and received similar antibiotic prophylaxis. Age, patient demographics, medical history, smoking history, and prior ipsilateral shoulder treatment and/or surgery were recorded. Multivariable logistic regression analysis was used to determine risk factors associated with development of postoperative shoulder infection.ResultsThirty-five patients did not meet minimum follow-up criteria and were lost to follow-up. Overall, of 721, 22 patients (3%) developed a postoperative ipsilateral shoulder infection. Previous nonarthroplasty surgery and history of rheumatoid arthritis were significantly associated with the development of postoperative shoulder infection. Amongst 196 patients who had previous nonarthroplasty shoulder surgery, there were 12 postoperative shoulder infections (6%) compared with those without previous shoulder surgery (10 of 525, 2%) (P = .003). Among 58 patients with rheumatoid arthritis, there were 5 postoperative shoulder infections (9%) compared with patients without rheumatoid arthritis (17 of 663, 3%) (P = .010). Patient age, gender, smoking status, history of diabetes mellitus, history of cancer/immunosuppression, and prior cortisone injection did not demonstrate significant associations with the development of postoperative infection.ConclusionPrior nonarthroplasty shoulder surgery and/or rheumatoid arthritis are independently associated with the development of postoperative infection after primary RTSA. Patients who demonstrate these risk factors should be appropriately evaluated and preoperatively counseled before undergoing primary RTSA. Strong consideration should be given to avoid minimally invasive nonarthroplasty surgery as a temporizing measure to delay definitive RTSA.

Early aseptic reoperation after shoulder arthroplasty increases risk of subsequent prosthetic joint infection.

BackgroundDespite the success of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), the clinical course of some patients necessitates operative intervention in the acute postoperative period. In this study, we evaluate the risk of subsequent prosthetic joint infection (PJI) in patients who undergo an aseptic reoperation within 90 days of primary shoulder arthroplasty.MethodA retrospective review of patients with primary TSA and RSA was performed using a commercially available national database (PearlDiver Inc., Fort Wayne, IN, USA). Queries were performed with use of International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Technology codes. Patients were divided into cohorts based on undergoing aseptic reoperation, reoperation for PJI, or no reoperations within 90 days of index procedure. Primary outcome was subsequent PJI within 1 year of index procedure. Observed PJI rates were compared using chi-square analysis. Risk factors for PJI were compared using logistic regression.ResultsFrom 2010 to 2018, a total of 96,648 patients underwent primary shoulder arthroplasty: 46,810 underwent TSA and 49,838 underwent RSA. The rate of aseptic reoperation within 90 days was 0.72% and 1.5% in the TSA and RSA cohorts, respectively. At 1 year postoperatively, patients who underwent an aseptic reoperation within 90 days had an elevated risk of subsequent PJI compared with the overall rate of PJI in the TSA (3.54% vs. 0.75%; P < .001) and RSA (3.08% vs. 0.73%; P < .001) cohorts. On multivariate logistic regression analysis, aseptic reoperation within 90 days was identified as a significant risk factor for subsequent PJI in the TSA cohort (odds ratio, 14.19; P < .001) and RSA cohort (odds ratio, 8.38; P < .001). The most common indication for aseptic reoperation was postoperative prosthetic joint instability in both the TSA (31%) and RSA (49%) cohorts.ConclusionAseptic reoperation within 90 days of primary TSA or primary RSA was associated with a notably increased risk of subsequent PJI.

Does application of hydrogen peroxide to the dermis reduce incidence of Cutibacterium acnes during shoulder arthroplasty: a randomized controlled trial.

Prosthetic joint infections (PJIs) following shoulder arthroplasty are a major source of morbidity and are most commonly caused by Cutibacterium acnes, a bacteria found concentrated in the dermis. Skin preparation using hydrogen peroxide has been shown to reduce positive cultures; however, direct application to the dermis has not been investigated. The purpose of this study is to determine whether the application of hydrogen peroxide to the dermis affects the incidence of positive C acnes cultures. A prospective, randomized controlled trial of patients undergoing primary shoulder arthroplasty by a single fellowship-trained surgeon was performed between February and November 2020. Enrolled patients were randomized to either receive standard skin preparation and antibiotic prophylaxis with or without an additional application of hydrogen peroxide to the dermis following incision. Culture samples were taken from the skin, dermis, glenohumeral joint, and air. Laboratory personnel and patients were blinded to randomization, and all cultures were held for 14 days. Culture positivity rate along with culture site, day of culture positivity, and bacterial abundance of positive cultures were analyzed. Stratified analysis by gender and age of ≤69 years was also performed. Sixty patients undergoing primary arthroplasty were randomized. The group receiving hydrogen peroxide (n =30) and the control group (n = 30) were similar in age (71.1 ± 7.1 vs. 73.4 ± 9.8; P = .30), body mass index (29.4 ± 5.7 vs. 28.5 ± 6.0; P = .57), gender (P = .64), hand dominance (P = .65), and surgery type (P = .90). The overall rate of at least 1 positive culture was 18%. All positive cultures were C acnes. The positive culture rate in the hydrogen peroxide (20%) and control group were similar (16%; P > .99). There were no positive glenohumeral joint cultures and no wound complications. There was no significance difference in the culture site, day of culture positivity, and bacterial abundance. Stratification analysis by gender and age also demonstrated similar rates of C acnes between study groups. Standard skin preparation and antibiotic prophylaxis results in an overall low rate of skin and dermis culture positivity. The use of hydrogen peroxide after initial incision did not significantly alter the rate of positive C acnes cultures during shoulder arthroplasty and did not increase wound complications.

CORR Insights®: A Comparison of Revision Rates for Osteoarthritis of Primary Reverse Total Shoulder Arthroplasty to Primary Anatomic Shoulder Arthroplasty with a Cemented All- polyethylene Glenoid: Analysis from the Australian Orthopaedic Association National Joint Replacement Registry.

CORR Insights®: A Comparison of Revision Rates for Osteoarthritis of Primary Reverse Total Shoulder Arthroplasty to Primary Anatomic Shoulder Arthroplasty with a Cemented All- polyethylene Glenoid: Analysis from the Australian Orthopaedic Association National Joint Replacement Registry.

Are primary and revision shoulder arthroplasty appropriately reimbursed based on relative value units?

BackgroundThe number of primary and revision shoulder arthroplasties performed each year continues to increase. Relative value units (RVUs) are currently used by the Centers for Medicare and Medicaid Services (CMS) to determine physician reimbursement based on time, effort, and complexity of services rendered. Compared to primary shoulder arthroplasty, revision shoulder arthroplasties are often more technically challenging, have longer operative times, and pose a greater risk of intraoperative and postoperative complications. This study aims to compare surgeon reimbursement between primary and revision shoulder arthroplasty. MethodsUtilizing a single institution shoulder arthroplasty database, we identified patients who underwent primary or revision shoulder arthroplasty between February 2011 and December 2013 by a single shoulder and elbow fellowship trained surgeon with over 20 years of experience at the time of data collection. The RVUs for primary and revision shoulder arthroplasty were obtained from the CMS Physician Fee schedule. Physician reimbursement for primary and revision shoulder arthroplasty was calculated using the CMS RVU to dollar conversion factor of $34.8921 per RVU. The RVU was divided by operative time to calculate an RVU/min for primary and revision shoulder arthroplasty. Monetary reimbursement per minute, case, day, and year was subsequently calculated. ResultsA total of 190 primary and 100 revision shoulder arthroplasties were performed during the study period. Mean RVU for primary shoulder arthroplasty was 22.13 ± 0.00 vs. 26.24 ± 1.10 for revision shoulder arthroplasty (P < .001). Mean operative time for primary shoulder arthroplasty was 111.17 ± 29.26 minutes vs. 145.12 ± 38.56 minutes for revision shoulder arthroplasty (P <.001). The RVU per minute for primary shoulder arthroplasty was 0.21 ± 0.05 and revision shoulder arthroplasty was 0.19 ± 0.04 (P < .001). The reimbursement for primary shoulder arthroplasty was $7.39/min ($772.16/case) and revision shoulder arthroplasty was $6.69/min ($915.92/case). With an estimated surgeon volume of 6 primary shoulder arthroplasties or 4 revision shoulder arthroplasties per day, reimbursement favors primary shoulder arthroplasty by a difference of $969.29 per day or $155,086.15 per year. ConclusionWhile the RVU/case is higher for revision shoulder arthroplasty, the difference does not account for the additional operative time and complexity compared to primary shoulder arthroplasty. In light of this data, the current RVU reimbursement model should be reevaluated to account for these differences between primary and revision shoulder arthroplasty. Level of EvidenceLevel III; Retrospective Comparative Study

Comparison study of patient demographics and patient-related risk factors for peri-prosthetic joint infections following primary total shoulder arthroplasty

BackgroundWhile studies have demonstrated favorable outcomes in utilization of primary total shoulder arthroplasty (TSA) for the treatment of glenohumeral osteoarthritis (OA), adverse events such as infections can still occur. Periprosthetic joint infections (PJIs) are associated with worse outcomes and patient morbidity. The purpose of this study was to: (1) compare patient demographics amongst TSA patients with and without PJIs following primary TSA; and (2) identify patient-related risk factors for PJIs following primary TSA. MethodsPatients undergoing primary TSA for the treatment of glenohumeral OA were identified using the Mariner administrative claims database by CPT code 23,472. Laterality modifiers were utilized to ensure PJIs were developing in the correct laterality as those patients undergoing primary TSA. Inclusion for the study group consisted of patients who developed PJIs within 2-years after the index procedure, whereas patients who did not develop PJIs served as the comparison cohort. Primary outcomes analyzed included patient demographics and patient-related risk factors for PJIs following primary TSA. A stepwise backwards elimination multivariate binomial logistic regression analyses was performed to determine the odds (OR) of PJIs in patients undergoing primary TSA. A P value less than .05 was considered statistically significant. ResultsThe query yielded 15,396 patients who underwent primary TSA for glenohumeral OA, of which 191 patients developed PJIs and 15,205 did not develop PJIs. The study found statistically significant differences amongst patients who did and did not develop PJIs following primary TSA with respect to age, sex, and presence of comorbid conditions. Risk factors associated with developing PJIs following primary TSA included: pathologic weight loss (OR: 2.06, P < .0001), obesity (OR: 1.56, P = .0001), male sex (OR: 1.52, P = .007), and peripheral vascular disease (OR: 1.46, P = .022). ConclusionAs the number of primary TSAs for the treatment of glenohumeral OA increase worldwide, identifying modifiable risk-factors to reduce the incidence of infection is critical. The study found various modifiable and non-modifiable risk factors associated with developing PJIs following primary TSA. This study is valuable to orthopedists in order to identify and risk-stratify patients with regard to PJI in the setting of primary TSA for OA. Level of EvidenceLevel III; Case-Control Study

Minimum clinically important difference for the American Shoulder and Elbow Surgeons score after revision shoulder arthroplasty

BackgroundPatients undergoing revision total shoulder arthroplasty (TSA) typically achieve smaller improvements in outcome measurements than those undergoing primary TSA. The minimum clinically important difference (MCID) in the American Shoulder and Elbow Surgeons (ASES) questionnaire for primary shoulder arthroplasty ranges from 13.6 to 20.9, but the MCID for revision shoulder arthroplasty remains unclear. This study aims to define the MCID in ASES score for revision TSA and ascertain patient factors that affect achieving the MCID threshold. MethodsPatients were identified from an institutional shoulder arthroplasty database. Prospective data collected included demographic variables, prior shoulder surgeries, primary and revision implants, indication for revision, and pre- and postoperative ASES scores. All patients provided informed consent to participate. An anchor-based method was used with a binary answer choice. The MCID was calculated using the receiver-operator curve (ROC) method, and the sensitivity, specificity, and area under the curve were obtained from the ROC. MCID values were compared between groups using Student's t-test. Multivariate logistic regression modeling was used to determine significant predictors for reaching MCID. Significance was defined as P< .05. ResultsA total of 46 patients underwent revision TSA with minimum 2-year follow-up. The MCID using ROC method was 16.7 with 71% sensitivity and 62% specificity. There was a trend toward males being more likely to reach MCID after revision arthroplasty (P= .058). There were also trends toward increased forward flexion and abduction range of motion in patients who met MCID (P= .08, P= .07). Multivariate logistic regression modeling demonstrated male sex to be associated with achieving MCID (P= .03), while younger age and fewer prior shoulder surgeries demonstrated a trend to association with achieving MCID (P= .06, P= .10). ConclusionThe MCID for ASES score in patients undergoing revision shoulder arthroplasty is similar to previously reported MCID values for patients undergoing primary shoulder arthroplasty. Younger, male patients with fewer prior shoulder surgeries were more likely to achieve MCID after revision TSA. Level of EvidenceLevel III; Retrospective Comparative Treatment Study

Congestive heart failure and renal failure in total shoulder arthroplasty: a national database study

BackgroundCongestive heart failure and renal failure are volume sensitive pathologies that lead to significant morbidity and mortality. Due to the aging population in the United States, more patients with volume sensitivity are expected to undergo shoulder arthroplasty. The purpose of this study was to determine the effect of volume sensitive comorbidities on acute postoperative outcomes following shoulder arthroplasty. MethodsThe American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent primary elective shoulder arthroplasty from January 1, 2011 to December 31, 2018. Patients who were diagnosed with volume sensitive diseases (congestive heart failure, kidney failure, and dialysis) were compared with non-volume sensitive patients. Demographic data, length of hospital stay, and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used isolate the effect of volume sensitivity on postoperative complications and readmission. ResultsA total of 23,761 patients underwent shoulder arthroplasty and 218 (0.9%) were volume sensitive. The overall adverse event rate across all patients was 6.5%. On univariate analysis, volume sensitive patients were more likely to need a reoperation within 30 days, require readmission within 30 days, have a minor or major complication, and were less likely to be discharged home (P < .05). However, multivariable logistic analysis found that volume sensitive comorbidities were not independently associated with readmission or major complications. Increasing age and higher ASA classification were associated with increased odds of both major and minor complications, and reduced odds of discharge home ConclusionThere is an increased rate of adverse acute outcomes following shoulder arthroplasty in the volume sensitive population which may be a result of comorbid factors, such as dependent functional status, increasing age, and higher ASA classification. Level of EvidenceLevel III; Retrospective Case-Control Study

Results after primary reverse shoulder arthroplasty with and without subscapularis repair: a prospective-randomized trial

IntroductionIndications for reverse shoulder arthroplasties (rTSA) have increased since their development by Paul Grammont in 1985. Prosthesis design was enhanced over time, but the management of the tendon of the M. subscapularis (SSC-tendon) in primary rTSA is still a controversial subject with regard to perform a refixation or not.Methods50 patients were randomized in a refixation group (A) and a non-refixation-group (B) of the SSC-tendon in a double-blinded fashion. SSC-function was assessed at baseline before surgery, such as 3 and 12 months after surgery. Constant–Murley-Shoulder Score (CS), American Shoulder and Elbow Surgeons Score (ASES), strength, range of motion (ROM), and pain on numeric rating scale (NRS) were measured in all examinations. An ultrasound examination of the shoulder was performed for evaluation of subscapularis tendon integrity at 3 and 12 month follow-up visits. Pain was evaluated on NRS via phone 5 days after surgery. Surgery was performed by a single experienced senior surgeon in all patients.ResultsPatients with a refixation of the SSC-tendon and primary rTSA had improved internal rotation [40° (20°–60°) vs. 32° (20°–45°); p = 0.03] at 12 months of follow-up. Additionally, the A-group had increased CS [74 (13–90) vs. 69.5 (40–79); p = 0.029] 1 year after surgery. Results were strengthened by subgroup analysis of successful refixation in ultrasound examination vs. no refixation. No differences were seen in ASES and NRS 1 year after rTSA.ConclusionSSC-tendon repair in rTSA improves CS and internal rotation 12 months after surgery.

Orthopedic Specialty Hospitals Are Associated With Lower Rates of Deep Surgical Site Infection Compared With Tertiary Medical Centers.

Orthopedic specialty hospitals may allow for more streamlined and efficient care, resulting in shorter lengths of stay, lower costs, and fewer complications. Surgical site infection can be a devastating complication of orthopedic procedures and is difficult to treat successfully, requiring substantial cost and resources. The goal of this study was to determine whether specialty hospitals had lower rates of infection than tertiary care institutions. Records were reviewed for patients undergoing primary total hip, knee, or shoulder arthroplasty and single-level lumbar fusion from 2010 to 2017 at 2 academic tertiary hospitals and 2 specialty hospitals. Patient demographic information, comorbidities, and the development of deep surgical site infection within 1 year of the index procedure were recorded and compared between the groups. Multivariate analysis identified variables that significantly correlated with infection rates. A total of 20,264 patients (73.9%) underwent surgery at a tertiary hospital, and 7169 (26.1%) underwent a procedure at a specialty hospital. Patients treated at orthopedic specialty hospitals had lower rates of infection at 1 year (0.6% vs 0.2%, P<.0001). Of the infections, 42 (32.3%) occurred in the knee, 50 (38.5%) in the hip, 24 (18.5%) in the spine, and 12 (10.8%) in the shoulder. When controlling for a healthier patient population, procedures performed at specialty hospitals were an independent predictor of infection within 1 year (odds ratio, 0.3693; P=.0012). Although tertiary hospitals care for older patients with more medical comorbidities, patients undergoing orthopedic procedures at a specialty hospital may be at lower risk for infection. Further study is needed to identify the processes associated with reduced infection rates and to determine whether they can be adopted at tertiary centers. [Orthopedics. 2021;44(4):e521-e526.].

Temporal and Geographic Trends in Medicare Reimbursement of Primary and Revision Shoulder Arthroplasty: 2000 to 2020.

A comprehensive understanding of the trends for financial reimbursement of shoulder arthroplasty is important as progress is made toward achieving sustainable payment models in orthopaedics. This study analyzes Medicare reimbursement trends for shoulder arthroplasty. We hypothesize that Medicare reimbursement has decreased for shoulder arthroplasty procedures from 2000 to 2020 and that revision procedures have experienced greater decreases in reimbursement. The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each Current Procedural Terminology code used in shoulder arthroplasty, and physician reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars. Both the average annual and the total percentage change in surgeon reimbursement were calculated based on these adjusted trends for all included procedures. Mean percentage change in adjusted reimbursement among primary procedures in comparison to revision procedures was calculated. The mean reimbursement was assessed and visually represented by geographic state. The average reimbursement for all shoulder arthroplasty procedures decreased by 35.5% from 2000 to 2020. Revision total shoulder arthroplasty (TSA) experienced the greatest mean decrease (-44.6%), whereas primary TSA (-23.9%) experienced the smallest mean decrease. The adjusted reimbursement rate for all included procedures decreased by an average of 1.8% each year. The mean reimbursement for revision procedures decreased more than the mean reimbursement for primary procedures (-41.1% for revision, -29.9% for primary; P < 0.001). The mean reimbursement for TSA in 2020, and the percent change in reimbursement from 2000 to 2020, varied by state. Medicare reimbursement for shoulder arthroplasty procedures has decreased from 2000 to 2020, with revision procedures experiencing the greatest decrease. Increased awareness and consideration of these trends will be important as healthcare reform evolves, and reimbursements for large joint arthroplasty are routinely adjusted.

The Clinical and Radiographic Impact of Increasing Medialization of the Bone-Prosthesis Interface in Primary Reverse Total Shoulder Arthroplasty At Short-Term Follow-Up

To compare the short-term clinical and radiographic outcomes of patients with differing amounts of medialization of the bone-prosthesis interface (MBPI) after primary reverse total shoulder arthroplasty (RTSA) using a prosthesis system with lateralization both in the humerus and the glenoid. We hypothesized that increases in MBPI by reaming the glenoid to neutral version using a lateralized system would not lead to decreased range of motion (ROM), decreased functional scores or increased scapular notching.

Comparison Study of Patient Demographics, Causes, Costs, and Risk-Factors Associated with Ninety-Day Readmissions Following Primary Reverse Shoulder Arthroplasty

The aim of this study was to 1) compare patient-demographics; 2) identify causes; 3) compare costs and identify patient-related risk factors for readmissions within 90-days following primary reverse total shoulder arthroplasty (rTSA).

Does the Subscapularis Refixation Effect the Clinical Outcome After Primary Reverse Shoulder Arthroplasty?

This prospective randomized study was conducted to evaluate the clinical benefit of the subscapularis refixation after reverse shoulder arthroplasty.

Role of Preoperative PROMIS Scores in Predicting Postoperative Outcomes and Likelihood of Achieving MCID Following Reverse Shoulder Arthroplasty

The purpose of this study was to investigate the influence of preoperative PROMIS scores in predicting postoperative PROMIS scores and the likelihood of achieving a minimal clinically important difference (MCID) following primary reverse total shoulder arthroplasty for cuff tear arthropathy.

Mid- to Long-Term Follow-Up of Shoulder Arthroplasty for Primary Glenohumeral Osteoarthritis in Patients Aged 60 or Under

Aim: The purpose of this multicenter study was to longitudinally evaluate young patients (<60 years old) undergoing primary shoulder arthroplasty for primary glenohumeral osteoarthritis.

Does fluoroscopy improve baseplate position compared to conventional technique in reverse shoulder arthroplasty? A preliminary study.

Accurate placement of glenoid component in reverse shoulder arthroplasty remains a challenge for surgeons of all levels of expertise; however, no studies have evaluated the utility of fluoroscopy as a surgical assistance method. Prospective comparative study of 33 patients undergoing primary reverse shoulder arthroplasty during a 12-month period. Fifteen patients had a baseplate placed using the conventional "free hand" technique (control group), and 18 patients using intraoperative fluoroscopy assistance group, in a case-control design. Postoperative glenoid position was evaluated on postoperative Computed Tomography (CT) scan. The mean deviation of version and inclination for fluoroscopy assistance vs. control group was 1.75° (0.675-3.125) vs. 4.2° (1.975-10.45) (p = .015), and 3.85° (0-7.225) vs. 10.35° (4.35-18.75) (p = .009). The distance from the central peg midpoint to the inferior glenoid rim (fluoroscopy assistance 14.61 mm/control 4.75 mm, p = .581) and the surgical time (fluoroscopy assistance 1.93 ± 0.57/control 2.18 ± 0.44 h, p = .400) showed no differences, with an average radiation dose of 0.45 mGy and fluoroscopy time of 14 s. Accurate axial and coronal scapular plane positioning of glenoid component is improved with intraoperative fluoroscopy at the cost of a greater radiation dose and without differences in surgical time. Comparative studies are needed to determine whether their use in relation to more expensive surgical assistance systems result in similar effectiveness.L evel of evidence : Level III, therapeutic study.

Return to Sports After Primary Reverse Shoulder Arthroplasty: Outcomes at Mean 4-Year Follow-up.

Background:With the expanding use of reverse shoulder arthroplasty (RSA) to treat various shoulder conditions, there has been a rise in the number of RSAs performed, especially in physically active patients. Limited information regarding sports after RSA is available to properly counsel patients on postoperative expectations.Purpose:To assess the rate of return to sports as well as the ability to return to the same level of preoperative intensity, frequency, and duration of sport after primary RSA.Study Design:Case series; Level of evidence, 4.Methods:This was a retrospective review of patients who underwent primary RSA at our institution between 2014 and 2016. Shoulder motion, Subjective Shoulder Value score, American Shoulder and Elbow Surgeons score, pre- and postoperative sports activities, and barriers to return to sport were assessed in 109 patients after RSA (93 patients with unilateral RSA and 16 patients with bilateral RSA). The mean age at the time of surgery was 70 years (range, 34-86 years), with a mean follow-up of 3.9 years (range, 2-12 years).Results:The mean rate of return to sports was 70.1% (range, 0%-100%). There was no difference in return to sports between those with uni- and bilateral RSA (P = .64). Fishing, swimming, elliptical/treadmill, and hunting were the most common sports after RSA with return rates of 91%, 73%, 86%, and 82% respectively. A majority of patients returned to the same level of preoperative intensity, frequency, and duration for all sports except for climbing and swimming. There was a lower mean rate of return for high-demand sports (62.9%) compared with low- and medium-demand sports (76.7%) (P = .005). The most common reasons for inability to return to sports included limited motion, fear of injury, and weakness.Conclusion:Patients who had undergone primary uni- or bilateral RSA reported a 70.1% rate of return to sports with maintenance of the same level of intensity, duration, and frequency of preoperative sport participation. Rates of return to high-demand sports were lower than low- and medium-demand sports. Patients also had difficulty returning to overhead sports.

Comparison of patient demographics and patient-related risk factors for dislocations following reverse shoulder arthroplasty

BackgroundDislocations following primary reverse total shoulder arthroplasty (rTSA) are a feared and concerning complication. With the increasing number of reverse total shoulder arthroplasty (rTSA) procedures being performed worldwide e, studies evaluating risk factors for dislocation following this procedure are limited. The purpose of this study was to utilize a large claims database to identify patient-related risk factors associated with dislocations following primary rTSA. MethodsA retrospective query of the Part A and Part B 100% Medicare Standard Analytical Files (SAF) claims database was performed identifying patients who underwent primary rTSA for the treatment of glenohumeral osteoarthritis. The inclusion criteria for the study group consisted of all patients who had a dislocation within 2-years following the index procedure. Patients with a record of other arthroplasty-type procedures were excluded. The query yielded 30,670 patients with (n = 703) and without (n = 29,967) dislocations. Multivariate binomial logistics regression analysis was performed to calculate odds (OR) on the impact of patient-related risk factors for dislocations following primary rTSA. A P value less than .002 was considered statistically significant. ResultsStudy group patients that sustained a dislocation following primary rTSA were generally younger than the age of 65 (16.8 vs. 8.3%) and male (59.6 vs. 38.8%). Study group patients had a higher comorbidity burden, as demonstrated by higher mean Elixhauser-Comorbidity Index (ECI) scores (9 vs. 6, P < .0001). The greatest risk factors for dislocations included being male (OR: 3.06, P < .0001), opioid use disorder (OR: 1.74, P = .0007), hypertension (OR: 1.56, P = .001), morbid obesity (OR: 1.43, P < .0001), electrolyte and fluid derangements (OR: 1.29, P = .0001), and depressive disorders (OR: 1.23, P = .0001). ConclusionAs the number of primary rTSA procedures increase worldwide, identification of patient-related risk factors for dislocations is of great importance. The study showed the greatest risk factors for dislocations included male sex with modifiable risk factors being opioid use disorder, hypertension, and morbid obesity. The study is vital as it can facilitate in guiding orthopedists and altering management for these high-risk patients. Level of evidenceLevel III, retrospective comparative study.

Primary and revision shoulder arthroplasty in patients with pulmonary hypertension: an underlying condition associated with high perioperative mortality and complications

BackgroundPulmonary hypertension is a progressive medical condition that has been identified as a risk factor for perioperative morbidity and mortality in both cardiac and non-cardiac surgery, including hip arthroplasty. Currently, there is very limited information on the impact of pulmonary hypertension (PHTN) on patients undergoing shoulder arthroplasty. This investigation analyzed the mortality, perioperative medical complications, implant survivorship, and clinical outcomes in this medically complex cohort. MethodsBetween January 2000 and July 2018, 380 primary and 59 revision shoulder arthroplasties were performed at a single institution in patients with a diagnosis of pulmonary hypertension prior surgery. Average age was 72.8 ± 11.0 and 72.1 ± 9.5 years for the primary and revision SA groups, respectively (P= .65). The median American Society of Anesthesiologists (ASA) scores were predominantly class 3 in both cohorts. Descriptions of group characteristics were calculated with student tests for numerical values. Mortality after primary and revision shoulder arthroplasties were individually calculated through a cumulative incidence analysis. Implant survivorship was analyzed with a competing risk model selecting death as the competing risk. ResultsThe 90-day mortality was 1.6% for primary and 3.4% for revision SA, respectively. The cumulative incidences of death at 2, 5, 10, and 15 years were 16.5%, 43.3%, 80.8%, and 88.5% for primary and 12.1%, 44.7%, 64.4%, and 100% for revision arthroplasties, respectively. Medical complications were observed in 13.4% of primary and 42.4% of revision shoulder arthroplasties. These included respiratory failure and/or acute respiratory distress syndrome (3.2%), arrhythmia (2.7%), deep vein thrombosis (1.8%), and pulmonary embolism (1.6%). The 10-year cumulative incidences of revision for any reason were 4.5% in primary and 10.4% in revision shoulder arthroplasties. At final follow-up, the mean VAS and ASES scores were 2.3 ± 2.5 and 72.0 ± 18.5 in primary SA and 4.1 ± 2.9 and 51.8 ± 21.8 in revision SA. ConclusionsA concomitant diagnosis of PHTN in patients undergoing primary or revision shoulder arthroplasty was associated with a high rate of perioperative medical complications and mortality rates at 90 days and at 10 years in both cohorts. This information should be considered to counsel patients, optimize their perioperative management, and anticipate a more complicated and costly postoperative recovery. Level of EvidenceLevel IV; Case Series with no Comparison Group