Primary Shoulder Arthroplasty Research Articles

A nationwide analysis on the effects of chronic obstructive pulmonary disease following primary total shoulder arthroplasty for glenohumeral osteoarthritis.

Chronic obstructive pulmonary disease patients have been shown in orthopedic literature to have poorer outcomes and higher rates of complications from surgery. In this retrospective review, medical complications, length of stay, and costs were obtained to explore the effects of chronic obstructive pulmonary disease on patients undergoing primary total shoulder arthroplasty. Total shoulder arthroplasty cases from January 2005 to March 2014 were queried and analyzed from a nationwide database. Study patients were matched 1:5 to controls by age, sex, and medical comorbidities associated with chronic obstructive pulmonary disease. In-hospital length of stay, 90-day medical complications, day of surgery, and total global 90-day episode of care costs were obtained for comparison. Chronic obstructive pulmonary disease patients were found to have higher incidence and odds (53.91 vs. 11.95%; OR: 3.58, 95%CI: 3.18-3.92, p < 0.0001) of 90-day medical complications, longer in-hospital length of stay (3 vs. 2 days, p < 0.0001), and significantly higher 90-day costs ($14,768.37 vs. $13,379.20, p < 0.0001) following primary total shoulder arthroplasty compared to matched controls. Chronic obstructive pulmonary disease patients undergoing primary total shoulder arthroplasty have higher rates of medical complications, in-hospital length of stay, and costs of care. This represents an important factor that will allow orthopedic surgeons to adequately manage expectations and educate chronic obstructive pulmonary disease patients of the potential complications which may occur following total shoulder arthroplasty.

A matched-control analysis on the effects of alcohol use disorder following primary reverse shoulder arthroplasty

IntroductionThe purpose of this study was to determine whether alcohol use disorder (AUD) patients undergoing reverse shoulder arthroplasty (RSA) have increased: 1) lengths of stay (LOS); 2) complications; and 3) costs. MethodsThe study identified 19,168 patients in the study (n = 3198) and control (n = 15,970) cohort. In-hospital LOS, 90-day complications, and costs were assessed. ResultsAUD patients had significantly longer LOS (3- vs. 2-days, p < 0.0001), higher9 0-day medical complications (49.59 vs. 14.81%; p < 0.0001), and 90-day costs of care ($18,763.25 vs. $16,035.49, p < 0.0001). ConclusionsThe study is useful as it can allow healthcare professionals to adequately counsel these patients.

Negligible Correlation between Radiographic Measurements and Clinical Outcomes in Patients Following Primary Reverse Total Shoulder Arthroplasty.

Previous attempts to measure lateralization, distalization or inclination after reverse total shoulder arthroplasty (rTSA) and to correlate them with clinical outcomes have been made in the past years. However, this is considered to be too demanding and challenging for daily clinical practice. Additionally, the reported findings were obtained from heterogeneous rTSA cohorts using 145° and 155° designs and are limited in external validity. The purpose of this study was to investigate the prognostic preoperative and postoperative radiographic factors affecting clinical outcomes in patients following rTSA using a 135° prosthesis design. In a multi-center design, patients undergoing primary rTSA using a 135° design were included. Radiographic analysis included center of rotation (COR), acromiohumeral distance (AHD), lateral humeral offset (LHO), distalization shoulder angle (DSA), lateralization shoulder angle (LSA), critical shoulder angle (CSA), and glenoid and baseplate inclination. Radiographic measurements were correlated to clinical and functional outcomes, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (STT), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) score, active forward elevation (AFE), external rotation (AER), and abduction (AABD), at a minimum 2-year follow-up. There was a significant correlation between both DSA (r = 0.299; p = 0.020) and LSA (r = −0.276; p = 0.033) and the degree of AFE at final follow-up. However, no correlation between DSA (r = 0.133; p = 0.317) and LSA (r = −0.096; p = 0.471) and AER was observed. Postoperative AHD demonstrated a significant correlation with final AFE (r = 0.398; p = 0.002) and SST (r = 0.293; p = 0.025). Further, postoperative LHO showed a significant correlation with ASES (r = −0.281; p = 0.030) and LSA showed a significant correlation with ASES (r = −0.327; p = 0.011), SANE (r = −0.308, p = 0.012), SST (r = −0.410; p = 0.001), and VAS (r = 0.272; p = 0.034) at terminal follow-up. All other correlations were found to be non-significant (p > 0.05, respectively). Negligible correlations between pre- and postoperative radiographic measurements and clinical outcomes following primary rTSA using a 135° prosthesis design were demonstrated; however, these observations are of limited predictive value for outcomes following rTSA. Subsequently, there remains a debate regarding the ideal placement of the components during rTSA to most sufficiently restore active ROM while minimizing complications such as component loosening and scapular notching. Additionally, as the data from this study show, there is still a considerable lack of data in assessing radiographic prosthesis positioning in correlation to clinical outcomes. As such, the importance of radiographic measurements and their correlation with clinical and functional outcomes following rTSA may be limited.

Increased severity of anemia is associated with postoperative complications following primary total shoulder arthroplasty.

Anemia has been demonstrated as a modifiable risk factor for postoperative complications following various types of primary and revision total joint arthroplasties. However, at present, we are not aware of any studies assessing postoperative complications following total shoulder arthroplasty (TSA) in patients with varying severity of anemia. The purpose of this study was to determine the influence of preoperative anemia severity on 30-day postoperative complications following primary TSA. Adult patients undergoing primary TSA from 2012 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients undergoing TSA were substratified into 3 cohorts: nonanemia (hematocrit >36% for women, >39% for men), mild anemia (hematocrit 33%-36% for women, 33%-39% for men), and moderate to severe anemia (hematocrit <33% for both women and men), based on World Health Organization definitions of anemia. In this analysis, 30-day wound, cardiac, pulmonary, renal, and thromboembolic complications, as well as sepsis, mortality, postoperative transfusion, extended length of stay, and reoperation were assessed. Bivariate analyses, including χ2 and analysis of variance, and multivariable logistical regression were performed. Of 13,921 total patients undergoing TSA, 11,330 patients (81.4%) did not have anemia, 1934 (13.9%) had mild anemia, and 657 (4.7%) had moderate to severe anemia. Following adjustment, patients with mild anemia were more likely to have a postoperative blood transfusion (odds ratio [OR] 4.7, P < .001), extended length of stay (OR 1.7, P = .002), and reoperation (OR 1.5, P = .028). Patients with moderate to severe anemia were at increased risk of cardiac complications (OR 3.0, P = .012), pulmonary complications (OR 2.2, P = .015), postoperative blood transfusion (OR 23.8, P < .001), extended length of stay (OR 6.6, P < .001), reoperation (OR 2.2, P = .003), and death (OR 3.8, P = .034). From mild anemia to moderate to severe anemia, there was a stepwise and approximately 2-fold increase in the odds of postoperative complications for patients undergoing primary TSA. Patients with moderate to severe anemia should be medically optimized before they undergo TSA.

Primary reverse shoulder arthroplasty in patients with metabolic syndrome is associated with increased rates of deep infection.

Metabolic syndrome (MetS) is an abnormal physiological condition that has been increasingly identified as a risk factor for complications after orthopedic surgery. Given the lack of information on the effect of MetS in shoulder arthroplasty (SA), this investigation analyzed the rates of postoperative complications and implant survivorship free from reoperation and revision in patients with and without MetS. Between 2007 and 2017, data from 4635 adults who underwent a primary SA were collected and classified based on the presence or absence of MetS. MetS was defined as the existence of type 2 diabetes mellitus and a minimum of 2 of the following diagnoses: hyperlipidemia, hypertension, and body mass index ≥ 30 kg/m2 within 1 year of surgery. Of the 4635 arthroplasties, 714 were performed in patients with MetS (anatomic total shoulder arthroplasty [aTSA] in 289 and reverse shoulder arthroplasty [RSA] in 425) and 3921 were performed in patients without MetS (aTSA in 1736 and RSA in 2185). Demographic characteristics, complications, reoperations, and revision surgery were compared. At a mean of follow-up of 4.5 ± 2.3 years, 67 MetS patients (9.4%) and 343 non-MetS patients (8.7%) had sustained at least 1 postoperative complication (P = .851). Rotator cuff failure was the most common complication overall, with 84 cases (1.8%) (15 MetS cases [2.1%] and 69 non-MetS cases [1.8%], P = .851), and in both MetS and non-MetS patients, followed by infection, with 68 cases (1.2%) (10 MetS cases [1.4%] and 58 non-MetS cases [1.2%], P = .913). For aTSAs, the most common complication was rotator cuff failure (84 shoulders, 1.8%); for RSAs, the most common complication was periprosthetic fracture (52 shoulders, 1.1%). In RSAs, the rates of deep infection (1.9% vs. 0.7%, P = .04), instability (3.1% vs. 1.5%, P = .04), and deep venous thrombosis or pulmonary embolism (0.5% vs. 0.3%, P = .03) were found to be significantly higher in patients with MetS than in those without MetS. Reoperations were observed in 36 MetS patients (5%) and 170 non-MetS patients (4.3%) (P = .4). Revisions were performed in 30 MetS patients (4.2%) and 127 non-MetS patients (3.2%) (P = .19). The Kaplan-Meier 5-year rate of survivorship free from reoperation, revision, and prosthetic joint infection was equal between groups. A preoperative diagnosis of MetS in patients undergoing primary SA did not significantly increase the risk of postoperative complications, infection, reoperation, or revision following primary SA. However, in the RSA subgroup, complications were significantly more common in patients with MetS. Individual risk factors may be more appropriate than the umbrella diagnosis of MetS prior to aTSA.

Value Analysis of Anatomic and Reverse Shoulder Arthroplasty for Glenohumeral Osteoarthritis with an Intact Rotator Cuff.

While anatomic total shoulder arthroplasty (TSA) has historically been considered the ideal treatment for end-stage glenohumeral osteoarthritis, reverse shoulder arthroplasty (RSA) has recently gained popularity. With substantial differences in implant design and cost between TSA and RSA, further investigation of outcomes and value is needed to support recent trends. The purpose of this study was to use the average and incremental cost-effectiveness ratio (ACER and ICER) and the procedure value index (PVI) to examine differences in outcomes and value between TSA and RSA for treatment of glenohumeral osteoarthritis with an intact rotator cuff. We performed a retrospective matched-cohort study of patients treated with primary shoulder arthroplasty for osteoarthritis with an intact rotator cuff who had a minimum 2-year follow-up. Outcome measures analyzed included the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) questionnaire, visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE), and overall satisfaction. Patients treated with TSA were matched 4:1 to those treated with RSA based on sex, age, and preoperative SST score. Value differences between TSA and RSA were calculated. Radiographs were analyzed for preoperative glenoid classification and postoperative radiolucent lines and gross loosening. Two hundred and fifty-two TSA-treated patients were matched to 63 RSA-treated patients with no significant differences in sex, age, or preoperative SST score. Total hospitalization costs, charges, and reimbursements along with outcome improvements in units of minimal clinically important differences (MCIDs) and patient satisfaction did not differ between the groups. For RSA, the implant cost was significantly higher than that for TSA, but the operating room, anesthesia, and cement costs were lower. The TSA group had a 3.2% rate of gross glenoid loosening and a 2.4% revision rate. There was no loosening or revision in the RSA group. None of the value analytics differed between groups even after inclusion of the outcomes and costs of early TSA revisions. TSA and RSA demonstrated similar outcomes and value when used to manage glenohumeral osteoarthritis with an intact rotator cuff. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The association between bisphosphonate use and aseptic revision risk in primary elective shoulder arthroplasty

BackgroundThe total joint literature has shown promising results of bisphosphonate use on decreasing early bone loss after hip and knee arthroplasty and reducing aseptic revision risk though a higher risk of periprosthetic fracture has also been reported. We sought to evaluate the association between bisphosphonate use and aseptic revision risk in patients undergoing shoulder arthroplasty. MethodsA US integrated healthcare system's registry was used to identify 6204 patients who underwent primary elective shoulder arthroplasty for osteoarthritis (2005-2016). Preoperative bisphosphonate users (defined as having at ≥6-month supply and 80% adherence) were compared to nonbisphosphonate users. Multivariable Cox proportional hazard regression was used to evaluate aseptic revision risk according to bisphosphonate use while adjusting for confounders. Secondary analysis stratified by age (40-64, ≥65 years) and bone quality status (normal, osteopenia, osteoporosis, or unknown). ResultsAt the time of index procedure, 564 (9.1%) were considered as bisphosphonate users. We failed to observe a difference in aseptic revision risk by bisphosphonate use (hazard ratio = 0.92, 95% confidence interval = 0.50-1.72). No association was observed even after stratifying by bone quality and age. No revisions for periprosthetic fracture occurred in the bisphosphonate user group during follow-up. ConclusionsWhile prior studies in lower extremity joint arthroplasty cohorts have observed a differential risk for revision surgery with bisphosphonate use, we failed to observe any associations between bisphosphonate use and revision risk in a cohort of shoulder arthroplasty patients. Level of EvidenceLevel III; Retrospective Cohort Comparative Study

Analysis of patient characteristics and outcomes related to distance traveled to a tertiary center for primary reverse shoulder arthroplasty.

The reasons for referral and travel patterns are lacking for patients undergoing reverse shoulder arthroplasty (RSA). The purpose of this study was to compare comorbidities, surgical time, cost and complications between local and distant primary RSA patients. Between 2007 and 2015, 1,666 primary RSAs were performed at our institution. Patients were divided into two cohorts, local patients (from within Olmstead county and surrounding counties, 492 RSAs) and those from a distance (1,174 RSAs). Local patients were older (74 vs 71years, p < .001), more likely to have RSA for fracture, had a higher Charlson comorbidity score (3.8 vs 3.2, p < .001) and longer hospital stays (2.0 vs 1.8days, p < 0.001) compared to referred patients. Referral patients required longer operative times (95 vs 88min, p = .002), had higher hospitalization costs ($19,101 vs $18,735, p < .001), and had a higher rate of prior surgery (32% vs 24%, p < .001). There were no differences between cohorts regarding complications or need for reoperation. Patients traveling from a distance to undergo primary RSA had longer operative times and were more likely to have had prior surgery than local patients. This may demonstrate the referral bias seen at large academic centers and should be considered when reviewing RSA outcomes, hospital performance, and calculating insurance reimbursement. Level IV.

Anatomic shoulder arthroplasty in workers’ compensation patients: predictors of success and return to work

BackgroundIn patients with shoulder arthritis, workers’ compensation (WC) status presents unique challenges to the clinician because of the socioeconomic and psychosocial aspects attendant to patients covered on this type of insurance. Patients, surgeons, and these insurance programs would be informed by a better understanding of the factors that may impact the results of a shoulder arthroplasty as treatment for glenohumeral arthritis in this population. The objectives of this study were to determine: (1) the extent to which patient-reported outcomes are impacted by WC status in comparison to patients covered by other types of insurance, (2) which factors are predictive of a successful outcome of shoulder arthroplasty as defined by improvement exceeding the minimal clinically important difference (MCID), (3) the ability of WC patients to return to their presurgical occupation after arthroplasty. MethodsThis was a retrospective study of a longitudinally maintained institutional database of 677 patients who underwent primary anatomic shoulder arthroplasty with a minimum 2-year follow-up, 39 of whom had WC insurance. These patients were compared to a matched cohort of 78 patients without WC insurance. Primary outcome measures included SST scores, SANE scores, and need for revision surgery. Univariate and multivariate analyses were performed to determine preoperative characteristics associated with success as defined by improvement greater than the MCID of the SST. ResultsSuccess, defined as improvement beyond MCID, occurred in a significantly lower proportion of WC patients compared to non-WC patients (64% vs. 94%, P< .001). Older age (P= .010) and a higher preoperative SF-36 role physical domain score (a measure of the patient's perceived limitations in routine activities;P= .007) were associated with improvement beyond the MCID on univariate analysis. Higher preoperative SF-36 role physical domain scores had the greatest correlation with a successful outcome (OR 1.19, 95% 0.99-1.43, P= .07). A significantly lower percentage of patients with physically-demanding jobs returned to previous occupation compared to patients with non-physically-demanding jobs (13% vs. 73%, P= .001). ConclusionsThe challenges in treating patients covered by WC are underscored by the high percentage of these patients that do not improve beyond the MCID and the high percentage of patients with physically-demanding jobs that are unable to return to their presurgical occupation. Those patients who report less disability with routine daily activities (ie, higher SF-36 role physical domain scores) may fare better with anatomic shoulder arthroplasty. Patients with physically-demanding jobs should be counseled that return to their previous occupation is unlikely. Level of EvidenceLevel III; Retrospective Cohort Comparative Study

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

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

Undergoing an Arthroscopic Procedure Prior to Shoulder Arthroplasty is Associated With Greater Risk of Prosthetic Joint Infection

To utilize a national all-payer claims dataset to understand whether a history of a prior shoulder arthroscopy is associated with adverse outcomes or complications after the index shoulder arthroplasty itself. The Symphony Integrated DataVerse, an all-payer claims database, was used to identify patients undergoing primary shoulder arthroplasty (hemiarthroplasty, anatomic total shoulder arthroplasty, or reverse total shoulder arthroplasty) between 2017 to 2018. Current Procedural Terminology codes were used to identify patients who had undergone a shoulder arthroscopic procedure on the ipsilateral side within 2 years before the arthroplasty. Multivariate logistic regression analyses were used to assess whether prior shoulder arthroscopy was associated with higher risks of wound complications, postoperative stiffness, mechanical complications, prosthetic joint infection, revision surgery and readmissions within 90 days of the arthroplasty. In total, 19,429 patients were included, of which 837 (4.3%) had undergone shoulder arthroscopy within 2 years before the arthroplasty. Prior shoulder arthroscopy was associated with a significantly higher risk of prosthetic joint infection (odds ratio [OR] 2.74 [95% confidence interval {CI} 1.51-4.69]; P < .001) within 90 days of the arthroplasty. The greatest risk of prosthetic joint infection was associated with arthroscopies that took place within 3 months before the arthroplasty (OR 5.32 [95% CI 1.42-15.14]; P= .005). Undergoing an arthroscopic procedure of the ipsilateral shoulder before undergoing an arthroplasty was associated with greater risk of prosthetic joint infection. Furthermore, it appears that patients who received arthroscopy within the 3 months before arthroplasty had the highest risk of prosthetic joint infections. Physicians should not only anticipate possible inferior outcomes in patients who have had prior arthroscopy, but also consider delaying the arthroplasty by at least 3 months after the arthroscopy to mitigate the risks of experiencing this costly adverse event. III.

Assessing the required glenoid peg penetration in native scapula when bone graft is used during primary and revision shoulder arthroplasty.

Achieving purchase in native glenoid bone is essential for the stability of the glenoid baseplate when bone graft is used to address bone loss in both primary and revision shoulder arthroplasty procedures. The aim of this study is to assess the required depth of the baseplate peg in native bone when bone graft is used to result in satisfactory integration. The CT scans of patients who underwent either primary or revision arthroplasty procedures with bone graft using the SMR Axioma Trabecular Titanium (TT) Metal Backed glenoid system were assessed. We measured the depth of the glenoid peg in native glenoid bone. Measurements were taken by two authors separately. The scans of 53 patients (mean age 68 years) with a minimum follow-up of two years were reviewed. Implants included 12 anatomical and 41 reverse geometry prostheses. There were 17 primaries and 36 revisions: hemiarthroplasties (20) total (14) and reverse (2) implants. Bone grafts were from humeral head (15), iliac crest (34) and allograft (4). The mean depths were 8.8 mm (first assessor) and 9.10 mm (second assessor). The glenoid peg violated the glenoid vault in 32 patients and this did not adversely affect the outcome. There were three failures of implants all of which were aseptic failures and had peg penetration of less than 6 mm. The mean depth of glenoid peg in native bone was 9 mm (variation between 0.2 and 0.52 mm at 95% confidence interval). Aseptic loosening was seen with peg penetration less than 6 mm in native bone. Glenoid vault violation was not associated with loosening.

Risk factors for postoperative blood transfusion after shoulder arthroplasty.

To identify the effect of surgical indication, patient factors, and perioperative characteristics on transfusion after shoulder arthroplasty (SA). Shoulder arthroplasties for osteoarthritis (OA) (N = 47), rotator cuff arthropathy (RCA) (N = 50), fracture (N = 76), revision (N = 66), and periprosthetic joint infection (PJI) (N = 35) performed at a single institution during a 6-year period were included. All other indications were excluded. Patient-based and surgical risk factors, including surgical indication, for postoperative allogeneic red blood cell transfusion were assessed with multivariate logistic regression analysis. A total of 274 SAs were included; transfusions were performed in 2% (2/97) of primary SAs for OA or RCA. Increased transfusion rates occurred in PJI (23%, p = 0.0006) and fracture (18%, p = 0.0018) cases. The mean preoperative hemoglobin (Hgb) was 12.2 ± 2.2 with PJI, 12.0 ± 2.1 with fracture, and 13.3 ± 1.6 g/dL for all other SAs. Independent risk factors for transfusion included lower preoperative hemoglobin (p < 0.001), PJI indication (p = 0.008), and fracture indication (p = 0.02), with no difference for fracture greater or less than 4 weeks old (p = 0.53). Risk factors for allogeneic red blood cell transfusion after SA were low preoperative hemoglobin and procedures for PJI or fracture.Level of Evidence: Level III, retrospective case-control study.

Creation of a Custom-Length, Humeral Antibiotic Cement Spacer for Use in Treatment of Shoulder Periprosthetic Joint Infection

Periprosthetic joint infection of the shoulder is a challenging clinical situation to manage owing to the fastidious organisms often present and delayed clinical presentation. While several treatment options have been described, the mainstay of treatment remains a staged revision with the use of a humeral antibiotic cement spacer. Such spacers are commercially available or can be made by hand. When an extended humeral osteotomy is required to remove a well-fixed long stem humeral component, it may be advantageous to place an antibiotic spacer with a stem length approximately as long as the hardware being removed. This technique demonstrates creation of a custom length, humeral antibiotic cement spacer for use in treatment of shoulder periprosthetic joint infection.

The rate of 2nd revision for shoulder arthroplasty as analyzed by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)

Background and purpose — The increase in shoulder arthroplasty may lead to a burden of revision surgery. This study compared the rate of (2nd) revision following aseptic 1st revision shoulder arthroplasty, considering the type of primary, and the class and type of the revision. Patients and methods — All aseptic 1st revisions of primary total reverse shoulder arthroplasty (rTSA group) and of primary total stemmed and stemless total shoulder arthroplasty (non-rTSA group) procedures reported to our national registry between April 2004 to December 2018 were included. The rate of 2nd revision was determined using Kaplan–Meier estimates and comparisons were made using Cox proportional hazards models. Results — There was an increased risk of 2nd revision in the 1st month only for the rTSA group (n = 700) compared with the non-rTSA group (n = 991); hazard ratio (HR) = 4.8 (95% CI 2.2–9). The cumulative percentage of 2nd revisions (CPR) was 24% in the rTSA group and 20% in the non-rTSA group at 8 years. There was an increased risk of 2nd revision for the type (cup vs. head) HR = 2.2 (CI 1.2–4.2), but not class of revision for the rTSA group. Minor (> 3 months) vs. major class revision, and humeral revision vs. all other revision types were second revision risk factors for the non-rTSA group. Interpretation — The CPR of revision shoulder arthroplasty was > 20% at 8 years and was influenced by the type of primary, the class, and the type of revision. The most common reasons for 2nd revision were instability/dislocation, loosening, and infection.

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

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

Screw-Tip Augmented Locked Plating Versus Primary Reverse Total Shoulder Arthroplasty in Displaced Proximal Humeral Fractures: A Retrospective Comparative Cohort Study With a Mean Follow-Up of 39 Months.

IntroductionThis study compared the clinical and radiologic outcomes of screw-tip augmented locking plate osteosynthesis (STA) vs primary reverse total shoulder arthroplasty (RSA) in elderly patients with displaced proximal humeral fractures.Methods60 patients (age >65 years) with a displaced proximal humeral fracture underwent open reduction and internal fixation with locking plate and fluoroscopy controlled screw-tip augmentation. Sixty matched individuals (age, gender, fracture pattern, and mean follow-up) treated by RSA for fractures were identified from the institutional database and outcomes as well as occurring complications and need for revision surgery were compared.ResultsAt 39 months’ follow-up, 25 patients in the STA group (mean age 74.5 ± 12 years, 76.7% woman) showed a mean Constant Score (CS) of 68 ± 18.8 points. Mean %CS compared to the contralateral side was 81.6 ± 19.8%. Of 60 matched individuals in the RSA group, 22 patients (mean age 78.9 ± 8.2 years, 76.7% woman) showed a mean CS of 60.6 ± 21.2 points (P = .33), and the mean %CS compared to the contralateral side was 81.6 (74.7 ± 18.6)% (P = .14). The overall complication rate in STA group was 32% (secondary varus or valgus displacement >10°, n = 4, avascular necrosis, n = 4). In RSA group, the overall complication rate was 4.5% (P = <.05). We observed one early onset infection. Revision surgery with removal of the prosthesis and PMMA spacer implantation for two-stage revision was necessary. The follow-up rate was 41.7 vs 36.7%.ConclusionsScrew-tip augmented locked plating and reverse total shoulder arthroplasty result in comparable satisfying functional outcome 3 years following a displaced proximal humeral fracture in elderly patients. However, we noted a higher complication and revision rate in the STA group. In contrast, primary reversed shoulder arthroplasty resulted in a lower rate of complications and revisions, which may be beneficial in elderly patients.

Outcomes after primary reverse total shoulder arthroplasty in patients with comorbid anxiety and depressive disorders: a retrospective cohort study

Background: Current literature generally indicates that anxiety and depressive disorders have negative effects on the outcomes of orthopaedic procedures. We studied a patient population with primary reverse total shoulder arthroplasty (RTSA) to evaluate the effect of these disorders on 2-year outcomes. Methods: Patients were classified as having depression or anxiety by documentation of such in the chart or the use of a prescription mood-stabilizing drug. Pain and function were evaluated with visual analog scale (VAS) and American Shoulder and Elbow Surgeons (ASES) scores, respectively. Data for complications, reoperations, and readmissions were also compiled, and radiographs were assessed for loosening or component failure at the most recent follow-up. Results: Database search identified 112 patients (114 shoulders) with primary RTSA and a minimum of 2-year clinical and radiographic follow-up. Thirty-one patients were categorized as having depression and/or anxiety, and 81 (83 shoulders) did not have these disorders. Significantly more women than men were in the anxiety and depression group (P=0.007). There were no significant differences in other patient demographics or VAS, ASES score, range of motion, or strength at 2-year follow-up (all P&gt;0.05). Three complications occurred in the anxiety/depression group, and 16 occurred in the group without these disorders (P=0.34). Conclusions: Contrary to most current literature, these results suggest that patients with anxiety and/or depression can expect similar outcomes as those of patients without these disorders after primary RTSA. Level of Evidence: Level III.

Relative value units and reimbursement for primary and revision total shoulder arthroplasty

BackgroundRelative value units (RVU), based on physician work and case expenses, are reimbursement and payment rates set by the Center for Medicare and Medicaid Services. Total shoulder arthroplasty (TSA) is performed less frequently than total hip and knee arthroplasty and may take longer to perform yet has a similar RVU assignment. The purpose of this study is to determine differences in RVU/minute and dollars/minute for primary and revision TSA and to compare the RVUs/minute and dollars/minute of shoulder arthroplasty to published reports of hip and knee arthroplasty. MethodsIn this retrospective cohort study, data were collected through the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2006 to 2018. Current procedural terminology (CPT) code 23472 was used to identify all primary TSA cases (N = 16,719), and CPT codes 23473 and 23474 were used for revision TSA cases (N = 948). Work RVU, operation time, and RVU per minute were compared between the primary and revision shoulder cohorts. The conversion factor for RVU to dollar was provided by the U.S. Centers for Medicare and Medicaid Services, and dollars per minute calculations were performed for the 2 cohorts. Multiple regression analysis was performed to control for age, gender, race, BMI, and American Society of Anesthesiologists classification. Univariate and multivariate analyses with a significance set at P < .05 were utilized for the study. ResultsThe mean operation times for primary and revision TSA were 109.42 minutes and 122.39 minutes, respectively (P < .001). This resulted in an RVU per minute of 0.233 for the primary shoulder cohort compared to 0.265 for the revision cohort (P < .001). Revision shoulder cases were valued higher with a dollars per minute of $9.56, whereas the dollars per minute for primary shoulder cases was $8.39 (P < .001). Multiple regression analysis showed a positive correlation between revision total shoulder cases and dollars per minute. ConclusionThe RVU per minute and reimbursement in dollars per minute of operative time are higher for revision TSA than for primary TSA. Compared with published reports on total hip and knee arthroplasty, primary TSA has lower RVU/minute assignment and lower dollars/minute reimbursement. Level of EvidenceLevel III; Retrospective Cohort Comparative Study

Nationwide trends of surgical site infections rates after primary shoulder arthroplasty

BackgroundSurgical site infections (SSI) are relatively uncommon, but can be debilitating complications following shoulder arthroplasty. Infections can result in further complications including sepsis and revision surgery. MethodsThe National Surgical Quality Improvement Program database was queried for all total and reverse total shoulder arthroplasty cases (Current Procedural Terminology code 23472) between 2012 and 2015 yielding 8438 total cases. The outcome of interest was 30-day SSI incidence, defined as a superficial and/or deep wound infection. The infection incidence for each year was calculated. ResultsThe total number of primary shoulder arthroplasties increased from 2012 to 2015 (1191 to 3227; 271% increase). Over the 4-year study period, the incidence of SSIs following TSA was 0.40%. A downward trend in SSI rates was observed over time. An inverse relationship between SSI rates and year of surgery (R2−0.17) was observed; however, this was not statistically significant (P> .05). Infection rates in 2015 decreased by 48% when compared to 2012 (0.31 vs. 0.50%, P> .05). A larger decrease in SSI rate (76%) was noted between 2015 and 2013 (0.31 vs. 0.69%, P> .05). ConclusionSSI rates following shoulder arthroplasty declined from 2012 to 2015 by 48%. There was an inverse relationship between SSI rate and year of surgery, with the lowest infection rate found to be in the most recent year studied. It is hoped that continued measures will further promulgate these downward trends of these devastating complications. Level of EvidenceLevel IV; Retrospective Case Series