Primary Total Shoulder Arthroplasty Research Articles

Hydrogen Peroxide May Reduce the Risk for Revision Surgery and Infection in Primary Shoulder Arthroplasty: Two-year Follow-up From a Prospective, Blinded, Controlled Trial.

The purpose of this study was to determine whether the addition of hydrogen peroxide to the preoperative skin preparation for primary total shoulder arthroplasty is associated with a difference in patient-reported outcomes, risk for postoperative infection, and risk for revision surgery at a minimum of 2-year follow-up. This was a prospective, blinded, and controlled trial, which included a consecutive series of patients undergoing primary shoulder arthroplasty. The control group underwent standard sterile skin preparation using ethyl alcohol and ChloraPrep applicators, and the peroxide group had the same preparation with the addition of hydrogen peroxide between the alcohol and ChloraPrep applications. We then compared patient-reported outcome scores (American Shoulder and Elbow Surgeons Shoulder Score [ASES], simple shoulder test [SST], visual analog scale [VAS]), infections, and revision surgeries between the two groups at 2-year follow-up. Of the 61 patients included in the original study, 52 of 58 (85%) living patients agreed to participate in this study. No preoperative differences were observed between groups. No difference was observed in ASES, SST, or VAS scores at 2 years. More revision surgeries were done in the control group (7 versus 2, P = 0.268) and Cutibacterium acnes infections (2 versus 0, P = 0.168). The addition of hydrogen peroxide to the preoperative skin preparation before primary shoulder arthroplasty is safe, and additional research is warranted to investigate whether it may decrease the risk for revision surgery and postoperative C acnes infection. III.

Delayed elective total shoulder arthroplasty: causes and eventual outcomes.

The purpose of this study is to identify risk factors for delays in planned total shoulder arthroplasty (TSA) and determine the perioperative outcomes of TSAs that experienced a delay. The American College of Surgeons National Quality Improvement Program (NSQIP) database was queried from 2006 to 2019 for primary TSA. Delayed TSA was defined as surgery that occurred greater than one day after hospital admission. Patient demographics, comorbidities, and post-operative complications were collected and compared; the incidence of delayed TSA was analyzed. The delayed patients were older, had a higher BMI, a higher rate of recent prior major surgery, and more comorbidities. Delayed patients had higher rates of postoperative complications, return to the OR, and 30-day readmission. Between 2006 and 2019, the rate of delayed TSA decreased. Surgeons should take care to ensure that patients with comorbidities undergo thorough preoperative clearance to prevent same-day cancellations and postoperative complications.

Regional Variation from 2013 to 2021 in Primary Total Shoulder Arthroplasty Utilization, Reimbursement, and Patient Populations

BackgroundTotal shoulder arthroplasty (TSA), encompassing both anatomical and reverse total shoulder arthroplasty, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level. MethodsThe Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data was stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions. ResultsBetween 2013 and 2021, TSA utilization increased by 121.8% nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1,108.59; p<0.001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1,223.44; p<0.001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; p<0.001). The average comorbidity burden of patients decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (p<0.001). ConclusionThis study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.

No Difference in 10-Year Survivorship of Total Shoulder Arthroplasty Versus Hemiarthroplasty for Avascular Necrosis of the Humeral Head

Avascular necrosis of the humeral head (AVN) is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty) is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies. Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio since TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox Proportional Hazard modeling. Chi-squared analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness. In total, 4,825 patients undergoing TSA and 1,969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = 0.017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = 0.148) and no difference in the observed etiologies for revision (P > 0.05 for all). After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10-years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

Comparing Comorbidity Burden Between Patients Undergoing Ambulatory Rotator Cuff Repair Versus Inpatient Anatomic Total Shoulder Arthroplasty

BACKGROUNDRotator cuff repair (RCR) patients routinely undergo same-day discharge in an ambulatory setting, while anatomic total shoulder arthroplasty (TSA) cases have historically been performed in an inpatient hospital setting. For healthier patients, however, TSA has increasingly transitioned to same-day discharge. Understanding whether a true difference in comorbidity burden exists between these patient groups would inform the appropriateness of outpatient TSA in an ambulatory setting. METHODSA retrospective review was performed of patients undergoing primary TSA and same-day, ambulatory RCR performed between September 2017 and May 2021 at a single institution by 3 fellowship-trained orthopedic surgeons. Selected sociodemographic factors and the Elixhauser Comorbidity Index (30 variables) were used to summarize and compare comorbidity burden. Only patients >50 years old were included. Chi-square and Kruskal-Wallis testing was used to compare the prevalence or severity for categorical and continuous variables, respectively. RESULTS1433 cases met inclusion criteria, including 146 (34%) primary inpatient TSAs and 287 (66%) ambulatory RCRs. There were few differences in comorbidity burden between TSA and RCR, with TSA having a significantly higher prevalence for only 4 Elixhauser comorbidities and RCR having a higher prevalence of 1 comorbidity, although none survive a Bonferroni correction. TSA patients had a significantly higher prevalence of uncomplicated (p = 0.04192) and complicated hypertension (p = 0.0336), chronic pulmonary disease (p = 0.0045), and cardiac arrhythmia (p = 0.0031). The prevalence of diabetes (p = 0.029758) was significantly higher among RCR patients. Additionally, age (p = 0.011) was significantly higher among TSA patients. Of the TSA cohort, there were 10 incidences (1%) of 90-day readmission whereas there were 14 incidences (5%) of 90-day readmissions after RCR. CONCLUSIONSOverall, few differences in the prevalence of individual comorbidities (and sociodemographic parameters) existed between patients undergoing outpatient rotator cuff repair and inpatient primary anatomic total shoulder arthroplasty. Comorbidities with larger differences can be either optimized preoperatively or managed chronically, and given these similarities, TSA may be similarly appropriate for ambulatory settings, particularly as efficiencies in operative time and improvements in regional anesthesia continue to evolve.

Same-Day Discharge vs. Inpatient Total Shoulder Arthroplasty: An Age Stratified Comparison of Postoperative Outcomes and Hospital Charges

As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly. This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and inpatient settings. The outcome measures included LOS, complications, hospital charges, ED utilization, readmissions, and reoperations within 90-days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P <0.05 was considered statistically significant. There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (ASA score P=0.12, ECI P=0.067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P<0.001), and the SDD group higher rate of intraoperative tranexamic acid use (P=0.015) and lower estimated blood loss (P=0.009). There were no differences in 90-day overall minor (P=0.20) and major complications (P=1.00), ED utilization (P=0.63), readmission (P=0.25) or reoperation (P =0.51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P=0.80) and minor (P=0.36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS=8.4 hours in ≥65 to < 75-year cohort vs. LOS=25.9 hours in ≥80-year cohort; P<0.001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P=0.82). SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting. Level III; Retrospective Comparative Study.

Complications associated with postoperative stiffness following primary anatomic and reverse total shoulder arthroplasty

BackgroundShoulder stiffness following both primary anatomic and reverse total shoulder arthroplasty (TSA) is a potential complication that is likely underreported. The deleterious effects of postoperative stiffness following TSA and the burden placed on both the patient and the healthcare system have not been well studied. The purpose of this study is to determine the incidence of postoperative stiffness following primary TSA and analyze the effect it has on short-term outcomes up to 180 days following primary TSA. MethodsThis was a retrospective, comparative cohort study. The Nationwide Readmissions Database was queried from 2010 to 2020 for patients who had undergone primary TSA using International Classification of Diseases Clinical Modification and Procedure Coding System codes. Patients were then separated into stiff and non-stiff cohorts. A one-to-one match was performed based on age, sex, and the Charlson comorbidity index. Statistical analyses included chi-square, sample t-tests, logistic, and linear regression. ResultsA total of 7792 subjects were included in the study. The overall incidence of postoperative stiffness was 1.8%. Patients with stiffness following primary TSA were 57% more likely to be readmitted within 180 days (odds ratio [OR] = 1.57) and had increased hospital costs by over $5000 (P < .001), but mortality rates were not increased. However, the odds of experiencing any medical complication or revision decreased by 52% and 76%, respectively, in the stiff group (OR = 0.48, and OR = 0.24, respectively). Postoperative stiffness was inversely predictive of prosthetic dislocation (OR = 0.03), loosening (OR = 0.03), and periprosthetic fracture (OR = 0.04). ConclusionThe incidence of postoperative stiffness following primary TSA was low at 1.8 %. These patients were found to be at increased risk for readmission within 180 days and incurred significantly higher hospital costs compared to the non-stiff cohort. However, postoperative stiffness did not increase the odds of experiencing increased medical complications, mechanical complications, mortality, or revision at 180 days. This information can help guide surgeons in discussion with and management of patients who develop stiffness following primary TSA.

Primary and revision reverse total shoulder arthroplasty using a patient-matched glenoid implant for severe glenoid bone deficiency

BackgroundSevere glenoid bone loss in the setting of both primary and revision reverse total shoulder arthroplasty (rTSA) continues to remain a significant challenge. The purpose of this study was to report on radiographic and clinical outcomes of primary and revision rTSA using a patient-matched, 3-dimensionally printed metal glenoid implant to address severe glenoid bone deficiency. This is a follow-up study to previously reported preliminary results. MethodsA retrospective review was performed on 62 patients with severe glenoid bone deficiency underwent either primary or revision rTSA using the Comprehensive Vault Reconstruction System (VRS) (Zimmer Biomet, Warsaw, IN, USA) at a single institution. Preoperative and postoperative values for the Disabilities of the Arm, Shoulder and Hand (DASH), Constant, American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale (VAS) pain scores as well as active range of motion (ROM) were collected and compared using the Wilcoxon signed rank test with the level of statistical significance set at P < 0.05. Percentage of patients achieving minimal clinical important difference (MCID) and substantial clinical benefit (SCB) was also calculated. ResultsFifty-five of 62 (88.7%) shoulders were able to be contacted at a minimum of 2-years postoperatively, with 47/62 (75.8%), having complete clinical and radiographic follow-up with a mean age of 67.5 years (range, 48-85 years) and follow-up of 39.2 months (range, 25-56 months). There were 19 primary and 28 revision rTSAs. Significant improvements were seen in mean active forward flexion (63.1° ± 30.3° to 116.8° ± 35°), abduction (48.1° ± 16.1 to 76.2° ± 13.4°) (P < 0.001), external rotation (16° ± 23.7° to 32.1° ± 24.5°) (P < 0.005), DASH (59.9 ± 17.7 to 35.7 ± 24.3), Constant (23.4 ± 13.1 to 53.1 ± 17.4), ASES (27.8 ± 16.2 to 69.1 ± 25.2), SST (3.3 ± 2.5 to 7.6 ± 3.5), SANE (28.9 ± 18.3 to 66.7 ± 21.2), and VAS pain (7.1 ± 2.4 to 1.8 ± 2.6) scores (P < 0.001). MCID and SCB was achieved in a majority of patients postoperatively. Overall complication rate was 29.1% with only 1 baseplate failure. ConclusionThis study demonstrates promising evidence that the VRS implant can be used as a viable option to achieve clinically important improvement in a majority of patients treated for severe glenoid bone deficiency with rTSA in both the primary and revision setting.

Comparison of genomic DNA sequencing to anerobic cultures to detect efficacy of hydrogen peroxide at reducing cutibacterium acnes bacterial burden during primary shoulder arthroplasty

BackgroundThe purpose of this investigation is to compare Cutibacterium acnes diagnosis using culturing vs. genomic DNA sequencing (NextGen) at various timepoints and locations during primary total shoulder arthroplasty. Additionally, we intend to compare the effects of hydrogen peroxide on standard culture technique results with genomic DNA sequencing. MethodsA prospective diagnostic study of 40 patients undergoing primary total shoulder arthroplasty was performed. Intraoperatively, 4 tissue samples were collected per patient: subdermal skin edge following initial skin incision, subdermal skin edge following hydrogen peroxide soak for 5 minutes, glenohumeral joint capsule, and subdermal skin edge prior to wound closure. Each tissue specimen was collected twice (one for culture analysis and the other for genomic (NextGen) DNA sequencing analysis) for a total of 8 specimens per patient and 320 tissue specimens in total. All anaerobic cultures were held for 14 days. Each culture plate was divided into quadrants and the amount of growth was quantified. Tissue samples were collected for genomic sequencing DNA analysis. Genomic sequencing results provided relative percentage of bacteria for each specimen detected. ResultsThere were 18/40 males (45%) and no postoperative complications. Average age was 72.2 ± 11.8. Overall, 18% (29/160) of standard anaerobic cultures were positive for C. Acnes and 26% (942/160) were positive with genomic (Nextgen) DNA sequencing. When comparing the NextGen results with anaerobic standard cultures, there was a calculated negative predictive value of 85.6% and positive predictive value of 28.6%. Sensitivity of the NextGen was 41.4% and specificity was 77.1%. Bacterial culture rates did not significantly change from the beginning to the end of surgery as demonstrated on standard culturing and the NextGen analysis (P > .05). After treatment with hydrogen peroxide, the standard culturing technique showed no significant difference between the samples; however, there was a significant increase in bacterial burden (12.4%) noted with NextGen analysis (P = .0147). ConclusionNextGen culturing is a novel technique to help identify shoulder prosthetic joint infections. These results show that, NextGen is better at identifying the absence of infection, but has a high false positive rate indicative of its ability to identify contaminants as compared to standard anaerobic culturing methods. The increase in bacterial burden after peroxide treatment noted with NextGen could also be secondary to the test’s increased ability to identify both living and dead bacterial pathogens.

What specific activities are patients performing 2 years after primary anatomic total shoulder arthroplasty?

BackgroundReturning patients to their desired activities following anatomic total shoulder arthroplasty (aTSA) is an important criterion to achieve high patient satisfaction. While patients who undergo aTSA return to sports at relatively high rates, individuals’ specific desired and achieved activities following aTSA remain poorly defined. MethodsA shoulder arthroplasty registry at a tertiary-care orthopedic hospital was reviewed retrospectively between February 1, 2016, and January 1, 2021, to identify specific patient activity and functional capabilities following aTSA at a minimum of 2 years postoperatively. Individual items and responses of the American Shoulder and Elbow Surgeons and Shoulder Activity Scale relating to activity levels, as well as free text responses pertaining to usual work and sport, were tabulated. ResultsAmong 597 patients who underwent 632 primary anatomic TSAs (mean age 65.9 ± 8.3 years, 41.5% female), the median American Shoulder and Elbow Surgeons score per affected limb improved from 40.0 (interquartile range (IQR) 27.4-54.7) preoperatively to 94.9 (IQR 83.8-98.3) at 2 years (P < .001), while median Shoulder Activity Scale improved from 8.0 (IQR 5.0-12.0) preoperatively to 10.0 (6.0-14.0) at 2 years (P < .001). Two years after surgery, 78.5%, 88.6%, and 83.5% of patients were able to comb their hair, manage toileting, and put on a coat without any difficulty, respectively. A relatively small proportion of patients were able to reach a high shelf (64.7%) and lift 10 pounds above the shoulder (57.4%) without difficulty. Of the 524 (82.9%) patients who returned to recreational activities 2 years after surgery, golf (25.6%), walking (22.7%), weight training (16.8%), and swimming (15.8%) were the most commonly reported activities. Cooking and cleaning (29.9%, n = 189), desk-related work (27.2%, n = 172), yard-work or gardening (14.2%, n = 90), heavy lifting activities (6.5%, n = 41), and grocery shopping (2.5%, n = 16) were the most common forms of usual work. ConclusionPatients undergoing aTSA report a wide spectrum of desired recreational activities. A range of functional capabilities exists within this patient population with regards to usual sporting activity, work activity, and activities of daily living. Preoperative patient counseling may attempt to identify patients’ desired postoperative activities for more individualized education regarding their prognosis for returning to desired activities.

Characteristics associated with rerevision of primary inlay and onlay reverse shoulder arthroplasty. Analysis from the Australian Orthopaedic Association National Joint Replacement Registry

BackgroundTwo designs of primary reverse total shoulder arthroplasty (rTSA), inlay reverse total shoulder arthroplasty (in-rTSA) and onlay reverse total shoulder arthroplasty (on-rTSA) that had undergone an aseptic revision were compared to determine differences in the rate of rerevision. MethodsIn this comparative observational national registry study between January 1, 2012, and December 31, 2021, all rTSA utilizing either a modular inlay or onlay metaphyseal humeral component that had been revised for aseptic reasons formed 2 cohort groups. The cumulative percentage rerevision (2nd CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazard models adjusted for age and sex. A minor category revision involved exchange of parts not fixed to bone whilst major revisions did. The primary and revision diagnoses, surgeon primary volume experience, and revision category were compared. Shoulder Modular Replacement (SMR)/SMR L1 or L2 combination (Lima Corporate, San Daniele del Friuli, Italy) was excluded at subanalysis. ResultsThe 2nd CPR at 3 years was 20.4% (95% confidence interval 17.1, 24.1) for in-rTSA (n = 571) and 16.1%(11.6, 22.2) for on-rTSA (n = 249). The risk of rerevision was not different between the 2 cohort groups. Primary diagnosis fracture was associated with an increased risk of rerevision for on-rTSA (entire period on-rTSA HR = 3.16(1.50, 6.68), P = .002), and in-rTSA at subanalysis (entire period on-rTSA HR = 2.91(1.33, 6.33), P = .007). 59.9% of in-rTSA and 24.1% of on-rTSA aseptic revisions were minor. The revision diagnosis, the surgical experience of rTSA and if the revision was major or minor did not change the rate of rerevision. The most common reason for both in-rTSA (50%) and (43.2%) on-rTSA rerevision was instability/dislocation. DiscussionRerevision rates of in-rTSA and on-rTSA after aseptic revision are high. The primary rather the revision diagnosis changed rerevision rates in contemporary rTSA surgery. Minor revisions did not reduce rerevision rates for in-rTSA or on-rTSA compared to humeral/glenoid revision. Increased surgical experience of primary rTSA did not change the rate of rerevision of in-rTSA or on-rTSA.

Structural bone grafting for glenoid bone loss in primary anatomic total shoulder arthroplasty: a case series and technique report

IntroductionPosterior glenoid bone loss in glenohumeral osteoarthritis poses significant challenges in shoulder arthroplasty. Anatomic total shoulder arthroplasty with a humeral head autograft to address the glenoid bone deficiency is an option for these difficult cases. Variable results with this procedure are reported in the literature. This article describes the surgical technique of posterior glenoid bone grafting in TSA using a glenoid implant with hybrid fixation, and a series of reported patient functional and radiographic outcomes. Materials and MethodsA retrospective chart review of cases from 2015 to 2020 by a single surgeon revealed 10 patients who underwent primary TSA with hybrid glenoid component and posterior glenoid bone grafting. Preoperative and postoperative radiographs were assessed for glenoid inclination, glenoid version, acromiohumeral distance, humeral stem status, and glenoid implant status. Functional outcomes were evaluated by range of motion, strength, and patient-reported clinical outcomes (pain and function on a visual analog scale, disabilities of the arm, shoulder, and hand score, single assessment numeric evaluation, American Shoulder and Elbow Surgeons score). Complications and reoperations were also evaluated. ResultsAverage follow-up was 31.4 months, active forward flexion and external rotation improved on average from 105o to 150o and 20o to 60o, respectively (P<0.001) and average abduction improved from 100o to 140o (P<0.002). At an average of 26.7 months, patients reported assessments (VAS pain and function, QuickDASH, SANE, ASES scores) reveal significant (P<0.05) improvement in pain and functional outcomes. Radiographically, at 23.0 ± 20.1 months, all patients demonstrated a well fixed humeral and glenoid component without evidence of lucent lines. The bone graft used in each patient was well unionized and no radiographic complications were reported. No patients underwent revision surgery, and there was one clinical complication reported, which consisted of a suspected rotator cuff injury at follow-up. ConclusionHybrid fixation with structural glenoid bone grafting in TSA resulted in excellent outcomes with no evidence of graft or component failure on follow-up radiographs and significantly reduced pain, improved functional scores, and improved active ROM.

Short-term comparative outcomes of LIMA hybrid, metal-backed, and all cemented polyethylene glenoids

BackgroundThis study aims to compare short-term functional outcomes and conversion rates to reverse shoulder arthroplasty between patients who underwent total shoulder arthroplasty (TSA) using a modular metal-backed glenoid component, a hybrid glenoid component, and an all-polyethylene component. MethodsA retrospective review of individuals undergoing TSA between October 2014 and December 2020 was performed. Inclusion criteria included patients undergoing primary TSA for osteoarthritis during this time frame by 1 surgeon. Preoperative and postoperative variables included demographic information, American Shoulder and Elbow Surgeons score (ASES), and range of motion. Revision rates were also documented. Summary statistics were performed, using a 1-way analysis of variance with Tukey post hoc pairwise comparisons when the outcome reached significance. ResultsFifty-two patients were included with age averaging 68 ± 8.1 years, with body mass index of 31 ± 5.8. 54% of patients were female with 12% having diabetes and only 2% were smokers. Follow-up averaged 42 months with patients undergoing metal-backed glenoid having longer follow-up at 56.5 months (P < .001). ASES, forward elevation, and external rotation (ER) for every implant type improved significantly postoperatively (P < .001) besides internal rotation and ER within the poly group (P = .072). No difference was found between the 3 groups for preoperative and postoperative ASES scores, forward elevation, internal rotation, and ER (P > .05). Two patients within the poly group required revision due to rotator cuff tear (P = .225). ConclusionAt 2 years, functional outcomes and patient-reported outcomes are similar in all 3 glenoid groups. There were slightly higher revision rates within the all-polyethylene group. If outcomes are similar among all groups, modular implant systems may be favorable to make conversion to revision TSA easier.

Total shoulder arthroplasty in patients with factor V Leiden

BackgroundAnatomic and reverse total shoulder arthroplasty (TSA) are effective treatment options for end-stage glenohumeral osteoarthritis. However, consideration for pre-existing conditions must be taken into account. Factor V Leiden (FVL), the most common inherited thrombophilia, is one such condition that predisposes to a prothrombotic state and may affect perioperative and longer-term outcomes following TSA. MethodsAdult patients undergoing primary TSA for osteoarthritis indication were identified in the 2010 through October 2021 PearlDiver M157 database. Patients with or without FVL were matched at a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and five-year revision rates were assessed and compared with multivariable logistic regression and rank-log tests, respectively. Finally, the relative use and bleeding/clotting outcomes were assessed based on venous thromboembolic (VTE) prophylactic agents utilized, with categories defined as (1) warfarin, heparin, or direct oral anticoagulant (DOAC) or (2) aspirin/no prescriptions found. ResultsOf 104,258 TSA patients, FVL was identified for 283 (0.27%). Based on matching, 1,081 patients without FVL and 272 patients with FVL were selected. Multivariable analyses demonstrated that those with FVL displayed independently greater odds ratios (ORs) of deep vein thrombosis (DVT, OR=9.50, p<0.0001), pulmonary embolism (PE, OR = 10.10, p<0.0001), and pneumonia (OR=2.43, p=0.0019). Further, these events contributed to the increased odds of aggregated minor (OR = 1.95, p=0.0001), serious (OR=6.38, p<0.0001), and all (OR=3.51, p<0.0001) adverse events. All other individual 90-day adverse events, as well as 5-year revision rates, were not different between the study groups. When compared to matched patients without FVL on the same anticoagulant agents, FVL patients on warfarin/heparin/DOAC agents demonstrated lesser odds of 90-day DVT and PE (OR=4.25, p<0.0001 and OR=2.54, p=0.0065) than those on aspirin/no prescriptions found (OR=7.64 and OR=21.95, p<0.0001 for both). Interestingly, those on VTE prophylactic agents were not at greater odds of bleeding complications (hematoma or transfusion). Discussion and ConclusionsTSA patients with FVL present a difficult challenge to shoulder reconstruction surgeons. The current study highlights the strong risk of VTE that was reduced but still significantly elevated for those with stronger classes of VTE chemoprophylaxis. Acknowledging this risk is important for surgical planning and patient counseling, but also noted was the reassurance of similar 5-year revision rates for those with versus without FVL.

Disease diagnosis and arthroplasty type are strongly associated with short-term postoperative patient-reported outcomes in patients undergoing primary total shoulder arthroplasty

BackgroundPrognostic factors for total shoulder arthroplasty (TSA) clinical outcomes are incompletely understood. This study investigates the associations of preoperative patient, disease-specific, and surgical factors with one-year postoperative PENN Shoulder Score (PSS) in patients undergoing primary TSA. MethodsCleveland Clinic patients undergoing primary anatomic TSA (aTSA) or reverse TSA (rTSA) for glenohumeral osteoarthritis (GHOA) or rotator cuff tear arthropathy (CTA) between February 2015 and August 2019, and having complete preoperative and one-year postoperative patient reported outcome measures (PROMs), were included. Twenty preselected preoperative patient and disease-specific/surgical factors were used to fit multivariable models for one-year PSS and its subscores. Results1,174 of 1,427 eligible primary TSAs had one-year follow-up by PROMs (82%), with 1,042 analyzed after additional exclusions, including 30% rTSAs for CTA (n=308), 26% rTSAs for GHOA (n=275), and 44% aTSAs for GHOA (n=459). All PROMs showed statistically significant improvements postoperatively, with 89% of patients reaching an acceptable symptom state. Lower one-year PSS was associated with younger age, female sex, current smoking, chronic pain diagnosis, history of prior surgery, worker’s compensation claim, lower preoperative mental health, lower baseline PSS, absence of glenoid bone loss, and diagnosis-arthroplasty type (CTA-rTSA<GHOA-rTSA<GHOA-aTSA). The most important prognostic factors associated with one-year PSS were diagnosis-arthroplasty type, baseline mental health status, and insurance status. ConclusionsDisease diagnosis, arthroplasty type, and several other baseline factors are strongly and individually associated with PROMs following primary TSA, with patients undergoing aTSA for GHOA demonstrating the highest PROMs at one-year follow-up. Patient, disease-specific, and surgical factors can be used to guide postoperative prognosis following primary TSA for improved preoperative patient counseling regarding expected outcomes of these procedures.

Higher complication rates following primary total shoulder arthroplasty in patients presenting from areas of higher social deprivation.

The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years. Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index. A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05). Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications.

Early radiographic and clinical outcomes of primary short stem anatomic total shoulder arthroplasty with a peripherally enhanced fixation glenoid: a multicenter study

BackgroundGlenoid component loosening remains the most common reason for revision of anatomic total shoulder arthroplasty (aTSA). We assessed early clinical and radiographic outcomes following aTSA using a press-fit short stem and a peripherally enhanced fixation glenoid. Methods275 consecutive patients with end-stage glenohumeral arthritis and Walch A- or B-type glenoid morphology who underwent primary aTSA in 2017-2018 at two high-volume shoulder arthroplasty institutions were evaluated, and patient-reported outcomes (PROMs) and radiographic findings were studied in those with completed baseline and minimum 2-year follow-up, respectively. Patient demographics, glenoid morphology, body mass index (BMI), Charlson Comorbidity Index (CCI), range of motion, American Shoulder and Elbow Surgeons (ASES) score, and Simple Assessment Numeric Evaluation score were collected. Radiographic analysis of glenoid and humeral components was performed. Multivariable logistic, equal adjacent odds ordinal, and beta regression were respectively used to identify predictors of glenoid radiolucent lines, humeral calcar resorption, and total ASES score. ResultsPatients were 43% female, with a mean age of 66, a median BMI of 30, and median follow-up of 28.4 months. ASES and Simple Assessment Numeric Evaluation scores improved by respective medians of 54.4 and 55.0 points, forward elevation by median 35°, and external rotation by median 30° (all P < .001 for preoperative to postoperative change). Postoperative radiographs of 177 cases showed 10 (5.7%) glenoid osteolysis, 51 (28.8%) glenoid radiolucent lines, and 81 (45.8%) calcar resorptions. The follow-up duration (median 40.1 vs. 27.2 months; P < .001), BMI (median 27.5 vs. 30.7; P < .001), and Charlson Comorbidity Index (Q3 0 vs. 1; P = .02) were associated with glenoid osteolysis in bivariate analyses. In multiple logistic regression, surgeon (C vs. A/B) was the only statistically significant predictor of glenoid radiolucent lines [OR 0.27, 95% CI (0.1, 0.8)]. By descending importance, Surgeon C [OR 6.5 (2.0, 20.5)], humeral canal filling ratio [upper vs. lower quartile OR 2.3 (1.3, 4.0)], mediolateral humeral head deviation [upper vs. lower quartile OR 1.9 (1.0, 3.5)], and glenoid osteolysis [OR 13.5 (2.6, 71.6)] significantly predicted greater calcar resorption. Longer follow-up duration marginally statistically significantly predicted lower ASES score [upper vs. lower quartile OR 0.8 (0.6, 1.0)]. ConclusionsFollowing aTSA with a peripherally enhanced fixation glenoid, pain, range of motion, and patient-reported outcomes significantly improved at a minimum of 2 years with only 5.7% glenoid osteolysis despite heterogeneous preoperative glenoid pathologies.

Risk factors for rotator cuff tears and aseptic glenoid loosening after anatomic total shoulder arthroplasty

BackgroundThe purpose of this study is to retrospectively analyze all primary anatomic total shoulder arthroplasty (aTSA) patients within a multicenter international database of a single prosthesis to identify risk factors for patients with rotator cuff tear (RCT) and aseptic glenoid loosening. MethodsTo investigate the risk factors for RCT and aseptic glenoid loosening, we retrospectively analyzed all aTSA patients with 2-year minimum follow-up from a multicenter international database of a single platform shoulder system, only excluding patients with a history of revision arthroplasty, infections, and humeral fractures. A univariate/multivariate analysis was conducted to compare primary aTSA patients who had report of: 1) a RCT and/or subscapularis failure and 2) aseptic glenoid loosening/cage glenoid dissociations, to identify the differences in (i) intrinsic patient demographics and comorbidities and (ii) implant and operative parameters. Finally, to adapt our statistical analysis for prospective identification of patients most at-risk for RCT and aseptic glenoid loosening, we stratified the dataset by multiple risk factor combinations and calculated the odds ratio (OR) to determine the impact of accumulating risk factors on the incidence rate of each complication. Results122 aTSA shoulders had a RCT for a rate of 3.2% and 123 aTSA shoulders had aseptic glenoid loosening for a rate of 3.3%. The multivariate analysis identified that aTSA patients with RCT were more likely to have previous shoulder surgery (P < .001) and small size glenoids (P = .002). Additionally, the multivariate analysis identified that aTSA patients with aseptic glenoid loosening were more likely to be younger (≤62 years at the time of surgery, P = .001), have small size glenoids (P = .033) and have a nonhybrid glenoids (P < .001). Stratifying patients with multiple risk factors identified multiple aTSA cohorts with ORs >2 for RCT or aseptic glenoid loosening. DiscussionThis analysis of 2699 primary aTSA identified risk factors for the two most common postoperative complications: RCTs and aseptic glenoid loosening. Using these risk factors, we calculated ORs for patient cohorts with multiple risk factors to identify the patients with the greatest risk for each complication. This information is useful to guide the surgeon in their preoperative counseling and potentially mitigate the occurrence of these complications, by indicating patients with these risk-factors for alternative treatment strategies, like rTSA, instead of aTSA.

Impact of accumulating risk factors on the incidence of dislocation after primary reverse total shoulder arthroplasty using a medial glenoid–lateral humerus onlay prosthesis

IntroductionThe aim of this study is to facilitate preoperative identification of patients at-risk for dislocation after reverse total shoulder arthroplasty (rTSA) using the Equinoxe rTSA prosthesis (medialized glenoid, lateralized onlay humerus with a 145° neck angle) and quantify the impact of accumulating risk factors on the occurrence of dislocation. MethodsWe retrospectively analyzed 10,023 primary rTSA patients from an international multi-center database of a single platform shoulder prosthesis and quantified the dislocation rate associated with multiple combinations of previously identified risk factors. To adapt our statistical results for prospective identification of patients most at-risk for dislocation, we stratified our dataset by multiple risk factor combinations and calculated the odds ratio for each cohort to quantify the impact of accumulating risk factors on dislocation. Results136 (52F/83M/1UNK) of 10,023 primary rTSA patients were reported to have a dislocation for a rate of 1.4%. Patients with zero risk factors were rare, where only 12.7% of patients (1,268 of 10,023) had no risk factors, and only 0.5% of these (6 of 1,268) had a report of dislocation. The dislocation rate increased in patient cohorts with an increasing number of risk factors. Specifically, the dislocation rate increased from 0.9% for a patient cohort with 1 risk factor to 1.0% for 2 risk factors, 1.6% for 3 risk factors, 2.7% for 4 risk factors, 5.3% for 5 risk factors, and 7.3% for 6 risk factors. Stratifying dislocation rate by multiple risk factor combinations identified numerous cohorts with either an elevated risk or a diminished risk for dislocation. DiscussionThis 10,023 rTSA multi-center study demonstrated that 1.4% of rTSA patients experienced dislocation with one specific medialized glenoid/lateralized humerus onlay rTSA prosthesis. Stratifying patients by multiple combinations of risk factors demonstrated the impact of accumulating risk factors on incidence of dislocation. rTSA patients with the greatest risk of dislocation were: male gender, age ≤67 years at the time of surgery, patients with BMI ≥31, patients who received cemented humeral stems, patients who received glenospheres having a diameter >40mm, and/or patients who received expanded/laterally offset glenospheres. Patients with these risk factors who are considering rTSA using a medial glenoid/lateral humerus, should be made aware of their elevated dislocation risk profile.

Reverse total shoulder arthroplasty for proximal humerus fracture: a complex episode of care associated with increased surgical and medical complications

IntroductionReverse total shoulder arthroplasty (rTSA) remains a viable treatment option in elderly patients with proximal humerus fractures (PHF). However, the risk profile of this procedure in this patient population has not been well established by prior studies. The aim of this study is to examine whether there are differences in sociodemographic variables, underlying medical comorbidities, and 90-day outcomes between patients undergoing rTSA for osteoarthritis (OA) vs. PHF. We hypothesized that patients with PHF would be older and have higher comorbidity burden compared to glenohumeral OA controls. Furthermore, we hypothesized that rTSA would yield inferior outcomes and higher costs of care in patients with PHF compared to glenohumeral OA. MethodsPatients who underwent primary rTSA from 2016 to 2020 were identified in the Premier Healthcare Database. PHF patients were identified using the International Classification of Diseases, Tenth Revision diagnosis codes and compared to OA controls. All patients < 18 years old and those who underwent rTSA for other indications were excluded. Patients were matched in a 2:1 fashion based on age (± 3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, comorbidities and 90-day surgical (wound complications, dislocation, periprosthetic fracture, periprosthetic joint infection, stiffness, loosening, mechanical complications, and revision) and medical (deep vein thrombosis/pulmonary embolism, pneumonia, respiratory failure, renal failure, stroke, myocardial infarction, and sepsis) complications and readmission were compared between the two cohorts. Descriptive statistics and regression analysis were employed with significance set at P < .05. Odds ratio (OR) and 95% confidence interval were calculated. ResultsBefore matching 51,150 OA controls and 11,394 PHF cases were identified. After matching, 8661 PHF cases were matched to 17,332 controls. Regarding surgical complications, PHF patients were at significantly increased risk of periprosthetic fracture (OR 2.35), dislocation (OR 2.87), superficial wound infection (OR 5.51), periprosthetic joint infection (OR 1.91) and 90-day revision (OR 4.76). PHF patients were at increased risk of all medical complications examined including hemorrhage (OR 2.20), anemia (OR 2.78) deep vein thrombosis (OR 3.10), pulmonary embolism (OR 2.83), pneumonia (OR 2.93), respiratory failure (OR 3.37), pneumonia (OR 2.93), stroke (OR 2.61), myocardial infarction (OR 2.79), acute renal failure (OR 4.06), urinary tract infection (OR 5.50) and sepsis (OR 3.71) as well as 90-day readmission (OR 2.13). Discussion/ConclusionPatients undergoing rTSA for PHF are at significantly increased risk of complications compared to OA controls. Furthermore, these patients are at increased risk of 90-day readmission. These findings should prompt diligent preoperative risk stratification by surgeons and healthcare providers to prevent patient morbidity.