Reverse Total Shoulder Arthroplasty Research Articles

Adoption of reverse total shoulder arthroplasty for surgical treatment of proximal humerus fractures differs by patient race

BackgroundReverse total shoulder arthroplasty (rTSA) has gained popularity for the operative treatment of proximal humerus fractures (PHF). The purpose of this study was to compare racial differences in surgical management of PHF between open reduction and internal fixation (ORIF), hemiarthroplasty, and rTSA. Our hypothesis was that there would be no difference in fixation by race. MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for ORIF, rTSA, and hemiarthroplasty between 2006 and 2020 for patients with a PHF. Race, ethnicity, age, sex, body mass index (BMI), and American Society of Anesthesiologists (ASA) class were recorded. Chi squared tests were performed to assess relationships between patient factors and operative intervention. Factors significant at the 0.10 level in univariable analyses were included in a multivariable multinomial model to predict operative intervention. Results7,499 patients underwent surgical treatment for a PHF, including 526 (7%) undergoing hemiarthroplasty, 5,011 (67%) undergoing ORIF, and 1,962 (26%) undergoing rTSA. 27% of white patients with PHF underwent rTSA compared to 21% of Black patients, 16% of Asian patients, and 14% of Native American and Alaskan Native patients (p<0.001). In the multivariable analysis, utilization of rTSA increased over time (OR 1.2 per year since 2006, p < 0.001) and hemiarthroplasty decreased over time (OR 0.86 per year since 2006, p < 0.001). Non-white patients had significantly lower odds of undergoing rTSA versus ORIF (OR 0.75, 95% CI 0.58-0.97), as did male patients (OR 0.77, 95% CI 0.66-0.88). Patients over 65 (OR 3.86, 95% CI 3.39-4.38), patients with higher ASA classifications (ASA2: OR 3.24, 95% CI 1.86-5.66, ASA3: OR 4.77, 95% CI 2.74-8.32, ASA4: OR 5.25, 95% CI 2.89-9.54), and patients who were overweight (OR 1.33, 95% CI 1.14-1.55) or obese (OR 1.52, 95% CI 1.32-1.75) had higher odds of undergoing rTSA versus ORIF. DiscussionAs utilization of rTSA increases, understanding disparities in surgical treatment of PHF is crucial to improving outcomes and equitable access to emerging orthopedic technologies. While patient factors such as age, BMI, and comorbidities are known to directly impact outcomes and thus may be predictive of the type of surgical intervention, patient race should not dictate treatment.

Cement-within-cement technique in revision reverse total shoulder arthroplasty: complications, reoperations, and revision rates at 5-year mean follow-up

Cement-within-cement technique in revision reverse total shoulder arthroplasty: complications, reoperations, and revision rates at 5-year mean follow-up

Reverse Shoulder Arthroplasty in the Treatment of Cuff Tear Arthropathy: Systematic Review

Purpose: In our study, we aimed to examine the results and complications of reverse shoulder prosthesis (RSA) applied after rotator cuff tear arthropathy (CTA) in the light of the current literature. Methods: The literature search was conducted simultaneously on 1 April 2024 in the Medline, Cochrane, EMBASE, Google Scholar and Ovid databases using the ''reverse total shoulder arthroplasty'', ''reverse total shoulder prosthesis'', ''cuff tear arthropathy'', ''outcomes'' and ''complications'' keywords. Only clinical review published in English in peer-reviewed journals was evaluated. The comparison between preoperative and postoperative clinical scores, as well as range of motion (ROM), was performed using the Wilcoxon–Mann–Whitney test. P values lower than 0.05 were considered statistically significant. Results: 12 articles were included in our study. When comparing the results of the pre- and postoperative examinations, a statistically significant improvement in the range of motion and the functional score was found. It was found that various complications occurred in 21.1% of patients. The most common complication is scapular notching, which occurred in 13.8% of patients. Revision surgery was required in 1.57% of patients. The most common cause of revision was a periprosthetic joint infection. Conclusion: In CTA patients, RSA can achieve both freedom from pain in the shoulder joint and an increase in function. Despite positive results, complications of varying degrees of severity can occur in around one fifth of patients. The lack of Level I studies limits a true understanding of the possibilities and limitations of RSA in the treatment of CTA patients.

Does preoperative forward elevation weakness affect clinical outcomes in anatomic or reverse total shoulder arthroplasty patients with glenohumeral osteoarthritis and intact rotator cuff?

This study sought to determine if preoperative forward elevation (FE) weakness affects outcomes of anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) for patients with rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA). A retrospective review of a single institution's prospectively collected shoulder arthroplasty database was performed between 2007 and 2020, including 333 aTSAs and 155 rTSAs for primary RCI-GHOA with a minimum 2-year follow-up. Defining preoperative weakness as FE strength ≤4.9 lb (2.2 kg), three cohorts were matched 1:1:1 by age, sex, and follow-up: weak (n=82) to normal aTSAs, weak (n=44) to normal rTSAs, and weak aTSAs (n=61) to weak rTSAs. Compared outcomes included range of motion, outcome scores, and complication and revision rates at latest follow-up. Weak aTSAs and weak rTSAs achieved similar postoperative outcome measures to normal aTSAs and normal rTSAs, respectively (P>0.05). Compared to weak rTSAs, weak aTSAs achieved superior postoperative passive (P=0.006) and active external rotation (ER) (P=0.014) but less favorable postoperative Shoulder Pain and Disability Index (P=0.032), American Shoulder and Elbow Surgeons (P=0.024), and University of California, Los Angeles scores (P=0.008). Weak aTSAs achieved the minimal clinically important difference and substantial clinical benefit at a lower rate for abduction (P=0.045 and P=0.003) and FE (P=0.011 and P=0.001). Weak aTSAs had a higher revision rate (P=0.025) but a similar complication rate (P=0.291) compared to weak rTSAs. Patients with RCI-GHOA and preoperative FE weakness obtain postoperative outcomes similar to patients with normal preoperative strength after either aTSA or rTSA. Preoperatively, weak aTSAs achieved greater ER but lower rates of clinically relevant improvement in overhead motion compared to weak rTSAs. Level of evidence: III.

Defining the tipping point for revision reverse shoulder arthroplasty

Background This study sought to characterize the tipping point values (the functional scores that patients deem dysfunctional enough to warrant surgery) for patients undergoing first revision reverse total shoulder arthroplasty (rTSA). Methods This study was a retrospective review of a prospectively collected single-institution database of patients undergoing first revision rTSA between August 2015 and December 2019. Tipping point evaluation utilized preoperative scores including the American Shoulder and Elbow Surgeons (ASES), raw and normalized Constant, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), and University of California-Los Angeles (UCLA) scores, and active range of motion including abduction, forward elevation (FE), external rotation (ER), and internal rotation score (IR) prior to elective revision rTSA. Results We included 125 revision rTSAs. Tipping points were 37.6 ASES score, 30.5 raw Constant score, 35.5 normalized Constant score, 68.1 SPADI, 3.7 SST, 13.2 UCLA score, 64° abduction, 69° FE, 23° ER, and 3.1 IR. Higher SST was found for older patients and patients with a lower body mass index. Lower abduction and FE tipping points were reported in patients undergoing revision rTSA for rotator cuff failure, unexplained pain, and implant wear. Discussion These tipping points can help surgeons counsel patients regarding when to undergo revision rTSA. Level of evidence Level III; retrospective cohort study; treatment study.

A unique tribological inverted bearing solution for reverse shoulder arthroplasty: Vitamin E and ceramic (unique inverse pairings in rTSR)

Background Reverse total shoulder arthroplasty has gained popularity for various shoulder conditions and has evolved over time to accommodate for material changes and design philosophy including inverse materials. The tribological behaviour of shoulder arthroplasty has been extensively studied in relation to biological osteolysis which is a notable concern regarding component loosening. Methods This study aims to assess the wear performance of a vitamin E-stabilised glenosphere or conventional ultra-high-molecular-weight polyethylene glenosphere whilst paired with ceramic or cobalt–chrome–molybdenum inlay in a shoulder joint wear simulator. A cumulative total of five million cycles was utilised with gravimetric and visual analysis of wear. Results Gravimetric wear was observed to be the lowest when a vitamin E-stabilised glenosphere was paired with a ceramic inlay – demonstrating the greatest wear resistance. Conclusion Our results demonstrate that the combination of vitamin E-stabilised polyethylene glenosphere and ceramic inlay has improved wear resistance properties in load simulations when compared to other bearing surface combinations. This supports the use of the novel inverse combination in clinical practice to attain longer-term survivorship in reverse total shoulder replacements. Level of evidence Basic Science Study; Tribology

Calcaneo-Achilles Allograft Shoulder Interposition Arthroplasty, Novel Technique for Superior Escape Post Hemiarthroplasty for Failed rTSA: A Case Report

Background: Reverse total shoulder arthroplasties have become common in orthopaedics to treat osteoarthritis in patients with rotator cuff deficiency. Complications of revision hemiarthroplasty from reverse total shoulder arthroplasty include anterosuperior escape, which is defined as a deficiency of the coracoacromial arch that allows the humeral head to migrate proximally. A 58-year-old woman, with superior escape and massive destruction of the shoulder suspensory complex after hemiarthroplasty conversion from a reverse total shoulder arthroplasty (rTSA), presented to our clinic with chronic, disabling shoulder pain. Materials and Methods: The patient underwent a novel salvage procedure with a calcaneo-achilles allograft fixed to the remaining glenoid through the proximal humeral shaft. The goal of this procedure was to preserve as much function in the patient’s arm as possible and reduce her chronic shoulder pain. Results: The patient continued to follow up in our clinic for 1 year postoperatively. She noted complete relief of pain by 6 weeks postoperatively. She also denied any neurologic symptoms in her operative extremity. Her patient-reported outcomes indicated major improvement in her preoperative symptoms. Conclusion: A calcaneal-achilles bone tendon allograft interposition arthroplasty may be a viable solution for failed conversion of rTSA to hemiarthroplasty or problems of end-stage arthritis with superior escape and destruction of the shoulder girdle.

Reverse Total Shoulder Arthroplasty Using Lateralized Glenoid Baseplates Has Superior Patient-determined Outcome Scores at Short-term Follow-up.

There are a variety of baseplate options when performing reverse total shoulder arthroplasty (RTSA). Currently, there is no consensus on the optimal glenoid baseplate. The hypothesis of this study was that the use of lateralized baseplates would improve patient-determined outcomes and postoperative range of motion after RTSA compared with standard baseplates without increasing the risk of complications. Patients undergoing RTSA were stratified into a standard baseplate group (SBG) and a lateralized baseplate group (LBG). The LBG included 3 mm lateralization, 6 mm lateralization, and full-wedge augmentation (8 mm lateralization). The Western Ontario Osteoarthritis Score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) were recorded at baseline, 1 year, and 2 years. Range of motion was recorded at baseline and 1 year. Differences in complications between groups were recorded. The LBG included 187 patients, and the SBG included 51 patients. No difference was observed in any patient-determined outcome score at 1-year follow-up. At 2 years, there were greater Western Ontario Osteoarthritis Score (84 ± 16 versus 74 ± 19; P = 0.01), American Shoulder and Elbow Surgeons score (81 ± 15 versus 70 ± 20; P = 0.001), SST (8.0 ± 2.4 versus 6.6 ± 2.6; P = 0.007), and SANE (82 ± 17 versus 68 ± 25; P = 0.0005). The improvement in SST (5.0 ± 2.7 versus 3.3 ± 3.6; P = 0.02) and SANE (54 ± 26 versus 37 ± 30; P = 0.004) at 2 years compared with baseline was greater in the LBG compared with the SBG. No difference was observed in any range-of-motion metric between groups. Total complications were similar between groups (P = 0.91). Scapular notching was more prevalent in the SBG (7.8% versus 1.6%; P = 0.01). The LBG had better patient-determined outcome scores compared with the SBG at 2-year follow-up with a similar rate of overall complications but a lower rate of scapular notching. Range of motion was not improved by the use of a lateralized baseplate compared with a standard baseplate.

Anatomic Versus Reverse Total Shoulder Arthroplasty for Primary Osteoarthritis With an Intact Rotator Cuff: A Midterm Comparison of Early Top Performers.

Several surgeons state that their best anatomic total shoulder arthroplasty (aTSA) outperforms their best reverse total shoulder arthroplasty (rTSA) when performed for rotator cuff-intact glenohumeral osteoarthritis. We identified the top-performing aTSAs and rTSAs at short-term follow-up and compared their clinical performance at midterm follow-up to validate this common claim. A retrospective review of a multicenter shoulder arthroplasty database was conducted. All shoulders undergoing primary aTSA or rTSA for rotator cuff-intact glenohumeral osteoarthritis between 2007 and 2020 were reviewed. Shoulders with a follow-up clinical visit between 2 and 3 years and a clinical follow-up of minimum 5 years were included. Two separate cohorts were identified: patients with a top 20% (1) American Shoulder and Elbow Surgeons (ASES) score and (2) Shoulder Arthroplasty Smart (SAS) score at 2 to 3 years of follow-up. Clinical outcomes including range of motion, outcome scores, and rates of complications and revision surgeries were compared at minimum 5-year follow-up. The ASES score cohort comprised 185 aTSAs (mean age 67 years, 42% female) and 49 rTSAs (mean age 72 years, 45% female). The SAS score cohort comprised 145 aTSAs (mean age 67 years, 59% female) and 42 rTSAs (mean age 71 years, 57% female). Active external rotation (ER) was greater after aTSA at midterm follow-up in both ASES and SAS score cohorts; however, preoperative to postoperative improvement was equivalent. Postoperative ER and SAS scores were greater after aTSA in both cohorts ( P < 0.05); however, no other significant differences in any preoperative or postoperative clinical outcomes were present ( P > 0.05), and patients achieved the minimal clinically important difference and substantial clinical benefit at similar rates for all outcomes. No difference was found in the incidence of complications and revision surgeries between top-performing aTSAs and rTSAs. Among top-performing shoulder arthroplasties at early follow-up, aTSA does not appear to outperform rTSA, except superior ER at midterm follow-up. Retrospective comparative cohort study, Level Ⅲ.

Functional assessment and quality of life of patients after reverse total shoulder arthroplasty in the late follow-up period.

Due to the systematically increasing number of shoulder replacement procedures among older people, the need to assess their quality of life is becoming more and more important. The aim of the study was to functionally assess the shoulder joint and the quality of life of patients before and after reverse total shoulder arthroplasty (rTSA). The observational study included 15 patients after the rTSA procedure (randomly selected). The quality of life and shoulder joint function before and after rTSA were assessed using the following scales: SF-36, Constant-Murley Score, Disabilities of the Arm, Shoulder and Hand Scale (DASH) and the University of California-Los Angeles Shoulder Rating Scale (UCLA scale) and Simple Shoulder Test (SST). There were statistically significant differences (p< 0.001) between measurements in the overall scores of the SF-36 questionnaire. Statistically significant differences (p< 0.001) were found between measurements in terms of the Constant-Murley, DASH, UCLA and SST scales results. Reverse total shoulder arthroplasty significantly improved the patients' quality of life and the functional condition of the operated limb.

Does morbid obesity negatively impact perioperative outcomes following elective reverse shoulder arthroplasty?: a propensity-matched comparative study

BackgroundThe incidence of primary reverse total shoulder arthroplasty (rTSA) and the prevalence of obesity have increased in the United States. Despite this, the literature assessing the effect of morbid obesity (body mass index (BMI)≥40 kg/m2) on perioperative surgical outcomes remains inconsistent. MethodsA retrospective review of consecutive elective primary rTSA cases from January 2016 through September 2023 at a single tertiary referral center was performed. All cases involved a short-stem humeral component and screw-in glenoid baseplate from the same implant manufacturer. Surgical and patient demographic data were collected. Morbidly obese patients were propensity matched at least 1:1 with non-morbidly obese patients based on age, gender, mFI-5 score, ACCI score, and 12-month preoperative ED visit. Regression analysis was utilized to assess the relationship between morbid obesity and operative time, LOS, ITVBL, surgical postoperative complications, in-hospital medical complications, disposition, and 90-day ED return and readmission. ResultsThere were a total of 175 short-stem rTSA cases performed with a median age of 71 years (IQR 66,76) and of which 19 (10.9%) had a BMI≥40 kg/m2. These 19 patients were propensity score matched to 41 non-morbidly obese patients (9 at 1:3, 4 at 1:2, and 6 at 1:1). There were no significant differences between the groups with regards to ITBVL, operative time, need for transfusion, hospital LOS, discharge disposition, prevalence for 90-day return to ED, or unplanned 90-day readmission. ConclusionsMorbid obesity should not be considered an absolute contraindication for elective rTSA, particularly in patients who have undergone appropriate preoperative medical clearance.

Short-Term Results after Reversed Total Shoulder Arthroplasty

Abstract Purpose Massive rotator cuff tear, with or without arthritis and proximal humerus fracture non-union or malunion, lead to the loss of center of rotation of shoulder, while anatomical total shoulder arthroplasty does not provide a stable center of rotation, Therefor reversed total shoulder arthroplasty (RTSA) is the suitable method for these indications, as well as in elderly patients with primary glenohumeralosteoarthritis because anatomical total shoulder arthroplasty has the risk of failure either due to loosening of glenoid component or cuff tear. This study aimed to determine the short-term results after RTSA in patients a with massive cuff tear, acute proximal humerus fracture, proximal humerus fracture malunion or non- union, and primary glenohumeralosteoarthritis. Methods This one arm clinical trial (interventional study) conducted in Ain Shams University Hospitals included 16 patients who underwent RTSA. Short-term outcomes included constant score, American Shoulder and Elbow Surgeon (ASES) score, and range of motion (ROM). Patients with rotator cuff arthropathy, massive irreparable cuff tear with or without glenohumeralarthritis, elderly patients with acute complex proximal humerus fracture, malunited or nonunited proximal humerus fracture, and patients with glenohumeralosteoarthritis were included. Patients who were aged &amp;lt;50 years were excluded, as well as patients with axillary nerve injury or deltoid muscle dysfunction. Results This study included 16 patients, including 8 males and 8 females. The mean age was 64.19 years and the duration of follow up-was 1 year postoperatively. Seven Patients with massive irreparable cuff tear were included, of them, 1 had associated anterior shoulder instability and recurrent anterior dislocation, 3 had a four-part proximal humerus fracture, 2 had fracture dislocation, 2 had proximal humerus fracture non –union, 1had neglected dislocation, and 2 had glenohumeralosteoarthritis. Outcomes were followed using constant and ASES scoring systems, and ROM. The global postoperative gain was statistically significant (p &amp;lt; 0.001). Complication in the form of dislocation occurred in one case that had RTSA after fracture non-union. Conclusion Good clinical and functional outcomes were achieved after RTSA, not only for classic massive cuff tear indication, but for other disorders, such as acute proximal humerus fracture, fracture non-union, and primary glenohumeralosteoarthritis. However, the outcomes after irreparable cuff tear were the best among all indications, while fracture non-union had the least improvement in clinical outcomes. Improvements in prosthesis design, surgeon’s experience, and clinical results are necessary to optimize this treatment for many shoulder conditions.

Peripheral Nerve Stimulation of the Axillary Nerve Improves Chronic Shoulder Pain and Dysfunction Following Reverse Total Shoulder Arthroplasty: A Case Report.

Reverse total shoulder arthroplasty (rTSA) is an effective procedure to improve shoulder pain, range of motion, and function for a variety of conditions, including glenohumeral osteoarthritis and rotator cuff arthropathy. However, up to 22% of patients have persistent shoulder pain 12 to 24 months following rTSA, even in the absence of surgical complications. Currently, there are no widely accepted non-pharmacological treatments for persistent postoperative pain after rTSA. This case report details the successful management of a 64-year-old woman with chronic postoperative shoulder pain following rTSA. She was treated with single-lead percutaneous peripheral nerve stimulation to the right axillary nerve for eight weeks with 12 Hz motor-level stimulation. She demonstrated improvement in shoulder flexion active range of motion, shoulder flexion strength, and shoulder abduction strength. Her Shoulder Pain and Disability Index total score improved from 26.93% to 8.46% one year following treatment. She reported an overall Global Rating of Change of +7 one year following treatment. This case's success demonstrates that short term peripheral nerve stimulation may provide long-term improvement of persistent post-operative pain and dysfunction in patients with painful rTSA.

Management of Massive Irreparable Posterosuperior Cuff Tears: A Systematic Review for Clinical &amp; Functional &amp; Radiological Outcomes

Abstract Background The management of massive irreparable cuff tears (MIRCT) remains a highly controversial subject with many possible surgical and non-surgical interventions and no clear evidence regarding the most effective and beneficial intervention. Different management options include: conservative management, partial repair, tendon transfer, superior capsular reconstruction, subacromial spacer insertion, reverse total shoulder arthroplasty (RTSA). Aim of the Work The aim of this systematic review is to compare the various methods of management of posterosuperior cuff tears without arthropathy to reach the most effective and sustainable mode of management. Patients and Methods A randomized controlled trial, non-randomized clinical trials, prospective and retrospective comparative cohort studies and case series. We will exclude cross-sectional studies, case reports and literature not in English. Results There is no high quality evidence on management of MIRCT. There was no Level I or II evidence. We included 69 papers that studied different modalities of management of MIRCT, 31 of level III and the remaining were of level IV evidence. Consequently, it’s still difficult to recommend one method of management over the other regarding the management of irreparable cuff tears. Patient age, demands, expectations, thorough clinical examination, surgeon experience and preference are still a major deciding factor when choosing and appropriate method. Conclusion Due to the unavailability of high-quality clinical studies available for guiding management of irreparable MRCT, it is consequently not possible to recommend for or against any specific treatment strategy. Rather, clinical experience, patient factors, patient expectations, and rotator cuff tear characteristics should guide clinical decision-making. Physical therapy compared to surgical treatments may have inferior outcomes. Standardized data collection, reporting and terminology are key to enhancing the quality of evidence-based medicine.

Poster 150: Subscapularis CT Evaluation in Patients following Treatment for Proximal Humerus Fractures: Reverse versus Anatomical Total Shoulder Arthroplasty

Objectives: Hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA) are both reliable treatment options for complex proximal humerus fractures. While the role of the subscapularis tendon is well defined in HA, its role in RTSA has not been clearly demonstrated. The purpose of our study is to evaluate the role of the subscapularis tendon in patients treated with HA and RTSA and investigate its association with clinical outcomes. Methods: Sixty-eight consecutive patients with proximal humeral fractures were prospectively enrolled in the study between June 2015 and May 2020 (RTSA = 36; HA = 32). Shoulder CT scans were performed pre- and postoperatively, and subscapularis muscle cross-sectional area (SMCSA) and supraspinatus fossa cross-sectional area (SFCSA) were measured. SMCSA/SFCSA ratio was employed to standardize values. Patient-reported outcomes (PROs) and range of motion (ROM) were evaluated at the final follow-up. Results: RTSA group demonstrated higher PROs compared to HA patients: Constant Score (p = .0001), Quick Dash (p = .0006), Simple Shoulder Test (p = .01). ROM was better in RTSA than HA: internal rotation (p = .0047 adduction and p = .026 abduction), external rotation (p = .001 adduction and p = .026 abduction) and forward flexion (p &lt; .0001). Reduction of subscapularis size of &gt;35% occurred in 20 RTSA and 8 HA (p = 0.01). The loss of subscapularis surface was greater in the RTSA patients (p = 0.018). Conclusions: RTSA demonstrated better results compared to HA, providing better PROs and ROM. Postoperative reduction in subscapularis size was significantly higher in RTSA compared to HA. Subscapularis condition demonstrated no correlation with functional outcomes in RTSA.

Poster 155: An Ultrasound and Clinical Evaluation in Patients Following Treatment for Proximal Humerus Fractures: Reverse Versus Anatomical Total Shoulder Arthroplasty

Objectives: Anatomic Total Shoulder Arthroplasty (ATSA) and Reverse Total Shoulder Arthroplasty (RTSA) are both viable treatment options for complex proximal humerus fractures. With its principal role as an abductor and internal rotator in a native joint, the subscapularis potentially plays an important functional and stability role postoperatively. Although less studied in RTSA, studies have found that failure of subscapularis repair is associated with anterior instability, and decreased range of motion (ROM), strength, and outcome scores following ATSA. The purpose of our study is to evaluate and compare the postoperative clinical, radiographic, and patient-reported outcomes following subscapularis reattachment in patients treated with either ATSA or RTSA. Methods: Sixty-eight consecutive patients with proximal humeral fractures were prospectively enrolled in the study between June 2015 and May 2020 (RTSA = 40; TSA = 28). Ultrasound scans of the subscapularis were performed postoperatively, and the subscapularis muscle cross-sectional area (iSMCSA) and contralateral subscapularis muscle cross-sectional area (cSMCSA) were measured. The ratio of the 2 values (iSMCSA/cSFCSA) was utilized to standardize values. Patient-reported outcomes (PROs) and ROM were evaluated at the final follow-up. Results: Demographically, there was no significant difference between age, arm dominance, surgical laterality, diabetes, or hypertension between the patient groups (Table 1). The RTSA group demonstrated higher PROs compared to TSA patients: Constant Score (p = .0007), Quick Dash (p = .0005), and ASES score (p = .09). ROM was better in the RTSA cohort, with statically significant values with internal rotation (p = .022 abduction), external rotation (p = .02 adduction and p = .01 abduction), abduction (p = 0.02), and forward flexion (p = .003). Radiographic ultrasound findings illustrated greater reduction in size of the subscapularis in the TSA cohort when compared to the contralateral, nonoperative subscapularis (40% vs 27%; p = 0.002). Reduction of subscapularis size of &gt;35% occurred in 2 RTSA (7%) and 8 TSA patients (44%) (p = 0.01) (Table 2). Conclusions: Subscapularis repair following RTSA demonstrated better results compared to subscapularis repair following TSA, providing better PROs and ROM. Subscapularis muscle tissue decreased 50% more in the ATSA versus RTSA patients (40% vs 27%). Subscapularis condition demonstrated no correlation with functional outcome in RTSA.

Short-Term Results after Reverse Total Shoulder Arthroplasty

Abstract Background: The loss of the shoulder’s center of rotation is caused by massive rotator cuff tears, which can occur with or without arthritis and proximal humerus fractures that are nonunion or malunion. Because anatomical total shoulder arthroplasty cannot provide a stable center of rotation, reverse total shoulder arthroplasty (RTSA) is the appropriate procedure for these indications and in older patients who have primary glenohumeral osteoarthritis. Anatomical total shoulder arthroplasty carries a risk of failure because of the loosening of the glenoid component or cuff tear. The purpose of this study was to determine the short-term outcomes following RTSA in patients who had primary glenohumeral osteoarthritis, acute proximal humerus fractures, malunited or nonunited proximal humerus fractures, and massive cuff tears. Materials and Methods: This single-arm clinical trial (interventional study) was done in Ain Shams University Hospitals; 16 patients were included who underwent RTSA. Constant score, American Shoulder and Elbow Surgeon score, Visual Analog Scale score, and range of motion (ROM) were the short-term outcomes. Patients with cuff tear arthropathy, irreparable cuff tear with or without glenohumeral arthritis, elderly patients with unreconstructable proximal humerus fracture, proximal humerus fracture malunion or nonunion, and patients with glenohumeral osteoarthritis were included. Patients under the age of 50, as well as those with deltoid muscle dysfunction or injuries to the axillary nerve, were excluded. Results: There were 16 patients in this study, 8 of whom were male and 8 of whom were female. The follow-up period lasted 2 years following surgery, with a mean age of 64.19 years. The study included 7 patients with irreparable cuff tears one of them had associated anterior shoulder instability and recurrent anterior shoulder dislocation. One patient had a neglected shoulder dislocation, two patients had proximal humerus fracture dislocation, two patients had a nonunited proximal humerus fracture, three patients had unreconstructable proximal humerus fracture, and two had glenohumeral osteoarthritis. Conclusion: Not only did RTSA provide good clinical and functional outcomes for the standard indication of a massive cuff tear, but it also proved beneficial for other disorders such as primary glenohumeral osteoarthritis, nonunited fracture, and acute proximal humerus fracture. Among all indications, irreparable cuff tears yielded the highest results; nonunited fractures displayed the least improvement regarding clinical outcomes. Enhancements in the design of prostheses, the expertise of surgeons, and clinical outcomes are crucial to maximize their effectiveness in treating various shoulder disorders.

Revising Failed Reverse Total Shoulder Arthroplasty: Comprehensive Techniques for Precise Explantation of Well-Fixed Implants.

With the increased utilization of reverse total shoulder arthroplasty (RTSA), there has been a corresponding increase in the incidence of and demand for revision RTSA3. In cases in which the patient has undergone multiple previous surgeries and presents with well-fixed shoulder implants, even the most experienced shoulder surgeon can be overwhelmed and frustrated. Having a simple and reproducible treatment algorithm to plan and execute a successful revision surgery will ease the anxiety of a revision operation and avoid future additional revisions. The extraction techniques described here strive to preserve the humeral and glenoid anatomy, hopefully facilitating the reimplantation steps to follow. The main principles of implant removal include several consistent, simple steps. In order to revise a well-fixed humeral implant, (1) identify the old implants; (2) create a preoperative plan that systematically evaluates the glenoid and humeral deficiencies; (3) prepare consistent surgical tools, such as an oscillating saw, osteotomes, and/or a tamp; (4) follow the deltoid; (5) dissect the soft tissue with a sponge; (6) dissect the bone with use of an osteotome; and (7) remove the humeral stem in rotation. In cases in which there is also a well-fixed glenoid implant, the surgical procedure will require additional steps, including (8) exposure of the anteroinferior glenoid, (9) disengagement of the glenosphere, and (10) removal of the glenoid baseplate in rotation. Alternatives to revision RTSA include nonoperative treatment, implant retention with conversion of modular components, extensile revision surgical techniques, and/or mechanical implant removal. With the advent of modular humeral and glenoid components, surgeons may choose to change the implant components instead of removing the entire humeral and glenoid implants; however, repeat complications may occur if the previous implant or implant position was not completely revised. When confronted with a tough humeral explantation, an extensile surgical approach involves creating a cortical window or humeral osteotomy to expose the humeral implant. This approach can compromise the humeral shaft integrity, leading to alternative and less ideal reconstruction implant choices, the use of cerclage wires, and/or the use of a strut graft, all of which may complicate postoperative mobilization. If glenoid implant removal is necessary, the glenosphere is removed first, followed by the underlying baseplate component(s). If the glenosphere is stuck or if screws are cold-welded, the use of a conventional mechanical extraction technique with a burr or diamond saw may be required; however, this may lead to additional metal debris and intraoperative sparks. Revision RTSA can lead to high complication rates, ranging from 12% to 70%2, which will often require additional revision surgeries4. The first steps to all revision RTSA procedures include careful surgical exposure and component explantation. A simplified approach to expose the humerus and glenoid, coupled with a systematic and atraumatic approach to remove the implants without inadvertent injuries, will prevent surgical complications and the need for re-revision. The proposed comprehensive technique hopefully will allow precise removal of the humeral and glenoid implants while also preserving the remnant humerus or glenoid for future reconstruction. Few studies have evaluated postoperative patient outcomes in revision RTSA. Chalmers et al. performed a meta-analysis and found that patients were able to achieve a mean elevation of 106°, a mean American Shoulder and Elbow Surgeons score of 63, and a mean Single Assessment Numeric Evaluation score of 522. Boileau showed very similar outcomes, with a mean elevation of 107° and a mean adjusted Constant score of 621. These outcomes are slightly inferior to those of primary RTSA, but patients remain satisfied with their improvement from their preoperative function. Preoperative preparation will reduce intraoperative reparation. Know the existing implant and the unique features of its design, understand the patient anatomy including bone defects, and anticipate all of the potential tools that may be needed.Know your anatomy. The anteromedial deltoid edge will help you identify the scarred-in humeral shaft.Da Vinci said that simplicity is the ultimate sophistication. Some of the most common surgical tools and instruments can be more effective than custom-designed ones.The implant should be removed in rotation.There are some company-specific explantation instruments that can be very helpful. Give the appropriate ones a try, but be prepared to consider alternative solutions. RTSA = reverse total shoulder arthroplastyCT = computed tomographyFE = forward elevation.

High delta angle after reverse total shoulder arthroplasty increases stresses of the acromion: biomechanical study of different implant positions

BackgroundAcromial fractures after Reverse Total Shoulder Arthroplasty (RTSA) are a common complication. Nevertheless, only a few studies have identified risk factors for acromial fractures after RTSA. High delta angle (combination of inferiorization and medialization of the center of rotation) after RTSA was identified as a risk factor in recent studies. The aim of this study was the biomechanical exploration of different delta angles and implant configurations with regard to the acromial stress. MethodsIn a rigid body model of the upper extremity muscle, forces of the deltoid muscle were calculated before and after implanting RTSA in different arm and implant positions. The deltoid muscle was divided into an anterior, middle, and posterior part. Implant positions of the glenoid components were changed in the medialization, lateralization and inferiorization of the center of rotation (COR) as well as lateralization of the humeral component. Further, in a finite element model of the upper extremity, the stresses of the acromion in the same implant design configurations were measured. ResultsDifferences in acromial stress between different delta angle model configurations were observed. Lateralization (5 mm, 10 mm) of the glenosphere reduced maximal acromial stress by 21% (1.5 MPa) and 31% (1.3 MPa), respectively. Inferiorization (5 mm, 10 mm) of the glenosphere increased maximal acromial stress by 5% (2.0 MPa) and 15% (2.2MPa), respectively. Changes in positioning the humeral component was found to have the highest impact in this model configuration. A 10 mm lateralized humeral component reduced acromial stress by 37% (1.2 MPa) while in the 6 mm medialized configuration, an increase in acromial stress by 83% (3.48 MPa) was observed. There was a high correlation between delta angle and acromial stress (R-squared = 0.967). ConclusionImplant design configuration has an impact on the acromial stress. High delta angles correlate with an increase in acromial stress. Both lateralization of the COR and the humerus decreased the acromial stress in our study. The lateralization of the humerus has the highest impact in influencing acromial stress. Due to contrary results in the current literature, further studies with focus on the acromial stress influenced by different anatomical variants of the shoulder and the acromion are needed before a clinical recommendation can be made.

Comparison of early and late aseptic baseplate failure in primary reverse shoulder arthroplasty with and without structural glenoid autograft

Early reverse total shoulder arthroplasty (RTSA) designs demonstrated high glenoid baseplate complication and revision rates. While contemporary designs have reduced the incidence of glenoid baseplate failures, there are reports of elevated failure risks in RTSA with glenoid bone grafting within the first 2 years. This study aims to evaluate the incidence and etiology of aseptic glenoid baseplate failure with a contemporary central screw baseplate. The null hypothesis is that majority of the baseplate failure occurs within the first 2 years and use of glenoid bone grafting does not lead to higher risk of baseplate failure. In 2014 - 2019, 753 consecutive patients who underwent primary RSA using the same inlay press-fit humeral stem and monoblock central screw baseplate were retrospectively reviewed. Fracture and septic arthropathy cases were excluded. All patients underwent preoperative radiographic and computed tomography evaluation. If there was significant glenoid erosion (Walch A2, B2, B3, C1, C2, E2, E3, and/or E4 variants), patient-specific structural glenoid bone grafting was performed. All patients underwent standardized radiographic follow-up and failure was strictly defined as any hardware breakage and/or shift in glenoid baseplate position. Failures were defined as "early" if occurring within 2 years and "late" if occurring greater than 2 years after surgery. Comparative analysis was performed to evaluate demographics, glenoid graft use, and graft union rates between the cohorts. There were 23 patients with baseplate failures (23/753, 3.0%) at mean of 23 months. Twenty-two failures (96%) occurred in patients who received structural glenoid bone grafting. Only 1 failure (0.2%) occurred when bone grafting was not indicated (p<0.001). The most common failure pattern was associated with B2 glenoid (16/23, 70%). There were 5 (22%) early failures and 18 (78%) late failures. There were no differences in any patient demographic characteristics between cohorts. All 5 early failures had graft nonunion and 4/5 occurred without trauma. In the 18 late failures , 9/18 (50%) occurred without trauma (p=0.135). Seventeen of these patients had glenoid grafting, of which 9/17 (53%) had graft nonunion. Contemporary RTSA glenoid baseplate designs have an acceptably low incidence of failure. However, the addition of structural bone graft to correct glenoid wear leads to higher aseptic baseplate failure rate. The majority of these patients suffer failure after the 2-year postoperative mark, highlighting the necessity of longer follow-up. Further analysis is necessary to quantify glenoid characteristics (severity of glenoid erosion, critical size of graft) associated with failure.