Revision Total Shoulder Arthroplasty Research Articles

Does non-spherical humeral head with inlay glenoid re-center the glenohumeral joint?

BackgroundTreatment of glenohumeral osteoarthritis (OA) with Walch type B glenoid poses a challenge for orthopedic surgeons. Although various techniques have been described, it is still a major concern in terms of management and long-term results. We hypothesized that total shoulder arthroplasty (TSA) using a combination of non-spherical humeral head resurfacing (HHR) and inlay glenoid replacement would re-center the glenohumeral joint in patients with Walch type B glenoid without surgical correction of glenoid version. MethodsWe retrospectively screened patients who underwent TSA using a combination of non-spherical HHR and inlay glenoid replacement for primary glenohumeral OA with posteriorly subluxated humeral head (HH) (Walch Type B1, B2 and B3) between 2015 and 2019. Ratios of preoperative and postoperative HH subluxation were compared using Walch index and the point of contact ratio method. Two orthopedic surgeons performed radiographic measurements blinded to each other. Means of 2 independent measurements were included in the final analysis for each shoulder. We also screened for postoperative complications, dislocation events and radiographic loosening. ResultsInitial cohort included 49 patients. A total of 29 shoulders in 28 patients were eligible for screening. The numbers of shoulders with Walch type B1, B2, and B3 glenoids were 3, 22, and 4, respectively. Mean preoperative and postoperative Walch indices were 56.57 ± 6.08% and 49.47 ± 4.78%, respectively. The mean preoperative and postoperative point of contact ratios were 62.97 ± 8.45% and 50.08 ± 3.87%, respectively. The difference between preoperative and postoperative subluxation ratios was significant for both methods (P < .01). Inter-rater reliability was found to be good-excellent. The overall complication rate at a mean follow-up period of 37.79 months was 10.34% (3/29). One patient experienced deep vein thrombosis (DVT) (3.22%) on postoperative day 8. Two patients experienced infection (6.45%), one of which required a revision TSA (3.22%) at 19 months after surgery. No patient experienced shoulder dislocation and no loosening was detected on postoperative radiographs. ConclusionWhen coupled with an inlay glenoid component in patients with eccentric glenoid wear and posterior subluxation, glenohumeral re-centering was consistently observed in this challenging patient population without the use of joint correction or augmentation procedures. It will be important to follow the clinical outcomes over the long-term to determine whether these observations translate to better clinical results than other techniques currently employed to deal with eccentric erosion and posterior subluxation of the arthritic glenohumeral joint although recent published mid-term results suggest results equal to or better than previously reported results in literature with different reconstructive techniques Level of evidenceLevel IV; Retrospective cohort

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

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

Disproportionate burden of septic versus aseptic revision total shoulder arthroplasty: a comparative assessment of operative time and work relative value units

Periprosthetic infection (PJI) remains a challenging complication in total shoulder arthroplasty. Surgical treatment options can include 1 or 2-stage revision procedures, temporizing articulating spacers, and resection arthroplasty, with many cases resulting in transfer of patient care to a tertiary care center. While these cases can impose significant cost and clinical burden for both surgeons and hospital systems, there is limited data about the operative time investment and reimbursement compared to aseptic revision cases. The purpose of the current study was to compare work relative value units and operative times for aseptic and septic shoulder arthroplasty revision procedures. We hypothesize that staged, PJI-related revision shoulder arthroplasty is associated with significant differences in operative time and work relative value units assigned as compared to aseptic revisions. This study utilized data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Inclusion criteria included all patients that underwent a revision total shoulder arthroplasty between January 1, 2010 and December 31, 2018. Procedures were grouped as either aseptic or septic revisions and further stratified into 1 stage and each stage of a 2-stage revision for septic cases. The RVU-to-dollar conversion factor was provided by the United States Centers for Medicare and Medicaid Services (CMS). This was used to obtain total reimbursement and reimbursement per minute estimates. When assessing the ratio of RVUs per minute of operative time across the groups, we found that the second stage of a 2-stage septic revision had a significantly lower RVU per minute operative time ratio (0.25) when compared to both the aseptic 2-component revision (0.34) and the first stage of a 2-stage septic revision (0.29). This translated to a significantly lower dollar per minute operative time value. The current study found that the second stage of a 2-stage septic revision was undervalued in the number of RVUs per minute of operative time when compared to an aseptic revision or even its first stage counterpart. An adjustment or redistribution of relative value units for these procedures may offset the disproportionate clinical burdens encountered with definitive treatment of these complications. Level III.

Incidence of peripheral nerve injury in revision total shoulder arthroplasty: an intraoperative nerve monitoring study

The incidence of nerve injuries in revision total shoulder arthroplasty (TSA) is not well defined in the literature and may be higher than that in primary procedures, with 1 study reporting a complication rate of 50% for shoulder revisions. Given that continuous intraoperative nerve monitoring (IONM) can be an effective tool in diagnosing evolving neurologic dysfunction and preventing postoperative injuries, the purpose of this study was to report on IONM data and nerve injury rates in a series of revision TSAs. A retrospective cohort review of consecutive patients who underwent revision TSA was performed from January 2016 to March 2020. Indications for revision included infection (n = 7); failed total arthroplasty and hemiarthroplasty secondary to pain, dysfunction, and/or loose components (n = 36); and periprosthetic fracture (n = 1). Of the shoulders, 32 underwent revision to a reverse TSA, 6 underwent revision to an anatomic TSA, and 6 underwent spacer placement. IONM data included transcranial electrical motor evoked potentials (MEPs), somatosensory evoked potentials, and free-run electromyography. The motor alert threshold was set at ≥80% signal attenuation in any peripheral nerve. Patients were screened for neurologic deficits immediately following surgery, prior to administration of an interscalene nerve block, and during the first 2 postoperative visits. Additional data collection included surgical indication, sex, laterality, age at surgery, procedure performed, body mass index, history of tobacco use, Charlson Comorbidity Index, medical history, and preoperative range of motion. A total of 44 shoulders in 38 patients were included, with a mean age of 63.2 years (standard deviation, 13.0 years). Of the procedures, 22.4% (n = 10) had an MEP alert, with 8 isolated to a single nerve (7 axillary and 1 radial) and 1 isolated to the axillary and musculocutaneous nerves. Only 1 patient experienced a major brachial plexus alert involving axillary, musculocutaneous, radial, ulnar, and median nerve MEP alerts, as well as ulnar and median nerve somatosensory evoked potential alerts. Age, sex, body mass index, Charlson Comorbidity Index, and preoperative range of motion were not found to be significantly different between cases in which an MEP alert occurred and cases with no MEP alerts. In the postoperative period, no minor or major nerve injuries were found whereas distal peripheral neuropathy developed in 4 patients (9.1%). Among 44 surgical procedures, no patients (0%) had a major or minor nerve injury postoperatively and 4 patients (9.1%) complained of distal peripheral neuropathy postoperatively. In this study, we have shown that through the use of IONM, the rate of minor and major nerve injuries can be minimized in revision shoulder arthroplasty.

Hospital Readmission Rates Following Outpatient Versus Inpatient Shoulder Arthroplasty.

Outpatient total shoulder arthroplasty (TSA) is an alternative to surgery with inpatient admission for appropriate patients. Controlled studies assessing differences in perioperative outcomes between inpatient and outpatient TSA are lacking. In this study, the primary outcome was 30-day all-cause hospital readmission following inpatient vs outpatient TSA. The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients undergoing both primary and revision TSA from 2010 to 2017. Patients were identified using Current Procedural Terminology codes. A 1:1 propensity score matching was used to create two groups of patients, those who underwent outpatient surgery and those who underwent inpatient surgery, while matching for age, sex, American Society of Anesthesiologists classification, primary vs revision surgery, smoking, diabetes, chronic obstructive pulmonary disease, and congestive heart failure. This study had a power of 85% to detect a difference of 1% in 30-day readmission. Following 1:1 propensity score matching, 1714 patients who underwent inpatient TSA and 1714 patients who underwent outpatient TSA were analyzed. All-cause 30-day readmission rates were 3.4% in the outpatient group and 1.7% in the inpatient group (P<.01). A total of 1.9% of patients who underwent outpatient surgery had a 30-day readmission for a surgical complication compared with 1.4% of patients who underwent inpatient surgery (P=.32). Although patients who underwent outpatient TSA had an increased risk of all-cause 30-day readmission compared with equally matched controls who underwent inpatient TSA, readmission for surgical complications was equivalent between the two groups. Careful patient selection for outpatient TSA should be emphasized to minimize the potential for postoperative hospital admission. [Orthopedics. 2021;44(2):e173-e178.].

Giant cell tumor formation due to metallosis after open latarjet and partial shoulder resurfacing

Shoulder metallosis with giant cell tumor formation is rarely seen in shoulder surgery. With an increase in shoulder arthroplasty and complex revision shoulder surgeries, clinicians should have an index of suspicion for possible metallosis in patients that presents with unexplained persistent pain with metal components on both the glenoid and humeral side. This case describes a 43-yearold female with a history of six prior shoulder surgeries who presented with shoulder metallosis and giant cell tumor formation after a screw from her open Latarjet procedure began rubbing against her Hemicap implant. She successfully underwent a revision total shoulder arthroplasty for post traumatic arthritis with pectoralis major transfer for her chronic subscapularis rupture and had complete symptom resolution.

Pathogenic genetic variations of C. acnes are associated with clinically relevant orthopedic shoulder infections.

Many surgeons continue to face the clinical dilemma of interpreting a positive aspiration or unexpected positive Cutibacterium acnes (C. acnes) culture. There are factors that complicate the interpretation of positive cultures including variations in both frequency of false positive cultures and virulence properties. As indices of virulence, hemolytic strains, from previously confirmed clinically infected shoulders, were compared with non-hemolytic isolates determined to be contaminants, by RNA-sequencing (RNA-Seq). Six C. acnes isolates from patients who underwent revision total shoulder arthroplasty (TSA) were identified based on previously described infection criteria. Three C. acnes isolates from each group underwent RNA-Seq. Differential gene expression analysis, principal component analysis (PCA), and heatmap analysis were used to determine the gene variation and patterning between the definite infection and probable contaminant isolates. Differential gene expression analysis identified genes that were differentially expressed between the isolates classified as definite infection and isolates classified as probable contaminants. PCA using a 500 gene subset of identified genes was able to find combinations of these genes that separated out the definite infection and probable contaminants isolates. The heatmap demonstrated similar gene expression in the three Definite Infections isolates, and significantly different expression when compared with the probable contaminant isolates. Clinical significance: C. acnes revision TSA isolates classified as definite infection and probable contaminant demonstrated a similar gene expression pattern to each respective group and different gene expression pattern when compared between groups. These findings indicate distinct differences in C. acnes strains associated with clinically relevant orthopedic TSA infections.

Clavicular osteotomy in complicated revision of total shoulder arthroplasty: indications, surgical technique, and outcomes.

Adequate exposure in revision of total shoulder arthroplasty (TSA) is important for optimal prosthesis placement and functional results. A clavicular osteotomy in difficult cases of revision TSA is a useful surgical technique that increases the superior exposure area, provides safer dissection, minimizes damage to the anterior deltoid muscle, improves glenoid access, and allows for superior dislocation of the humeral component. There is a paucity of literature analyzing the clavicular osteotomy during challenging cases of revision TSA. The aims of this study were to describe the application, surgical technique, and outcomes of revision TSA with a clavicular osteotomy. This was a retrospective study of consecutive patients who underwent revision TSA with a clavicle osteotomy at a single institution (2004-2016). A curved longitudinal clavicular osteotomy is created parallel to the origin of the anterior deltoid muscle. This allows for lateral reflection of the osteotomy and anterior deltoid muscle to significantly increase superior exposure and reduce damage to remaining deltoid muscle fibres. Osteotomy closure is simple with four or five Nice knot osteosutures. The Constant-Murley score and osteotomy healing were assessed at every follow-up. All complications were reviewed. Forty patients who had a mean age of 63.8years (range 37-87) at time of surgery and mean follow-up duration of 34months (range 12-88) were analyzed. Pre-operative Constant-Murley scores improved significantly from 32 ± 19.0 to 58 ± 15.0 (p < 0.001) at oneyear and 65 ± 13.1 (p < 0.001) at twoyears. Primary osteotomy healing and callus formation were evident in 95% of cases by threemonths. Five patients developed post-operative complications (13%) related to the clavicular osteotomy: three mid-diaphyseal clavicular fractures sustained after trauma (8%), one clavicular stress fracture (3%), and case of one loosening (3%). Three patients (8%) required surgical revision of the osteotomy (two internal fixation and one revision osteosuturing). No neurovascular injuries or scapular fractures were encountered. A curved longitudinal clavicular osteotomy is beneficial in difficult revision TSA and is another tool in the arsenal of experienced shoulder surgeons who manage these challenging cases. This surgical technique increases glenoid exposure, facilitates superior dislocation of the humeral component, minimizes anterior deltoid damage, and reduces the risk of neurovascular injuries. All clavicular complications occurred within fourmonths prior to osteotomy union, with many sustained due to trauma. However, patients who developed a complication had comparable shoulder function as those without.

Preoperative opioid use is associated with increased readmission, revision surgery and cost after total shoulder arthroplasty

BackgroundPreoperative opioid use has been associated with higher pain scores and lower functional outcomes after total shoulder arthroplasty (TSA), but the association between preoperative opioid use and readmission, revision surgery and cost following TSA is less well-known. The purpose of this study is to determine the association between preoperative opioid use and readmission, revision surgery and cost after total shoulder arthroplasty. MethodsUsing the Marketscan© administrative claims database, we identified patients from 2010–2015 who underwent primary TSA using Current Procedural Terminology codes. 5,621 patients aged 18–64 were identified who had 6-months of continuous coverage preoperatively and one year of continuous coverage postoperatively. Patients who were using opioids up until the 30-day period prior to surgery were classified as preoperative opioid users. Our primary outcomes were rates of 90-day all-cause hospital readmission, 1-year rates of revision surgery, and 1-year healthcare payments. Logistic regression and a generalized linear model were used to analyze binomial and payment data, respectively. All models were controlled for age, gender and Charlson comorbidity index. ResultsMean age of patients was 57 ± 5.6 years, 42% were females. Average length of stay was 1.7 ± 1.2 days. 28% of patients were using opioids preoperatively. Preoperative opioid use was associated with significantly increased odds of 90-day readmission (OR 2.6, p<0.001), having a revision TSA within 1-year (OR 2.35, p<0.001), and higher total postoperative 1-year healthcare payments (+$10,034, p<0.001). Preoperative opioid use was also associated with a small, but significant increased length of stay (+0.13 days, p = 0.001). ConclusionsPreoperative opioid use is associated with increased rates of readmission and revision surgery following TSA. Patients undergoing TSA have significantly higher total healthcare costs and a modest increase in length of hospital stay. Level of evidenceLevel II

Vitamin D deficiency and total shoulder arthroplasty complications.

The primary objective of this study was to examine the relationship between vitamin D deficiency and implant-related and medical complications following total shoulder arthroplasty. Using the PearlDiver database, patients who underwent total shoulder arthroplasty from 2005 to 2016 with vitamin D deficiency were identified. These were compared to a 3:1 control group matched by age, sex, and presence of a concomitant osteoporosis diagnosis. Primary outcome measures were implant-related complications (loosening, periprosthetic fracture, periprosthetic joint infection, and revision total shoulder arthroplasty) in addition to medical complications within 90 days of surgery. A multivariable logistic regression analysis was utilized to control for patient demographics and comorbidities. One thousand and six hundred and seventy-four patients with vitamin D deficiency were identified and compared to 5022 controls. There was a significantly higher rate of revision total shoulder arthroplasty in the vitamin D deficient patients compared to controls (2.3% versus 0.8%, odds ratio 3.3, p < 0.0001). After controlling for confounding variables, there were no significant differences in any of the remaining implant-related or medical complications with the exception of higher rates of urinary tract infections in patients with vitamin D deficiency. Vitamin D deficiency is associated with a higher rate of all-cause revision total shoulder arthroplasty but not medical complications compared to controls.Level of evidence: Level III case control study.

Glenoid reconstruction in revision shoulder arthroplasty

The aim of the surgical technique is the stable fixation of aglenoid baseplate and reconstruction of bone loss with correction of version, inclination, and medialization of the joint line. Significant glenoid bone loss due to glenoid loosening or wear in revision shoulder arthroplasty. Active infection, inoperability due to poor health condition. Reconstruction of advanced glenoid bone stock in case of glenoid loosening of total shoulder arthroplasty can be performed either with autografts and allografts or metallic augmentation together with reverse baseplates in aone- or two-stage procedure. The preferred fixation mode was atransfixation technique using autograft and baseplates with extra-long coated or threaded post with 2-4locking screws. Baseplates with an extended post and locking screws adjustable in various inclination are required to achieve fixation along the "3-column concept" which is used by the authors based on a recently introduced classification algorithm, which is based on the remaining bone stock available for fixation of the post in native bone stock. The standard protocol with an abduction brace for 6weeks and passive exercises is modified, depending on the extent of reconstruction on the humeral and glenoid side, and the type of implant. In all, 145 cases of revision total shoulder arthroplasty suffering from moderate or advanced bone loss were retrospectively evaluated and 95followed up for a mean of 2.7years (range 1-7years). We classified the remaining bone stock as grade 4 or 5 in 61patients and grade 2 and 3 in 84patients. Our preferred surgical technique was cementless fixation of structural bone grafts using areverse baseplate in transfixation technique. In all, 56cases required substantial iliac crest bone grafts, of which 36patients were operated on in a2-stage procedure. In 20patients the bone defect in the iliac crest was secured by alocking plate in order to avoid afatigue fracture of the anterior iliac spine. Only in 5cases with intact rotator cuff was an anatomical "platform" component used; the remaining cases were converted to reverse shoulder arthroplasty. Asuccess rate of more than 90% for both one- and two-stage reconstructions, which is mainly related to the high rate of incorporation of autografts taken from the iliac crest, is comparable to the majority of data published in the literature.

Treatment of severe glenoid deficiencies in reverse shoulder arthroplasty: the Glenius Glenoid Reconstruction System experience

The treatment of glenoid bone deficiencies in primary or revision total shoulder arthroplasty is challenging. This retrospective study evaluated the short-term clinical and radiologic results of a new custom-made patient-specific glenoid implant. We treated 10 patients with severe glenoid deficiencies with the Glenius Glenoid Reconstruction System (Materialise NV, Leuven, Belgium). Outcome data included a patient-derived Constant-Murley score, a visual analog score (VAS), a satisfaction score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Simple Shoulder Test. We compared the postoperative position of the implant with the preoperative planned position on computed tomography scans. At an average follow-up period of 30.5 months, the mean patient-derived Constant-Murley score was 41.3 ± 17.5 points (range, 18-76 points) with a visual analog scale of 3.3 ± 2.5 points (range, 0-7 points). The mean 11-item version of the Disabilities of the Arm, Shoulder and Hand score was 35.8 ± 18.4 (range, 2-71), and the mean Simple Shoulder Test was 47.5% ± 25.3% (range, 8%-92%). Eight patients reported the result as better (n = 3) or much better (n = 5). One patient had an elongation of the brachial plexus, and 1 patient had a period of instability. The average preoperative glenoid defect size was 9 ± 4 cm3 (range, 1-14 cm3). The mean deviation between the preoperative planned and the postoperative version and inclination was 6° ± 4° (range 1°-16°) and 4° ± 4° (range 0°-11°), respectively. Early results of the Glenius Glenoid Reconstruction System are encouraging. Adequate pain relief, a reasonable functionality, and good patient satisfaction can be obtained in these difficult cases. Further follow-up will determine the bony ingrowth and subsequent longevity of this patient-specific glenoid component.

Endoprosthetic replacement of the proximal humerus in revision shoulder arthroplasty

Reconstruction of proximal humeral bone defects in the setting of shoulder revision arthroplasty by implantation of amodular humeral component. Severe segmental humeral bone defects in revision total shoulder arthroplasty, after tumor resection, trauma, pathological fractures, post-infectious or after failed osteosynthesis. Acute or chronic local infections, large diaphyseal bone defects preventing adequate anchorage of the prosthesis, very short life expectancy (<3months). Removal of the implant using an extended deltopectoral approach. Periarticular arthrolysis with preservation of neurovascular structures. Resection of the meta-diaphyseal bone and reconstruction of the humeral length with the help of different extension sleeves and amodular humeral component. Soft tissue management is crucial, especially with reverse shoulder arthroplasty. Three weeks postoperatively immobilization in ashoulder sling, active assisted movement therapy by gradual pain-adapted increase of movement, muscle coordination, and strength. The results of 11 consecutive patients treated with amodular humeral component due to afailed shoulder arthroplasty between 2008 and 2016 were evaluated retrospectively. Mean length of reconstruction was 100 mm. Due to recurrent dislocations one patient required revision and conversion to areverse component. No cases of aseptic loosening or periprosthetic infection were observed.

Significance of Perioperative Tests to Diagnose the Infection in Revision Total Shoulder Arthroplasty

The purpose of this study was to evaluate the value of perioperative tests for the diagnosis of infection in revision shoulder arthroplasty. A retrospective analysis was performed on 537 shoulder arthroplasties (429 patients) that underwent revision shoulder arthroplasty at our institution. Periprosthetic tissue cultures were positive in 169/537 surgeries. White-blood cell count (WBC) was elevated in 3.8% revision arthroplasties. Erythrocyte sedimentation rate (ESR) was elevated in 23.1% revision arthroplasties. The C-reactive protein (CRP) was elevated in 20.8% revision arthroplasties. Bone scans (technetium, indium) were performed on 9.9% patients and it was positive for osteomyelitis in just one revision arthroplasty. Intra-operative pathology was read as consistent with acute inflammation in 11.9% revision arthroplasties. The positive and negative predictive values for intra-operative pathology were 56.7% and 71.6% respectively. All of the perioperative tests had a high specificity and negative predictive value, but low sensitivity and positive predictive value.

Risk factors for and timing of adverse events after revision total shoulder arthroplasty.

Despite increasing rates of revision total shoulder arthroplasty (RTSA), there is a paucity of literature on optimizing perioperative outcomes. The purposes of this study were to identify risk factors for unplanned readmission and perioperative complications following RTSA, risk-stratify patients based on these risk factors, and assess timing of complications. Bivariate and multivariate analyses of risk factors were assessed on RTSA patients from the ACS-NSQIP database from 2011 to 2015. Patients were risk-stratified and timing of severe adverse events and cause of readmission were evaluated. Of 809 RTSA patients, 61 suffered a perioperative complication or readmission within 30 days of discharge. Multivariate analysis identified operative time, BMI > 40, infection etiology, high white blood cell count, and low hematocrit as significant independent risk factors for 30-day complications or readmission after RTSA (p ≤ 0.05). Having at least one significant risk factor was associated with 2.71 times risk of complication or readmission within 15 days compared to having no risk factors (p < 0.001). The majority of unplanned readmission, return to the operating room, open/deep wound infection, and sepsis/septic shock occurred within two weeks of RTSA. Patients at high risk of complications and readmission after RTSA should be identified and optimized preoperatively to improve outcomes and lower costs.

Patient-Specific Implants in Severe Glenoid Bone Loss.

Complex glenoid bone deformities present the treating surgeon with a complex reconstructive challenge. Although glenoid bone loss can be encountered in the primary setting (degenerative, congenital, post-traumatic), severe glenoid bone loss is encountered in most revision total shoulder arthroplasties. Severe glenoid bone loss is treated with various techniques including hemiarthroplasty, eccentric reaming, and glenoid reconstruction with bone autografts and allografts. Despite encouraging short- to mid-term results reported with these reconstruction techniques, the clinical and radiographic outcomes remain inconsistent and the high number of complications is a concern. To overcome this problem, more recently augmented components and patient specific implants were introduced. Using the computer-aided design and computer-aided manufacturing technology patient-specific implants have been created to reconstruct the glenoid vault in cases of severe glenoid bone loss. In this article we describe a patient specific glenoid implant, its indication, technical aspects and surgical technique, based on the author's experience as well as a review of the current literature on custom glenoid implants.

Outcomes of lesser tuberosity osteotomy in revision anatomic shoulder arthroplasty

Lesser tuberosity osteotomy (LTO) is a common surgical approach during anatomic shoulder arthroplasty. Outcomes of LTO have been shown to be similar to subscapularis tenotomy and peel techniques, but little is known about the outcomes of LTO during revision arthroplasty. This retrospective case series included 10 consecutive patients who underwent LTO during revision shoulder arthroplasty at a single institution from 2012 to 2016. Patients underwent a preoperative computed tomography scan to evaluate the lesser tuberosity bone stock. Demographic information, radiographic evidence of LTO healing, outcomes of range of motion, subscapularis strength, and visual analog scale pain scores were analyzed. Revision total shoulder arthroplasty with LTO was performed for glenoid arthritis after hemiarthroplasty in 10 patients. Average age at surgery was 59.8 years, and no humeral stems were revised. Eight of 10 patients had prior subscapularis tenotomy. Average follow-up after revision surgery was 9.2 months. LTO union was documented in 80% and nondisplaced nonunion in 20%. At follow-up, 50% reported mild pain. Subscapularis strength testing was graded normal in 80% and weak in 20%. Average visual analog scale pain improved from 9.4 prerevision to 4.8 postrevision (P < .05). On average, range of motion improved in active forward elevation from 123° to 141° and remained unchanged in active external rotation from 42° to 42°. Patients undergoing LTO during revision anatomic shoulder arthroplasty demonstrate successful LTO bony healing, improvement in pain, and improved forward elevation. In select patients not requiring humeral stem revision, LTO is a safe and effective surgical approach to subscapularis management during revision anatomic shoulder arthroplasty.

Revision Total Shoulder Arthroplasty is Associated with Increased Thirty-Day Postoperative Complications and Wound Infections Relative to Primary Total Shoulder Arthroplasty

With an increasing volume of primary total shoulder arthroplasties (TSA), the number of revision TSA cases is expected to increase as well. However, the postoperative medical morbidity of revision TSA has not been clearly described. The purpose of this study was to determine the rate of postoperative complications following revision TSA, relative to primary TSA. In addition, we sought to identify independent predictors of complications, as well as to compare operative time and postoperative length of stay between primary and revision TSA. Patients who underwent primary/revision TSA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Differences in complications, readmission rates, operative time, length of stay, and predictors of complications were evaluated using bivariate and multivariate analyses. A total of 10,371 primary TSA (95.4%) and 496 revision TSA cases (4.6%) were identified. The overall complication rate was 6.5% in primary and 10.7% in revision TSA patients (p<0.001). Multivariate analysis identified an increased risk of any complication (odds ratio 1.73, p<0.001), major complication (2.08, p=0.001), and wound infection (3.45, p=0.001) in revision TSA patients, relative to primary cases. Operative time was increased in revision cases (mean±standard deviation, 125±62.5), relative to primary (115±47.7, p<0.001). Age >75, female sex, history of diabetes or chronic obstructive pulmonary disease, and American Society of Anesthesiologists classification ≥3 were associated with increased risk of any complication. Smoking history was the only significant predictor of wound infection. Revision TSA, in comparison to primary, poses an increased risk of postoperative complications, particularly wound infections. A history of smoking was an independent predictor of wound infections.

Convertible implants: Simplifying the revision from anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty

Modern shoulder arthroplasty techniques include hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse shoulder arthroplasty (RSA). Out of all arthroplasty procedures, total shoulder arthroplasty produces more satisfactory outcomes for osteoarthritis and inflammatory arthropathy (Sanchez-Sotelo, 2011 [1]). As shoulder arthroplasty procedures continue to increase in popularity, so do revision surgeries (revision TSAs and revision RSAs). Implants used in shoulder arthroplasty procedures have been transformed substantially from generation to generation, going from 1st to 4th generation implants. We propose 5th generation convertible implants that enable a more patient-specific, anatomic reconstruction with the potential to solve major issues that exist with implants from previous years.

Medical comorbidities and perioperative allogeneic red blood cell transfusion are risk factors for surgical site infection after shoulder arthroplasty

Multiple perioperative factors have been implicated in infection risk after shoulder arthroplasty. The purpose of this study was to determine surgical site infection (SSI) risk due to medical comorbidities or blood transfusion after primary or revision shoulder arthroplasty. Comprehensive data on medical comorbidities, surgical indication, perioperative transfusion, and SSI were obtained for 707 patients who underwent primary or revision hemiarthroplasty or total shoulder arthroplasty in a single hospital system. Multivariate Poisson regression was used to determine the independent association between allogeneic red blood cell transfusion, medical comorbidities, and SSI after controlling for procedure. The SSI rate was 1.9% for primary hemiarthroplasties and 1.3% for primary total shoulder arthroplasties. Among patients without prior shoulder infection, revision arthroplasty or prior open reduction and internal fixation had higher SSI risk than primary arthroplasties (incidence risk ratio [IRR], 11.4; 95% confidence interval [CI], 3.84-34.0; P < .001); among primary arthroplasties, SSI risk factors included male gender (IRR, 60.0; CI, 4.39-819; P = .002), rheumatoid arthritis (IRR, 8.63; CI, 1.84-40.4; P = .006), and long-term corticosteroid use (IRR, 37.4; CI, 5.79-242; P < .001). Perioperative allogeneic red blood cell transfusion significantly increased SSI risk and was dose dependent (IRR, 1.68 per unit packed red blood cell; CI, 1.21-2.35; P = .002). Gender, rheumatoid arthritis, and long-term (>1 year) corticosteroid use affect SSI risk after shoulder arthroplasty. Revision surgery, particularly in the setting of prior infection, increased risk of future infection. Finally, allogeneic red blood cell transfusion increases SSI risk after shoulder arthroplasty in a dose-dependent manner.