Shoulder Arthroplasty For Primary Osteoarthritis Research Articles

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.

Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty

BackgroundReverse total shoulder arthroplasty (RSA) has been increasingly utilized for a variety of shoulder pathologies that are difficult to treat with anatomical shoulder arthroplasty (TSA). Few studies have compared the outcomes of TSA versus RSA in patients with cuff intact GHOA and poor preoperative forward elevation. This study aimed to determine whether there is a difference in functional outcomes and postoperative ROM between TSA and RSA in these patients. MethodsThis retrospective cohort study included 116 patients who underwent RSA or TSA between 2013 and 2022 for the treatment of rotator cuff intact primary osteoarthritis with restricted preoperative forward flexion (FF) and a minimum 1-year follow-up. Each arthroplasty group was divided into two subgroups: patients with preoperative FF between 91 and 120 degrees or FF lower than or equal to 90 degrees. Patients' clinical outcomes, including active range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) score, Visual analog scale (VAS) for pain, and Subjective Shoulder Value (SSV) were collected. Clinical and radiographic complications were evaluated. ResultsThere was no significant difference between RSA and TSA in terms of sex (58.3% male vs 62.2% male, p=0.692), or follow-up duration (20.1 months vs 17.7 months, p=0.230). However, the RSA cohort was significantly older (72.0± 8.2 vs 65.4 ± 10.6, p=0.012) and weaker in FF and ER before surgery (p<0.001). There was no difference between RSA (57 patients) and TSA (59 patients) in VAS pain score (1.2 ± 2.3 vs 1.3 ± 2.3, p=0.925), SSV score (90 ± 15 vs 90 ± 15, p=0.859) or ASES score (78.4 ± 20.5 vs 82.1 ± 23.2, p=0.476). Postoperative active ROM was statistically similar between RSA and TSA cohorts in FF (145 ± 26 vs 146 ± 23, p= 0.728), and ER (39 ± 15 vs 41 ± 15, p= 0.584). However, IR was lower in the RSA cohort (p <0.001). This was also true in each subgroup. RSA led to faster postoperative FF and ER achievement at 3 months (p<0.001). There was no statistically significant difference in complication rates between cohorts. ConclusionThis study demonstrates that patients with GHOA who have a structurally intact rotator cuff but limited preoperative forward elevation can achieve predictable clinical improvement in pain, range of motion, and function after either TSA or RSA. Reverse arthroplasty may be a reliable treatment option in patients at risk for developing rotator cuff failure.

Exactech Equinoxe anatomic versus reverse total shoulder arthroplasty for primary osteoarthritis: case controlled comparisons using the machine learning-derived Shoulder Arthroplasty Smart score.

The role of reverse total shoulder arthroplasty (rTSA) for glenohumeral osteoarthritis (GHOA) with an intact rotator cuff remains unclear with prior investigations demonstrating similar patient-reported outcome measures (PROMs) to anatomic total shoulder arthroplasty (aTSA). However, legacy PROMs are subject to skewed distributions with many patients achieving the maximum possible score (ceiling scores). We evaluated a cohort of primary rTSAs performed for GHOA with an intact rotator cuff compared with a case-matched cohort of aTSAs using the Shoulder Arthroplasty Smart (SAS) score, a machine learning-derived outcome measure that eliminates the ceiling effect. A retrospective review of an international shoulder arthroplasty database was performed between 2001 and 2020. Patients undergoing rTSA for rotator cuff intact GHOA (n=367) were matched 1:1 with aTSA controls (n=367) with a minimum of 2-year follow-up. Assessed variables included patient demographics, range of motion, American Shoulder Elbow Surgeons score (ASES), Constant score, Simple Shoulder Test (SST), and the SAS score. Preoperatively, the SAS (49.0 vs. 45.2; P<.001), SST (4.7 vs. 4.1; P=.002), and Constant score (42.5±15.3 vs. 38.1±14.2; P<.001) were greater in aTSA vs. rTSA. Similarly, the SAS score (82.3 vs. 77.6; P<.001) and SST score (10.8 vs. 10.3; P=.003) remained greater in aTSA postoperatively. In contrast, no differences in the ASES (P=.103) or Constant scores (P=.108) were found between aTSA and rTSA patients postoperatively. Improvement preoperatively to postoperatively did not differ between aTSA and rTSA patients when assessed using the SAS (P=.257), ASES (P=.888), or SST scores (P=.510). However, a higher rate of improvement in the Constant score (35.0 vs. 31.8; P=.022) was observed in rTSA compared with aTSA. Higher rates of complications (5.4% vs. 1.6%; P=.008) and revision surgery (4.1% vs. 0.5%; P=.002) were observed in aTSA compared with rTSA. Patients undergoing shoulder arthroplasty for rotator cuff intact GHOA experienced higher rates of complications and revisions in aTSA compared with rTSA, but similar levels of clinical improvement between implants when evaluated using a validated outcome score without a ceiling effect. Unlike the ASES and SST scores that are limited by ceiling effects, a higher mean postoperative SAS score after aTSA was observed, but preoperative to postoperative SAS differences were similar after rTSA.

Midterm results of stemless impaction shoulder arthroplasty for primary osteoarthritis: a prospective, multicenter study.

Stemless shoulder arthroplasty using 4 open-fin press-fit anchors has been showing promising short-term clinical and radiographic results for patients' primary osteoarthritis. This prospective, multicenter study presents 5-year postoperative clinical and radiological outcomes of a stemless shoulder arthroplasty for primary osteoarthritis. Between November 2012 and December 2015, 100 patients were treated for primary osteoarthritis with the Sidus stem-free shoulder system at 7 European centers. Clinical assessment included the Constant-Murley Score, American Shoulder and Elbow Standardized Shoulder Assessment Form score, Subjective Shoulder Value, and range of motion. True anteroposterior, axial and lateral radiographs were reviewed for osteolysis, glenoid and humerus loosening, heterotopic ossification, radiolucent lines, component migration and humeral bone resorption. In addition to a Kaplan-Meier survival analysis, a comparative analysis between total shoulder arthroplasty and hemiarthroplasty was performed. Seventy-one patients (36 females) with a mean age of 63.8 years (range: 47-79 years) were available for the 5-year clinical and radiographic follow-up (range: 52-79 months). There was a significant increase (P<.0001) in all outcome scores compared to baseline values. Patients with total shoulder arthroplasty (n=48) achieved significantly better functional outcome than patients with shoulder hemiarthroplasty (n=23) with regard to the absolute and relative Constant-Murley Score, American Shoulder and Elbow Standardized Shoulder Assessment Form score, and Subjective Shoulder Value as well as greater abduction strength and range of motion in forward elevation and external rotation (P≤.004). There were no cases of osteolysis or humeral loosening. There were some cases of heterotopic ossification (1.4%), radiolucency around the humerus (1.4%) or glenoid (25%), glenoid migration (2.1%), inferior osteophytes (1.4%) or humerus bone resorption (9.9%). The 5-year survival was 94%. Patients treated with the Sidus stem-free shoulder system for primary osteoarthritis continue to achieve good clinical and radiographic results without any signs of aseptic humeral implant loosening at 5 years postsurgery.

Long-term survival and failure analysis of anatomical stemmed and stemless shoulder arthroplasties.

The purpose of this study was to compare clinical results, long-term survival, and complication rates of stemless shoulder prosthesis with stemmed anatomical shoulder prostheses for treatment of osteoarthritis and to analyze radiological bone changes around the implants during follow-up. A total of 161 patients treated with either a stemmed or a stemless shoulder arthroplasty for primary osteoarthritis of the shoulder were evaluated with a mean follow-up of 118 months (102 to 158). The Constant score (CS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, and active range of motion (ROM) were recorded. Radiological analysis for bone adaptations was performed by plain radiographs. A Kaplan-Meier survivorship analysis was calculated and complications were noted. The ROM (p < 0.001), CS (p < 0.001), and DASH score (p < 0.001) showed significant improvements after shoulder arthroplasty for both implants. There were no differences between the groups treated with stemmed or stemless shoulder prosthesis with respect to the mean CS (79.2 (35 to 118) vs 74.4 (31 to 99); p = 0.519) and DASH scores (11.4 (8 to 29) vs 13.2 (7 to 23); p = 0.210). The ten-year unadjusted cumulative survival rate was 95.3% for the stemmed anatomical shoulder prosthesis and 91.5% for the stemless shoulder prosthesis and did not differ between the treatment groups (p = 0.251). The radiological evaluation of the humeral components in both groups did not show loosening of the humeral implant. The main reason for revision for each type of arthroplasties were complications related to the glenoid. The use of anatomical stemless shoulder prosthesis yielded good and reliable results and did not differ from anatomical stemmed shoulder prosthesis over a mean period of ten years. The differences in periprosthetic humeral bone adaptations between both implants have no clinical impact during the follow-up. Cite this article: Bone Joint J2021;103-B(7):1292-1300.

Radiographic humeral head restoration after total shoulder arthroplasty: does the stem make a difference?

Humeral stem designs for total shoulder arthroplasty have varied over the years, with a recent trend towardshorter stems. The purpose of this study was to examine the impact of humeral component stem length on the ability to restore the native humeral head anatomy. We performed a retrospective review including patients who underwent total shoulder arthroplasty for primary osteoarthritis between 2007 and 2017 with complete operative reports and adequate radiographs. Surgical data including stem designwere collected. Preoperative and postoperative radiographic measurements of the center of rotation (COR), humeral head height (HH), and neck-shaft anglewere performed. Restoration of the native humeral anatomy was deemed "acceptable" based on postoperative differences in the COR ≤ 3 mm, HH ≤ 5 mm, and neck-shaft angle > 130°. Deviations between preoperative and postoperative measurements were compared across stem types. All available 2-year stemless implant radiographs were also analyzed. In total, 261 patients were included, with 31 stemless, 43 short-stem, and 187 standard-stem implants. There was no significant difference in COR restoration in the x-axis direction (P = .060) or y-axis direction (P = .579). There was no significant difference in restoration of acceptableHH by stem type (P = .339). Stemless arthroplasty implants were more likely to be placed in varus (22.6%) compared with short-stem (7.0%) and standard-stem (3.7%) designs (P < .001). Restoration of humeral anatomic parameters occurred significantly less with stemless implants than with short- and standard-stemimplants. The stem of a shoulder arthroplasty implant aids surgeons in accurately restoring patient-specific anatomy.

Outcomes of total shoulder arthroplasty for instability arthropathy with a prior coracoid transfer procedure: a retrospective review and matched cohort

Many surgeons are concerned about reports of increased complications, worse outcomes, and early failures in patients undergoing anatomic total shoulder arthroplasty after coracoid transfer. The purpose of this study was to evaluate minimum 2-year outcomes following anatomic total shoulder arthroplasty for instability arthropathy with a prior coracoid transfer procedure and compare them with a matched cohort of patients undergoing total shoulder arthroplasty for primary osteoarthritis. We identified 11 primary anatomic total shoulder arthroplasties performed by a single surgeon for instability arthropathy with a prior coracoid transfer procedure with a minimum of 2 years' follow-up (mean, 58 ± 35 months). A matched cohort of 33 patients with a total shoulder arthroplasty for primary osteoarthritis served as the control group. The American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, patient satisfaction, complications, and revisions were evaluated in both cohorts. The coracoid transfer cohort showed no difference in the final ASES score (88 vs. 82, P = .166) or SANE score (85 vs. 67, P=.120) vs. the matched cohort. The postoperative ASES pain score (45 vs. 41, P = .004) was higher in the coracoid transfer cohort, but the mean improvement from preoperative to postoperative values for the ASES score (P = .954), ASES pain score (P = .183), and SANE score (P = .293) was no different between cohorts. Both cohorts had high patient satisfaction without a statistically significant difference(P = .784). At early- to mid-term follow-up, total shoulder arthroplasty performed after a coracoid transfer demonstrated similar results to total shoulder arthroplasty performed for primary osteoarthritis. Longer follow-up and larger patient cohorts will provide further insights and highlight any potential differences in outcomes or revision rates.

Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder arthroplasty for primary osteoarthritis: a prospective, randomized controlled trial

There is no current consensus on subscapularis mobilization during total shoulder arthroplasty. The purpose of this prospective, randomized controlled trial was to compare functional and radiographic outcomes of the more traditional subscapularis tenotomy (ST) versus lesser tuberosity osteotomy (LTO). This study enrolled 60 shoulders in 59 patients with primary osteoarthritis. Thirty shoulders were preoperatively randomized to each group. Preoperative and 6-week, 3-month, 6-month, and 1-year postoperative data were collected. Ultrasound was performed at 3 months to evaluate subscapularis healing in tenotomy subjects, whereas radiographs were used to evaluate osteotomy healing. Intraoperative data included operative time, tenotomy or osteotomy repair time, and osteotomy thickness. No significant differences in range of motion or clinical outcomes occurred at baseline or 1 year postoperatively between the 2 groups. The mean total case duration for ST was significantly less than that for LTO (129.3 minutes vs 152.7 minutes), along with a significantly shorter subscapularis repair time for ST (34.3 minutes vs 39.3 minutes, P = .024). At final follow-up, 27 of 29 LTO shoulders (93.1%) showed bone-to-bone healing on radiographs, whereas 26 of 30 ST shoulders (86.7%) had no full-thickness tear of the subscapularis on ultrasound at 3 months. Both techniques produced successful objective and subjective clinical outcomes. LTO heals more reliably than ST. Mean total case and subscapularis repair times were significantly greater for LTO than for ST.

Clinical and Radiographic Outcomes of a Posteriorly Augmented Glenoid Component in Anatomic Total Shoulder Arthroplasty for Primary Osteoarthritis with Posterior Glenoid Bone Loss.

The primary objectives of this study were to evaluate the ability of a posteriorly stepped augmented glenoid component, used in patients with primary glenohumeral osteoarthritis with B2 or B3 glenoid morphology, to correct preoperative retroversion and humeral head subluxation and to identify factors associated with radiographic radiolucency and patient-reported clinical outcomes. We identified 71 shoulders with B2 or B3 glenoid morphology that underwent anatomic total shoulder arthroplasty with use of a posteriorly stepped augmented glenoid component and with a preoperative 3-dimensional computed tomography (3D-CT) scan and a minimum of 2 years of clinical and radiographic follow-up. The Penn Shoulder Score (PSS), shoulder range of motion, glenoid center-peg osteolysis, and postoperative version and humeral head subluxation were the main outcome variables of interest. Follow-up was a median of 2.4 years (range, 1.9 to 5.7 years); the mean patient age at treatment was 65 ± 7 years (range, 51 to 80 years). PSS, range of motion, humeral head centering, and glenoid version were significantly improved among all patients (p < 0.0001). Patients with persistent posterior subluxation of the humeral head postoperatively had worse preoperative fatty infiltration of the teres minor and greater postoperative component retroversion (p < 0.05). Patients with center-peg osteolysis had more preoperative joint-line medialization and posterior glenoid bone loss (p < 0.05). Patients with more preoperative humeral head posterior subluxation had a lower PSS, adjusting for confounders (p < 0.05). Posteriorly stepped augmented glenoid components can improve pathologic retroversion and posterior subluxation of the humeral head in B2 and B3 glenoids, with significant improvements found in clinical outcome scores at a minimum of 2 years of follow-up in the vast majority of patients. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total shoulder arthroplasty using an inlay mini-glenoid component for glenoid deficiency: a 2-year follow-up of 9 shoulders in 7 patients

Glenoid bone loss and severe retroversion can pose difficulties when implanting a glenoid component for total shoulder arthroplasty for primary osteoarthritis. Mini-glenoid implants may be useful in the setting of severe glenoid wear in which a standard pegged glenoid component cannot be placed. This study is a retrospective review, performed over a 3-year period, of patients who received a total shoulder arthroplasty using an inset mini-glenoid in the setting of severe glenoid dysplasia and/or medial glenoid bone loss. We identified patients with a minimum of 2 years' follow-up and evaluated preoperative and postoperative range of motion, visual analog scale scores, Single Assessment Numeric Evaluation scores, complications, and patient satisfaction. Seven patients (4 female and 3 male patients; 9 shoulders) with a mean age of 66 years were treated with the described procedure and had a mean follow-up of 34 months. There were 6 primary arthroplasties and 3 revision cases. Four shoulders were classified as Walch type A2 glenoids, 2 were classified as Walch type C, and 3 were unable to be classified. There was a statistically significant increase in range of motion (forward elevation, 48°; external rotation, 14°), decrease in pain scores (8 points to 1 point), and improvement in Single Assessment Numeric Evaluation scores (31.7% to 89.4%). The mean patient satisfaction score was 8.6 points on a 10-point scale. At 2-year follow-up, total shoulder arthroplasty with a mini-glenoid component can offer adequate pain relief and functional results in the setting of glenoid bone loss or severe retroversion.

Computer-assisted preoperative planning: the future is now! Commentary on an article by Joseph P. Iannotti, MD, PhD, et al.: "three-dimensional imaging and templating improve glenoid implant positioning".

Commentary Iannotti et al. present a very interesting and useful investigation into the use of three-dimensional preoperative imaging and templating to assist in planning the positioning of the glenoid component during anatomic shoulder arthroplasty. Additionally, any possible benefit of patient-specific instrumentation was evaluated. To my knowledge, this is the first investigation into the clinical efficacy of this particular emerging technology. All too often, new technological innovations are rapidly adopted without any proven efficacy. This study provides evidence of the role of three-dimensional imaging and templating in the surgical treatment of patients with primary osteoarthritis. This article provides a glimpse into the near future of anatomic shoulder arthroplasty. The Materials and Methods portion of this article was appropriate to achieve the goals of the study. The study consisted of a prospective, randomized controlled trial involving a comparison of patients undergoing three-dimensional imaging and templating with patients undergoing the same imaging and templating technique with the addition of patient-specific instrumentation to assist in glenoid component positioning; a third cohort of patients who had undergone conventional two-dimensional templating was used to serve as a historical control. The retrospective latter part of this study slightly weakens its experimental design. However, given that all of the surgical procedures were performed by experienced surgeons well into their learning curve, I doubt that prospectively collecting the data on the two-dimensional group would have appreciably impacted the results. It is unclear why the authors included twenty-five patients in one group, twenty-one patients in another group, and seventeen patients in the third group. Because no patient was lost to follow-up or withdrew from the study, a better explanation of the choice of the number of the subjects to be included in each group seems warranted. This investigation was limited to a computed tomographic evaluation of glenoid component positioning at a short-term follow-up (less than three weeks). No clinical data are provided, nor would they have been useful that early in the postoperative period. The Results portion of this article yields two very important points. First, three-dimensional imaging and templating are superior to conventional two-dimensional planning in achieving the desired placement of the glenoid component in anatomic shoulder arthroplasty for primary osteoarthritis. Second, the addition of patient-specific instrumentation did not appreciably improve the surgeon’s ability to place the glenoid component in the desired location. Unfortunately, because the follow-up was too short for any meaningful clinical data to be provided, the ultimate clinical implications of this improvement in glenoid component positioning with use of three-dimensional imaging and templating compared with two-dimensional imaging and templating remains unknown. Glenoid component loosening remains a pervasive factor in the failure of anatomic shoulder arthroplasty1. Although many factors undoubtedly contribute to glenoid component failure, proper positioning of the glenoid component would seem to be critical in avoiding this complication. Iannotti et al. have shown a reproducible and accurate method to place the glenoid component in the desired position with use of three-dimensional imaging and templating and have further demonstrated the superiority of this technique over conventional two-dimensional preoperative planning. The methods of glenoid positioning used in this study would seemingly prove useful in nearly all cases of anatomic total shoulder arthroplasty. The value of this method would likely prove more beneficial in difficult cases involving substantial glenoid wear. Another potential area of applicability for the three-dimensional preoperative planning shown in this study that was not discussed by the authors is the use of this technique to preserve existing glenoid bone. Walch et al. recently demonstrated the importance of preservation of subchondral bone in preventing glenoid component failure2. Using information gained from three-dimensional imaging and templating described by Iannotti et al., the radius of curvature of the native glenoid could be established to allow the use of instrumentation and implants that do not require removal of subchondral bone to permit component placement. Importantly, this investigation did not show the benefit in using patient-specific instrumentation. In the increasingly cost-conscious environment of health care, higher cost must yield substantial benefit. The main limitation of this study was the lack of clinical correlation with the radiographic results. Although the three-dimensional preoperative planning proved to be better than two-dimensional preoperative planning at achieving the desired glenoid component positioning, the clinical relevance of this is unclear. I would encourage the authors to continue to follow these patients and to correlate clinical outcomes, complications, and revision rates with glenoid component positioning. If a relationship is subsequently demonstrated, more value will be added to this technique. Congratulations to Dr. Iannotti and his associates for their work on this study. This article shows that the future is now in using novel technology to improve our radiographic results. Time will tell if these radiographic improvements will translate into better clinical results, lower complication rates, and improved prosthetic longevity for our patients.

Intermediate and long-term follow-up of total shoulder arthroplasty for the management of postcapsulorrhaphy arthropathy

The purpose of this study was to evaluate the subjective and objective outcomes in patients undergoing total shoulder arthroplasty for treatment of postcapsulorrhaphy arthropathy (CA) and compare them with outcomes in patients undergoing total shoulder arthroplasty for primary glenohumeral osteoarthritis (OA). Total shoulder arthroplasty was used to treat 25 consecutive CA patients (25 shoulders) at our institution; of these, 22 patients were available for follow-up. An age-matched cohort of 19 consecutive patients (20 shoulders) who were treated with total shoulder arthroplasty for primary glenohumeral OA was compared with the CA group. Patients were evaluated by physical examination and patient outcome measures (American Shoulder and Elbow Surgeons assessment and Simple Shoulder Test). Complications, reoperations, and subscapularis function was also recorded. Compared with the CA group, the OA group achieved greater forward elevation (165° vs 147°; P = .036) and greater external rotation (56° vs. 45°; P = .04); however, no significant differences were seen in subjective patient scores between the 2 groups for Simple Shoulder Test (P = .90), American Shoulder and Elbow Surgeons assessment (P = .65), and pain scores (P = .80). The difference in the number of revision surgeries in the OA group compared with the CA group (1 vs 4) was not significant (P = .35). A significantly higher number of patients in the CA group had subscapularis insufficiency compared with the OA group (5 CA vs 0 OA; P = .049). Our findings suggest that when compared with patients undergoing total shoulder arthroplasty for primary OA, CA patients experience similar outcomes with respect to revision surgery, pain relief, and subjective self-assessment and have a higher incidence of subscapularis insufficiency.

Secondary Rotator Cuff Dysfunction Following Total Shoulder Arthroplasty for Primary Glenohumeral Osteoarthritis: Results of a Multicenter Study with More Than Five Years of Follow-up

Secondary rotator cuff dysfunction is a recognized complication following shoulder arthroplasty. We hypothesized that the rate of secondary rotator cuff dysfunction would increase with follow-up and result in less satisfactory clinical and radiographic outcomes. Our aim was to investigate the rate of secondary rotator cuff dysfunction following shoulder arthroplasty for primary osteoarthritis and identify factors associated with the dysfunction. Between 1991 and 2003, in ten European centers, 704 total shoulder arthroplasties were performed for primary glenohumeral osteoarthritis. Complete radiographic and clinical follow-up of more than five years was available for 518 shoulders. The diagnosis of secondary rotator cuff dysfunction was made when moderate or severe superior subluxation of the prosthetic humeral head was present on radiographs. Multivariate logistic regression identified factors associated with the development of rotator cuff dysfunction. Kaplan-Meier survivorship analysis was performed, with the end point being secondary rotator cuff failure. Clinical outcome was assessed with use of the Constant score, a subjective assessment of the shoulder, and an evaluation of shoulder motion. At an average of 103.6 months (range, sixty to 219 months) after shoulder arthroplasty, the rate of secondary rotator cuff dysfunction was 16.8%. Survivorship free of secondary cuff dysfunction was 100% at five years, 84% at ten years, and 45% at fifteen years. Duration of follow-up (p < 0.0001), implantation of the glenoid implant with superior tilt (p < 0.001), and fatty infiltration of the infraspinatus muscle (p < 0.05) were risk factors for the development of secondary cuff dysfunction. Patients with secondary rotator cuff dysfunction had significantly worse clinical outcomes (Constant score, subjective assessment, and range of motion; p < 0.0001) and radiographic results (radiolucent line score, radiographic loosening, glenoid component migration; p < 0.0001). In this study, rates of secondary rotator cuff dysfunction with moderate or severe superior subluxation of the prosthetic humeral head increased with the duration of follow-up and significantly influenced the clinical and radiographic outcome of total shoulder arthroplasty performed for primary glenohumeral osteoarthritis. Preoperative fatty infiltration of the infraspinatus muscle and implantation of the glenoid component with superior tilt were prognostic factors.

Important Factors in the Development of Loosening of Polyethylene Keeled Glenoid Components in Shoulder Arthroplasty for Primary Osteoarthritis: The European Experience

Important Factors in the Development of Loosening of Polyethylene Keeled Glenoid Components in Shoulder Arthroplasty for Primary Osteoarthritis: The European Experience

Patterns of Loosening of Polyethylene Keeled Glenoid Components After Shoulder Arthroplasty for Primary Osteoarthritis

The aim of this study was to radiographically analyze the long-term glenoid migration patterns following total shoulder arthroplasty to better understand the factors responsible for loosening. Complete radiographic follow-up of more than five years was available for 518 total shoulder arthroplasties performed for primary glenohumeral osteoarthritis with use of an anatomically designed prosthesis with a cemented, all-polyethylene, keeled glenoid component. Radiographs were assessed for humeral head subluxation, periprosthetic radiolucent lines, and shifting of the position of the glenoid component. The type of migration of the glenoid was defined according to the direction of tilt, or as subsidence in the case of medial migration. Definite radiographic evidence of glenoid loosening was observed in 166 shoulders (32%) and was characterized by radiolucency of ≥2 mm over the entire bone-cement interface in thirty shoulders and by a migration of the glenoid component (shift or subsidence) in 136 shoulders. Three predominant patterns of migration of the glenoid component were observed: superior tilting in fifty-two shoulders (10%), subsidence in forty-one shoulders (7.9%), and posterior tilting in thirty-three shoulders (6.4%). Superior tilting of the glenoid was associated with three risk factors: low positioning of the glenoid component, superior tilt of the glenoid component on the immediate postoperative coronal plane radiographs, and superior subluxation of the humeral head (p < 0.05 for all). Subsidence of the glenoid component was associated with the use of reaming to optimize the seating and positioning of the glenoid component (p < 0.001). Posterior tilting of the glenoid component was associated with preoperative posterior subluxation (i.e., a Walch type-B glenoid) and with excessive reaming (p < 0.01 for both). The three patterns of migration observed in this study underscore the potential importance of the supporting bone beneath the glenoid component. In some shoulders, use of a keel or pegs to provide fixation of a polyethylene component in the absence of good support from subchondral bone may not be sufficient to resist compressive and eccentric forces, resulting in loosening. Preserving subchondral bone may be important for long-term longevity of the glenoid component.

The role of concomitant biceps tenodesis in shoulder arthroplasty for primary osteoarthritis: results of a multicentric study.

This study evaluated the effects of concomitant biceps tenodesis in patients undergoing shoulder arthroplasty for primary osteoarthritis. Six hundred eighty-eight shoulders that had undergone replacement for primary glenohumeral arthritis were reviewed at a mean 43 months postoperatively. One hundred twenty-one patients had undergone a biceps tenodesis at arthroplasty, while the remaining patients did not. Tenodesis was significantly better than no tenodesis in most outcome parameters. No difference was found between the groups in complication rate. Biceps tenodesis is a useful adjunct to shoulder arthroplasty in the treatment of primary osteoarthritis.

Functional outcome after shoulder arthroplasty for primary osteoarthritis: A multicenter study

Shoulder arthroplasty outcomes have been reported in many case series. Typically, these series have followed either a single prosthesis used to treat a variety of arthritic disorders of the shoulder or experience in a single institution. In contrast, this report of a prospective study summarizes the experience of several surgeons with a single prosthetic design for treatment of primary osteoarthritis of the shoulder. A prospective, multicenter clinical outcome study evaluated 176 shoulders in 160 patients with primary osteoarthritis. This study evaluated a single prosthetic design (Global Shoulder) used by 19 contributing surgeons. Enrollment included 133 total shoulder replacements and 43 humeral head replacements (hemiarthroplasty) in 98 men and 62 women. Neither age nor sex affected whether hemiarthroplasty or total shoulder arthroplasty was performed. Patients with full-thickness cuff tears preferentially had hemiarthroplasty. The decision to perform total shoulder arthroplasty or hemiarthroplasty was based on the surgeon's preference. There were significant improvements (P <.001) in all evaluated and self-assessed outcome parameters from the preoperative baseline for both total shoulder arthroplasty and hemiarthroplasty. The results confirm that prosthetic arthroplasty leads to dramatic improvement in pain, function, and patient satisfaction. Intraoperative complications occurred in 5.4% of cases, and postoperative complications occurred in 7.8%. The most common intraoperative complications were intraoperative fractures, occurring in 9 cases. The most common postoperative complications were glenoid component loosening and humeral head subluxation. Almost all cases of humeral head instability were associated with rotator cuff tears or glenoid component loosening (or both). Seven shoulders underwent 9 additional surgeries during the 5-year study period. Thirteen shoulders in 11 patients were lost as a result of death unrelated to the procedure; 2 shoulders in 1 patient were lost within 3 days/3 months after the bilateral replacements as a result of death from pulmonary embolism. Nine percent of the shoulders (16/176) had full-thickness rotator cuff tears. Eight of the 16 shoulderswith full-thickness supraspinatus cuff tears had hemiarthroplasty. All of these tears were isolated to the supraspinatus tendon, and all were repairable. There were no differences in postoperative pain, function, American Shoulder and Elbow Surgeons scores, or range of motion. There were no differences between total shoulder arthroplasty and hemiarthroplasty in those patients with a reparable rotator cuff tear. Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis result in good or excellent pain relief, improvement in function, and patient satisfaction in 95% of cases. Avoiding intraoperative humeral shaft fractures through use of an uncemented, canal-filling prosthetic stem requires careful attention to reaming and component sizing. Postoperative humeral head subluxation is often associated with other factors including rotator cuff tears or glenoid component loosening. (J Shoulder Elbow Surg 2002;11:130-135)