Total Shoulder Arthroplasty Patients Research Articles

Long-term clinical and radiographic outcomes of total shoulder arthroplasty in patients under age 60 years.

We aimed to characterize the long-term clinical and radiographic outcomes of total shoulder arthroplasty (TSA) in patients aged < 60 years. We hypothesized meaningful improvements in shoulder functionality and pain with TSA and an acceptably low rate of prosthesis complications and revisions. This was a retrospective cohort study of 29 patients (34 shoulders) undergoing TSA before age 60 years with a minimum follow-up period of 10 years. Shoulder range of motion, functionality (American Shoulder and Elbow Surgeons and Simple Shoulder Test scores), and pain (visual analog scale score) were evaluated. Radiographs were assessed for lateral humeral offset, the acromiohumeral interval, and glenoid loosening. The mean age of the patients was 54.4±5.5 years (range, 35.5-59.8 years), with a mean follow-up period of 16.1±4.5 years (range, 10.0-26.1 years). In patients aged < 60 years, TSA significantly improved forward elevation (from 119°±26° to 146°±21°, P=.0002), external rotation (from 21°±25° to 52°±15°, P=.0001), and internal rotation (from L5 to L1, P=.002). Additionally, TSA significantly increased American Shoulder and Elbow Surgeons scores (from 32±20 to 64±27, P=.0008) and Simple Shoulder Test scores (from 3±2 to 7±4, P=.0004) and reduced visual analog scale pain scores (from 7±3 to 3±3, P=.0001). Radiographically, there was no significant difference in mean lateral humeral offset (13±6 mm vs. 10±12 mm, P=.472) or the mean acromiohumeral interval (20±4.2 mm vs. 16±6 mm, P=.061) between immediate postoperative and final follow-up radiographs. Radiographic evidence of glenoid loosening was noted in 2 patients. Complications occurred in 6 patients (17.6%), all of which were cases of aseptic glenoid loosening. Ultimately, 4 patients underwent conversion to a reverse TSA and 2 underwent arthroscopic glenoid removal. The rate of prosthesis survivorship was 97.1% (95% confidence interval [CI], 91.4%-100%) at 10 years, 85.4% (95% CI, 73.7%-97.2%) at 15 years, and 80.1% (95% CI, 65.1%-98.4%) at 20 years. TSA consistently improved shoulder functionality and reduced pain while limiting the need for further revisions. These findings suggest that TSA is a viable treatment option for glenohumeral arthritis in younger patients.

Clinical and radiographic outcomes after reverse total shoulder arthroplasty in patients 80 years of age and older.

Previous studies have found less favorable outcomes for patients aged 80 years and older after primary reverse total shoulder arthroplasty (rTSA). However, they are based on small sample sizes with no control group for comparison. The purpose of this study is to compare the clinical, functional, and radiographic outcomes after primary rTSA in patients aged 80 years and older with a younger cohort of patients aged 60-79 years. Patients undergoing primary rTSA between 2004 and 2018 were identified within a multi-institutional database with a minimum of 2 years of follow-up. All patients received the same platform prosthesis. Patients were divided into 2 groups based on age: 80 years and older (n = 369) and 60-79 years (n = 1764). Statistical analyses were performed to compare the 2 age cohorts based on pre- and postoperative function and range of motion (ROM) scores, adverse event rates, pain scores, and patient satisfaction. Patients aged 80 years and older had lower preoperative functional and ROM scores relative to patients aged 60-79 years. The differences observed in active abduction, active forward elevation, and Constant scores exceed the minimal clinically important difference (MCID). The evaluation of function and ROM at latest follow-up showed that patients in both age cohorts had significant improvements that exceeded both the MCID and substantial clinical benefit, but older patients still scored lower relative to younger patients, with the differences in active abduction and Constant scores exceeding the MCID. Despite the lower scores observed in older patients, both groups report similar satisfaction (93% in older patients vs. 92% in younger patients, P = .379). There were no differences between the 2 age cohorts with regard to humeral radiolucent lines (9.2% vs. 8.7%, P = .765), scapular notching (11.0% vs. 10.3%, P = .727), adverse events (3.5% vs. 3.3%, P = .863), and revisions (0.8% vs. 1.8%, P = .188). Patients aged 80 years and older can expect significant improvements in function and ROM after primary rTSA, with satisfaction similar to that of patients aged 60-79 years. Patients in both age cohorts have similar rates of adverse events and revisions, and the rates observed in patients 80 years and older are much lower than what has previously been reported in the literature. rTSA in patients age 80 years and older is a beneficial surgery with outcomes similar to those found in younger patients, and age should not be a limiting factor when considering rTSA.

Reverse total shoulder arthroplasty in patients 80 years and older: a national database analysis of complications and mortality.

Although reverse total shoulder arthroplasty (RSA) is considered a safe surgical option in elderly patients, large-scale analyses of complications and mortality after RSA in patients 80 years and older are scarce. The goals of the current study were to identify revision, complication, and early mortality rates after RSA in patients 80 years and older and compare these to younger patients. The PearlDiver Database, which contains services rendered to Medicare, Medicaid, and commercial insurance patients, was queried for patients undergoing RSA using International Classification of Diseases, Ninth/Tenth Revision (ICD-9/ICD-10) procedure codes. Patients were separated into 2 groups based on their age: 80 years and older and <80 years of age. The incidence of revision arthroplasty, medical, and surgical complications after RSA were extracted. Multivariate regression was used to compare revision arthroplasty and complication rates between groups. Statistical significance was set at P<.05. A total of 29,430 cases of RSA were included, with 486 cases in patients 80 years and older (median age, 80 years; age range, 2 years). Patients 80 years and older had 1- and 2-year revision rates of 3.9% and 5.1%, compared with the younger cohort at 3.0% and 3.1%, respectively. In patients 80 years and older, there were higher rates of deep venous thrombosis (DVT) (odds ratio [OR] 2.87, 95% CI 1.5-4.97), urinary tract infection (OR 1.42, 95% CI 1.01-1.94), acute renal failure (OR 2.18, 95% CI 1.44-3.17), and pneumonia (OR 1.75, 95% CI 1.09-2.68) within 90 days postoperatively. Ninety-day surgical complications were similar between the cohorts; however, younger patients experienced higher rates of dislocation, stiffness, periprosthetic fracture, and implant complications 1 year postoperatively. Patients 80 years and older had a significantly higher 90-day mortality rate at 2.7% compared with 1.5% in younger patients (P=.002). RSA is a generally safe procedure even in patients 80 years and older, with low complication and revision rates. Patients 80 years and older had higher early mortality and medical complication rates, including DVT, renal failure, and pneumonia than patients <80 years of age. However, patients 80 years and older had lower rates of dislocation, periprosthetic fracture, and implant-related complication at 1 year postoperatively.

The impact of external beam radiation therapy on shoulder surgical outcomes: a case series study

External beam radiation therapy (XRT) is a commonly used treatment adjunct in patients with breast cancer and is known to cause soft tissue dysfunction. However, data on XRT as a preoperative risk factor for shoulder surgery is limited. The purpose of this study was to assess whether prior history of breast cancer treated with XRT has an impact on surgical complications or outcomes. We hypothesize that patients treated with XRT will have a higher rate of surgical complications and lower outcomes. A 20-year retrospective chart review across a large, academic health care system was performed. Inclusion criterion comprised any patient with history of breast cancer of the upper-outer or axillary region treated with XRT. Patients also must have undergone a surgical procedure to the ipsilateral shoulder with at least 1-year postoperative follow-up. Patients were stratified by demographics, hand dominance, and surgery type. Postoperative outcomes including range of motion (ROM) and visual analog scale (VAS) scores for pain were also collected. Eighteen patients were identified (100% female) with an average age of 66.3 years (standard deviation 10.5 years). Ten shoulders underwent rotator cuff repair (RCR), 4 total shoulder arthroplasty (TSA), 3 reverse shoulder arthroplasty (RSA), and 1 arthroscopic superior labrum anterior to posterior (SLAP) repair. Four patients treated with RCR (40%) experienced postoperative complications related to their procedure. These included scapular winging, adhesive capsulitis, stiffness, and one retear. Two patients treated with shoulder arthroplasty (28.6%) experienced postoperative complications that included lymphedema and periprosthetic fracture following a mechanical fall in one RSA patient and periprosthetic infection in a TSA patient. ROM across all groups improved, most significantly in forward flexion and internal rotation among RCR patients (P<.001). Furthermore, a statistically significant improvement in VAS scores was achieved in each group (6.2±2.14 preoperation, 1.06±1.75 postoperation; P<.001). When compared to national averages, complication rates in our cohort were higher (40% vs. 10%-17% in RCR patients and 28.6% vs. 4%-14% in arthroplasty patients). On further scrutiny, many of these complications were independent of a history of XRT and many resolved with appropriate therapy. Most importantly, functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. Thus, our results suggest that performing shoulder surgery after ipsilateral XRT for breast cancer is likely safe and may offer improved pain and ROM compared to forgoing surgery without necessarily increasing the risk for postoperative complication.

Can the reverse total shoulder arthroplasty provide as good of an outcome as an anatomic shoulder arthroplasty

BackgroundReverse total shoulder arthroplasty (RTSA) is an excellent treatment option for a variety of shoulder pathologies. Anatomic total shoulder arthroplasty (TSA) remains an excellent treatment for patients with glenohumeral arthritis and a functioning rotator cuff. RTSA has become a much more common procedure than TSA in recent times. It is currently unclear if patients who have a good outcome following TSA outperform patients who have a good outcome following RTSA. The purpose of this study was to compare the 2-year outcomes of patients with good outcomes, defined as having forward flexion of >130° and American Shoulder and Elbow Surgeons score of >70, following TSA and RTSA. MethodsAll patients who underwent TSA or RTSA between 2015 and 2019 with minimum 2-year follow-up were eligible for inclusion. Patients were included if their postoperative forward flexion was >130° and American Shoulder and Elbow Surgeons score was >70. Patients were excluded if they were a revision surgery, were treated with an arthroplasty for fracture, or had a latissimus transfer. Demographic variables were analyzed between groups. Range of motion (ROM), strength, and patient-reported outcome (PRO) scores were compared between groups. ResultsOverall, 318 TSAs were included; 155 (49%) met the criteria for a “good” outcome. Among RTSAs, 428 were included; 154 (36%) met the criteria for a “good” outcome. When comparing PROs between groups, RTSA patients had worse preoperative and postoperative PRO scores (all P < .05). When comparing preoperative physical examination findings, RTSA patients had worse ROM and strength (all P < .05) and worse Constant Power scores and Constant scores (P < .001 in both cases). Postoperatively, RTSA patients had worse ROM and strength (all P < .05) and worse Constant scores (P = .028). The magnitude of change (delta) from preoperative to postoperative function was often greater following RTSA than TSA. There were no significant differences in whether expectations were met or exceeded between RTSA and TSA patients in regards to pain control (99% vs. 98%; P = .177), motion and strength (93% vs. 96%; P = .559), ability to return to activities of daily living (98% vs. 99%; P = .333), or return to sporting activities (95% vs. 91%; P = .268). ConclusionPatients do well following both TSA and RTSA. In patients who have a good outcome following either TSA or RTSA, those patients who underwent TSA have superior outcomes to patients following RTSA. However, the change in outcome scores from pre- to post-surgery is often more significant with RTSA, as they often start out with worse motion and clinical scores.

Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review.

The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population. Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence. RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve. RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures. RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.

Evaluation of clinical and radiographic outcomes after total shoulder arthroplasty with inset Trabecular Metal-backed glenoid.

Trabecular Metal (TM)-backed glenoid implants were introduced for their theoretical ability to increase osseointegration while minimizing wear and the risk of loosening in total shoulder arthroplasty (TSA). Initial follow-up studies of TM-backed glenoids demonstrated high rates of metallic debris formation around the implant site, raising concerns about longevity. More recent data suggest that metallic debris formation may be less prevalent than previously reported and that the implants may have positive long-term outcomes regardless of debris. The goal of our study was to assess the clinical and radiographic outcomes at mid-term follow-up of TSA using a TM-backed glenoid implant placed with full backside support using an inset technique. We hypothesized that our clinical and radiographic outcomes would be good using this technique. We retrospectively reviewed the charts of 39 patients who underwent 41 TSA procedures with a Zimmer Biomet TM-backed glenoid component performed by a single surgeon between January 2010 and March 2016. After exclusions for death unrelated to surgery and loss to follow-up, 35 patients (37 shoulders) with minimum 2-year clinical follow-up were included in the study. The glenoids were all placed in an inset fashion with full backside support. Clinical, patient-reported, and radiographic outcomes were analyzed. The average follow-up period was 7.2 years (range, 2-11 years). At final follow-up, average shoulder elevation was 153° ± 22° and average external rotation was 53° ± 12°. The average American Shoulder and Elbow Surgeons score was 86.8 ± 19.0, and the average visual analog scale score was 1.3 ± 2.4. Metallic debris was found in 9 shoulders (27%), and radiolucency was observed around the glenoid components in 13 shoulders (39%) on the final postoperative radiographs. Metallic debris and radiolucency findings were low in severity, with average grades of 0.32 (standard deviation, 0.54) and 0.39 (standard deviation, 0.50), respectively. There were no reoperations. This study of 37 shoulders undergoing TSA with a TM-backed glenoid demonstrated 100% implant survivorship at an average follow-up of 7 years. Clinical outcomes were excellent despite the occurrence of some metallic debris formation. The findings suggest that a TM-backed glenoid component implanted in an inset fashion to achieve full backside support can provide good clinical and patient-reported outcomes in TSA patients at mid-term follow-up and suggest that continued consideration of the role of TM-backed glenoids and the optimal technique for implantation may be warranted.

Outcomes and complications after arthroplasty in patients with osteonecrosis of humeral head- systematic review

BackgroundThe purpose of this study was to investigate the outcomes and complications of hemiarthroplasty (HA) and total shoulder arthroplasty (TSA) in patients of osteonecrosis of humeral head (ONHH) through systematic review. MethodsPRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, Scopus, Ovid, and Cochrane Library databases. Keywords included ONHH, avascular necrosis, head replacement, hemiarthroplasty, or total shoulder arthroplasty. Methodological Index for Nonrandomized Studies (MINORS) was used for quality assessment. ResultsTen studies (416 shoulders) were finally eligible and mean MINORS score was 11.9 (ranges, 8–16). HA was performed in 255 shoulders (61.3%) and TSA in 161 (38.7%). Mean age of the patients at the time of surgery was 50.6 years and mean follow-up period was 73.1 months. All clinical scores with range of motion were significantly improved after surgery. Overall complication rate was 20.0% with 10.1% in HA and 17.5% in TSA (p = 0.077). Overall reoperation rate was 11.2% with 7.0% in HA and 15.0% in TSA (p = 0.046). Overall revision rate was 6.4% with 5.7% in HA and 9.2% in TSA (p = 0.349). ConclusionsBoth HA and TSA in patients with ONHH yielded functional improvement with pain relief, but TSA had higher reoperation rate compared to HA.

Soft Tissue Standardization Improves Humerus Tissue Thickness Precision and Lowers BMD in Total Shoulder Arthroplasty Patients

DXA technology requires soft tissue attenuation measurement. This sampling is confined within a standard soft tissue region of interest (ROI) defined by the blue squares on Figure 1, which is automatically placed and used to compare with radiation absorption over bone. Variable placement of the soft tissue ROI likely alters BMD measurement and reproducibility. The aim of this study was to measure humeral BMD in total shoulder arthroplasty (TSA) patients. As no shoulder feature is available in GE Lunar enCORE v18, hip atypical femur fracture (AFF) software was utilized. In preliminary evaluation, we observed that soft tissue ROI placement and amount of tissue sampled were inconsistent (Figure 2). We hypothesized that use of a consistent soft tissue ROI would change BMD and improve precision. The purpose of this analysis was to compare humerus BMD and precision prior to and following soft tissue ROI standardization. After manufacturer consultation, all scans were reanalyzed using a soft tissue ROI of a fixed size (100 pixels tall, 50 pixels wide) manually placed on every scan distal and lateral to the humeral head (Figure 3). This study of TSA patients, 1-5 years post-surgery, included full humerus scans obtained on a GE Lunar iDXA with v17 or v18 software and analyzed with v18. Each participant had bilateral shoulder scans performed twice to assess precision and humerus BMD was measured at custom ROIs. BMD and tissue thickness obtained with automated and manual approaches were compared using T-test. Precision was determined using the ISCD calculator and compared between methods with F-test. Thirty subjects were included (20M/10F) with mean age and years’ post-surgery of 70.6 and 2.7 respectively. Average tissue thickness was reduced 13.5% (p < 0.01) with manual tissue sampling. Mean BMD among the nine custom ROIs was 2.2-8.5% lower (p < 0.01) with manual tissue sampling (Table 1). Additionally, tissue thickness %CV improved (p < 0.01) from 47.6 to 14.8% and 25.9 to 9.6%. Similarly, BMD precision improved (p < 0.01) at the 1/3 humerus and distal implant ROIs on the TSA side (Table 2). When measuring skeletal sites without optimized software available, it is necessary to critically evaluate software performance. In this study, soft tissue ROI standardization markedly improved tissue thickness sampling and reduced BMD at custom humerus ROIs. Optimization and automation of humerus DXA software would likely further improve BMD precision and measurement.

Risks of chronic steroid or immunosuppressive therapy on total shoulder arthroplasty patients.

Patients on chronic corticosteroids/immunosuppressants (SI) undergoing orthopaedic surgery are at an increased risk for surgical complications and worse outcomes. However, whether or not chronic preoperative SI use increases the risk for 30-day complications in patients undergoing primary total shoulder arthroplasty (SA) has yet to be explored. From 2006 to 2019, the National Surgical Quality Improvement Program (NSQIP) database was used to identify all patients who underwent primary SA (anatomic TSA and reverse TSA). Patients were stratified into two cohorts: chronic preoperative SI users and those without use. Bivariate and multivariate analyses were utilized in this study. Of the 26,979 patients who underwent primary SA, 25,656 (95.1%) patients did not have SI usage whereas 1323 (4.9%) patients had chronic preoperative SI usage. Following adjustment on multivariate analyses, compared to the non-SI usage cohort, patients who used SI had an increased risk of urinary tract infections (UTIs) (OR 1.87; p = 0.009) and septic shock (OR 7.14; p = 0.002). There were no differences in mortality between the two cohorts (p = 0.058). Chronic pre-operative SI use is an independent risk factor for septic shock and UTIs following primary SA. Surgeons and patients should be aware of these risks to better inform patient counseling and surgical decision making.

Outcomes of shoulder arthroplasty by year of index procedure: are we getting better?

The purpose of this study was to determine whether postoperative patient-reported outcomes improved over time following anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). We performed a retrospective analysis of prospectively collected patient-reported outcomes from our institution's registry between 2008 and 2018 (N = 1899). American Shoulder and Elbow Surgeons (ASES) scores at a minimum of 2 years postoperatively were required. Univariable linear models were used to test the association between year of surgery and improvement in ASES scores at 2- and 5-year follow-up, as well as any association with age, sex, primary or revision surgery, hand dominance, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, and Walch classification. Multivariable models were created to analyze ASES score improvement by index year while controlling for significant factors. In the univariable analysis, 5-year ASES difference scores increased each year by a mean of 1.65 (P < .001; 95% confidence interval [CI], 0.75-2.55) for TSA, 2.50 (P = .014; 95% CI, 0.52-4.49) for RTSA, and 1.64 (P < .001; 95% CI, 0.81-2.47) for the overall population. Patient sex, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, Walch classification, and revision procedures were also significant factors affecting ASES scores. On multivariable analysis controlling for these factors, 5-year ASES difference scores were still significantly associated with year of surgery, increasing each year by a mean of 2.20 (P<.001; 95% CI, 0.91-3.50) for TSA, 4.83 (P < .001; 95% CI, 1.17-8.49) for RTSA, and 1.66 (P < .001; 95% CI, 0.81-2.51) for the entire population. Both anatomic TSA and RTSA patients reported increasing ASES difference scores at 5-year follow-up as time passed. These findings may indicate that advances in shoulder arthroplasty have resulted in better patient outcomes over time. Further research is needed to clarify which factors influence improvements in outcomes, particularly for revision procedures.

Effects of chronic kidney disease on perioperative and 180-day complication rates after total shoulder arthroplasty

BackgroundChronic kidney disease (CKD) is associated with increased risk of complications in total hip arthroplasty and total knee arthroplasty. Despite this known association, there are little data regarding the effect of outcomes in patients undergoing total shoulder arthroplasty (TSA). The purpose of this study is to identify the effects of CKD on patient outcomes after TSA. MethodsThe National Readmissions Database was queried from 2010 to 2017 to identify all primary TSA patients (n = 62,455). CKD was identified using International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes. Chi-squared analysis and multivariate regression were used to analyze differences in outcomes and the impact of CKD stage. ResultsCKD patients had higher rates of 180-day readmissions, 180-day mortality, acute renal failure (ARF), transfusions, urinary tract infections (UTI), acute respiratory distress syndrome (ARDS), pneumonia, and gastrointestinal (GI) complications. Stage 3 CKD (odds ratio [OR] = 1.378; P = .002), stage 4 CKD (OR = 1.805; P = .027), and unspecified CKD stage (OR = 1.787; P < .001) were at increased odds of 180-day readmission. Stage 4 CKD (OR = 10.647; P = .034) was associated with increased odds of 180-day mortality. Stage 2 CKD had increased odds of GI complications (OR = 8.365; P = .004). Both stage 3 CKD (OR = 1.463; P = .038) and stage 4 CKD (OR = 2.465; P = .033) had increased odds of UTI. Stage 5 CKD (OR = 36.143; P < .001) had increased odds of ARDS. Stage 2 CKD had increased odds of thrombosis (OR = 7.869; P = .007). Stage 2 (OR = 4.826; P < .001), stage 3 (OR = 5.724; P < .001), stage 4 (OR = 11.162; P < .001), stage 5 (OR = 31.328; P < .001), and unspecified CKD stage (OR = 4.801; P < .001) were associated with increased odds of ARF. Stage 2 CKD (OR = 12.809; P = .014), stage 3 (OR = 7.351; P = .001), and stage 4 (OR = 39.684; P < .001) were associated with increased odds of transfusions. ConclusionCKD is associated with increased risk of complications, including postoperative ARF, transfusions, UTI, ARDS, pneumonia, and GI complications. Patients with CKD also have increased 180-day readmission rates and 180-day mortality rates. Increasing stage of CKD is associated with increasing odds of 180-day readmission, postoperative ARF, and transfusions. Surgeons should consider these increased risks in the decision-making process during preoperative evaluation. These complications would likely increase cost, which raises the need for further evaluation and stratification of risk in patients who use bundled payment systems. Level of evidenceLevel III; Case-Control Study

Revision reverse total shoulder arthroplasty in patients 65 years old and younger: outcome comparison with older patients

BackgroundReverse total shoulder arthroplasty (RTSA) is a procedure growing in prevalence among younger populations. Consequently, its use in revision arthroplasty is growing in this demographic. However, studies examining the functional outcomes of revision RTSA in younger populations compared with older populations are lacking. The primary purpose of this study is to evaluate the functional outcomes of revision RTSA in patients 65 years old and younger compared with older patients who underwent revision RTSA. We hypothesized that younger patients would have similar outcomes to older patients and both groups would demonstrate improvement in outcomes.MethodsA retrospective review was conducted on a prospectively collected research database at a single tertiary referral center of all patients who underwent RTSA between 2007 and 2018. Patients 65 years old or younger who underwent a revision RTSA and had minimum 2-year follow-up were evaluated. A control group of patients ≥70 years old who underwent revision RTSA were also evaluated. Demographics, surgical factors, active range of motion (ROM), and patient-reported outcomes (PROMs) were compared. The ROM parameters measured were forward elevation, abduction, external rotation, and level of internal rotation. The PROMs collected included American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, University of California–Los Angeles score, Constant score, normalized Constant, and Shoulder Pain and Disability Index 130. The differences in outcomes were compared against the minimal clinically important difference and substantial clinical benefit reported for primary reverse shoulder arthroplasty.ResultsA total of 81 patients undergoing revision RTSA were evaluated at a mean follow-up of 4.5 years with 42 patients in the study group and 39 patients in the control group. Both groups demonstrated similar demographics and rates of prior surgeries. Preoperative outcome scores were lower in the study group (≤65 years old) than those in the older control group with American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and Shoulder Pain and Disability Index 130 remaining worse postoperatively. Both groups experienced statistically significant improvements in ROM from before operation to after operation, with slightly higher improvements in overhead motion in the younger cohort. Both the study group and the control group demonstrated statistically significant improvements in all PROMs with improvement above the substantial clinical benefit for the Constant and Simple Shoulder Test scores. Despite lower functional outcomes reported in the study group postoperatively, the improvement from before operation to after operation in all PROMs was similar between groups.ConclusionRevision RTSA is a viable option for patients ≤65 years old with a poorly functioning shoulder arthroplasty. ROM and outcome improvements are similar compared with older patients undergoing revision RTSA, but the preoperative and postoperative functional outcomes are worse in the younger patients.

Clinical Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Primary Glenohumeral Osteoarthritis Compared With Rotator Cuff Tear Arthropathy: Does Preoperative Diagnosis Make a Difference?

The primary purpose of this study was to evaluate the clinical outcomes of patients who underwent reverse total shoulder arthroplasty performed for primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff compared with rotator cuff tear arthropathy (CTA). This was a retrospective review of prospectively collected data including consecutive patients who underwent primary reverse total shoulder arthroplasty for GHOA or CTA with a minimum of 2-year follow-up. Baseline patient demographics and clinical outcomes including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation, and visual analog scale for pain were collected. Univariate and multivariate regression analyses were performed to evaluate the effect of preoperative diagnosis on clinical outcomes. Patients with a preoperative diagnosis of GHOA demonstrated significantly better postoperative active forward elevation (138.6° versus 127.3°; P < 0.01), external rotation (54.2° versus 43.8°; P < 0.01), and change in internal rotation (Δ 2.1 points versus Δ 1.2 points; P < 0.01). Patients with GHOA demonstrated significantly better postoperative ASES (86.8 versus 76.6; P < 0.01), Single Assessment Numerical Evaluation (89.7 versus 78.5; P < 0.01), and visual analog scale scores (0.63 versus 1.2; P < 0.01). Minimal clinically important difference for ASES score was achieved by 97.5% of patients with GHOA compared with 86.7% of patients with CTA (P < 0.01), whereas substantial clinical benefit was achieved by 90.4% of patients with GHOA and 71.7% of patients with CTA (P < 0.01). After a multivariate linear regression analysis, postoperative ASES scores were independently associated with previous ipsilateral shoulder surgery (P = 0.042), preoperative ASES score (P = 0.01), and primary diagnosis of GHOA (P < 0.01). RTSA performed in patients with GHOA and an intact rotator cuff is associated with improved functional and clinical outcomes compared with those patients treated for CTA. Level III Therapeutic Study.

No significant difference in risk of prolonged opioid use following outpatient versus inpatient total shoulder arthroplasty: A propensity matched analysis.

The purpose of this investigation was to compare rates of filled opioid prescriptions and prolonged opioid use in opioid naïve patients undergoing total shoulder arthroplasty (TSA) in inpatient versus outpatient settings. A retrospective cohort study was conducted using a national insurance claims database. Inpatient and outpatient cohorts were created by identifying continuously enrolled, opioid naïve TSA patients. A greedy nearest-neighbor algorithm was used to match baseline demographic characteristics between cohorts with a 1:1 inpatient to outpatient ratio to compare the primary outcomes of filled opioid prescriptions and prolonged opioid use following surgery between cohorts. A total of 11,703 opioid naïve patients (mean age 72.5 ± 8.5 years, 54.5% female, 87.6% inpatient) were included for analysis. After propensity score matching (n = 1447 inpatients; n = 1447 outpatients), outpatient TSA patients were significantly more likely to fill an opioid prescription in the perioperative window compared to inpatients (82.9% versus 71.5%, p < 0.001). No significant differences in prolonged opioid use were detected (5.74% inpatient versus 6.77% outpatient; p = 0.25). Outpatient TSA patients were more likely to fill opioid prescriptions compared to inpatient TSA patients. The quantity of opioids prescribed and rates of prolonged opioid use were similar between the cohorts. Therapeutic Level III.

Patient-reported drug and latex allergies negatively affect outcomes after total and reverse shoulder arthroplasty.

Patient-reported allergies (PRAs) have been identified as a risk factor for worse outcomes and less satisfaction in patients undergoing knee and hip arthroplasty. Similar associations have not been elucidated in shoulder arthroplasty patients; however, previous research is sparse. The purpose of this study was to assess the outcomes following shoulder arthroplasty surgery with respect to patient-reported drug allergies. It was hypothesized that a higher number of allergies would be associated with worse patient-reported outcomes (PROs) following shoulder arthroplasty surgery. Consecutive patients aged 18-89 years at the time of surgery who underwent primary shoulder arthroplasty between October 2005 and March 2018 performed by a single surgeon and had a minimum follow-up period of 1 year were reviewed. PRO scores, including the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, and 12-Item Short Form Health Survey Physical Component Summary and Mental Component Summary scores, as well as patient satisfaction, were collected preoperatively and postoperatively. Early clinical failures were reported. Subjects were categorized into a 3-level factor based on the number of PRAs (0, 1, or ≥2), and bivariate comparisons of mean postoperative PRO scores were performed using Kruskal-Wallis analyses. Additionally, multivariate regression was performed to assess the effect of PRAs on PROs while controlling for age, sex, arthroplasty type, baseline PRO scores, and Charlson Comorbidity Index. Overall, 411 shoulders were included in the final study population (367 patients, 44 of whom were treated bilaterally). The population was predominately male patients (n = 265, 64.5%), and the median age at the time of surgery was 66.5 years (first quartile-third quartile, 61.3-71.4 years). Of the patients, 253 (61.6%) underwent total shoulder arthroplasty (TSA) whereas 158 (38.4%) underwent reverse TSA. Five patients (2 TSA and 3 reverse TSA patients) experienced early clinical failure and required revision surgery. Minimum 1-year PROs were obtained for 345 of 406 patients (85.0%) with a mean follow-up period of 1.9 ± 1.2 years. Nearly all postoperative PROs reflected a trend of worse outcomes with more preoperative PRAs; however, the QuickDASH score was the only score showing a significant difference between allergy groups (P = .004). Pair-wise comparison using Nemenyi post hoc testing showed that the QuickDASH score was significantly higher (worse outcomes) for the group with ≥2 allergies compared with the group with 0 allergies. PRA was found to be a statistically significant predictor of higher postoperative QuickDASH scores (P = .043) and was more influential than the Charlson Comorbidity Index and sex. Additionally, PRA was the only statistically significant predictor of patient satisfaction (P = .016). An increasing number of preoperative PRAs is associated with worse PROs and patient satisfaction following shoulder arthroplasty. The number of PRAs was the most influential predictor of patient satisfaction.

Computed tomography revealed the correlation between radiolucency and alignment of all-polyethylene pegged glenoid component more than 10 years after total shoulder arthroplasty in the Japanese population

BackgroundAnatomical total shoulder arthroplasty (TSA) provides successful long-term outcomes but complications can occur after 10 years that require revision. Computed tomography (CT) is a useful tool for assessing radiolucent lines around the glenoid component of TSA; however, the merits of long-term post-TSA follow up with CT are unclear. The purpose of this study was to evaluate the long-term outcomes after TSA of Japanese population and to identify factors related to radiolucency around the glenoid component using CT. MethodsA retrospective review was conducted of TSA patients who had completed at least 10 years of clinical follow up. Radiographs and CT images of the affected shoulder obtained at the last follow up were evaluated for radiolucent lines around the stem and each peg, superior inclination and retroversion of the glenoid component, subluxation index, and critical shoulder angle (CSA). Shoulder ROM, Constant–Murley score and UCLA score were compared between the preoperative and last follow up period. ResultsEighteen shoulders in 16 patients met the inclusion criteria. Mean patient age was 61 years, mean follow up period was 137 months, and mean Yian CT score was 19%. CT score was significantly highest in pegs located inferiorly (p < 0.05). Mean glenoid superior inclination was 12.6°, retroversion was −0.3°, subluxation index was 46%, and CSA was 33.7°. Glenoid superior inclination was significantly lower (p = 0.007) in shoulders with possible loosening than in cases with no loosening (5.0° vs 15.6°). Mean Constant score and UCLA score improved significantly after TSA, from 25.8 to 10.7 points preoperatively to 70.1 and 28.9 points postoperatively, respectively. Mean shoulder flexion, internal rotation, and external rotation also showed improvement postoperatively. ConclusionTSA provides good long-term outcomes. Radiolucency was present most frequently around the inferior pegs of the glenoid component. Glenoid superior inclination may affect the formation of radiolucent lines around glenoid pegs. Level of evidenceLevel IV; Case Series; Treatment study.

Reverse total shoulder arthroplasty for patients with preserved active elevation and moderate-to-severe pain: a matched cohort study.

BackgroundPatients undergoing reverse total shoulder arthroplasty (RTSA) predictably report reduced pain and improved function postoperatively. However, it is not known if patients with differing preoperative active motion achieve the same benefit after surgery. The purpose of the present study is to evaluate patient-reported outcomes (PROs), range of motion (ROM), and satisfaction after RTSA in patients with moderate-to-severe pain with preserved active preoperative ROM compared with matched controls with restricted preoperative active ROM.MethodsA multicenter shoulder arthroplasty registry was utilized to identify patients with at least two-year clinical follow-up after RTSA with a 135° implant. The study cohort with preserved motion included patients with greater than one standard deviation above the overall mean for preoperative forward elevation (FE) (140°) as well as a preoperative visual analog pain scale (VAS) ≥ 5.0. The control cohort with more restricted motion had preoperative FE of less than 140° and also with preoperative VAS ≥5.0. The control patients were matched 2:1 to study patients by age (±2 years), sex, and preoperative VAS (±1.5). Outcomes measured were as follows: PROs, ROM, strength, and strength and satisfaction.ResultsTwenty-seven patients were identified that comprised the preserved preoperative FE study cohort; 54 patients were included in the restricted elevation cohort as controls. The groups were similar at baseline for demographics, surgical diagnoses, and most PROs, other than the Constant-Murley, which was higher in the preserved motion cohort. At two years postoperatively, both cohorts demonstrated similar PROs, strength, and ROM (other than internal rotation with the arm abducted 90 degrees) and had a similar number of patients who rated the RTSA as meeting or exceeding their expectations. The change in ROM from preoperatively was significantly different with the restricted cohort, achieving a larger increase in forward flexion (51 ± 26° vs. −13 ± 35°, P < .001).ConclusionPatients indicated for RTSA with preserved preoperative FE and moderate pain achieve similar final ROM, pain reduction, increases, and strength compared with patients who undergo RTSA with restricted preoperative FE. Despite losing on average 13 degrees of FE from preoperatively by two years postoperatively, patients with preserved preoperative FE are comparably satisfied with their outcome.

Anatomic total shoulder arthroplasty for patients with preserved preoperative motion

BackgroundFor patients with end-stage glenohumeral osteoarthritis, anatomic total shoulder arthroplasty (TSA) serves as a reliable option for pain relief and improving function. It is not well understood if patients with pain due to osteoarthritis but preserved preoperative active range of motion (ROM) experience a similar postoperative benefit compared with those with more pronounced preoperative ROM deficits. MethodsA multicenter shoulder arthroplasty registry was queried to identify all patients who underwent TSA with minimum 2-year clinical follow-up. These patients were separated into two cohorts: (1) preserved preoperative active motion, defined as both forward flexion (FF) and external rotation (ER) at the side a minimum of one standard deviation greater than the mean (>140° FF and >45° ER), and (2) a control group with restrictions in preoperative motion, defined by both preoperative FF < 140° and ER < 45°. Controls were matched 2:1 to study patients by preoperative visual analog pain scale ± 1.5 points, sex, and age ± 2 years. Outcome measures were patient-reported outcomes, active ROM, and strength and satisfaction at a minimum of 2 years postoperatively. ResultsThirty patients were identified in the preserved preoperative motion group (mean baseline 154 ± 10° FF and 57 ± 11° ER). Sixty control patients with restricted motion were matched (mean baseline 97 ± 24° FF and 23 ± 16° ER). There were no significant differences in other baseline patient characteristics other than the Constant-Murley score and strength. At 2-year follow-up, there were no significant differences in visual analog pain scale (0.8 vs. 1.1, P = .446), all patient-reported outcomes, or any ROM measures other than FF which was higher in the preserved group (158 ± 15° vs. 146 ± 19°, P = .003). The change in ROM was significantly higher for all ROM measurements in the restricted motion cohort with restricted preoperative motion compared with study patients. Patients with restricted motion had a significantly greater increase in Constant scores than those with preserved motion (32.6 vs. 19.0, P < .001). There were no significant differences in rates of patients who were satisfied with their surgical result for all domains assessed between groups. ConclusionPatients undergoing TSA with preserved preoperative active ROM can expect similar final pain levels and improvement in pain compared with patients with greater limitations in preoperative ROM. As expected, patients with more restricted preoperative ROM have substantially greater improvement in ROM after TSA. However, there are no differences in satisfaction at 2 years after TSA regardless of preoperative active ROM. Level of evidenceLevel III; Retrospective Cohort Comparison; Treatment Study

Validation of a machine learning-derived clinical metric to quantify outcomes after total shoulder arthroplasty.

We propose a new clinical assessment tool constructed using machine learning, called the Shoulder Arthroplasty Smart (SAS) score to quantify outcomes following total shoulder arthroplasty (TSA). Clinical data from 3667 TSA patients with 8104 postoperative follow-up reports were used to quantify the psychometric properties of validity, responsiveness, and clinical interpretability for the proposed SAS score and each of the Simple Shoulder Test (SST), Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), University of California Los Angeles (UCLA), and Shoulder Pain and Disability Index (SPADI) scores. Convergent construct validity was demonstrated, with all 6 outcome measures being moderately to highly correlated preoperatively and highly correlated postoperatively when quantifying TSA outcomes. The SAS score was most correlated with the UCLA score and least correlated with the SST. No clinical outcome score exhibited significant floor effects preoperatively or postoperatively or significant ceiling effects preoperatively; however, significant ceiling effects occurred postoperatively for each of the SST (44.3%), UCLA (13.9%), ASES (18.7%), and SPADI (19.3%) measures. Ceiling effects were more pronounced for anatomic than reverse TSA, and generally, men, younger patients, and whites who received TSA were more likely to experience a ceiling effect than TSA patients who were female, older, and of non-white race or ethnicity. The SAS score had the least number of patients with floor and ceiling effects and also exhibited no response bias in any patient characteristic analyzed in this study. Regarding clinical interpretability, patient satisfaction anchor-based thresholds for minimal clinically importance difference and substantial clinical benefit were quantified for all 6 outcome measures; the SAS score thresholds were most similar in magnitude to the Constant score. Regarding responsiveness, all 6 outcome measures detected a large effect, with the UCLA exhibiting the most responsiveness and the SST exhibiting the least. Finally, each of the SAS, ASES, Constant, and SPADI scores had similarly large standardized response mean and effect size responsiveness. The 6-question SAS score is an efficient TSA-specific outcome measure with equivalent or better validity, responsiveness, and clinical interpretability as 5 other historical assessment tools. The SAS score has an appropriate response range without floor or ceiling effects and without bias in any target patient characteristic, unlike the age, gender, or race/ethnicity bias observed in the ceiling scores with the other outcome measures. Because of these substantial benefits, we recommend the use of the new SAS score for quantifying TSA outcomes.