Total Shoulder Arthroplasty Group Research Articles

Comparing bone resorption after anatomical shoulder arthroplasty between various surgical procedures using a single-stem model

In shoulder arthroplasty, bone resorption around the stem can lead to stem loosening and makes surgery difficult at the time of revision. Proximal bone resorption after reverse shoulder arthroplasty can cause instability because of a decrease of deltoid wrapping effect. As factors of the stem itself, such as stem coating, shape, length, and use of bone cement, may also affect bone resorption, a single-stem model should be used to compare bone resorptions between different pathologies and surgical procedures. However, to date, a few reports have compared these differences in detail using a single-stem model. Therefore, we investigated the prevalence and location of humeral bone resorption in a single-stem model. The study included 100 shoulders that underwent anatomical total shoulder arthroplasty (TSA) or humeral head replacement (HHR) with a single uncemented humeral stem from 2008 to 2018. The patients were 31 men and 69 women. The mean age at surgery was 72.9 years (range, 41-86 years). The patients were divided into three groups: especially, 25, 61, and 14 shoulders received TSA for primary osteoarthritis without rotator cuff tears (TSA group), HHR using an anatomical head with rotator cuff repair for cuff tear arthropathy (CTA) (HHR group), and HHR using a CTA head without rotator cuff repair (CTA group), respectively. Patients were monitored for a mean of 56 months (range, 12-98 months). The location of bone resorption was divided into seven zones as follows: zone 1, greater tuberosity; zone 2, lateral diaphysis; zone 3, lateral diaphysis beyond the deltoid tuberosity; zone 4, tip of the stem; zone 5, medial diaphysis beyond the deltoid tuberosity; zone 6, medial diaphysis; and zone 7, calcar region. The degree of bone resorption was classified from grade 0 to 4. Bone resorption of grade 3 or higher was significantly more frequent at the greater tuberosity in the HHR and CTA groups ( P < .001 and P < .001, respectively) than that in the TSA group. Grade 4 bone resorption was significantly more frequent in the CTA than that in the TSA and HHR groups in zone 1 ( P = .016 and P = .041, respectively). The state of attachment of the rotator cuff to the greater tuberosity might affect bone resorption at the greater tuberosity, such as the greater tuberosity after shoulder arthroplasty. In cases of shoulder arthroplasty for arthropathy with rotator cuff tear, performing rotator cuff repair might prevent bone resorption. Level IV; Prognosis Study

Preoperative risk factors for lower physical therapy compliance rates after shoulder arthroplasty

BackgroundParticipation in postoperative rehabilitation is thought to be an important step in achieving a good outcome after total shoulder arthroplasty. The effects of common preoperative risk factors on physical therapy compliance are not well defined. This study compared physical therapy compliance rates in patients with and without a history of smoking, mood disorders, and preoperative opioid pain medication use. MethodsA retrospective chart review of primary anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) completed at a single institution from 2010 to 2015 was carried out. Postoperative physical therapy was conducted using a standardized 12-week shoulder arthroplasty program. Preoperative risk factors captured in the electronic medical record were a history of mood disorder, chronic preoperative opioid use, and tobacco use. Compliance rates in the 90-day global period after surgery were calculated by identifying attendance at physical therapy appointments. Compliance rates were then compared by the presence or absence of these risk factors. Two-tailed t-tests and analysis of variance were used to determine the significance of any differences in compliance between groups. ResultsA total of 214 shoulder arthroplasties (92 RTSAs, 122 TSAs) performed by a single surgeon were identified. In the global period after surgery, 82% of all physical therapy visits were attended. There were no statistically significant differences between groups regarding laterality. The overall compliance rates for the RTSA and TSA groups were similar at 83% and 82%, respectively, (P = .66). Patients with a history of mood disorder had a significantly lower compliance rate (76%) than those without (85%, P = .004), patients with a history of smoking had significantly lower compliance rates at 79% vs. 83% (P = .05), and patients with a history of chronic preoperative opioid use showed a statistically insignificant trend toward lower compliance at 78% vs. 84% (P = .06). Forty-two patients had multiple concurrent comorbidities, with a compliance rate of 72%. Patients with multiple comorbidities were significantly less compliant than patients with a single comorbidity (82%, P = .017) or patients with no comorbidities (85% P = .001). ConclusionPatients with mood disorders and a history of tobacco use were significantly less compliant with postoperative physical therapy programs after shoulder arthroplasty. Our data also suggest that the effects of these risk factors may be additive, with patients diagnosed with multiple comorbid conditions having the lowest therapy compliance rate of any group. Patients with the identified comorbidities may benefit from preoperative counseling and management of these risk factors to achieve optimal results after shoulder arthroplasty. Level of evidenceLevel III, Retrospective Prognostic Study

Return to Golf Following Reverse Total Shoulder Arthroplasty.

The object of this study was to examine return to golf and changes in golf performance after shoulder arthroplasty. Additionally, we set out to determine if there were differences in return to play and performance between total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). We also examined pain during the golf swing to determine if there is a change in pain level after surgery. Patients were identified using a Current Procedural Terminology code 23472 search for TSA. A 19-question online survey was sent out to each patient with questions detailing golfing performance and pain during the swing before and after surgery. Comparisons were made to determine differences in pain, performance and enjoyment between TSA and RTSA groups before and after surgery. A total of 586 patients who underwent shoulder arthroplasty were sent the online survey via email. Of those patients, 33 identified themselves as golfers and who responded to the survey, resulting in an overall response rate of 5.6%. Twenty-three of 31 (74%) patients were able to return to golf following their procedure. Overall, the respondents who reported pain associated with golfing activity had significantly decreased pain after undergoing either TSA or RTSA. The RTSA group had a significant drop in driving distance following the procedure and this was significantly lower than the postoperative driving distance in the TSA group, despite an insignificant preoperative difference. Overall, TSA offers a safe and effective means for reducing pain during the golf swing in patients suffering from advanced shoulder osteoarthritis. While there were no significant changes in performance following TSA, individuals undergoing RTSA can be counseled that they are at risk for lower driving distances due to altered mechanics. Overall, patients were satisfied with their procedure and their ability to return to the golf course.

Total Shoulder Arthroplasty After Previous Arthroscopic Surgery for Glenohumeral Osteoarthritis: A Case-Control Matched Cohort Study

Background: When comprehensive arthroscopic management (CAM) for glenohumeral osteoarthritis fails, total shoulder arthroplasty (TSA) may be needed, and it remains unknown whether previous CAM adversely affects outcomes after subsequent TSA. Purpose: To compare the outcomes of patients with glenohumeral osteoarthritis who underwent TSA as a primary procedure with those who underwent TSA after CAM (CAM-TSA). Study Design: Cohort study; Level of evidence, 3. Methods: Patients younger than 70 years who underwent primary TSA or CAM-TSA and were at least 2 years postoperative were included. A total of 21 patients who underwent CAM-TSA were matched to 42 patients who underwent primary TSA by age, sex, and grade of osteoarthritis. Intraoperative blood loss and surgical time were assessed. Patient-reported outcome (PRO) scores were collected preoperatively and at final follow-up including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), visual analog scale, and patient satisfaction. Revision arthroplasty was defined as failure. Results: Of 63 patients, 56 of them (19 CAM-TSA and 37 primary TSA; 88.9%) were available for follow-up. There were 16 female (28.6%) and 40 male (71.4%) patients with a mean age of 57.8 years (range, 38.8-66.7 years). There were no significant differences in intraoperative blood loss (P > .999) or surgical time (P = .127) between the groups. There were 4 patients (7.1%) who had failure, and failure rates did not differ significantly between the CAM-TSA (5.3%; n = 1) and primary TSA (8.1%; n = 3) groups (P > .999). Additionally, 2 patients underwent revision arthroplasty because of trauma. A total of 50 patients who did not experience failure (17 CAM-TSA and 33 primary TSA) completed PRO measures at a mean follow-up of 4.8 years (range, 2.0-11.5 years), with no significant difference between the CAM-TSA (4.4 years [range, 2.1-10.5 years]) and primary TSA (5.0 years [range, 2.0-11.5 years]) groups (P = .164). Both groups improved significantly from preoperatively to postoperatively in all PRO scores (P < .05). No significant differences in any median PRO scores between the CAM-TSA and primary TSA groups, respectively, were seen at final follow-up: ASES: 89.9 (interquartile range [IQR], 74.9-96.6) versus 94.1 (IQR, 74.9-98.3) (P = .545); SANE: 84.0 (IQR, 74.0-94.0) versus 91.5 (IQR, 75.3-99.0) (P = .246); QuickDASH: 9.0 (IQR, 3.4-27.3) versus 9.0 (IQR, 5.1-18.1) (P = .921); SF-12 PCS: 53.8 (IQR, 50.1-57.1) versus 49.3 (IQR, 41.2-56.5) (P = .065); and patient satisfaction: 9.5 (IQR, 7.3-10.0) versus 9.0 (IQR, 5.3-10.0) (P = .308). Conclusion: Patients with severe glenohumeral osteoarthritis who failed previous CAM benefited similarly from TSA compared with patients who opted directly for TSA.

Preoperative screening in patients having elective shoulder surgery reveals a high rate of fall risk.

Fall risk is an acknowledged but relatively understudied concern for older patients undergoing shoulder surgery. The cause is multifactorial, and it includes advanced age, impaired upper extremity function, use of shoulder abduction braces, and postoperative use of opioid medications. No previous study has examined preoperative fall risk in patients undergoing elective shoulder surgery. Previous literature looking at fall risk in elective orthopedic procedures has predominantly focused on falls occurring in the hospital setting, although falls have also been shown to occur in the outpatient setting. Gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cutoff scores indicating increased fall risk. The purpose of this study was to quantify gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA) in order to assess overall risk of fall in these populations. A total of 198 patients scheduled for TSA or RCR surgery were evaluated preoperatively from multiple outpatient physical therapy clinics within Greenville, South Carolina. The TUG score (>14 seconds considered high fall risk) and 10 Meter Walk test (<0.7m/s considered high risk for falls) were recorded for each patient. Patient-reported outcomes were also collected, including Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Single Assessment Numeric Evaluation. Patients undergoing TSA (n = 80; 65.4 ± 11.4 years) were older than those undergoing RCR (n = 118; 59.0 ± 14.2 years). Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed <0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group (62% vs. 38%; χ2 = 8.9, P = .03). There were no significant differences in ambulatory status, Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, or Single Assessment Numeric Evaluation scores between groups (P= .11). Both patient groups demonstrated a high rate of fall risk in preoperative evaluation. Patients undergoing TSA more often displayed fall risk compared with patients undergoing RCR. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk. Our results suggest that fall risk screening may be important for patients undergoing TSA and RCR surgeries. The higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.

Short-stem uncemented anatomical shoulder replacement for osteoarthritis in patients older than 70 years: is it appropriate?

BackgroundDespite a new trend to systematically use reverse shoulder arthroplasty (RSA) in elderly population regardless of the indication, total anatomical shoulder arthroplasty can get good functional results in this population. The purpose of this study was to evaluate clinical and radiological outcomes of uncemented short-stem anatomic total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis in patients older than 70 years and to compare these results to a matched population with an uncemented short-stem RSA.MethodsIn this retrospective monocentric study, clinical outcomes were based on constant score (Cst), subjective shoulder value (SSV) score, and range of motion. The aim of radiographic analysis was to identify glenoid component loosening and humeral bone remodeling around the uncemented short stem.ResultsAt an average follow-up of 44 ± 12.5 months, 32 uncemented short-stem TSA in 31 patients with a minimum of 2 years of follow-up were included and were compared to 32 uncemented RSA. Fifty three percent of the patients had “a forgotten prosthesis”. ROM was significantly improved in all cases. Cst reached 73 ± 9 pts and SSV 90 ± 10.8% (P < .001). In 8 patients with repairable supraspinatus tendon tears, clinical outcomes were not statistically different from patients with an intact rotator cuff: Cst (77 ± 6.2 points vs 72 ± 9.6 points, P = .3) and SSV (88 ± 11.5% vs. 91 ± 10.5%; P = .59). The type of glenoid wear (A vs B) did not influence the constant score: 73 ± 9 points versus 74 ± 11 points respectively; P = .81. Despite a complication rate of 6% (n = 2), no prosthesis revision was performed. At last follow-up, range of motion was better in the TSA group compared to the RSA group for internal (7.8 ± 1.3 vs 6.25 ± 2; P = .001) and external (47 ± 14 vs 24 ± 21; P < .001) rotations. The postoperative SSV score was also better in the TSA group (91.3 ± 10% vs 82.2 ± 13%; P = .002).ConclusionsAt medium-term, uncemented short-stem anatomic TSA in patients older than 70 years provided satisfactory clinical results. Patients have forgotten their prosthesis in over 50% of cases. This prosthetic design is still indicated in this patient population in case of primary osteoarthritis with a functional rotator cuff with an almost normal rotator cuff muscle trophicity.

Value Analysis of Anatomic and Reverse Shoulder Arthroplasty for Glenohumeral Osteoarthritis with an Intact Rotator Cuff.

While anatomic total shoulder arthroplasty (TSA) has historically been considered the ideal treatment for end-stage glenohumeral osteoarthritis, reverse shoulder arthroplasty (RSA) has recently gained popularity. With substantial differences in implant design and cost between TSA and RSA, further investigation of outcomes and value is needed to support recent trends. The purpose of this study was to use the average and incremental cost-effectiveness ratio (ACER and ICER) and the procedure value index (PVI) to examine differences in outcomes and value between TSA and RSA for treatment of glenohumeral osteoarthritis with an intact rotator cuff. We performed a retrospective matched-cohort study of patients treated with primary shoulder arthroplasty for osteoarthritis with an intact rotator cuff who had a minimum 2-year follow-up. Outcome measures analyzed included the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) questionnaire, visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE), and overall satisfaction. Patients treated with TSA were matched 4:1 to those treated with RSA based on sex, age, and preoperative SST score. Value differences between TSA and RSA were calculated. Radiographs were analyzed for preoperative glenoid classification and postoperative radiolucent lines and gross loosening. Two hundred and fifty-two TSA-treated patients were matched to 63 RSA-treated patients with no significant differences in sex, age, or preoperative SST score. Total hospitalization costs, charges, and reimbursements along with outcome improvements in units of minimal clinically important differences (MCIDs) and patient satisfaction did not differ between the groups. For RSA, the implant cost was significantly higher than that for TSA, but the operating room, anesthesia, and cement costs were lower. The TSA group had a 3.2% rate of gross glenoid loosening and a 2.4% revision rate. There was no loosening or revision in the RSA group. None of the value analytics differed between groups even after inclusion of the outcomes and costs of early TSA revisions. TSA and RSA demonstrated similar outcomes and value when used to manage glenohumeral osteoarthritis with an intact rotator cuff. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Drivers of lower inpatient hospital costs and greater improvements in health-related quality of life for patients undergoing total shoulder and ream-and-run arthroplasty.

With increasing emphasis on value-based care and the heavy demands on the US health care budget, surgeons must be cognizant of factors that drive cost and quality of patient care. Our objective was to determine patient-level drivers of lower costs and improved health-related quality of life (HRQoL) in 2 anatomic shoulder arthroplasty procedures: total shoulder arthroplasty (TSA) and ream-and-run arthroplasty. This study included 222 TSAs and 211 ream-and-run arthroplasties. Simple Shoulder Test, Single Assessment Numeric Evaluation, and Short Form 36 scores were collected preoperatively and 2 years postoperatively. Quality-adjusted life-years (QALYs) were calculated as a measure of HRQoL. Univariate and multivariate analyses determined factors significantly associated with decreased hospitalization costs and improved HRQoL. In the TSA group, female sex, lower American Society of Anesthesiologists class, diagnosis other than capsulorrhaphy arthropathy, lower pain score, and higher Single Assessment Numeric Evaluation score were associated with decreased total hospitalization costs; in addition, female sex was an independent predictor of lower total costs. Insurance other than workers' compensation, a diagnosis of chondrolysis, and higher optimism led to greater QALY gains, but a diagnosis of capsulorrhaphy arthropathy was the only independent predictor of greater QALY gains. In the ream-and-run arthroplasty group, older age, lower body mass index (BMI), lower American Society of Anesthesiologists class, insurance other than Medicaid, diagnosis other than capsulorrhaphy arthropathy, no history of surgery, higher preoperative Simple Shoulder Test score, and higher preoperative Short Form 36 Physical Component Summary score were associated with lower total costs; moreover, lower BMI was an independent predictor of lower costs. Higher preoperative optimism was an independent predictor of greater QALY gains. Identifying factors associated with decreased costs and increased quality is becoming increasingly important in value-based care. This study identified fixed (sex and diagnosis) and modifiable (BMI) factors that drive decreased hospitalization costs and increased HRQoL improvements in shoulder arthroplasty patients. Higher preoperative patient optimism is a consistent predictor of improved HRQoL for both TSA patients and ream-and-run arthroplasty patients, and further study on optimizing the influence of patient expectations and optimism may be warranted.

Establishing and comparing reference preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores in patients undergoing shoulder surgery

The Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular among orthopedic surgeons treating shoulder pathology. Despite this, there have been few studies that have described and compared preoperative reference scores for specific shoulder surgical procedures. The primary purpose of this study was to establish and compare baseline preoperative PROMIS scores for 3 common types of shoulder surgery: rotator cuff repair (RCR), total shoulder arthroplasty (TSA), and labral repair (LR). The secondary goal was to stratify these operative groups by diagnosis and compare preoperative PROMIS scores. In this cross-sectional study, adult and pediatric patients who underwent surgery for either RCR, TSA, or LR were included. PROMIS-Upper Extremity (UE), PROMIS-Pain Interference (PI), and PROMIS-Depression (D) scores that were collected at each patient's preoperative visit were reviewed. Continuous and categorical variables were compared between operative groups using analysis of variance and χ2 or Fisher exact tests, respectively. Multivariable general linear models were used to identify significant independent predictors of PROMIS scores when controlling for age, sex, and body mass index. A total of 413 patients were included in the study: 272 in the RCR group, 84 in the TSA group, and 57 in the LR group. The average PROMIS-UE score was 39.8 in the LR group vs. 29.9 in the RCR group (P < .001) and 29.6 in the TSA group (P < .001). There was no difference between the mean RCR and TSA PROMIS-UE scores (P = .93). The average PROMIS-PI score was 56.6 in the LR group vs. 62.8 in the RCR group (P < .001) and 63.9 in the TSA group (P < .001). There was no difference between RCR and TSA PROMIS-PI scores (P = .09). The average PROMIS-D score was 43.5 in the LR group vs. 47.7 in the RCR group (P = .004) and 50.3 in the TSA group (P < .001). The TSA group had a higher mean PROMIS-D score than the RCR group (P = .03). For PROMIS-UE scores, age and body mass index were not found to be significant independent predictors (P = .98 and P = .88, respectively). For PROMIS-PI scores, age, body mass index, and sex were not found to be significant independent predictors (P = .31, P = .81, and P = .48, respectively). Patients undergoing shoulder LR had higher preoperative function scores and lower pain interference and depression scores than those undergoing TSA and RCR. These baseline PROMIS scores should be taken into consideration when tracking a patient's outcomes after surgery, as a certain score could mean drastically different functional and pain outcomes depending on the underlying pathology.

Clinical characteristics and patient-reported outcomes of total shoulder arthroplasty after anterior stabilization: a retrospective matched control study

Instability arthropathy is a known cause of glenohumeral osteoarthritis (OA) among patients with and without prior shoulder stabilization. This study aims to compare the clinical, radiographic, and patient-reported outcome measure (PROM) scores among total shoulder arthroplasty (TSA) patients with and without a history of shoulder stabilization. A case-control study was performed comparing 20 patients with a history of anterior shoulder stabilization (11 open, 9 arthroscopic) who underwent TSA to a matched cohort of 20 TSA patients without a history of shoulder surgery (mean follow-up = 2.8 years). Patients were matched by sex, age, and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score within 10 points (mean age 59.6 ± 9.6 years). Patient characteristics, operative findings, and preoperative and postoperative radiographic characteristics for both groups were reported. Comparisons were made regarding PROM scores (ASES, 12-Item Short Form Health Survey (SF-12), Shoulder Activity Scale [SAS], numeric rating scale for pain) at baseline, 2 years, and 5 years and patient satisfaction at 2 years. Intraoperative findings of subscapularis scarring or attenuation was common among patients with prior anterior stabilization. The instability cohort did have a higher percentage of B2/B3 glenoid types than the OA cohort (45% vs. 15%), but this was not significantly different possibly because of the small sample size. At 2 years, both instability and OA groups reported significant improvement in pain, function, and activity level. There was no difference between groups on any PROMs or patient satisfaction level. At 5 years, instability patients had significantly lower scores on the ASES and the SF-12 PCS than the OA group. There was notable alterations in both soft tissue and bony morphology among patients with prior anterior stabilization. After TSA, both instability and primary OA groups showed significant improvements at 2 years. However, PROMs for instability patients deteriorated at 5 years compared with the control group. Complex bony and soft tissue imbalances may contribute to more unpredictable long-term PROM scores. Thoughtful preoperative consideration of these factors should influence decision making regarding selection of TSA for management of OA in this complex patient cohort.

A Word of Caution: Success May Be Limited to 2 Years and Highly Displaced OTA/AO B2 and C2 Injuries: Commentary on an article by Alexander Nilsskog Fraser, MD, et al.: "Reverse Total Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly. A Multicenter Randomized Controlled Trial".

Commentary I would like to congratulate Fraser et al. on a well-conducted study from which we are able to draw a narrow but strong conclusion: for the displaced anatomic neck fracture with involvement of the lesser and greater tuberosities, a reverse total shoulder arthroplasty (TSA) yields improved outcome at a 2-year follow-up across a population of patients. It is important to acknowledge that results are superior at 2 years and superior in this injury pattern, not generally superior postoperatively or for other broad definitions of proximal humeral fracture. There was a mean difference in the Constant score of 13.4 points overall and 18.7 points for C2 fractures for this modest timeframe and in these fracture patterns. Both exceeded the minimal clinically important difference of 10 points, according to the article by Fraser et al. This article is well organized and written, easy to understand, and comprehensive. The strengths of the investigation include a well-powered cohort for the primary outcome variable, the Constant score, although it was underpowered for secondary outcomes and subgroup analysis. Additionally, the inclusion and exclusion criteria were well established, and I like that Fraser et al. stuck to the controversial treatment groups of the OTA B2 and C2 fractures and, at that, only those with severely angulated and displaced parameters of >45° valgus or >30° varus on an anteroposterior radiographic view or >45° angulation on a scapular Y radiographic view. Although there was a high percentage of excluded patients (54% [146 of 270 patients] with OTA/AO B2 and C2 fractures), most exclusions were due to the patients not meeting displacement criteria, ultimately leaving 60 patients in the open reduction and internal fixation (ORIF) group and 64 patients in the reverse TSA group. It was outstanding that the physiotherapists performing measurements were blinded to the procedure during the measurement of outcome parameters and were different from those physiotherapists rendering treatment. Further, in this study, the same surgeons performed the arthroplasties and ORIF, which has the advantage of consistency of technique and protocol in each treatment arm. However, the possible downside is that this circumstance may also introduce bias for 1 treatment arm given that the operating surgeons were likely shoulder surgeons by training. We should not conclude that, for every patient and every surgeon, improved results can be expected with one modality over another. The randomized controlled trial (RCT) helps to give us a guideline for a population of patients treated by a population of surgeons; therefore, it should be obvious that within those populations there exist patients who will outperform the mean in both treatment groups, and the same is true for the surgeon. This RCT does not tell us what the optimal outcome is at the onset of treatment for any individual patient, nor even whether optimal reverse TSA is better than optimal ORIF; therefore, we must be circumspect in counseling our patients, taking into consideration variables that could make them better candidates for a particular technique or that may make the surgeon more facile with another technique. What would not be appropriate is to conclude that reverse TSA is better than ORIF for proximal humeral fractures. We must beware; it is only a 2-year study. If there was a 25% revision rate for reverse TSA at 5 to 10 years, then the superior results would be reversed, and we would be reinventing another wheel in orthopaedics again. I commend the authors for an excellent study, and I am pleased to learn that this study group is in the midst of mining longer-term results that would elevate our understanding further regarding this very important fracture for which excellent treatment results have been hard to find.

Osteoporosis and Implant-Related Complications After Anatomic and Reverse Total Shoulder Arthroplasty.

Osteoporosis is a widespread and growing medical condition, with significant orthopaedic implications. However, the effect of osteoporosis on outcomes after total shoulder arthroplasty (TSA) is not well understood. The goal of the present study was to characterize the incidence of osteoporosis in patients undergoing shoulder arthroplasty and to examine whether patients with osteoporosis undergoing anatomic and reverse TSA are at an increased risk of prosthetic-related complications. Complication rates were calculated for patients with osteoporosis who underwent anatomic and reverse TSA as separate cohorts within 2 years of surgery including loosening/osteolysis, periprosthetic fracture, periprosthetic dislocation, and revision shoulder arthroplasty and compared using a multivariable logistic regression analysis to control for patient demographics and comorbidities during comparisons, including the indication for reverse TSA. The prevalence of an osteoporosis diagnosis at the time of surgery was 14.3% for anatomic TSA patients and 26.2% of reverse TSA patients. Anatomic TSA patients with osteoporosis experienced significantly higher rates of periprosthetic fracture (odds ratio [OR], 1.49; P = 0.017) and revision shoulder arthroplasty (OR, 1.21; P = 0.009) within 2 years of surgery compared with matched controls without osteoporosis. Patients in the reverse TSA group with osteoporosis also had significantly higher rates of periprosthetic fracture (OR, 1.86; P = 0.001) and revision shoulder arthroplasty (OR, 1.42; P = 0.005) within 2 years of surgery compared with matched controls. A significant number of patients undergoing both anatomic and reverse TSA have a concurrent diagnosis of osteoporosis. Osteoporosis represents a significant independent risk factor for periprosthetic fracture and revision shoulder arthroplasty within 2 years of surgery, regardless of the type of implant. Patients with osteoporosis should be counseled on their increased risk of complications after shoulder arthroplasty.

Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly

UpdateThis article was updated on May 20, 2020, because of a previous error. On page 482, in the legend for Figure 5, the sentence that had read “The Oxford Shoulder Score consists of 12 questions concerning shoulder pain, shoulder function, and activities of daily living and ranges from 12 points (worst) to 60 points (best)” now reads “The Oxford Shoulder Score consists of 12 questions concerning shoulder pain, shoulder function, and activities of daily living and ranges from 0 points (worst) to 48 points (best).”An erratum has been published: J Bone Joint Surg Am. 2020 June 17;102(12):e63.Background:Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate.Methods:The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients.Results:There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, −3.8 to 19.1 points; p = 0.19).Conclusions:At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Reliability of stemless shoulder arthroplasty in rheumatoid arthritis: observation of early lysis around the humeral component.

To evaluate whether stemless shoulder implants in rheumatoid arthritis (RA) patients provide comparable functional outcomes to patients with osteoarthritis or post-traumatic arthritis. In addition, the study assessed for differences in incidence of radiolucent lines or proximal humeral bone loss during radiographic follow-up. Consecutive stemless shoulder arthroplasties performed in RA patients and a matched control group were retrospectively identified between February 2012 and 2018. Thirty-five patients were included in each group: 24 total shoulder arthroplasty (TSA) and 11 hemiarthroplasty (HA). Patients were evaluated annually using the Oxford Shoulder Score (OSS) and radiographically. The mean OSS significantly improved in all groups until 24months. The mean improvement for RA TSA and HA patients at 24months was 19.86 (95% CI 10.66-29.05, p = 0.0004) and 19.71 (95% CI 7.33-32.31, p = 0.0084), respectively. The mean improvement in the control TSA and HA patients at 24months was 20.86 (95% CI 17-24.71, p = 0.0001) and 17.86 (95% CI 1.36-34.35, p = 0.0381), respectively. During the study period, two patients in the RA TSA group (8%), one patient in the control TSA group (4%) and one patient in the control HA group (9%) required revision. The proportion of progressive proximal humeral bone loss after TSA was 33% in the RA group and 13% in the control group. Stemless shoulder implants can provide significant improvement in functional scores in RA patients in the short term. However, early bone loss around the humeral implant is a concern and the authors recommend long-term clinical and radiological follow-up.

Postoperative radiographic findings of an uncemented convertible short stem for anatomic and reverse shoulder arthroplasty

Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA. There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio. At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014). The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study.

Sports Participation Is an Appropriate Expectation for Recreational Athletes Undergoing Shoulder Arthroplasty.

Background:Several studies have investigated sports participation in patients who undergo total shoulder arthroplasty (TSA). However, there are limited data in the setting of hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA), particularly regarding the frequency of participation in common sports.Hypothesis:The majority of patients who undergo TSA or HA will be able to maintain active lifestyles with high levels of sports participation after their procedure, while patients who undergo rTSA will have lower levels of sports participation.Study Design:Case series; Level of evidence, 4.Methods:We identified patients who underwent TSA, rTSA, stemmed HA, or humeral head resurfacing (the latter 2 were defined collectively as the HA group) by surgeons within our department since January 2004. We excluded patients who (1) underwent revision arthroplasty, (2) had a history of chronic pain syndrome, (3) experienced septic arthritis of the involved shoulder, and/or (4) were deceased at the time of follow-up. The minimum follow-up from the time of surgery was 2 years. Qualified patients were sent a questionnaire that asked about sports participation and the frequency of participation at the time of follow-up. Frequency was rated as 0, 1 to 3, or 4 to 7 times a week. Sports were defined as lower extremity sport, volleyball, tennis, skiing, bowling, swimming, weight lifting, golf, and other sport.Results:Overall, 95% of the TSA group, 40% of the rTSA group, and 76% of the HA group who had participated in at least 1 sport before surgery indicated that they were doing so at the time of follow-up. Among active patients in the TSA and HA groups, the most common sports at the time of follow-up were weight lifting (52%), swimming (36%), and golf (25%). For the 2 active patients in the rTSA group, 1 participated in swimming and hunting and fishing, while the other participated in weight lifting. For the active patients in the TSA and HA groups who were participating in at least 1 of the 3 most common sports, most patients indicated that they were doing so 1 to 3 times a week at the time of completing the questionnaire.Conclusion:Patients undergoing shoulder arthroplasty can maintain an active lifestyle with moderate to high frequencies of participation after surgery, particularly regarding weight lifting, swimming, and golf.

Patient-specific instrumentation for total shoulder arthroplasty: not as accurate as it would seem

There is an increasing body of literature suggesting that the use of patient-specific instrumentation (PSI) in total shoulder arthroplasty (TSA) results in improved positioning of the glenoid component. The aim of this in vivo study was to assess the accuracy of PSI of the glenoid component in TSA in a consecutive series at a single center. Eleven consecutive TSAs (7 TSAs and 4 reverse TSAs) were performed using custom-made patient-specific positioning guides for the glenoid component. Each patient had preoperative computed tomography scans and guides produced to allow 0° of glenoid inclination and version in anatomic TSAs and 10° of inferior inclination for reverse TSAs. Postoperative computed tomography imaging was performed to determine accuracy of component implantation. Patients were observed to the 1-year mark. For the conventional TSA group, the mean version was measured at 8° ± 10° retroversion and 1° ± 4° inclination. For reverse TSAs, mean version was 10° ± 10° retroversion and -1° ± 5° inclination. There were 5 cases classified as outliers in terms of version (>10° anteversion or retroversion). We had a mean correction of version of 22° ± 9° and 17° ± 9° in inclination compared with preoperative measurements. Our results suggest that the in vivo accuracy of PSI-guided glenoid positioning is not as successful as suggested in the literature.

Paper #29 - Anatomic shoulder arthroplasty with plication of the posterior capsule compared to reverse shoulder arthroplasty for osteoarthritis with B2 glenoid: a matched cohort study

Introduction: A subset of patients with primary glenohumeral osteoarthritis presents with posterior subluxation and eccentric posterior glenoid bone loss (B2 glenoid). Posterior capsular plication is sometimes required to balance the shoulder when performing an anatomic shoulder arthroplasty. More recently, reverse arthroplasty has been advocated for glenohumeral osteoarthritis with severe posterior subluxation. To date, no study has compared these two alternatives for shoulders with marked posterior subluxation. The purpose of this study was to compare the clinical and radiographic outcomes of a matched cohort of shoulders with B2 glenoids treated with either anatomic total shoulder arthroplasty (TSA) with plication of the posterior capsule or a reverse shoulder arthroplasty (RSA). Methods: All shoulder arthroplasties performed for glenohumeral osteoarthritis at a single institution between 1975 and 2013 were reviewed to identify two matched cohorts. Group 1 included 15 TSA in shoulders with B2 glenoids that required posterior capsule plication. Group 2 included 16 RSA in shoulders with B2 glenoids. Both groups were similar in terms of age (70 ± 7.5 years vs 72 ± 5.4 years), BMI (31 ± 3.9 vs 32. ± 1.6) and follow-up (42.8 ± 18.4 vs 35.1 ± 14.2). The records of these patients were reviewed to determine pain, range of motion (ROM), strength, Neer rating scale, simple shoulder test, ASES score, satisfaction, complications, reoperations, radiolucency lines and implant loosening. Radiographic information was obtained preoperatively, in the immediate postoperative period and at last radiographic follow-up. Results: With the numbers available, at most recent follow-up, there were no significant differences in pain (P = .2), forward flexion (P = .7), external rotation (P = .5), internal rotation (P = .4), forward flexion strength (P = .3), abduction strength (P = .8), external rotation strength (P = .5), internal rotation strength (P = .8), ASES scores (P = .08), or satisfaction (P = .3). The simple shoulder test score was significantly better in TSA compared to RSA (10.6 vs 8.5, P = .01). There were no reoperations in either group. Radiographically, in the TSA group there were 2 shoulders with glenoid loosening, 2 shoulders with progressive cuff insufficiency, and 1 shoulder with recurrent posterior subluxation and 1 additional shoulder with recurrent posterior subluxation and glenoid loosening. In the RSA, there were no cases of loosening or notching. Conclusions: The overall clinical outcome of anatomic TSA in patients with a B2 glenoid and subluxation requiring posterior capsular plication seems to be similar to the outcome of RSA in patients with a B2 glenoid. However, the rate of radiographic glenoid loosening, cuff insufficiency, and recurrent posterior subluxation after TSA remains of concern.

Prevalence of Rotator Cuff Atrophy and Fatty Infiltration in Patients Undergoing Total Shoulder Arthroplasty

Background Rotator cuff fatty infiltration and atrophy are risk factors for worse outcomes after total shoulder arthroplasty (TSA). The purpose of this study is to evaluate the prevalence of preoperative fatty infiltration and atrophy in TSA patients compared to control patients without glenohumeral osteoarthritis. Methods We retrospectively identified 30 patients undergoing TSA for primary glenohumeral arthritis who had preoperative magnetic resonance imaging. TSA patients were matched by age and sex with control patients without arthritis or full-thickness rotator cuff tears. Blinded observers graded fatty infiltration of the 4 rotator cuff muscles and measured supraspinatus atrophy by the occupation ratio. A multivariate analysis was used to correlate arthritis, age, sex, and body mass index with rotator cuff atrophy and fatty infiltration. Results Goutallier grade ≥ 2 fatty infiltration was seen in at least one muscle for 13/30 (43%) TSA patients and 1/30 (3%) control patients ( P &lt; .01). The average supraspinatus fossa occupation ratio was 0.72 ± 0.24 in the TSA group compared to 0.92 ± 0.23 for controls ( P &lt; .01). Moderate to severe supraspinatus muscle atrophy (occupation ration &lt; 0.6) was observed in 10/30 (33%) TSA patients and 0/30 (0%) controls. Glenohumeral arthritis was an independent predictor of atrophy and fatty infiltration ( P &lt; .01). Age, sex, and body mass index were not significantly correlated with atrophy or fatty infiltration. Conclusion Glenohumeral arthritis is associated with rotator cuff atrophy and fatty infiltration. In the absence of rotator cuff tendon tearing, glenohumeral arthritis may contribute to the pathophysiology of rotator cuff muscle degeneration.

Comparative study of total shoulder arthroplasty versus total shoulder surface replacement for glenohumeral osteoarthritis with minimum 2-year follow-up

Compared with total shoulder arthroplasty (TSA), total shoulder surface replacement (TSSR) may offer the advantage of preservation of bone stock and shorter surgical time, possibly at the expense of glenoid component positioning and increasing lateral glenohumeral offset. We hypothesized that in patients treated for osteoarthritis with a sufficient rotator cuff, TSA and TSSR patients have comparable functional outcome, glenoid component version, and lateral glenohumeral offset. We conducted a retrospective cohort study with a minimum of 2 years of follow-up. Patients in the TSA and TSSR groups received a cemented, curved, keeled, all-poly glenoid component. A cemented anatomical humeral stem was used in TSA. TSSR involved a humeral surface replacement (all components from Tornier Inc., St Ismier, France). Patients were assessed for functional outcome. Radiographs were assessed for radiolucent lines. Glenoid component position and lateral glenohumeral offset were assessed using computed tomography images. After 29 and 34 months of mean follow-up, respectively, TSA (n = 29) and TSSR (n = 20) groups showed similar median adjusted Constant Scores (84% vs. 88%), Oxford Shoulder Scores (44 vs. 44), Disabilities of the Arm, Shoulder and Hand scores (22 vs. 15), and Dutch Simple Shoulder Test scores (10 vs. 11). Glenoid components showed similar radiolucent line counts (median, 0 vs. 0), similar anteversion angles (mean, 0° vs. 2°), and similar preoperative to postoperative increases in lateral glenohumeral offset (mean, 4 vs. 5 mm). One intraoperative glenoid fracture occurred in the TSSR group. Short-term functional and radiographic outcomes were comparable for TSA and TSSR.