Total Shoulder Arthroplasty Patients Research Articles

Postoperative complications associated with congestive heart failure inaseptic revision total shoulder arthroplasty.

The aim of this study is to explore potential complications and risk factors associated with revision TSA in patients with congestive heart failure (CHF). This study examined all individuals who underwent revision total shoulder arthroplasty (TSA) from 2015 to 2022, sourced from the American College of Surgeons National Surgical Quality Improvement database. The analysis encompassed patient demographics, comorbidities, and 30-day postoperative complications. Logistic regression was employed to analyze the postoperative complications linked to patients with preoperative CHF. Compared to patients without CHF, patients with CHF were significantly associated with dependent functional status (P < .001), chronic obstructive pulmonary disease (P < .001), and hypertension (P = .002). Compared to patients without CHF, patients with CHF were independently associated with a significantly greater likelihood of experiencing any complication (OR 2.19, 95%CI 1.12-4.29; P = .022) and non-home discharge (OR 3.02, 95%CI 1.37-6.65; P = .006). Congestive heart failure was identified as an independent risk factor for experiencing any complication and non-home discharge in patients undergoing revision TSA. Awareness of the cardiovascular health status of a patient and its severity can influence the decision-making process when considering revision TSA. Retrospective Cohort Comparison Using Large Database; Prognosis Study.

Initiating chemotherapy in joint arthroplasty patients increases the risk of periprosthetic joint infections.

Total Joint Arthroplasties (TJAs) are becoming more popular, resulting in a growing economic burden due to potential postoperative complications, with periprosthetic joint infections (PJIs) playing a significant role. The effect of immunosuppression on PJI risk, particularly in cancer patients following chemotherapy, is unknown. The hypothesis of this study investigated whether chemotherapy increases PJI rates in patients who received post-arthroplasty chemotherapy within one year of surgery. Data from the M161Ortho dataset of PearlDiver patient records database were utilized using ICD-9, ICD-10, and CPT codes. The cohort includes Total Knee Arthroplasty (TKA), Total Hip Arthroplasty (THA), and Total Shoulder Arthroplasty (TSA) patients who underwent post-arthroplasty chemotherapy within one year after surgery between 2010 and 2022. Patients in the matched control group did not receive post-arthroplasty chemotherapy. Pre-arthroplasty chemotherapy recipients, PJI, and post-op first year revisions were excluded. Analyses including the linear logistic regression were performed via R statistical software. Totally, 17,026 patients (8,558 TKAs, 6,707 THAs, and 1,761 TSAs) were included. At two (OR = 1.59, p = 0.034), three (OR = 1.57, p = 0.009), and four (OR = 1.40, p = 0.032) years for TKA, and two (OR = 2.27, p = 0.008), three (OR = 2.32, p < 0.001), and four (OR = 2.25, p0.001) years for THA, PJI rates were significantly higher in the chemotherapy group. TSA patients had a significant rise in PJI after four years (OR = 2.20, p = 0.031). This study reveals a possible relationship between postoperative chemotherapy and an increased incidence of PJI in patients with arthroplasty. Chemotherapy suppresses the immune system, rendering patients more vulnerable to infections. Additional research is required to confirm these findings.

No Difference in 10-Year Survivorship of Total Shoulder Arthroplasty Versus Hemiarthroplasty for Avascular Necrosis of the Humeral Head

Avascular necrosis of the humeral head (AVN) is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty) is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies. Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio since TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox Proportional Hazard modeling. Chi-squared analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness. In total, 4,825 patients undergoing TSA and 1,969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = 0.017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = 0.148) and no difference in the observed etiologies for revision (P > 0.05 for all). After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10-years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

Revision rate in metal compared to ceramic humeral head total shoulder arthroplasty and hemiarthroplasty.

Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey. NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation. A total of 4,799 TSAs (3,578 metal, 1,221 ceramic) and 1,363 HAs (1,020 metal, 343 ceramic) were included. The rate of revision was higher for metal compared with ceramic TSA, hazard ratio (HR) 3.31 (95% confidence interval (CI) 1.67 to 6.58). At eight years, prosthesis survival for ceramic TSA was 98.7% (95% CI 97.3 to 99.4) compared with 96.4% (95% CI 95.2 to 97.3) for metal TSA. The majority of revision TSAs were for cuff insufficiency or instability/dislocation. There was no significant difference in the revision rate for ceramic compared with metal head HA (HR 1.33 (95% CI 0.76 to 2.34)). For ceramic HA, eight-year prosthetic survival was 92.8% (95% CI 86.9 to 96.1), compared with 91.6% (95% CI 89.3 to 93.5) for metal HA. The majority of revision HAs were for cuff failure. The rate of all-cause revision was higher following metal compared with ceramic humeral head TSA in patients with OA and an intact rotator cuff. There was no difference in the revision rate for HA according to bearing surface.

Regional Variation from 2013 to 2021 in Primary Total Shoulder Arthroplasty Utilization, Reimbursement, and Patient Populations

BackgroundTotal shoulder arthroplasty (TSA), encompassing both anatomical and reverse total shoulder arthroplasty, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level. MethodsThe Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data was stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions. ResultsBetween 2013 and 2021, TSA utilization increased by 121.8% nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1,108.59; p<0.001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1,223.44; p<0.001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; p<0.001). The average comorbidity burden of patients decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (p<0.001). ConclusionThis study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.

Functionality, complications, and survivorship of total shoulder arthroplasty in patients under 60 years old

BackgroundAs total shoulder arthroplasty (TSA) expands to younger patients, it is crucial to weigh the benefits of early intervention against potential complications and implant longevity in patients under 60 years of age. This study examines mid-term outcomes in this patient subset. MethodsBetween 2009 and 2019, a retrospective analysis was conducted on 50 patients (25 male, 25 female) who underwent anatomic TSA (TSA) under the age of 60 with minimum 5 years follow-up. Demographic and baseline variables were extracted from medical records. Pre-operative and post-operative outcomes of range of motion (ROM) and strength were recorded. Patient-reported outcomes (PROs) were obtained. ResultsFifty patients were followed for an average of 8.7 ± 2.4 years, having a mean age of 54.1 ± 8.4 years. Comparison of pre-operative and post-operative measurements revealed significant improvements in active ROM, including external rotation (ER) (p < 0.0001), forward elevation (FE) (p < 0.0001), and internal rotation (IR) (p = 0.0001). There were significant improvements in functional strength scores, including ER (p = 0.0005) and FE (p = 0.0002). PROs included visual analog scale (VAS) (2.2 ± 2.6), Single Assessment Numeric Evaluation (SANE) (80.3 ± 17.6), American Shoulder and Elbow Surgeons (ASES) score (76.4 ± 22.8), and Simple Shoulder Test (SST) (8.9 ± 3.2). The 5-year and 10-year implant survival rates were found to be 98.0 % and 83.3 %, respectively. There were 7 postoperative complications in 5 patients (14.0 %), including glenoid loosening (n = 2), infection (n = 1), atraumatic instability (n = 1), lesser tuberosity avulsion (n = 1), painful arthroplasty (n = 1) and traumatic rotator cuff insufficiency (n = 1). Subsequently, all 5 patients underwent revision shoulder arthroplasty at an average of 6.5 years after the initial procedure. ConclusionPositive mid to long-term outcomes, including significant improvements in ROM and strength, along with high 5-year and 10-year implant survival rates support TSA as an effective treatment option for patients under the age of 60.

Patient-related risk factors for early unplanned reoperation following revision total shoulder arthroplasty

Purpose There has been an increase in the number of total shoulder arthroplasty (TSA) revisions performed as the number of primary surgeries increases rapidly. Revision procedures have a higher failure rate and there is a lack of understanding of patient risk factors for needing another repeat surgery following revision TSA. Methods Revision patients were separated into two cohorts: those needing an unplanned reoperation and those that did not within 30 days following revision TSA. Multivariate logistic regression was performed to identify independent risk factors for an unplanned reoperation. Results 1909 revision TSA patients were included in the final analysis. Sixty-nine of these patients underwent an unplanned reoperation within 30 days and 1840 did not. Multivariate logistic regression analyses found an ASA class of III or IV, male sex, congestive heart failure, and inpatient setting to be independent risk factors. Conclusion 3.6% of revision TSA patients require an unplanned reoperation within 30 days postoperatively. An ASA class of III or IV, male sex, congestive heart failure, and inpatient setting were found to be independent risk factors for early reoperation. Surgeons should be aware of these risks to improve preoperative patient optimization and guide shared decision making with patients considering revision.

Comparing Comorbidity Burden Between Patients Undergoing Ambulatory Rotator Cuff Repair Versus Inpatient Anatomic Total Shoulder Arthroplasty

BACKGROUNDRotator cuff repair (RCR) patients routinely undergo same-day discharge in an ambulatory setting, while anatomic total shoulder arthroplasty (TSA) cases have historically been performed in an inpatient hospital setting. For healthier patients, however, TSA has increasingly transitioned to same-day discharge. Understanding whether a true difference in comorbidity burden exists between these patient groups would inform the appropriateness of outpatient TSA in an ambulatory setting. METHODSA retrospective review was performed of patients undergoing primary TSA and same-day, ambulatory RCR performed between September 2017 and May 2021 at a single institution by 3 fellowship-trained orthopedic surgeons. Selected sociodemographic factors and the Elixhauser Comorbidity Index (30 variables) were used to summarize and compare comorbidity burden. Only patients >50 years old were included. Chi-square and Kruskal-Wallis testing was used to compare the prevalence or severity for categorical and continuous variables, respectively. RESULTS1433 cases met inclusion criteria, including 146 (34%) primary inpatient TSAs and 287 (66%) ambulatory RCRs. There were few differences in comorbidity burden between TSA and RCR, with TSA having a significantly higher prevalence for only 4 Elixhauser comorbidities and RCR having a higher prevalence of 1 comorbidity, although none survive a Bonferroni correction. TSA patients had a significantly higher prevalence of uncomplicated (p = 0.04192) and complicated hypertension (p = 0.0336), chronic pulmonary disease (p = 0.0045), and cardiac arrhythmia (p = 0.0031). The prevalence of diabetes (p = 0.029758) was significantly higher among RCR patients. Additionally, age (p = 0.011) was significantly higher among TSA patients. Of the TSA cohort, there were 10 incidences (1%) of 90-day readmission whereas there were 14 incidences (5%) of 90-day readmissions after RCR. CONCLUSIONSOverall, few differences in the prevalence of individual comorbidities (and sociodemographic parameters) existed between patients undergoing outpatient rotator cuff repair and inpatient primary anatomic total shoulder arthroplasty. Comorbidities with larger differences can be either optimized preoperatively or managed chronically, and given these similarities, TSA may be similarly appropriate for ambulatory settings, particularly as efficiencies in operative time and improvements in regional anesthesia continue to evolve.

Total shoulder arthroplasty in patients with factor V Leiden

BackgroundAnatomic and reverse total shoulder arthroplasty (TSA) are effective treatment options for end-stage glenohumeral osteoarthritis. However, consideration for pre-existing conditions must be taken into account. Factor V Leiden (FVL), the most common inherited thrombophilia, is one such condition that predisposes to a prothrombotic state and may affect perioperative and longer-term outcomes following TSA. MethodsAdult patients undergoing primary TSA for osteoarthritis indication were identified in the 2010 through October 2021 PearlDiver M157 database. Patients with or without FVL were matched at a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and five-year revision rates were assessed and compared with multivariable logistic regression and rank-log tests, respectively. Finally, the relative use and bleeding/clotting outcomes were assessed based on venous thromboembolic (VTE) prophylactic agents utilized, with categories defined as (1) warfarin, heparin, or direct oral anticoagulant (DOAC) or (2) aspirin/no prescriptions found. ResultsOf 104,258 TSA patients, FVL was identified for 283 (0.27%). Based on matching, 1,081 patients without FVL and 272 patients with FVL were selected. Multivariable analyses demonstrated that those with FVL displayed independently greater odds ratios (ORs) of deep vein thrombosis (DVT, OR=9.50, p<0.0001), pulmonary embolism (PE, OR = 10.10, p<0.0001), and pneumonia (OR=2.43, p=0.0019). Further, these events contributed to the increased odds of aggregated minor (OR = 1.95, p=0.0001), serious (OR=6.38, p<0.0001), and all (OR=3.51, p<0.0001) adverse events. All other individual 90-day adverse events, as well as 5-year revision rates, were not different between the study groups. When compared to matched patients without FVL on the same anticoagulant agents, FVL patients on warfarin/heparin/DOAC agents demonstrated lesser odds of 90-day DVT and PE (OR=4.25, p<0.0001 and OR=2.54, p=0.0065) than those on aspirin/no prescriptions found (OR=7.64 and OR=21.95, p<0.0001 for both). Interestingly, those on VTE prophylactic agents were not at greater odds of bleeding complications (hematoma or transfusion). Discussion and ConclusionsTSA patients with FVL present a difficult challenge to shoulder reconstruction surgeons. The current study highlights the strong risk of VTE that was reduced but still significantly elevated for those with stronger classes of VTE chemoprophylaxis. Acknowledging this risk is important for surgical planning and patient counseling, but also noted was the reassurance of similar 5-year revision rates for those with versus without FVL.

Total shoulder arthroplasty in patients with a history of cerebrovascular accident: a matched case–control study

BackgroundWith increasing survivorship following cerebrovascular accidents (CVAs), more patients with a history of CVA are undergoing total shoulder arthroplasty (TSA). The purpose of this study is to determine the impact of prior CVA on the perioperative outcomes following TSA. MethodsThe Nationwide Readmissions Database was queried from 2010 to 2019 to identify all patients with a history of CVA undergoing TSA. Eight hundred seventeen cases were identified and case matched on a 1:2 ratio for age, sex, obesity status, and year of procedure. Patient demographic characteristics were collected and analyzed for differences between the 2 groups. Data on length of stay, 180-day complications, 180-day readmissions, and 180-day mortality were collected and analyzed for differences between the 2 groups. ResultsEight hundred seventeen cases of patients with a history of CVA were matched with 1634 patients without a history of CVA undergoing TSA. The average age was 71. Fifty six percent of patients were female, and 23% of patients were obese. Patients with CVA had higher incidence of tobacco use (P < .001), deficiency anemia (P < .001), electrolyte disorders (P < .001), paralysis (P < .001), coagulopathy (P < .001), heart valve disorders (P < .001), history of myocardial infarction (P < .001), and higher rates of chronic diseases, such as hypertension (P < .001), diabetes (P < .001), liver disease (P < .001), congestive heart failure (P < .001), renal failure (P < .001), and peripheral vascular disease (P < .001). Patients with a history of CVA had higher rates of complications, readmissions, and revisions within 180 days (P < .001). One hundred eighty–day mortality was similar between the 2 groups. The average length of stay was 3.2 days in patients with a history of CVA compared to 1.4 days in those without a history of CVA (P < .001). ConclusionPatients with a history of CVA have a higher rate of medical comorbidities than those without. These patients have higher rates of complications within 180 days of procedure, 180-day readmissions, and 180-day revisions. One hundred eighty–day mortality was similar between the 2 groups. Surgeons should take care to ensure thorough preoperative optimization and risk discussions to try and minimize postoperative adverse outcomes.

Judicious use of corticosteroid injections prior to shoulder arthroplasty does not compromise outcomes at a minimum of 2 years following surgery

BackgroundThe use of total shoulder arthroplasty is continuing to rise with its expanding indications. For patients with chronic conditions, such as glenohumeral arthritis and rotator cuff arthropathy, nonoperative treatment is typically done prior to arthroplasty and often includes corticosteroid injections. Recent studies in the shoulder arthroplasty literature as well as applied from the hip and knee literature have focused on the risk of periprosthetic infection. Literature is lacking as to whether the judicious use of corticosteroids in the year prior to arthroplasty influences patient reported outcomes. The purpose of this study was to determine if preoperative corticosteroid injections prior to shoulder arthroplasty affected two-year patient-reported outcomes. MethodsRetrospective review of anatomic and reverse total shoulder arthroplasty patients (n=230) was performed at a single institution including multiple surgeons. Patients were included if they had preoperative and a minimum of 2-year postoperative patient reported outcomes, including: ASES, VAS, SANE, VR12-PCS, and VR12-MCS. Patients were included in the injection group if they had received an injection, either glenohumeral or subacromial, within twelve months prior to arthroplasty (inject=134). Subgroup analysis included anatomic (TSA=92) and reverse total shoulder arthroplasty (RSA=138) as well as those with no injection within 12 months prior to surgery. An ANOVA was used to compare outcomes between patients who received an injection and those who did not prior to TSA and RSA. ResultsThere were 230 patients included with 134 patients in the injection group and 96 in the no injection group. Patients who received an injection in the year prior to arthroplasty displayed a significantly higher ASES [82 (16.23SD) vs. 76 (19.43SD), p < .01] and SANE [70 (24.49SD) vs. 63 (29.22SD), p < .01] scores versus those who had not received injection. There was no difference when comparing preoperative injection versus no injection in patients undergoing TSA. Those patients undergoing RSA displayed significantly higher ASES scores (p<.01). There were no significant differences in VAS, VR12-PCS, and VR12-MCS among any analysis (P>0.05), and the MCID in ASES was not different between groups (p.09). ConclusionCorticosteroid injections within twelve months prior to anatomic and reverse total shoulder arthroplasty do not compromise patient reported outcomes during a minimum of two-year follow-up. Although more complications occurred in the injection group, it did not reach statistical significance and warrants further study in a larger population.

Higher complication rates following primary total shoulder arthroplasty in patients presenting from areas of higher social deprivation.

The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years. Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index. A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05). Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications.

Risk factors for rotator cuff tears and aseptic glenoid loosening after anatomic total shoulder arthroplasty

BackgroundThe purpose of this study is to retrospectively analyze all primary anatomic total shoulder arthroplasty (aTSA) patients within a multicenter international database of a single prosthesis to identify risk factors for patients with rotator cuff tear (RCT) and aseptic glenoid loosening. MethodsTo investigate the risk factors for RCT and aseptic glenoid loosening, we retrospectively analyzed all aTSA patients with 2-year minimum follow-up from a multicenter international database of a single platform shoulder system, only excluding patients with a history of revision arthroplasty, infections, and humeral fractures. A univariate/multivariate analysis was conducted to compare primary aTSA patients who had report of: 1) a RCT and/or subscapularis failure and 2) aseptic glenoid loosening/cage glenoid dissociations, to identify the differences in (i) intrinsic patient demographics and comorbidities and (ii) implant and operative parameters. Finally, to adapt our statistical analysis for prospective identification of patients most at-risk for RCT and aseptic glenoid loosening, we stratified the dataset by multiple risk factor combinations and calculated the odds ratio (OR) to determine the impact of accumulating risk factors on the incidence rate of each complication. Results122 aTSA shoulders had a RCT for a rate of 3.2% and 123 aTSA shoulders had aseptic glenoid loosening for a rate of 3.3%. The multivariate analysis identified that aTSA patients with RCT were more likely to have previous shoulder surgery (P < .001) and small size glenoids (P = .002). Additionally, the multivariate analysis identified that aTSA patients with aseptic glenoid loosening were more likely to be younger (≤62 years at the time of surgery, P = .001), have small size glenoids (P = .033) and have a nonhybrid glenoids (P < .001). Stratifying patients with multiple risk factors identified multiple aTSA cohorts with ORs >2 for RCT or aseptic glenoid loosening. DiscussionThis analysis of 2699 primary aTSA identified risk factors for the two most common postoperative complications: RCTs and aseptic glenoid loosening. Using these risk factors, we calculated ORs for patient cohorts with multiple risk factors to identify the patients with the greatest risk for each complication. This information is useful to guide the surgeon in their preoperative counseling and potentially mitigate the occurrence of these complications, by indicating patients with these risk-factors for alternative treatment strategies, like rTSA, instead of aTSA.

External Rotation Strength After TSA in Osteoarthritic Shoulders with Eccentric Deformity Is Not Impacted by Posterior Rotator Cuff Deficiency.

Patients with persistent glenohumeral osteoarthritis symptoms despite nonoperative management may pursue anatomic total shoulder arthroplasty (TSA). TSA revision rates are higher in patients with preoperative eccentric (asymmetric posterior erosion) compared with concentric (symmetric) glenoid deformity. If posterior rotator cuff deficiency demonstrated preoperatively in patients with eccentric deformity persists after TSA, it may manifest as relative weakness in external compared with internal rotation secondary to deficient activity of the shoulder external rotator muscles. Persistent posterior rotator cuff deficiency is hypothesized to contribute to TSA failures. However, it remains unknown whether rotational strength is impaired after TSA in patients with eccentric deformity. Our goal was to determine if patients with eccentric deformity exhibit relative external rotation weakness that may be explained by posterior rotator cuff deficiency after TSA. Patients who were >1 year after TSA for primary glenohumeral osteoarthritis and had had preoperative eccentric or concentric deformity were prospectively recruited. Torque was measured and electromyography was performed during maximal isometric contractions in 26 three-dimensional direction combinations. Relative strength in opposing directions (strength balance) and muscle activity of 6 shoulder rotators were compared between groups. The internal (+) and external (-) rotation component of strength balance did not differ in patients with eccentric (mean internal-external rotation component of strength balance: -7.6% ± 7.4%) compared with concentric deformity (-10.3% ± 6.8%) (mean difference: 2.7% [95% confidence interval (CI), -1.3% to 6.7%]; p = 0.59), suggesting no relative external rotation weakness. Infraspinatus activity was reduced in patients with eccentric (43.9% ± 10.4% of maximum voluntary contraction [MVC]) compared with concentric (51.3% ± 10.4% of MVC) deformity (mean difference: -7.4% [95% CI, -13.4% to -1.4%] of MVC; p = 0.04). A relative external rotation strength deficit following TSA was not found, despite evidence of reduced infraspinatus activity, in the eccentric-deformity group. Reduced infraspinatus activity suggests that posterior rotator cuff deficiencies may persist following TSA in patients with eccentric deformities. Longitudinal study is necessary to evaluate muscle imbalance as a contributor to higher TSA failure rates. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinically significant outcome thresholds and rates of achievement by shoulder arthroplasty type and preoperative diagnosis

BackgroundClinically significant outcome (CSO) benchmarks have been previously established for shoulder arthroplasty by assimilating preoperative diagnoses and arthroplasty types. The purpose of this study was to establish unique CSO thresholds and compare the time-to-achievement of these for reverse shoulder arthroplasty (RSA) for osteoarthritis (GHOA), RSA for rotator cuff arthropathy (RCA), and total shoulder arthroplasty (TSA) for GHOA. Materials & MethodsConsecutive patients who underwent elective RSA for GHOA, TSA for GHOA, or RSA for RCA between February 2015 and May 2020, with 2-year minimum follow-up, were retrospectively identified from a prospectively maintained single surgeon registry. The American Shoulder and Elbow Surgeons (ASES) score was administered preoperatively and postoperatively at 2-week, 6-week, 3-month, 6-month, 1-year, and 2-year timepoints. Satisfaction and subjective overall improvement anchor questionnaires were administered at the time of final follow-up. Distribution-based methods was used to calculate the Minimal Clinically Important Difference (MCID), and anchor-based methods were used to calculate the Substantial Clinical Benefit (SCB) and the Patient Acceptable Symptom State (PASS) for each patient group. Median time to achievement, individual incidence of achievement at each time point, and cumulative incidence of achievement calculated using Kaplan-Meier survival curve analysis with interval censoring were compared between groups for each CSO. Cox-regression analyses were also performed to determine which patient factors were significantly associated with early or delayed achievement of CSOs. ResultsThere were 471 patients eligible for study analysis: 276 RSA for GHOA, 107 TSA for GHOA, 88 RSA for RCA. The calculated MCID, SCB, and PASS scores differed for each group. There were no significant differences in median time to achievement of any CSO between groups. Log-rank testing revealed that cumulative achievements significantly differed between groups for MCID (P = 0.014) but not for SCB (P = 0.053) or PASS (P = 0.620). On cox regression analysis, TSA patients had earlier achievement of SCB, whereas TSA and RSA for GHOA patients had earlier achievement of MCID. At two-years, a significantly higher percentage of RSA for GHOA patients achieved MCID and SCB compared to RSA for RCA (MCID:100%, 95.5%, P = 0.003, SCB:94.6%, 86.4%, P = 0.036). ConclusionCalculated CSO thresholds differ according to preoperative diagnosis and shoulder arthroplasty type. Patients undergoing TSA and RSA for GHOA achieve CSOs earlier than RSA for RCA patients, and a significantly higher percentage of RSA for GHOA patients achieve CSOs by 2 years compared to RSA for RCA patients.

Is preoperative 3D planning reliable for predicting postoperative clinical differences in range of motion between two stem designs in reverse shoulder arthroplasty

Primary gleno-humeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue since they may be responsible for a deterioration in long term clinical and radiological outcomes. The aim of this study was to perform a CT-analysis of patients who underwent Total Shoulder Arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3- or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively. We performed a retrospective, single-center study including 62 TSA patients with a pre-operative PHS of the glenohumeral joint (31 men, 31 women, 70±9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases) or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT-scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up the CT-images were reconstructed in a scapular plan. A PHS index of >65% defined persistence. The revision free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ=0.58) and strong at final follow-up (ρ=0.73). Postoperative CT-scans on average showed a surgical correction of PHS compared to preoperatively (79% vs 65% respectively, p<0.05) and retroversion (20° vs 10° respectively, p<0.05). At final follow-up, 25/62 patients had a persistence in 2D model and 41/62 in 2D corrected model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs 59%, p<0.05). Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance.

Total shoulder arthroplasty for primary glenohumeral osteoarthritis: does posterior humeral subluxation persist after correction of the glenoid version at 5 years minimum?

Primary glenohumeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue because they may be responsible for a deterioration in long-term clinical and radiologic outcomes. The aim of this study was to perform a computed tomographic (CT) analysis of patients who underwent total shoulder arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3-, or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively. We performed a retrospective, single-center study including 62 TSA patients with a preoperative PHS of the glenohumeral joint (31 men, 31 women, 70±9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases), or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up, the CT images were reconstructed in the scapular plane. A PHS index >65% defined persistence. The revision-free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ=0.58) and strong at final follow-up (ρ=0.73). Postoperative CT scans on average showed a surgical correction of PHS compared to preoperatively (79% vs. 65% respectively, P<.05) and retroversion (20° vs. 10° respectively, P<.05). At final follow-up, 25 of 62 patients had a persistence in the 2-dimensional (2D) model and 41 of 62 in the corrected 2D model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs. 59%, P<.05). Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow-up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance.

The functional and radiographic outcomes of nonaugmented anatomic total shoulder arthroplasty in patients with Walch B3 glenoid deformities

BackgroundAchieving a durable result with anatomic total shoulder arthroplasty (aTSA) in shoulders with glenoid retroversion deformities, specifically Walch B3 glenoid deformities, can be a challenge. In this retrospective series, we report the mid-term clinical and radiographic follow-up of aTSA in patients with B3 glenoids with nonaugmented polyethylene implants. MethodsPatients who had undergone aTSA at a single institution by fellowship-trained surgeons between January 2013 and August 2017 with a preoperative computed tomography scan demonstrating a B3 glenoid were identified. All patients underwent aTSA with a lesser tuberosity osteotomy and a nonaugmented all-polyethylene glenoid. Eccentric reaming was performed to achieve near complete seating of the glenoid component with less emphasis on retroversion. Patients were contacted to complete patient-reported outcome scores and radiographic review. Immediate postoperative radiographs were assessed for posterior humeral subluxation measured relative to the axis of the glenoid component and implant seating. Final radiographs were reviewed for glenoid loosening using Lazarus rating and change in posterior humeral subluxation. ResultsTwenty-five subjects met inclusion criteria and were available for follow-up. The cohort had a mean age of 65.1 (range: 55-81) years and consisted of 6 females (24%; 6/25). These patients had a mean follow-up of 6.2 years (range: 3.9-8.4). American Shoulder and Elbow Surgeons improved from 38.2 ± 13.2 to 90.0 ± 16.9 (P < .001). Eighty percent (20/25) of these patients were available for radiographic review and had an average Lazarus grade of 1.9 (range: 0-5). There was no change in mean posterior glenohumeral subluxation (4.6% vs. 2.3%; P = .15) relative to their immediate postoperative films. The 12 patients with a Lazarus grade less than 2 had a greater Western Ontario Osteoarthritis of the Shoulder Index (96.9 ± 1.3 vs. 67.4 ± 12.8; P < .001), American Shoulder and Elbow Surgeons (94.0 ± 5 vs. 76.3 ± 16; P = .03), Single Assessment Numeric Evaluation (88.2 ± 8.7% vs. 66.7 ± 15%; P = .02), and satisfaction (98.5 ± 0.7% vs. 79.9 ± 13.2%; P = .002) compared to the 8 patients with a Lazarus grade more than or equal to 2. These 8 patients were more likely to have had severe preoperative biplanar deformity (retroversion >25° and inclination >10°) than the 12 without early glenoid radiolucency (63% [5/8] vs. 17%; P = .04). ConclusionAt mid-term follow-up, aTSA with standard implants for B3 glenoid deformity provides a reliable treatment option for restoration of function and improvement in pain. Mid-term radiographic review demonstrated development of early glenoid component lucencies in shoulders with severe biplanar deformities with associated deterioration in their clinical function. Long-term follow-up is needed to understand the clinical and radiographic outcome durability after aTSA in the setting of a B3 glenoid.

Clinical outcomes of anatomical versus reverse total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and limited forward elevation.

Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE. This was a retrospective review of a single institution's prospectively collected shoulder arthroplasty database for TSAs undertaken between 2007 and 2020. A total of 344 aTSAs and 163 rTSAs, which were performed in patients with OA and an intact rotator cuff with a minimum follow-up of two years, were included. Using the definition of preoperative stiffness as passive FE ≤ 105°, three cohorts were matched 1:1 by age, sex, and follow-up: stiff aTSAs (85) to non-stiff aTSAs (85); stiff rTSAs (74) to non-stiff rTSAs (74); and stiff rTSAs (64) to stiff aTSAs (64). We the compared ROMs, outcome scores, and complication and revision rates. Compared with non-stiff aTSAs, stiff aTSAs had poorer passive FE and active external rotation (ER), whereas there were no significant postoperative differences between stiff rTSAs and non-stiff rTSAs. There were no significant differences in preoperative function when comparing stiff aTSAs with stiff rTSAs. However, stiff rTSAs had significantly greater postoperative active and passive FE (p = 0.001 and 0.004, respectively), and active abduction (p = 0.001) compared with stiff aTSAs. The outcome scores were significantly more favourable in stiff rTSAs for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, and the Constant score, compared with stiff aTSAs. When comparing the proportion of stiff aTSAs versus stiff rTSAs that exceeded the minimal clinically important difference and substantial clinical benefit, stiff rTSAs achieved both at greater rates for all measurements except active ER. The complication rate did not significantly differ between stiff aTSAs and stiff rTSAs, but there was a significantly higher rate of revision surgery in stiff aTSAs (p = 0.007). Postoperative overhead ROM, outcome scores, and rates of revision surgery favour the use of a rTSA rather than aTSA in patients with glenohumeral OA, an intact rotator cuff and limited FE, with similar rotational ROM in these two groups.

Patients 75 years or older with primary glenohumeral arthritis and an intact rotator cuff show similar clinical improvement after reverse or anatomic total shoulder arthroplasty

BackgroundThe optimal management of primary glenohumeral arthritis (GHOA) in the elderly is an ongoing topic of debate. The purpose of this study was to compare functional outcomes and complications in patients aged 75 years or older treated with anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) for primary GHOA with an intact rotator cuff. MethodsA retrospective study was performed on a prospectively maintained database which was queried for patients 75 years of age or older who underwent TSA or RSA for primary GHOA with an intact rotator cuff at a single institution between 2012 and 2021 with minimum 2-year follow-up. Patient-reported outcomes (PROs), including Visual Analog Scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES), and Subjective Shoulder Value (SSV), as well as active range of motion including forward flexion (FF), external rotation (ER), internal rotation (IR), were collected pre- and postoperatively. Complications, reoperations, and satisfaction were also recorded. The percentage of patients achieving clinically significant improvement was evaluated with the minimally clinical important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for each PRO. ResultsOne-hundred and four patients were available for analysis, including 67 TSA patients and 37 RSAs with a mean follow-up of 39.4 months. Preoperative baseline characteristics, PROs, and ROM were similar between groups. RSA was more commonly performed for eccentric glenoid wear (Walch B2/B3, 62% vs 22%; p < 0.001). While clinical outcomes improved comparably in both groups, the TSA cohort showed significantly greater improvement in ER (36° vs 26°; p=0.013). Both cohorts had low revision (3% for TSA vs 0% for RSA) and complication (7% for TSA vs 5% for RSA; p=0.677) rates. Satisfaction was similar in both groups (93% for TSA vs 92% for RSA; p=0.900). Clinically significant improvement was comparable between groups based on the ASES score (MCID, 93% for TSA vs 100% for RSA; SCB, 82% vs 95%; PASS, 67% vs 78%; p > 0.05). ConclusionIn this retrospective small sample size comparison study, TSA and RSA provide similar short-term clinical outcomes for patients 75 years and older with primary GHOA and an intact rotator cuff. Complication and revision rates are comparably low at short-term follow-up. Our data suggests that advanced age alone should not be used as a decision-making tool for TSA versus RSA in the setting of primary GHOA with an intact rotator cuff.