Western Ontario Osteoarthritis Of The Shoulder Research Articles

Glenoid wear and migration pattern of a humeral head resurfacing implant: a prospective study using radio stereometric analysis

Background and purposeThe humeral head resurfacing arthroplasty (HHR) is normally used as a hemi shoulder arthroplasty and has been in use for the treatment of Gleno-Humeral osteoarthritis of the shoulder (OA) for more than 30 years. Some studies, however, shows that anatomical total shoulder arthroplasty provides better improvement in function than a HHR for patients with OA. Reasons for this may be a progressive glenoid wear (GW) or loosening of the HHR. We therefore wanted to investigate the migration pattern (MP) of the HHR and also GW by using Radio Stereometric Analysis (RSA). Patients and methods21 patients (21 shoulders) with OA and a mean age of 64 years were enrolled in the study. They all received the Copeland humeral resurfacing head and were followed for 2 years with RSA. We evaluated the clinical outcome at 2 years with Western Ontario Osteoarthritis of the Shoulder (WOOS), EuroQol 5 dimension 3L (EQ-5D) and Constant Shoulder Score (CSS). In addition, we assessed data on WOOS and revisions until 5 years follow-up by using the local clinic data within the Swedish Shoulder Arthroplasty Register. ResultsAfter an initial migration at two months the implants were stable in relation to the humerus with no statistically significant difference between the 2 months and the 2 years value (p=0.23). The GW continued to increase during the study period with an initial migration of mean 2.3 mm and at 2 years 3.5 mm with a statistically difference between the 6 months and 2 years value (p=0.046). The WOOS, EQ-5D and CSS were all improved at 2 years compared to the preoperative values. We found a weak correlation between GW at 2 years and the WOOS score at 2 and 5 years, but these did not reach statistical significance. There were 4 revisions within 5 years after the primary operation, all due to pain. ConclusionThe marker-free RSA can be used in clinical studies for assessing migration in HHR implants and was also for the first time used to measure GW. The Copeland HHR seems to obtain a secure fixation in the humerus but shows continuous GW up to two years.

Anatomic total shoulder arthroplasty using hybrid glenoid fixation with a porous-coated titanium post. Two- to ten-year follow-up of 256 cases with primary glenohumeral osteoarthritis

BackgroundAnatomic total shoulder arthroplasty is one of the recommended surgical treatments for severe glenohumeral osteoarthritis, providing good pain relief and function. Aseptic loosening of the glenoid component, however, is a major cause for revision. Hybrid components have been introduced, combining traditional cemented fixation with porous titanium bone ingrowth to improve fixation. The purpose of this study was to report our midterm to longterm experience using such a component, including clinical outcomes and implant survival. MethodsWe reviewed all patients who were operated for primary osteoarthritis during the period 2011-19, leaving a minimum of 2-year follow-up. The severity of the osteoarthritis was graded using Samilson-Prieto score, while glenoid morphology was graded using the modified Walch classification. Clinical outcomes included Western Ontario Osteoarthritis of the Shoulder (WOOS) index, EQ-5D-5L, and Constant-Murley score. Postoperative radiographs were analyzed for radiolucent lines. Patient records were studied for complications including revisions. Supplementary data for revision and outcome were obtained from the Danish Shoulder Arthroplasty Registry. Kaplan-Meier estimates for implant survival were calculated. ResultsA total of 256 arthroplasties in 224 patients were included (mean age: 69 years ± 9 years, 149 females). 81% of cases were graded radiographically as severe osteoarthritis, according to Samilson-Prieto. Walch type B1 was most commonly followed by B2 (29% and 28% respectively). The mean follow-up time was 49 months (range 24-127). The response rate for patient reported outcomes was 91%. The median WOOS index was 94% (81%-99%), the median EQ-5D-5L was 0.87 (0.69-0.95), and the mean Constant-Murley score was 75 (SD 17.7). 13 cases (6%) had a WOOS index below 50%. 8.2% had complications related to surgery. A radiolucent line had developed around the central post in six cases and at the bone-cement interface in three cases at follow-up. Six cases had been revised (2.3%); three due to aseptic loosening of the glenoid. The 10-year survival estimate was 95.6 % (95% CI: 87.9%-98.5%). ConclusionAnatomic total shoulder arthroplasty with hybrid glenoid fixation provides excellent clinical outcome with a low complication rate in patients, with primary glenohumeral osteoarthritis. The 10-year survival rate is high and comparable to that reported for the best- performing all-polyethylene components. Longer observation is needed to see if hybrid fixation will outperform standard all-cemented components.

Validity, reliability and responsiveness of a French translation of the Western Ontario Osteoarthritis of the Shoulder index (WOOS)

IntroductionWhile several general questionnaires can be used to evaluate shoulder conditions, very few tools specifically evaluate the impact of shoulder osteoarthritis. The Western Ontario Osteoarthritis of the Shoulder index (WOOS) is a patient-reported outcome measure with excellent psychometric properties intended for patients suffering from shoulder osteoarthritis. Unfortunately, there is no validated French version of this questionnaire. ObjectiveProduce a validated French version of the WOOS that is suitable for the Francophone populations of Europe and North America. Material and methodsA validated protocol was used to create a French version of the WOOS (WOOS-Fr). Included were patients whose first language was French, who could read French and who had shoulder osteoarthritis destined for treatment (surgical treatment=arthroplasty). The WOOS-Fr was compared to the Disability of the Arm, Shoulder and Hand–French translation (F-QuickDASH-D/S) to assess its validity. Reliability and responsiveness were also analyzed. ResultsA French version of the WOOS (WOOS-Fr) was accepted by a multinational committee. The WOOS-Fr was validated in 71 French-speaking subjects. A strong positive correlation was found between the WOOS-Fr and the F-QuickDASH-D/S during the initial evaluation. The intra-class correlation (ICC) of the total WOOS-Fr score indicated good reliability between the initial WOOS and the 1-week WOOS (ICC: 0.84; 95% CI: [0.767; 0.896]; p-value: <0.001) in 57 patients. The responsiveness between the initial WOOS-Fr and at 1 year postoperative was high in the 36 operated patients (standardized mean response of 1.95). DiscussionA French translation of the WOOS questionnaire was created and validated for use in French-speaking populations. This questionnaire will make it easier to evaluate the psychometric results of patients with shoulder osteoarthritis in Francophone countries. Level of evidenceIII; multicenter cohort study.

BIO-RSA vs metal augmented baseplate in shoulder osteoarthritis with multiplanar glenoid deformity: a comparative study of radiographic findings and patient outcomes.

Reverse shoulder arthroplasty (RSA) requiring extensive reaming to address severe glenoid bone loss increases the risk of glenoid medialization and baseplate failure. We hypothesized that i) metal augmented baseplate prevents the medialization of the joint line and preserves glenoid bone stock similarly to BIO-RSA; ii) bone graft viability and healing in BIO-RSA patients become compromised over time. Eighty-one patients (83 shoulders) underwent glenoid lateralization with bone (BIO-RSA group, 44) or metal augmented baseplate (MIO-RSA group, 39) and a minimum follow-up of 24 months were included. The orientation and direction of glenoid erosion was identified and recorded using computerized 3D planning. Active range of motion, and the Western Ontario Osteoarthritis of the Shoulder (WOOS) index were assessed before arthroplasty and at the last follow-up visits. Radiographic changes around the glenoid and humeral components were assessed. Healing and thickness of bone graft were evaluated by predefined criteria. Postoperative global glenoid inclination (β angle) and retroversion were also measured. Delta scores of active anterior elevation were higher in the MIO-RSA group (p= 0.027). The differences in the other planes of shoulder motion and in WOOS index scores between the groups were not significant. Preoperative glenoid retroversion was higher in BIO-RSA patients, glenoid inclination was similar in both groups. Type B2 and B3 glenoids had a posterior-central (91%) and posterior-superior (90%) erosion with a mean posterior humeral head subluxation of 76% and 78%, respectively. The direction of erosion in Type E2 and E3 glenoids was posterior-superior, with a mean posterior humeral head subluxation of 74%. The rate of high position of the glenosphere was higher in the BIO-RSA group (p = 0.022), while the values of β angle and postoperative retroversion were similar in the two groups. BIO-RSA group showed radiolucent lines < 2mm around the bone graft in 16 patients (36.4%) and decreased thickness in 15 (34.1%). Incomplete baseplate seating was found in 4 MIO-RSA patients (10%). We found higher rate of humerus condensation lines in MIO-RSA patients (p= 0.01) and higher rate of cortical thinning and tuberosity resorption in the BIO-RSA group (p= 0.027 and p = 0.004, respectively). Metal augmented glenoid is a suitable alternative to BIO-RSA to preserve bone and prevent the medialization of the joint line in arthritic glenoid with multiplanar glenoid deformity. Bone and metal augmentation provided satisfactory clinical outcomes. Bone graft resorption in BIO-RSA patient raise concern about the risk of baseplate loosening and requires further long term studies.

Can the Single Assessment Numeric Evaluation (SANE) be used as a stand-alone outcome instrument in patients undergoing total shoulder arthroplasty?

There is no consensus as to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes for either clinical or research purposes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. To date, the Single Assessment Numeric Evaluation (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis of this study was that the SANE would correlate with and be equal or superior in responsiveness to other outcome measures that have been used in a stand-alone fashion in patients undergoing total shoulder arthroplasty (American Shoulder and Elbow Surgeons [ASES], Western Ontario Osteoarthritis of the Shoulder [WOOS], and Simple Shoulder Test [SST] scores). In addition, it was hypothesized that the SANE would be more relevant to each patient than the ASES assessment, further supporting the use of the SANE as a stand-alone shoulder-specific outcome measure. A retrospective review of a database of patients undergoing total shoulder arthroplasty was performed, in which the SANE score was recorded simultaneously with the ASES, WOOS, and/or SST score. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine whether correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean and the effect size of all scores.The relevance of the SANE and ASES assessments was examined using the scores of 150 consecutive patients to determine the number of questions on each assessment that were not answered. Correlation was excellent for the SANE score and the ASES score (n=1447, r=0.82, P<.0001), WOOS score (n=1514, r=0.83, P<.0001), and SST score (n=1095, r=0.81, P<.0001). The correlation of preoperative scores was moderate and that of postoperative scores was strong-moderate when the SANE score was compared with all 3 other scores. All scores were highly responsive, with standardized response mean values of 2.2 for the SANE score, 2.3 for the ASES score, 1.4 for the WOOS score, and 1.6 for the SST score. The effect size of the SANE score was 2.9; ASES score, 2.9; WOOS score, 2.9; and SST score, 2.3. One hundred percent of the SANE questions were answered completely compared with 61% of the ASES questions (P<.0001). In patients undergoing total shoulder arthroplasty, the SANE score highly correlated with the WOOS, ASES, and SST scores, which have been used as stand-alone shoulder-specific outcome measures. The SANE score may provide the same information as the WOOS, ASES, and SST score regarding outcomes with a significant reduction in responder burden. It is logical that the SANE can be used as a stand-alone instrument for patients undergoing total shoulder arthroplasty.

Are progressive shoulder exercises feasible in patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy?

BackgroundLittle is known about the feasibility of progressive shoulder exercises (PSE) for patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA). The aim of this study was to investigate whether 12 weeks of PSE is feasible in patients with glenohumeral OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program.MethodsTwenty patients were included. Eighteen patients (11 women, 15 with OA), mean age 70 years (range 57–80), performed 12 weeks of PSE with one weekly physiotherapist-supervised and two weekly home-based sessions. Feasibility was measured by dropout rate, adverse events, pain, and adherence to PSE. At baseline and end of intervention, patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Data to assess feasibility were analyzed using descriptive statistics.ResultsTwo patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (≥ 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions with no numeric rating scale (NRS) score over five for any exercise. WOOS improved with a mean of 23 points (95% CI 13;33), and DASH improved with a mean of 13 points (95% CI 6;19).ConclusionAdherence to PSE was high and dropout rates were low. PSE is feasible, safe and may relieve shoulder pain, improve function and ROM in patients with glenohumeral OA or CTA. The patient-experienced gains after PSE seem clinically relevant and should be compared to arthroplasty surgery in a RCT setting.Trial registrationAccording to Danish law, this study did not need an approval by the Central Denmark Region Committee on Health Research Ethics. Approval from The Danish Data Protection Agency (journal number 1-16-02-15-20) was obtained.

Short-term survival and patient-reported outcome of total stemless shoulder arthroplasty for osteoarthritis are similar to that of stemmed total shoulder arthroplasty: a study from the Danish Shoulder Arthroplasty Registry

BackgroundThe use of stemless total shoulder arthroplasty (TSA) for osteoarthritis increases, but there is a paucity on its safety and efficacy and how it performs in comparison with stemmed TSA. The aim was to compare the 5-year cumulative survival rate and patient-reported outcome after stemless and stemmed TSA for osteoarthritis.MethodsWe included all stemmed (n = 1197) and stemless (n = 253) TSA for osteoarthritis reported to the Danish shoulder arthroplasty registry from January 1, 2014, to December 31, 2018.ResultsSix (2.4%) stemless and 24 (2%) stemmed TSA were revised. The 5-year cumulative implant survival rates were 0.96 for stemless TSA and 0.97 for stemmed TSA. In the multivariate Cox regression model, the hazard ratio for revision was 1.1 (95% confidence interval, 0.5-2.6) for stemless TSA compared with stemmed TSA. The mean Western Ontario Osteoarthritis of the Shoulder (WOOS) index was 82 (standard deviation = 21) for stemmed and 86 (standard deviation = 19) for stemless TSA. The stemless TSA had a statistically significant better WOOS compared with stemmed TSA, but the difference of 6.2 (95% confidence interval, 1.4-10.4) was not regarded as clinically relevant. There was no difference in WOOS between the Nano and the Eclipse systems.DiscussionWe found a good 5-year cumulative implant survival rate of stemless TSA, which was comparable with stemmed TSA. Although the stemless TSA had a statistically significant better patient-reported outcome compared with stemmed TSA, the difference was not clinically relevant. Sparing the humeral shaft canal for later revision could be an argument for using stemless TSA instead of stemmed TSA.

Previous surgery for instability is a risk factor for a worse patient-reported outcome after anatomical shoulder arthroplasty for osteoarthritis: a Danish nationwide cohort study of 3,743 arthroplasties.

Background and purposeAlthough most patients have good outcomes after shoulder arthroplasty for osteoarthritis, certain risk factors may lead to disappointing outcomes. We assessed risk factors for a worse outcome after anatomical shoulder arthroplasty for osteoarthritis. Our hypothesis was that previous surgery for instability would be a risk factor for a worse outcome independent of age, sex, and arthroplasty type.Patients and methodsWe included arthroplasties reported to the Danish Shoulder Arthroplasty Registry between 2006 and 2018 (n = 3,743). The Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 1 year was used as outcome. The total score was converted to a percentage of a maximum score. The general linear model was used to analyze differences in WOOS. Age, sex, arthroplasty type, and previous surgery were included in the multivariate model. Estimates were given with 95% confidence intervals (CI).ResultsThe mean WOOS score was 78 for patients with no previous surgery and 55 for patients with surgery for instability. The mean difference was –16 (CI –10 to –22) in the multivariate model. Hemiarthroplasty had a worse outcome compared with total shoulder arthroplasty and young patients had a worse outcome compared with older patients. The mean differences in the multivariate model were –12 (CI –10 to –14) and –11 (CI –8 to –14) respectively.InterpretationPatients with previous surgery for instability had worse results independent of age, sex, and arthroplasty type and should be informed about their individual risk of a worse outcome.

A 135° short inlay humeral stem leads to comparable radiographic and clinical outcomes compared with a standard-length stem for reverse shoulder arthroplasty.

BackgroundHumeral stem length in reverse total shoulder arthroplasty (RTSA) has decreased in recent years in an attempt to preserve more bone and facilitate stem removal in the revision setting. The purpose of this study was to compare the clinical and radiographic outcomes of a short- to standard-length stem RTSA. The authors hypothesized that there would be no difference in radiographic or clinical outcomes at short-term follow-up.MethodsPatients who underwent RTSA using a press-fit standard- or short-length humeral component with a consistent geometry (Univers Revers, or Revers Apex; Arthrex, Inc., Naples, FL, USA) were evaluated in a multicenter retrospective review. The minimum clinical follow-up was 2 years. Immediate postoperative radiographs were used to assess initial alignment and filling ratios. In addition, radiographs at 2 years were evaluated for signs of stress shielding and/or loosening. Clinical outcome scores and range of motion were evaluated at the final follow-up and compared between groups.ResultsA total of 220 patients with short-stem RTSA and 357 patients with standard-length stem RTSA were analyzed. There was no difference in baseline function between short- and standard-length stem patients. Patients in the short stem group had higher postoperative American Shoulder and Elbow Surgeons (84.6 vs. 80.8; P = .014) and Western Ontario Osteoarthritis of the Shoulder (86.5 vs. 82.7; P = .025). Patients in the short stem group also had greater postoperative active forward flexion (139° vs. 132°; P = .003) and internal rotation with the arm at 90° of abduction (43° vs. 32°; P < .001) than patients in the standard-length group. Radiographically, there was a higher metaphyseal (P = .049) and diaphyseal (P < .001) fill ratio in the short stem group, although there was no difference in postoperative alignment, radiographic signs of loosening, or revision for loosening between groups (all P > .05).ConclusionA short inlay stem leads to comparable radiographic findings and revision-free survival compared with a standard-length stem when placed with a press-fit technique for RTSA. Clinical outcomes are also equivalent or slightly improved with a short stem compared with a standard-length stem.

Good long-term patient-reported outcome after shoulder arthroplasty for cuff tear arthropathy

BackgroundThe use of the reverse shoulder arthroplasty (RSA) for cuff tear arthropathy (CTA) has increased within the last decades, but there is still limited information about the long-term outcome and how it performs in comparison with hemiarthroplasty (HA). The aim of this study was to compare the long-term patient-reported outcomes of RSA and HA for CTA.MethodsWe included all patients with CTA, who according to the Danish Shoulder Arthroplasty Registry, underwent either HA or RSA between 2006 and 2010. Patients who were alive were sent the Western Ontario Osteoarthritis of the Shoulder (WOOS) questionnaire in 2020. One hundred twenty (65%) patients returned a complete questionnaire. The linear regression model was used to compare RSA and HA. Sex, age, and previous surgery were included in the multivariable model.ResultsForty-two HAs and 78 RSAs were evaluated with a mean follow-up time of 11.5 and 10.6 years, respectively. The mean WOOS score was 66.7 for HA and 71.7 for RSA. The difference of 5.0 was neither statistically significant nor clinically important (95% confidence interval: -4.3 to 14.2, P = .17), nor were there any significant risk of a worse WOOS score for sex, age, or previous surgery.ConclusionTo our knowledge, this is the first study to compare the long-term patient-reported outcomes of HA and RSA for CTA. Our results indicate that RSA is a reliable and durable treatment option for CTA with good long-term results. Based on this observational study, it is not possible to make safe estimates about the effect of RSA compared with HA, but similar to RSA, HA was associated with relatively good long-term results.

Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial

PurposeTo compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA).MethodsInclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale.ResultsThe study included 25 shoulders of 22 patients who completed baseline and 12 months’ patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA.ConclusionsThe results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings.Level of EvidenceLevel II, randomized controlled trial.

Validity and Reliability of the Turkish Version of Western Ontario Osteoarthritis of the Shoulder Index.

Objectives This study aims to adapt the Western Ontario Osteoarthritis of the Shoulder (WOOS) index specific to shoulder osteoarthritis into Turkish and to evaluate its validity and reliability.Patients and methods The WOOS index was translated and culturally adapted into Turkish, systematically. It was applied to a total of 68 patients (17 males, 51 females; mean age: 61.5±8.7 years; range, 45 to 80 years) with osteoarthritis of the shoulder treated conservatively. The reliability of the scale was checked through internal consistency and test-retest methods. Internal consistency was analyzed with Cronbach alpha value. Test-retest reliability was assessed using an intraclass correlation coefficient (ICC) with 25 patients. The Western Ontario Rotator Cuff (WORC), the Shoulder Pain and Disability Index (SPADI), and the Society of American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) scores were used to conduct concurrent validity.Results The Cronbach alpha value of the scale was found to be excellent as 0.92 (p<0.001). The ICC value was also excellent as 0.97 (p<0.001). There was an excellent positive correlation with WORC (0.847; p<0.001) and a very good positive correlation with SPADI (0.788; p<0.001). It was also negatively very good to correlate with the ASES (-0.754; p<0.001). Additionally, subsections of WOOS had a good correlation with the corresponding subsections of WORC (0.779-0.664; p<0.001).Conclusion The Turkish version of the WOOS index is a valid and reliable tool and is recommended for use in the assessment of patients with osteoarthritis of the shoulder.

Ten-year follow-up of stemmed hemiarthroplasty for acute proximal humeral fractures.

There is no consensus on the treatment of proximal humeral fractures. Hemiarthroplasty has been widely used in patients when non-surgical treatment is not possible. There is, despite extensive use, limited information about the long-term outcome. Our primary aim was to report ten-year patient-reported outcome after hemiarthroplasty for acute proximal humeral fractures. The secondary aims were to report the cumulative revision rate and risk factors for an inferior patient-reported outcome. We obtained data on 1,371 hemiarthroplasties for acute proximal humeral fractures from the Danish Shoulder Arthroplasty Registry between 2006 and 2010. Of these, 549 patients (40%) were alive and available for follow-up. The Western Ontario Osteoarthritis of the Shoulder (WOOS) questionnaire was sent to all patients at nine to 14 years after primary surgery. Revision rates were calculated using the Kaplan-Meier method. Risk factors for an inferior WOOS score were analyzed using the linear regression model. Mean age at surgery was 67 years (24 to 90) and 445 (81%) patients were female. A complete questionnaire was returned by 364 (66%) patients at a mean follow-up of 10.6 years (8.8 to 13.8). Mean WOOS score was 64 (4.3 to 100.0). There was no correlation between WOOS scores and age, sex, arthroplasty brand, or year of surgery. The 14-year cumulative revision rate was 5.7% (confidence interval 4.1 to 7.2). Patients aged younger than 55 years and patients aged between 55 to 74 years had 5.6-times (2.0 to 9.3) and 4.3-times (1.9 to 16.7) higher risk of revision than patients aged older than 75 years, respectively. This is the largest long-term follow-up study of acute proximal humeral fractures treated with hemiarthroplasty. We found a low revision rate and an acceptable ten-year patient-reported outcome. The patient-reported outcome should be interpreted with caution as we have no information about the patients who died or did not return a complete WOOS score. The long-term outcome and revision rate suggest that hemiarthroplasty offers a valid alternative when non-surgical treatment is not possible. Cite this article: Bone Joint J2021;103-B(6):1063-1069.

Clinical and patient-reported outcomes of reverse shoulder arthroplasty in patients receiving Social Security Disability Insurance or workers’ compensation

BackgroundEvidence suggests that reverse shoulder arthroplasty (RSA) patients receiving workers’ compensation (WC) have worse patient-reported outcomes (PROs) than those not receiving WC. It is unknown whether Social Security Disability Insurance (SSDI) recipients also have worse outcomes of RSA. Our goals were to (1) compare PROs and range of motion (ROM) after RSA according to whether patients were receiving SSDI, WC, or neither form of assistance, and (2) identify factors associated with poor PROs. MethodsFrom a US institutional database of 454 patients who underwent RSA from January 2009 through December 2016, we identified 19 SSDI recipients and 25 WC recipients. From the same database, we created a control group of 81 patients not receiving SSDI or WC, matched by demographic variables. Between groups, we compared age, sex, operative arm dominance, preoperative diagnosis, number of previous shoulder surgeries, primary or revision arthroplasty, and Charlson Comorbidity Index value. Patients were evaluated preoperatively and at a minimum of 2 years postoperatively by physical examination, including range of motion, visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, L'Insalata score, Simple Shoulder Test (SST), and Western Ontario Osteoarthritis of the Shoulder (WOOS) score. Significance was set at P< .05. Clinical relevance of improvements in forward flexion and abduction, VAS for pain, ASES, and SST were evaluated using established minimal clinically important difference (MCID) values. ResultsBoth the SSDI and WC groups experienced statistically significant improvements from preoperatively to postoperatively; these improvements exceeded MCID thresholds for forward flexion and abduction, VAS for pain, ASES (except in WC group), and SST score (all, P< .05). These outcomes were not significantly different between the SSDI and WC groups. Compared with the control group, both the SSDI and WC groups had statistically significantly worse outcomes for these same measures. The only factor associated with poor clinical outcomes was having undergone ≥2 previous surgical procedures on the same shoulder for which RSA was performed in both SSDI (odds ratio = 2.4, 95% confidence interval: 1.0-5.4) and WC (odds ratio = 1.6, 95% confidence interval: 1.1-4.5) groups. ConclusionAmong RSA patients, SSDI recipients did not have worse clinical outcomes than WC recipients. Having undergone ≥2 previous procedures on the same shoulder was associated with poor outcomes in both groups. These findings should be considered when determining the appropriateness of RSA for SSDI and WC recipients. Level of evidenceLevel III; Retrospective Cohort Comparison; Treatment Study

The impact of subscapularis integrity on functional outcome in reverse total shoulder arthroplasty utilizing a 135˚ stem

BackgroundReverse shoulder arthroplasty (RSA) predictably restores overhead function and provides pain relief in patients with glenohumeral arthritis and rotator cuff deficiency. Implant design with an anatomic inclination angle of 135˚ may provide an advantage in the healing rates of subscapularis tendon (SST) repairs. The purpose of this study was to use ultrasound to evaluate the subscapularis repair healing rate, and secondarily, to compare outcomes between healed and non-healed SSTs, in patients undergoing RSA with a 135˚ inclination angle. MethodsA prospectively collected, multicenter shoulder arthroplasty registry was queried to identify patients undergoing RSA with a 135˚ inclination stem with a minimum of 1 year follow-up. Ultrasound analysis was performed at final follow-up to assess subscapularis integrity. Exclusion criteria included RSA for fracture, fracture sequelae or failed prior arthroplasty. Outcome measures included American Shoulder and Elbow Surgeons score (ASES), Western Ontario Osteoarthritis of the Shoulder (WOOS), Single Anatomic Numeric Evaluation (SANE), and Constant scores. Additionally, subscapularis functional assessments included range of motion, belly-press and shirt-tuck tests. Statistical analysis was performed using ANOVA, Chi-square, and student t-tests with SPSS. Results were considered significant at P < .05. ResultsSeventy-eight patients meeting the inclusion criteria were identified from the registry, however, only seventy-five patients had ultrasound and healing data. The subscapularis was repaired in 60 patients and healing via ultrasound was noted in 56.7% (34/60). In most cases, a subscapularis peel was performed, with lesser tuberosity osteotomy performed in 9.38% of cases. Patients whose subscapularis was repaired were found to be older (72.2 vs. 64.9, P < .001) and the majority of patients with an unrepaired subscapularis were male (13/15, 86.7% unrepaired vs. 27/60, 45.0% repaired). Both healed and non-healed patient cohorts showed statistical improvement in all pain and functional outcome scores from their baselines. However, there were no significant differences in outcome scores between healed and non-healed SST. With regards to SST repair, only overall WOOS (Δ+15.62, P = .049) and physical component of the WOOS score (Δ+15.97, P = .040) were higher in patients with nonrepaired SST. There was no correlation between the ability to perform a belly-press or shirt-tuck test and subscapularis repair or evidence of radiographic healing. Patients who did not have their subscapularis repaired demonstrated greater passive external rotation at the side from 31° to 51° (P = .044). A significant increase in passive forward flexion was noted in patients with healed subscapularis from 117° to 135° (P = .042). There was no statistical difference in active range of motion between either the repaired/nonrepaired or healed/non-healed cohorts. ConclusionOur study demonstrates a healing rate of 57% following repair in patients undergoing RSA with a 135˚ angle. Standardized outcome measures overall demonstrated no difference between patients with a healed subscapularis compared to those with a non-healed or unrepaired subscapularis. Level of EvidenceIV, case series, treatment study.

The American Shoulder and Elbow Surgeons score has excellent correlation with the Western Ontario Osteoarthritis score.

The purpose of this study was to compare the correlation, responsiveness, and responder and administrator burden of the American Shoulder and Elbow Surgeons (ASES) score with the Western Ontario Osteoarthritis of the Shoulder (WOOS) score for patients undergoing total shoulder arthroplasty. The goal was to determine whether one score was superior to the other to limit the use of multiple scoring measures when tracking patient outcomes. The hypothesis of this study was that for patients undergoing total shoulder arthroplasty, the WOOS score would have (1) a high level of correlation with the ASES score, (2) comparable responsiveness to the ASES score, and (3) a higher responder and administrator burden than the ASES score. We performed a retrospective review of a database of patients undergoing total shoulder arthroplasty in which the ASES score was recorded with the WOOS score. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine whether correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations and by type of arthroplasty (anatomic vs. reverse). Responsiveness was determined by calculating the standardized response mean and the effect size of both scores. Responder and administrator burden was examined using 50 consecutive preoperative patients to determine the number of incorrectly completed WOOS and ASES scores. The correlation of the ASES and WOOS scores for all patients was excellent (n = 1218, r = 0.88, P < .0001). The correlation of the ASES and WOOS scores was excellent for patients undergoing anatomic total shoulder arthroplasty (n = 695, r = 0.71, P < .0001) and reverse total shoulder arthroplasty (n = 523, r = 0.88, P < .0001). The correlation of preoperative scores was strong-moderate (n = 606, r=0.62, P < .0001), and that of postoperative scores was strong-moderate (n = 612, r = 0.69, P < .0001). The standardized response mean (WOOS score, 2.1; ASES score, 2.1) and the effect size (WOOS score, 3.0; ASES score, 3.0) demonstrated comparable responsiveness. Twenty-six percent of the WOOS scores were completed incorrectly and were invalid compared with 0% of the ASES scores (P < .0001). There is excellent correlation and comparable responsiveness between the ASES score and WOOS score. Including these scores simultaneously when tracking patient-determined outcomes appears to be redundant and therefore unnecessary. Because there is higher responder and administrative burden for the WOOS score, we recommend use of the ASES score over the WOOS score in patients undergoing total shoulder arthroplasty.

Midterm results of two-stage revision surgery for periprosthetic shoulder infection

BackgroundTo our knowledge, no studies have reported clinical results at a midterm follow-up after two-stage revision for periprosthetic shoulder infection (PSI). Our purpose was to determine the recurrent infection rate and clinical outcomes of two-stage revision for PSI at a minimum follow-up of 5 years. The secondary aim was to evaluate the application of the new guidelines from the International Consensus Meeting (ICM) in 2018 for diagnosis of PSI in this cohort. MethodsWe identified 17 patients with infection after shoulder arthroplasty between 2005 and 2014 who were treated with a two-stage revision and had a minimum follow-up of 5 years (range, 5-9 years). The mean time from the involved arthroplasty to first-stage revision was 40 months. All patients were revised to a reverse shoulder arthroplasty at second-stage revision. Complications, patient-reported outcomes (PROs), visual analogue scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, Western Ontario Osteoarthritis of the Shoulder (WOOS) score, and range of motion (ROM) were noted. Patients were retrospectively scored and categorized using the ICM 2018 diagnostic criteria. Mean patient age was 64 ± 7 years, and 65% of patients were male. ResultsA recurrent infection developed in 3 (18%) of the 17 patients. The cumulative incidence of recurrence of infection was 0% at 1 year, 6% at 2 years, and 18% at 5 years. There were 6 (36%) other complications, including 4 periprosthetic fractures, 1 spacer fracture, and 1 dislocation. Two (12%) patients had scapular notching. At latest follow-up, patients who did not have recurrent infection had a statistically and clinically meaningful improvement from preoperative to postoperative PROs, including VAS for pain, ASES score, SST score, and WOOS score, and active ROM, including abduction and forward flexion. Using the ICM 2018 criteria at first-stage revision surgery, the category of PSI for 10 (59%) patients was “definite PSI,” 4 (23%) patients was “probable PSI”, and 3 (18%) patients was “possible PSI.” ConclusionThe rate of reinfection after a two-stage revision surgery for PSI at midterm follow-up was 18%. Clinical outcomes were favorable in the patients who remained free of infection. Further prospective study of the ICM criteria as they apply to making the diagnosis of infection in these patients would be beneficial. Level of evidenceLevel IV; Case Series; Treatment Study

A multicenter, prospective 2-year analysis of the Sidus stem-free shoulder arthroplasty system

BackgroundThe purpose of this multicenter, prospective study was to evaluate the efficacy and safety of a stemless total shoulder arthroplasty compared with a traditional stemmed control.MethodsNinety-five shoulders were selected for participation in this Food and Drug Administration investigational device exemption clinical trial and underwent stemless total shoulder arthroplasty. Subjects returned for follow-up at 6 weeks, 6 months, 12 months, and 2 years postoperatively. Outcome measures included pain; range of motion; American Shoulder and Elbow Surgeons, Western Ontario Osteoarthritis of the Shoulder, and Short Form 12 scores; and radiographic review. Baseline data were compared with 2-year follow-up data to determine the rate of composite clinical success compared with the stemmed control.ResultsAll outcome assessments demonstrated significant improvements (P ≤ .007). The mean American Shoulder and Elbow Surgeons score improved from 20 to 89 (P < .0001), and the mean shoulder pain score decreased from 8.3 ± 1.6 to 0.7 ± 1.5 (P < .0001). The mean Western Ontario Osteoarthritis of the Shoulder score decreased from 1443 ± 256 to 203 ± 267 (P < .0001). On the Short Form 12, the mean physical health score increased from 33 ± 7 to 48 ± 9 (P < .0001) and the mean mental health score increased from 50 ± 13 to 54 ± 8 (P = .007). Mean active forward elevation increased from 97° ± 27° to 143° ± 25° (P < .0001), and mean active external rotation increased from 21° ± 16° to 53° ± 18° (P < .0001). Kaplan-Meier analysis showed an implant survivorship rate of 98% at 2 years. The composite clinical success rate was 87% compared with 85% for the stemmed control.ConclusionsThis study showed that a stemless rough-blasted humeral implant with metaphyseal bone fixation provides good clinical and radiographic outcomes and survivorship at 2 years, with outcomes comparable to a traditional stemmed implant.

Substantial clinical benefit, responsiveness, and sensitivity to change of three common outcome measures following shoulder arthroplasty.

Objectives:It is important for clinicians involved in the care of patients with advanced glenohumeral osteoarthritis to determine clinically significant change when using outcome measures. There is little information on the amount of substantial clinical benefit in shoulder outcomes after shoulder arthroplasty. The purpose of this study was twofold: (1) to quantify substantial clinical benefit for the American Shoulder and Elbow Surgery score, the Constant Murley Score, and the Western Ontario Osteoarthritis of the Shoulder index and (2) to provide estimates of responsiveness and sensitivity to change for these measures following shoulder arthroplasty.Methods:The study involved a secondary analysis of previously collected data. The substantial clinical benefit and responsiveness of the measures were calculated based on external anchors related to change in pain, range of motion, and ability to carry out activities of daily living. The areas under curve and standardized response mean represented responsiveness and sensitivity to change.Results:The data of 159 and 131 patients with complete follow-up at 6 months and 2 years were reviewed. The amount of substantial clinical benefit was dependent on the outcome measure and the external anchor and increased for all measures from 6 months to 2 years. Responsiveness was high (areas under curve > 0.80) at 6 months and further improved at 2 years (areas under curve > 0.88). The standardized response mean values of both time points were over 2.00, indicating high effect sizes. The standardized response means of the Constant Murley Score were statistically significantly higher than the standardized response means of the American Shoulder and Elbow Surgery and Western Ontario Osteoarthritis of the Shoulder.Conclusion:Amount of substantial clinical improvement in pain, range of motion, and activities of daily living following shoulder arthroplasty depends on the type of outcome measure used. All three measures, the American Shoulder and Elbow Surgery, absolute and relative Constant Murley Score, and Western Ontario Osteoarthritis of the Shoulder, demonstrated good to excellent accuracy and optimal standardized response means.Level of evidence:Level III, Retrospective Cohort study

What Factors are Associated with Revision or Worse Patient-reported Outcome after Reverse Shoulder Arthroplasty for Cuff-tear Arthropathy? A Study from the Danish Shoulder Arthroplasty Registry.

Reverse shoulder arthroplasty has been proven to improve function in shoulders with cuff-tear arthropathy, but existing studies are primarily single-center studies with a small number of patients, which limits their ability to identify patients who have an increased risk of revision or a worse functional outcome. (1) What is the estimated 10-year cumulative revision rate after reverse shoulder arthroplasty for cuff-tear arthropathy, and what factors are associated with the risk of revision? (2) What is the patient-reported outcome 1 year after surgery, and what factors are associated with a worse patient-reported outcome? We included all patients treated with reverse shoulder arthroplasty for cuff-tear arthropathy reported in the Danish Shoulder Arthroplasty Registry from 2006 to 2015. During the study period, the completeness of reporting was 93% for both primary and revision arthroplasties. Estimated revision rates were illustrated using the Kaplan-Meier method, and hazard ratios were calculated using a Cox regression model. Patient-reported outcome was measured with a postal survey at 12 months (range 10-14 months) postoperatively using the Western Ontario Osteoarthritis of the Shoulder (WOOS) index. The WOOS is a patient-administered questionnaire that measures the quality of life of patients with glenohumeral osteoarthritis. A visual analog scale that ranges from 0 to 100 is used for each question. There are 19 questions, giving a total score ranging from 0 to 1900, with 1900 being the worst. For simplicity of presentation, raw scores were converted to a percentage of the maximum score, with 100 being the best. There is no defined minimal clinically important difference of the WOOS, but the Danish Shoulder arthroplasty registry has for many years regarded an arbitrary difference of 10 or above as being clinically relevant. The rate of response to the WOOS was 71%. The estimated 10-year cumulative revision rate was 8.5% (95% confidence interval, 5.7%-11.3%) with differences between the arthroplasty model (21.0%; 95% CI, 11.8% to 30.8% for the Delta Mark III and 5.5%; 95% CI, 3.7% to 7.3% for the Delta Xtend) and gender (6.0%; 95% CI, 3.0% to 9.0% for women and 13.1%; 95% CI, 7.1% to 19.1% for men). After controlling for potential confounding variables including gender, previous surgery, arthroplasty model, and period of surgery, the risk of revision was higher with the Delta Mark III than with the Delta Xtend (hazard ratio 2.7; 95% CI, 1.3 to 5.4; p < 0.01) and higher in men than in women (hazard ratio 2.7; 95% CI, 1.6 to 4.7; p < 0.01). Thirty-three percent (19 of 57) of the revision arthroplasties were performed for dislocation and 32% (18 of 57) were to treat periprosthetic joint infection. After controlling for confounding variables, only previous surgery was associated with a worse WOOS score (mean difference -10.6; 95% CI, -15.2 to -5.9; p < 0.01); there were no associations between a worse score and gender, arthroplasty model, age group, or period of surgery. The results from the present study can be used to inform patients about their individual risk of revision or a disappointing functional outcome. The study also demonstrates the need for proper patient selection and attention to technical details to reduce the risk of revision, especially for men. Our follow-up time was, however, short, with only an estimate of the 10-year revision rate. Future studies with a long-term follow-up duration are needed to confirm our results. Level III, therapeutic study.