Clinical results of revision shoulder arthroplasty for glenoid component loosening

We retrospectively reviewed 32 patients who underwent glenoid revision surgery after total shoulder arthroplasty to compare the results of revision total shoulder arthroplasty with those of revision hemiarthroplasty and to identify factors associated with poor results after revision shoulder arthroplasty for glenoid component loosening. Results were reviewed at a mean follow-up of 4 years (range, 2-8 years). Glenoid reimplantation resulted in significant pain relief (P < .0001), improvement in American Shoulder and Elbow Surgeons (ASES) score (P < .02), and external rotation (24 degrees to 44 degrees , P < .004). Revision to a hemiarthroplasty also resulted in significant pain relief (P < .01) and improvement in ASES score (P < .05). For the treatment of glenoid loosening without glenohumeral instability, both reimplantation of a glenoid component and revision to a hemiarthroplasty improved function, satisfaction, and level of pain. Reimplantation of a new glenoid component offered greater improvements in pain (P < .008) and external rotation (increase of 20 degrees versus 3 degrees , P < .03) compared with hemiarthroplasty. For patients with preoperative glenohumeral instability, revision surgery did not improve motion, function, or pain significantly. Risk factors associated with a poor outcome after revision arthroplasty included persistent glenohumeral instability, rotator cuff tears, and malunion of the greater tuberosity.     

二期反式肩关节置换治疗肱骨近端骨折内固定术后感染

目的总结二期反式肩关节置换治疗肱骨近端骨折内固定术后感染的疗效。方法2014年6月—2018年1月,收治17例肱骨近端骨折内固定术后感染伴肱骨头坏死或骨不连患者。男8例,女9例;年龄52~78岁,平均63.8岁。初次内固定术后19~66个月确诊发生感染,平均34.8个月。关节腔液体微生物培养14例阳性、3例阴性。术前Constant评分为(36.41±8.65)分,美国肩肘外科协会(ASES)评分为(31.06±7.43)分,疼痛视觉模拟评分(VAS)为(7.29±0.99)分。肩关节前屈(45.88±12.46)°,外展(42.18±12.31)°,外旋(16.76±4.92)°,内旋达臀部9例、腰骶关节3例、L35例。一期扩创、内固定物取出及植入抗生素骨水泥占位器,待感染消失后行二期反式肩关节置换。两期手术间隔时间为3.0~6.5个月,平均4.2个月。结果两期手术术后切口均Ⅰ期愈合,均无感染复发、血管神经损伤等并发症发生。患者均获随访,随访时间15~32个月,平均22.0个月。末次随访时,肩关节前屈(109.00±23.66)°、外展(98.53±16.92)°、外旋(41.41±6.82)°,内旋达腰骶关节5例、L38例、T124例,Constant评分为(64.88±8.70)分,ASES评分为(65.18±8.10)分,VAS评分为(2.94±1.25)分,均较术前明显改善(P<0.05)。X线片复查示均无假体松动。结论二期反式肩关节置换治疗肱骨近端骨折内固定术后感染伴肱骨头坏死或骨不连,能有效控制感染复发,改善肩关节功能,近期疗效满意。     

Impact of fatty infiltration of the teres minor muscle on the outcome of reverse total shoulder arthroplasty

BACKGROUND: Reports have demonstrated that reverse shoulder arthroplasty restores overhead elevation but fails to restore active external rotation. The teres minor muscle-tendon unit contributes to active external rotation, and its deficiency may impair the clinical outcome. It was therefore the purpose of this study to evaluate the influence of fatty infiltration of the teres minor muscle on the clinical outcome after reverse total shoulder replacement. METHODS: Forty-two shoulders in forty-two patients (average age, seventy-one years) with painful cuff tear arthropathy or an irreparable rotator cuff deficiency with pseudoparesis were treated with a reverse Delta-III shoulder arthroplasty and followed clinically for a minimum of twenty-four months. Preoperatively, fatty infiltration of the teres minor was assessed, according to the grading system of Goutallier et al., with use of magnetic resonance imaging. The effect of teres minor fatty infiltration on the subjective and objective outcomes of the reverse shoulder arthroplasty was evaluated. RESULTS: The thirty shoulders with stage-0, 1, or 2 fatty infiltration of the teres minor muscle (group 1) had a significantly better ultimate Constant score, a significantly better subjective shoulder value, and significantly greater preoperative-to-postoperative improvement than the twelve shoulders with stage-3 or 4 fatty infiltration (group 2). In group 1 the relative Constant score increased by an average of 41% and the subjective shoulder value increased by an average of 44%, whereas in group 2 the respective increases were 32% (p = 0.033) and 25% (p = 0.018). Group 1 had an average increase of 6.2 points in the score for extremity positioning, whereas group 2 gained only 5.3 points (p = 0.033). Group 1 had a net gain of 9 degrees of external rotation with the arm at the side compared with an average net loss of 7 degrees in group 2 (p < 0.001). CONCLUSIONS: Stage-3 or 4 fatty infiltration of the teres minor compromises the clinical outcome of reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tears.     

Shoulder arthroplasty in patients with osteoarthritis and dysplastic glenoid morphology

Fifteen shoulders with primary osteoarthritis and dysplastic glenoid morphology underwent shoulder arthroplasty (eleven total shoulder arthroplasties and four hemiarthroplasties). Patients were evaluated at a mean of 37 months after replacement with clinical examination, Constant score, subjective patient opinion, and radiographic examination. One glenoid component was loose, necessitating removal; the remainder of the prostheses were in place at latest follow-up. Significant improvement was observed in Constant score (32 points preoperatively vs 71 points postoperatively) and active mobility (anterior elevation, 89 degrees preoperatively vs 146 degrees postoperatively; external rotation, 7 degrees preoperatively vs 45 degrees postoperatively) after arthroplasty. This study demonstrates that the rare scenario of osteoarthritis coupled with a dysplastic glenoid can be treated successfully with shoulder arthroplasty.     

反式全肩关节置换治疗盂肱关节骨关节炎伴巨大肩袖撕裂

目的探讨反式全肩关节置换术治疗盂肱关节骨关节炎合并巨大肩袖撕裂的近期临床疗效。 方法回顾性分析2016年1月至2018年12月在南部战区总医院接受初次反式全肩关节置换术治疗的15例盂肱关节骨关节炎合并巨大肩袖撕裂患者,均有肩关节持续性疼痛、功能障碍,且三角肌无损伤具有功能;排除有臂丛或腋神经损伤以及有肩关节手术史的患者。评估其术前、术后1年的肩关节主动活动度,使用美国肩肘外科协会(ASES)肩关节评分、加州大学洛杉矶分校(UCLA)最终结果评分评价肩关节功能,分析X线及CT并发症出现情况。采用配对t检验对术前及术后的活动度和评分差异进行性分析。 结果15例患者均顺利完成手术并获得随访,随访时间17个月(范围12～36个月)。反式全肩关节置换术后1年肩关节主动前屈(124±11)°较术前(58±18)°提高(t＝14.316,P<0.01),外展(120±12)°较术前(58±20)°提高(t＝9.959,P<0.01),内旋较术前改善,外旋(26±8)°较术前(25±9)°无明显变化(t＝1.598,P>0.05),术后1年ASES评分(78±7)显著高于术前(33±8)(t＝16.487,P<0.01);术后1年UCLA评分(31±4)显著高于术前(15±3)(t＝12.826,P<0.01)。 结论RTSA能够有效治疗盂肱关节骨关节炎合并巨大肩袖撕裂,取得了良好的早期临床效果,但术后肩关节外旋无明显改善,术前需评价小圆肌情况以确定相关治疗方案。     

Determinants of patient satisfaction with outcome after shoulder arthroplasty

The purpose of this investigation was to identify the determinants of patient satisfaction with outcome after hemiarthroplasty and total shoulder arthroplasty. Seventy patients who underwent shoulder arthroplasty were studied to determine predictors of patient satisfaction. Patient satisfaction was graded on an ordinal scale from 1 to 10. There was a significant association between patient satisfaction and age (P = .010) and between patient satisfaction and worker's compensation status (P = .018). There was no significant decrease in patient satisfaction for patients with rotator cuff tears. Patient satisfaction was significantly associated with all pain and function variables at follow-up (P < .05). The American Shoulder and Elbow Surgeons score was significantly correlated with patient satisfaction (P = 0.680, P < .05). Independent predictors of satisfaction included pain with activities of daily living, painless use of the arm above the shoulder, and difficulty with toileting (R(2) = 0.555). Subjective variables associated with pain were independent predictors of patient satisfaction. Thus, in assessing patient satisfaction after shoulder arthroplasty, we emphasize the importance of patient-derived subjective assessment of symptoms and function.     

Replacement arthroplasty in the weight-bearing shoulder of paraplegic patients

We review the early results of shoulder arthroplasty in the weight-bearing shoulder of long-term paraplegic patients. We have been unable to find previously published results of this subgroup of shoulder arthroplasty patients in the literature. Five paraplegic, female patients who had undergone shoulder arthroplasty were analyzed. All patients had been prospectively assessed with the American Shoulder and Elbow Surgeons (ASES) function score and the Constant score. The mean age at the time of surgery was 70 years. Three shoulders had full-thickness rotator cuff tears, and two were repaired at the time of shoulder arthroplasty. The mean preoperative Constant score was 30 out of 100, improving to 52 out of 100 at a mean follow-up of 30 months (range, 24-36 months). The mean preoperative ASES function score was 28 out of 55, improving to 37 out of 55. One patient was pain-free after surgery, and the mean postoperative pain score was 10 out of 15. There were no features of progressive radiolucency around the glenoid or the humeral components at last review apart from one case in which glenoid implant migration occurred. In view of the satisfactory improvement in terms of pain, mobility, and independence, we believe that it is reasonable to continue to offer this procedure to this subgroup of patients. We will, however, remain vigilant with regard to any further complications arising in these prostheses in the medium to long term as a result of increased loading.     

Predictors of patient satisfaction and outcomes following reverse total shoulder arthroplasty

BackgroundObjective clinical outcomes and patient satisfaction via patient reported outcome measures (PROMs) can vary following reverse total shoulder arthroplasty (rTSA). The purpose of this study was to analyze patient specific preoperative factors that may predict postoperative PROMs and satisfaction following rTSA.MethodProspective data was collected on 144 consecutive patients who underwent primary rTSA at our institution between 2012 and 2018, all with minimum 2 year follow-up. Age, gender, race, BMI, previous surgery on the index shoulder, and comorbidity burden were analyzed as potential predictors. Shoulder specific clinical measures were collected both pre- and postoperatively via range of motion testing with active abduction, internal, and external rotation. PROMs included global shoulder function, Simple Shoulder Test (SST) and the American Shoulder and Elbow Surgeons (ASES) scoring systems, and cumulative patient satisfaction. Statistical analysis included comparison of pre- and postoperative outcome measures across the cohort as a whole and between each of the potential predictors in question. The relationship between predictors and postoperative cumulative satisfaction was investigated, with specific attention to identify the strongest predictors and account for confounding variables. Statistical significance was determined at P < .05.ResultsAll range of motion scores and PROMs were significantly improved from preoperative to postoperative assessment. Patient satisfaction was excellent with 92% rating their shoulder as “much better” or “better.” Women and minority patients displayed significantly worse preoperative active abduction, SST, and ASES, but were found to have no significant difference in these measures postoperatively. Younger age was associated with a significantly worse postoperative ASES score. Female sex was associated with significantly higher postoperative satisfaction, while minority status was associated with significantly lower cumulative satisfaction. Postoperative global shoulder function, SST, and ASES were not significantly influenced by sex, race, previous surgery, BMI, or comorbidity burden. Postoperative ASES and global shoulder function demonstrated to be independent predictors of “much better” satisfaction rating.ConclusionPostoperative PROMs and cumulative satisfaction are not influenced by BMI, previous surgery, or comorbidity burden in our cohort. Relative to their respective counterparts, older patients, females, and white patients are more likely to demonstrate higher satisfaction with their outcome following rTSA as measured by PROMs or cumulative satisfaction. Improvements in the ASES and global shoulder function scores most consistently predict higher postoperative satisfaction.Level of evidenceLevel IV; Case Series; Treatment Study     

Defining maximal outcome improvement thresholds for patient satisfaction after reverse total shoulder arthroplasty: a minimum two-year follow-up study

BackgroundPrevious research has investigated the percentage of maximal outcome improvement (MOI) for the American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores after reverse total shoulder arthroplasty (rTSA); however, few other outcome scores have been validated. The purpose of this study was to establish thresholds of MOI percentage for the Single Assessment Numeric Evaluation (SANE) and subjective Constant-Murley (Constant) scores associated with patient satisfaction at 2 years following rTSA.MethodsA retrospective review of institutional registry data for all patients who underwent primary rTSA between 09/2016 and 02/2018 was performed. All patients completed the ASES, SANE, and Constant outcome measures preoperatively and at a minimum of 2 years postoperatively. Changes were assessed with Wilcoxon signed-rank tests. MOI percentage was defined as the score improvement from baseline divided by the highest possible improvement from baseline based on the maximum value of the outcome score used. Receiver operating characteristic (ROC) analyses were used to determine optimal MOI percentage thresholds associated with postoperative satisfaction. Stepwise multivariate logistic regression was performed to identify variables associated with achieving the MOI.ResultsA total of 105 patients were included in the final analysis, with a mean (±standard deviation) age of 70.0 ± 7.5 years and BMI of 28.9 ± 5.6 kg/m². The majority of patients were satisfied postoperatively (81.0%). Statistically significant increases were observed from baseline to 2 years postoperatively for the outcome measures assessed (P < .001 for all). ROC analysis demonstrated that the optimal MOI percentage threshold for achieving satisfaction was 66.9% for ASES ([Area under curve, AUC]: 0.87), 71.0% for SANE (AUC: 0.89), and 37.5% for Constant (AUC: 0.85). The linear regression model fit between the proportion of satisfied patients and the calculated MOI percentages was moderate for SANE (r² = 0.313, P < .001) and weak for Constant (r² = 0.228, P < .001). Multivariate logistic regression demonstrated that comorbid diabetes was associated with a decreased likelihood of MOI achievement for SANE ([Odds Ratio, OR]: 0.66, P = .020) and Constant (OR: 0.72, P = .027). Preoperative diagnosis of rotator cuff arthropathy (OR: 0.84, P = 0.049) was associated with a decreased likelihood of MOI achievement for Constant. No factors were significantly associated with MOI achievement for ASES.ConclusionAchieving 66.9%, 71.0%, and 37.5% of the MOI for the ASES, SANE, and Constant scores is associated with postoperative satisfaction following rTSA. Comorbid diabetes and diagnosis of rotator cuff arthropathy were significantly associated with a decreased likelihood of MOI achievement.Level of evidenceLevel III; Retrospective Case Series (Prognostic)     

The effect of an early mobilization rehabilitation protocol on outcomes after reverse shoulder arthroplasty

BackgroundGiven the continued growth of reverse shoulder arthroplasty (RSA), it is important to optimize factors that contribute to successful outcomes. Rehabilitation after RSA is critical to achieve successful outcomes including patient function and satisfaction; however, the ideal rehabilitation program has not been established. The purpose of this study was to evaluate the effect of early mobilization (EM) compared with delayed mobilization (DM) on outcomes and function after RSA.MethodsA retrospective study of prospectively collected data was performed comparing 67 patients who underwent RSA in two groups: the EM group began a rehabilitation program immediately after surgery, and the DM group began after 4-6 weeks postoperatively. Preoperative and postoperative Constant shoulder score, American Shoulder and Elbow Surgeons (ASES) score, Penn Shoulder Score (PSS), shoulder satisfaction value as well as demographics, opioid usage, range of motion, 90-day complications, reoperation, and readmission rates were collected. Statistical analysis was performed between each group’s outcomes and for the change (delta) of outcomes from baseline to each postoperative time point.ResultsAt 6 weeks postoperatively, the EM group showed significantly higher scores in ASES function, PSS, active forward elevation, passive forward elevation, active external rotation, and passive external rotation. There was significantly lower narcotic usage in the EM group at 6 weeks. At 3 months postoperatively, the EM group showed a lower numerical rating score for pain and higher active forward elevation. At the last follow-up, there was a lower numerical rating score and greater degree for all ranges of motion for the EM group than that for the DM group. A greater change from baseline to 6 weeks postoperatively was seen for the EM group in shoulder satisfaction value, ASES function, PSS, active forward elevation, passive forward elevation, and internal rotation. From baseline to 3 months postoperatively, ASES pain, PSS, active forward elevation, and passive forward elevation improved significantly in the EM group. At the final follow-up, active forward elevation increased greater for the EM group. There were 3 complications (2 hematomas and 1 infection) in the DM group and none in the EM group.ConclusionThe EM rehabilitation protocol after RSA achieved lower opioid usage at 6 weeks, lower pain scores at each time point, and better range of motion during the final follow-up than DM protocol. There were no complications reported with the EM protocol, suggesting it is a safe alternative for postoperative recovery. Orthopedic surgeons should consider the EM rehabilitation protocol after RSA.     

Acromial fracture after reverse shoulder arthroplasty

In this article, we report on our experience with patients who sustained a fracture of the acromion after reverse shoulder arthroplasty (RSA), and on the results of a comprehensive survey regarding this complication- a survey of American Shoulder and Elbow Surgeons (ASES) members. Patients were assessed with radiographs and validated functional outcome measures. Eight (4.9%) of the 162 patients that underwent RSA had radiographic evidence of postoperative fracture of the acromion. Mean active forward elevation was 71°, and mean ASES score was 70. Four patients reported no pain; 2 had mild pain; 1 had moderate pain; and 1 patient had severe pain. Six of the 8 fractures did not unite. Survey results showed that 74% of ASES respondents treated these patients nonoperatively and that 53% of respondents thought that acromial fractures after RSA led to reduced shoulder function, but without persistent pain. The natural history of nonoperative management is characterized by reduced global shoulder function and a high rate of nonunion. However, most of the patients who experienced this complication did not report chronic pain. Given these patients' outcomes, and the surveyed opinions of ASES members, conservative management is a reasonable option for this complication.     

Midterm outcomes of revision shoulder arthroplasty

BackgroundSince the introduction of shoulder arthroplasty, the indications have been expanding. Because of the increasing number of arthroplasty procedures, revision surgeries are also inevitable. The purpose of our study is to delineate a large number of revision shoulder arthroplasty cases treated in different ways, including antibiotic spacer placement (ABX), hemiarthroplasty (HA), anatomic total shoulder arthroplasty (aTSA), and reverse total shoulder arthroplasty (rTSA), and to analyze the relationship between preoperative factors and clinical outcomes.MethodsWe reviewed our institution's records of revision shoulder arthroplasty between January 1, 2000, and October 1, 2017. Preoperative information included age at the time of surgery, gender, body mass index, and infection status. Pre- and postoperatively, we gathered 6 patient-reported clinical outcomes and 3 range-of-motion parameters (elevation, abduction, and external rotation). Postoperative complications were also assessed. Then, we examined the differences between the pre- and postoperative outcomes. As a secondary analysis, we performed multivariable regression analysis on the same outcomes, accounting for age at the time of surgery, infection status, and previous surgery type.ResultsAmong the 341 revisions performed, 138 cases met inclusion criteria of at least a 2-year follow-up with pre- and postoperative functional outcome scores. The majority of our revision procedures were to a rTSA (92 cases, 67%), followed by aTSA (28 cases, 20%), and ABX/HA (18 cases, 13%). The mean age at the time of our index surgery was 66 years old. In aTSA and rTSA, all the postoperative outcomes (ie, ASES, Constant, UCLA, SST, SPADI, SF-12 scores, and 3 AROMs) were significantly improved beyond the minimal clinically important difference (MCID) except SF-12 scores in aTSA (P = .25) and active external rotation in rTSA (P = .73). None of the ABX/HA's postoperative outcomes achieve significant improvement or MCID. Multivariable regression analysis showed that older age at the time of surgery was significantly associated with better outcomes in 3 of the 6 patient-reported outcomes (ASES, SST, and SPADI; P = .023, .023, and .028, respectively).ConclusionRevision aTSA and rTSA showed statistically and clinically significant improvement postoperatively. ABX and HA did not achieve meaningful postoperative improvement. Overall, patients getting revision shoulder arthroplasty at an older age had better patient-reported outcomes.Level of evidenceLevel III; Retrospective Cohort Study     

Primary unconstrained shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation

BACKGROUND: Reports of shoulder arthroplasty for the treatment of fixed glenohumeral dislocation are rare. The purpose of this study was to analyze the results following shoulder arthroplasty in patients with a fixed anterior shoulder dislocation. METHODS: Eleven patients were evaluated at a minimum of twenty-four months after they underwent an arthroplasty for the treatment of a fixed anterior shoulder dislocation. Four patients underwent a total shoulder arthroplasty, and the remainder were treated with a hemiarthroplasty. Four shoulders had osseous reconstruction of the anterior aspect of the glenoid. The patients were evaluated with use of the Constant score, measurement of active anterior elevation and external rotation, the patient's subjective grading of the result, and a radiographic examination. RESULTS: The mean Constant score improved from 21.1 points preoperatively to 46.0 points following the arthroplasty, and the mean active anterior elevation improved from 48.6 degrees to 90.0 degrees . The pain component of the Constant score was the most reliably improved parameter, increasing from a mean of 4.8 points preoperatively to a mean of 11.0 points postoperatively. Eight patients reported that the result was excellent or good, and the remaining three considered it to be fair. We observed seven complications in five patients, including four cases of anterior instability of the shoulder. Two of the four patients treated with a total shoulder replacement were seen to have definite loosening of the glenoid component on follow-up radiographs. CONCLUSIONS: Shoulder arthroplasty in patients with a fixed anterior shoulder dislocation is fraught with difficulties and complications. Although arthroplasty reliably relieved shoulder pain in this population, limited functional results should be expected.     

Reverse Delta-III total shoulder replacement combined with latissimus dorsi transfer. A preliminary report

BACKGROUND: Reverse total shoulder arthroplasty allows the restoration of active overhead elevation in patients with a massive rotator cuff tear and pseudoparesis of elevation. However, it does not restore active external rotation, the lack of which can also constitute a substantial functional handicap and compromise the outcome of this arthroplasty. Latissimus dorsi tendon transfer reliably restores control of active external rotation in rotator-cuff-deficient shoulders. In this preliminary study, we assessed the results of the combination of a latissimus dorsi transfer to the greater tuberosity and a reverse total shoulder arthroplasty in the presence of lost active external rotation. METHODS: Twelve shoulders in eleven patients (ten women and one man; average age, seventy-three years) with combined pseudoparesis of anterior elevation and external rotation were enrolled in the study. All demonstrated severe dysfunction of the teres minor with an external rotation lag sign, a hornblower's sign, and fatty degeneration of the teres minor classified as stage 2 or greater according to the system of Goutallier et al. or Fuchs et al. All were treated with a reverse total shoulder arthroplasty and a latissimus dorsi transfer during one operative procedure. One patient had a postoperative infection necessitating removal of the prosthesis. Another patient could not be examined because of an unrelated medical disability, leaving ten shoulders in nine patients available for evaluation on the basis of the history, results of a physical examination, and patient-based outcomes. RESULTS: On the average, forward flexion improved from 94 degrees preoperatively to 139 degrees at the time of follow-up (p = 0.028), abduction improved from 87 degrees to 145 degrees (p = 0.007), and strength improved from 0.25 to 4.12 kg (p = 0.005). The subjective shoulder value increased from 23% to 64% (p = 0.005), the relative Constant score increased from 47% to 93% (p = 0.005), and the pain score improved from 6.1 to 10.9 points (p = 0.012). While improvement in active external rotation with the arm at the side (from 12 degrees to 19 degrees ) was not significant, the score for functional active external rotation improved from 4.6 to 8.2 of 10 points according to the system of Constant and Murley (p = 0.024). The score for activities of daily living improved from 2.3 to 7.9 of 10 points (p = 0.005). CONCLUSIONS: In the presence of severe loss of active elevation and external rotation, combined latissimus dorsi transfer and reverse total shoulder arthroplasty can restore elevation and external rotation, at least in the short term.     

肩袖撕裂患者肩部力量和肩部功能的相关性研究

目的探讨肩袖撕裂患者手术前肩部力量和肩部功能状况及两者之间的关系。 方法选择2016年3月至2019年7月在本院进行手术治疗的全层肩袖撕裂患者243例。在患者手术前应用等速肌力测试检测患者肩部力量，应用临床评分系统测量患者肩部功能。根据患者撕裂程度大小将患者分为4组：小型撕裂组、中型撕裂组、大型撕裂组、巨大型撕裂组。分析每组患者肩部力量和肩部功能的相关性。 结果在肩袖小型撕裂患者中，外展力量和视觉模拟评分（visual analogue scale，VAS）存在负相关（r=-0.307，P=0.018）；在肩袖中型撕裂患者中，外展力量和美国加州大学肩关节评分系统（ University of California at Los Angeles ,UCLA）（r=0.262，P=0.015）、SF-36躯体健康总评（physical component summary,PCS）（r=0.226，P=0.038）存在正相关；外旋力量和UCLA评分存在正相关（r=0.289，P=0.007）；在肩袖大型撕裂患者中，外展力量和Constant评分（r=0.282，P=0.043）、加州大学肩关节评分系统（American shoulder and elbow surgeon' form , ASES）（r=0.309，P=0.026）、SF-36PCS评分（r=0.317，P=0.022）存在正相关；外旋力量和UCLA评分（r=0.288，P=0.038）、Constant评分（r=0.293，P=0.035）、ASES评分（r=0.329，P=0.017）存在正相关；内旋力量和UCLA评分（r =0.383，P=0.005）、Constant评分（r=0.401，P=0.003）、ASES评分（r=0.314，P=0.023）、SF-36PCS评分（r=0.285，P=0.041）、SF-36精神健康总评（mental component summary , MCS）（r=0.304，P=0.028）存在正相关；在肩袖巨大型撕裂患者中，外展力量和VAS评分（r=-0.308，P=0.035）存在负相关，和UCLA评分（r=0.413，P=0.004）、Constant评分（r=0.489，P=0.000）、ASES评分（r=0.473，P=0.001）、SF-36PCS评分（r=0.772，P=0.000）、SF-36 MCS评分（r=0.293，P=0.046）存在正相关；外旋力量和VAS评分（r=-0.292，P=0.046）存在负相关，和UCLA评分（r=0.629，P=0.000）、Constant评分（r=0.413，P=0.004）、ASES评分（r=0.695，P=0.000）、SF-36 PCS评分（r=0.583，P=0.000）存在正相关；内旋力量和VAS评分（r=-0.309，P=0.035）存在负相关，和UCLA评分（r=0.512，P=0.000）、Constant评分（r=0.709，P=0.000）、ASES评分（r=0.802，P=0.000）、SF-36PCS评分（r=0.501，P=0.000）存在正相关。 结论撕裂程度可能是决定患者肩部力量和肩部功能相关程度的关键因素，部分修复不可修复的巨大撕裂非常重要。     

The effect of humeral stem alignment in reverse shoulder arthroplasty

BackgroundThe impact of stem alignment on hip arthroplasty outcomes has been thoroughly evaluated, but there is limited data assessing this relationship in reverse shoulder arthroplasty (RSA). In this study, we investigated the association of humeral stem alignment with patient outcomes following RSA.MethodsUsing our prospectively maintained institutional registry, we identified patients who underwent reverse shoulder arthroplasty between July 2015 and September 2017 with minimum 2-year follow-up. Two raters independently assessed stem alignment using full-length humeral view radiographs. Stem alignment was correlated to American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, range of motion, complications, and scapular notching at 2-year follow-up.ResultsOf the 117 patients that fit our inclusion criteria, 68 (58%) had neutral or valgus alignment and 49 (42%) had varus alignment. ASES score, VAS pain score, range of motion, complications, and scapular notching showed no differences between the 2 cohorts at 2-years postoperatively. Change (mean, SD) in ASES scores (52.5 ± 17.7 vs. 41.3 ± 21.2, P = .01) and VAS pain scores (−5.7 ± 2.5 vs. −4.6 ± 2.6, P = .02) were greater in the neutral/valgus cohort compared to the varus cohort. Demographics analysis revealed that the neutral or valgus cohort had a larger female population (74% vs. 59%, P < .01) while men were more likely to be in the varus cohort.ConclusionHumeral stem alignment does not appear to affect clinical outcomes at 2-years postoperatively. Improvement in ASES score and VAS pain score were slightly inferior in varus patients, however this difference was not clinically relevant. There may be a correlation between male gender and varus alignment, likely due to better bone quality and larger musculature. Further investigation into the association between stem angulation and clinical outcomes is warranted.Levels of EvidenceLevel III; Retrospective Cohort Study.     

Outcomes for reverse total shoulder arthroplasty after failed open reduction internal fixation versus primary reverse total shoulder arthroplasty for proximal humerus fractures

BackgroundThe purpose of this study is to determine the clinical and radiographic outcomes of reverse total shoulder arthroplasty (RTSA) after failed open reduction internal fixation (ORIF) for proximal humerus fracture (PHF) and compare them to outcomes of primary RTSA for PHF.MethodsWe performed a retrospective comparative study of patients who underwent RTSA between 2008 and 2015 at our institution by one of two fellowship-trained shoulder and elbow surgeons for an acute PHF or for continued pain or functional limitations following ORIF of a PHF. We compared the American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, range-of-motion, and radiographic measurements between cohorts.ResultsIn total, there were 20 patients treated with RTSA after failed ORIF and 30 patients treated acutely with RTSA for PHF. The average ASES score was significantly greater for primary RTSA (82.0 ± 13.5) than for delayed RTSA (64.0 ± 27.2, P = 0.016). The average SST score for primary RTSA (69.4%±19.1%) was significantly higher than the average for delayed RTSA (49.1%±8.9%, P = 0.020). Forward elevation achieved postoperatively was significantly greater for patients treated with primary RTSA versus those with delayed RTSA (130±31° vs 107±31°, P = 0.035). No difference was detected between groups in postoperative external rotation (P = 0.152) or internal rotation (P = 0.872). Radiographically, the tuberosities healed in an anatomic position in 70% of the primary cases versus the prior ORIF group in which the tuberosities were in an anatomic position in all cases (P = 0.007).ConclusionsIn an elderly population, primary RTSA for PHF resulted in better clinical outcomes compared to RTSA following failed ORIF in this retrospective cohort study.Level of EvidenceLevel III; Retrospective Comparative Study     

Reverse shoulder arthroplasty for proximal humeral fractures: better clinical midterm outcome after primary reverse arthroplasty versus secondary reverse arthroplasty after failed ORIF in the elderly

BackgroundJoint replacement surgery as a treatment for complex proximal humeral fractures is an established option, especially in the elderly. In light of the increased attention to reverse total shoulder arthroplasty (rTSA), this study has analyzed the outcomes of patients with primary reverse arthroplasty and after secondary reverse arthroplasty for failed osteosynthesis.MethodsWe retrospectively reviewed 57 patients with an average age of 76 years (min. 55; max. 94; SD 7) from 2010 and 2015 who underwent primary rTSA (30) and secondary rTSA after the failure of plate osteosynthesis (27) after proximal humeral fractures. The functional outcome of the operated shoulder was evaluated by clinical scores (Constant-Score, ASES, DASH and Oxford), range of motion (RoM), pain and activity level.ResultsPrimary rTSA had a significantly better functional outcome, mean-follow-up 37.3 months, measured by Constant-Score (57.13 vs 45.78 points; p= .015) compared to secondary RTSA, mean follow-up 42.1 months. A significantly better active abduction (P= .002), forward flexion (P = .003) and internal rotation (P = .037) was observed in the primary rTSA group, especially in the follow-up > 35 months.ConclusionReverse shoulder arthroplasty is an effective treatment for proximal humeral fractures as primary or revision surgery. The reliable clinical outcome especially in the follow-up to 40 months after primary reverse arthroplasty may suggest to prefer rTSA for complex humeral fractures in the elderly.Level of evidenceLevel III; Retrospective comparative study     

Reverse arthroplasty for osteoarthritis and rotator cuff deficiency after previous surgery for recurrent anterior shoulder instability

Purpose

Osteoarthritis in combination with rotator cuff deficiency following previous shoulder stabilisation surgery and after failed surgical treatment for chronic anterior shoulder dislocation is a challenging condition. The aim of this study was to analyse the results of reverse shoulder arthroplasty in such patients.

Methods

Thirteen patients with a median follow-up of 3.5 (range two to eight) years and a median age of 70 (range 48–82) years were included. In all shoulders a tear of at least one rotator cuff tendon in combination with osteoarthritis was present at the time of arthroplasty. The Constant score, shoulder flexion and external and internal rotation with the elbow at the side were documented pre-operatively and at the final follow-up. Pre-operative, immediate post-operative and final follow-up radiographs were analysed. All complications and revisions were documented.

Results

Twelve patients were either satisfied or very satisfied with the procedure. The median Constant score increased from 26 points pre-operatively to 67 points at the final follow-up (p = 0.001). The median shoulder flexion increased significantly from 70° to 130° and internal rotation from two to four points (p = 0.002). External rotation did not change significantly (p = 0.55). Glenoid notching was present in five cases and was graded as mild in three cases and moderate in two. One complication occurred leading to revision surgery.

Conclusions

Reverse arthroplasty leads to high satisfaction rates for patients with osteoarthritis and rotator cuff deficiency who had undergone previous shoulder stabilisation procedures. The improvements in clinical outcome as well as the radiographic results seem to be comparable with those of other studies reporting on the outcome of reverse shoulder arthroplasty for other conditions.     

Minimum clinically important difference for the American Shoulder and Elbow Surgeons score after revision shoulder arthroplasty

BackgroundPatients undergoing revision total shoulder arthroplasty (TSA) typically achieve smaller improvements in outcome measurements than those undergoing primary TSA. The minimum clinically important difference (MCID) in the American Shoulder and Elbow Surgeons (ASES) questionnaire for primary shoulder arthroplasty ranges from 13.6 to 20.9, but the MCID for revision shoulder arthroplasty remains unclear. This study aims to define the MCID in ASES score for revision TSA and ascertain patient factors that affect achieving the MCID threshold.MethodsPatients were identified from an institutional shoulder arthroplasty database. Prospective data collected included demographic variables, prior shoulder surgeries, primary and revision implants, indication for revision, and pre- and postoperative ASES scores. All patients provided informed consent to participate. An anchor-based method was used with a binary answer choice. The MCID was calculated using the receiver-operator curve (ROC) method, and the sensitivity, specificity, and area under the curve were obtained from the ROC. MCID values were compared between groups using Student's t-test. Multivariate logistic regression modeling was used to determine significant predictors for reaching MCID. Significance was defined as P< .05.ResultsA total of 46 patients underwent revision TSA with minimum 2-year follow-up. The MCID using ROC method was 16.7 with 71% sensitivity and 62% specificity. There was a trend toward males being more likely to reach MCID after revision arthroplasty (P= .058). There were also trends toward increased forward flexion and abduction range of motion in patients who met MCID (P= .08, P= .07). Multivariate logistic regression modeling demonstrated male sex to be associated with achieving MCID (P= .03), while younger age and fewer prior shoulder surgeries demonstrated a trend to association with achieving MCID (P= .06, P= .10).ConclusionThe MCID for ASES score in patients undergoing revision shoulder arthroplasty is similar to previously reported MCID values for patients undergoing primary shoulder arthroplasty. Younger, male patients with fewer prior shoulder surgeries were more likely to achieve MCID after revision TSA.Level of EvidenceLevel III; Retrospective Comparative Treatment Study