Return to sports after shoulder arthroplasty

Many patients prioritize the ability to return to sports following shoulder replacement surgeries, including total shoulder arthroplasty(TSA), reverse total shoulder arthroplasty(RTSA), and hemiarthroplasty(HA). While activity levels after hip and knee replacements have been well-established in the literature, studies on this topic in the field of shoulder arthroplasty are relatively limited. A review of the literature regarding athletic activity after shoulder arthroplasty was performed using the PubMed database. All studies relevant to shoulder arthroplasty and return to sport were included. The majority of patients returned to their prior level of activity within six months following TSA, RTSA, and shoulder HA.Noncontact, low demand activities are permitted by most surgeons postoperatively and generally have higher return rates than contact sports or high-demand activities. In some series, patients reported an improvement in their ability to participate in sports following the arthroplasty procedure. The rates of return to sports following TSA(75%-100%) are slightly higher than those reported for HA(67%-76%) and RTSA(75%-85%). Patients undergoing TSA, RTSA, and shoulder HA should be counseled that there is a high probability that they will be able to return to their preoperative activity level within six months postoperatively. TSA has been associated with higher rates of return to sports than RTSA and HA,although this may reflect differences in patient population or surgical indication.     

Anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty for dislocation arthropathy yield comparable functional outcomes with the matched cohort

BackgroundThe aim of this study was to compare outcomes of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) after prior shoulder stabilization versus matched cohorts without previous stabilization surgery. Hypotheses were as follows: (1) patients undergoing aTSA or rTSA after stabilization procedures would have worse outcomes than matched cohorts and (2) patients undergoing TSA would have better outcomes after soft-tissue stabilization procedures (aTSA_ST or rTSA_ST) than after bony stabilization procedures (aTSA_B or rTSA_B).MethodsRetrospective cohort study was performed comparing (1) 36 patients who underwent aTSA and (2) 32 patients who underwent rTSA with prior shoulder stabilization with 3-to-1 matched cohorts (based on age, gender, and follow-up length) with no prior shoulder instability or surgery. Baseline demographics, perioperative data, adverse events (AEs), radiographic outcomes, functional outcome scores, range of motion (ROM), and patient satisfaction were analyzed. Subgroup analyses compared patients who underwent aTSA_ST or rTSA_ST with patients who underwent aTSA_B or rTSA_B.ResultsThe postoperative AE rate was 8.3% and 4.6% in the aTSA group and matched cohort, respectively (P = .404), with a trend toward a significantly higher incidence of aseptic glenoid loosening in the aTSA group (8.3% vs. 1.9%, P = .067). Functional outcomes, ROM, and patient satisfaction did not differ at follow-up >4 years. In the subgroup analysis, two AEs required reoperation among 25 patients who underwent aTSA_ST versus one among 11 patients who underwent aTSA_B, all related to aseptic loosening. There was a trend toward greater functional outcomes and satisfaction among patients who underwent aTSA_ST. There was a trend toward a clinically significant difference in active abduction at final follow-up favoring aTSA_ST (128 vs. 108 degrees, P = .096).The postoperative AE rate was 6.3% and 4.2% among the rTSA group and matched cohort, respectively (P = .632). Functional outcomes, ROM, and patient satisfaction did not differ at 4-year follow-up. In the subgroup analysis, no AEs were reported among 18 patients who underwent rTSA_ST and 14 patients who underwent rTSA_B. A trend toward greater functional outcomes and patient satisfaction favored patients who underwent rTSA_B, who achieved greater improvements in ROM from baseline and greater ROM in all planes at the final follow-up.ConclusionBoth aTSA and rTSA are reliable options for the treatment of dislocation arthropathy in appropriately selected patients. aTSA and rTSA after prior shoulder stabilization procedures have nearly equal rates of AEs and yield similar clinical and functional outcomes as matched cohorts. There may be an increased risk of glenoid aseptic loosening in aTSA after prior shoulder stabilization. Functional outcomes tend to be greater for patients who underwent aTSA_ST than those for patients who underwent aTSA_B. On the contrary, rTSA may optimize postoperative function when performed for dislocation arthropathy after bony rather than soft-tissue stabilization procedures.Level of evidenceLevel III; Retrospective Cohort Design; Treatment Study     

The use of an eccentric glenosphere compared with a concentric glenosphere in reverse total shoulder arthroplasty: two-year minimum follow-up results

Purpose

The current models of reverse shoulder arthroplasty (RSA) expose the procedure to the risk of scapular notching, possibly leading to loosening of the glenoid. We compared the clinical and radiographic results obtained with a concentric or eccentric glenosphere to assess whether the eccentric design might give better clinical results and avoid or decrease the risk of scapular notching

Methods

Of our patients, 31 underwent RSA using a concentric glenosphere (group A), while 29 had an eccentric glenosphere (group B). Postoperatively, patients were followed-up at one to 12 months and annually thereafter, with the mean being 33 months in group A and 27.5 in group B. In both groups the minimum follow up (F-U) was 24 months. Preoperatively and at each F-U starting from six months, patients were assessed using the Constant score. On radiographs, prosthesis scapular neck angle (PSNA), distance between scapular neck and glenosphere (DBSNG) and peg-glenoid rim distance (PGRD) were calculated. The severity of notching was classified in four grades.

Results

In group A the mean Constant score increased by 30 points compared to the preoperative score and the active ROM increased considerably. At latest F-U, the mean PSNA, DBSNG and PGRD were, respectively, 87°, 3.4 mm and 19.8 mm. Glenoid notching was present in 42 % of cases. In group A, the mean Constant score increased by 34 points and the mean ROM was better than in group A. The average PSNA, PGRD and DBSNG were, respectively, 92°, 21.2 mm and 4.3 mm. Radiographs showed no inferior scapular notching.

Conclusions

The eccentric glenosphere yielded better clinical results than the concentric glenosphere and was associated with no scapular notching.     

Significant variability exists in preoperative planning software measures of glenoid morphology for shoulder arthroplasty

Background & HypothesisWe sought to assess the reliability of 4 different shoulder arthroplasty 3-dimensional preoperative planning programs. Comparison was also made to manual measurements conducted by 2 fellowship-trained musculoskeletal radiologists. We hypothesized that there would be significant variation in measurements of glenoid anatomy affected by glenoid deformity.MethodsA retrospective review of computed tomography (CT) scans of patients undergoing shoulder arthroplasty was undertaken. A total of 76 computed tomographies were analyzed for glenoid version and inclination by 4 templating software systems (VIP, Blueprint, TrueSight, ExactechGPS). Inter-rater reliability was assessed via intra-class correlation coefficient (ICC). For those shoulders with glenohumeral arthritis (58/76), ICC was also calculated when sub-grouping by modified Walch classification. Lin's concordance correlation coefficient was calculated for each system with 2 musculoskeletal-trained radiologists’ measurements.ResultsMeasurements of glenoid version and inclination differed between at least 2 programs by 5º-10º in 75% and 92% of glenoids respectively, and by >10º in 18% and 45% respectively. ICC was excellent for version but only moderate for inclination. ICC was highest among Walch A glenoids for both version (near excellent) and inclination (good), and lowest among Walch D for version (near poor) and Walch B for inclination (moderate). When measuring version, VIP had the highest concordance with manual measurement; Blueprint had the lowest. For inclination Blueprint had the highest concordance; ExactechGPS had the lowest.Discussion & ConclusionDespite overall high reliability for measures of glenoid version between 4 frequently utilized shoulder arthroplasty templating softwares, this reliability is significantly affected by glenoid deformity. The programs were overall less reliable when measuring inclination, and a similar trend of decreasing reliability with increasing glenoid deformity emerged that was not statistically significant. Concordance with manual measurement is also variable. Further research is needed to understand how this variability should be accounted for during shoulder arthroplasty preoperative planning.Level of EvidenceLevel III; Retrospective Comparative Study     

Two-stage revision for periprosthetic infection in shoulder arthroplasty: an institutional experience

BackgroundPeriprosthetic joint infection involving shoulder arthroplasty is often treated with a 2-stage approach, involving resection and placement of an antibiotic cement spacer followed by staged reimplantation after eradication of the infection. While there are several studies examining the near-term clinical course and outcomes of this sequence, there is still ambiguity surrounding the diagnosis and treatment of periprosthetic joint infection, including the nature of the infection as well as treatment failure rates, and we hypothesized that trends may be observed in an institutional cohort of periprosthetic shoulder arthroplasty infections.MethodsA retrospective review of all shoulder arthroplasty cases performed at a tertiary care health system between May 2013 and September 2021 was conducted, revealing 32 patients who underwent a 2-stage treatment for periprosthetic infection, including reimplantation. Cases were reviewed for basic demographic factors, preoperative inflammatory markers, intraoperative frozen specimens and cultured organisms, and antibiotic regimen. Inpatient length of stay, discharge location, and unplanned 90-day readmissions were recorded, as well as subsequent clinical course including further post-reimplantation revisions.ResultsAll 32 cases underwent reimplantation, with a median time of 3.3 months (14.3 weeks) between stages and a post-reimplantation median follow-up of 0.6 years (minimum 1 year: 40%). Twenty-four (75%) cases required no further revision surgery, and in no cases was there a recurrence of deep infection or repeat 2-stage treatment after reimplantation. Four patients subsequently underwent aseptic revision, 3 sustained a periprosthetic fracture, and 1 underwent an irrigation and débridement for superficial cellulitis. At spacer placement, 17 cases (57%) were culture-negative infections, while 6 cases (20%) grew Cutibacterium acnes. Intraoperative frozen sections were taken in 17 cases, but only 3 (18%) were positive for acute inflammation.ConclusionTwo-stage treatment for periprosthetic infection in shoulder arthroplasty appears to have a high efficacy in preventing recurrence of deep infection, but patients should be counseled regarding its high all-cause revision rate following reimplantation. Further, many infections can be culture-negative with no intraoperative evidence of acute inflammation.     

Implantation accuracy of custom-made glenoid implants for treating severe glenoid bone deficiencies with reverse shoulder arthroplasty

BackgroundCustom-made three dimensional–printed glenoid implants for reverse shoulder arthroplasty are a modern treatment option for severe glenoid bone deficiencies. The potential advantages of not only achieving primary stability but also being able to realize the preoperative plan in terms of implantation accuracy at the same time have not yet been sufficiently investigated. The purpose of this study was to quantify the implantation precision of custom-made glenoid implants.MethodsTwelve consecutive patients with severe glenoid bone defects were treated between May 2019 and August 2020 using a custom-made glenoid implant (ProMade) (LimaCorporate, San Daniele, Italy) with reverse shoulder arthroplasty at a single hospital. All patients were eligible for inclusion and could be enrolled in this institutional review board–approved study. The immediate postoperative computer tomography–evaluated position of the glenoid implant was compared with the preoperative computer-based plan, on which the manufacturing process was based. As a result of this comparison, deviation measurements in six degrees of freedom (inclination, version, mediolateral offset, anteroposterior offset, superoinferior offset, and roll rotation) emerged.ResultsThe absolute average (mean value ± standard deviation) implantation deviation related to the plan was 1.6° ± 5.4° for version, 1.9° ± 4.1° for inclination, 0.3 mm ± 3.3 mm for mediolateral offset, 0.1 mm ± 1.9 mm for anteroposterior offset, 0.0 mm ± 2.4 mm for superoinferior offset, and 1.0° ± 6.3° for roll rotation. The augment volume averaged 9.0 cm³ ± 2.6 cm³. All custom-made glenoid implants were implanted with a subjectively sufficient primary stability.ConclusionThis study gives an indication that custom-made three dimensional–printed glenoid implants can be implanted with statistically high accuracy. To evaluate the clinical benefit and radiographic stability, a longer follow-up investigation is needed.     

Reverse total shoulder arthroplasty in wheelchair-dependent patients: a matched cohort study

BackgroundShoulder function in wheelchair-dependent patients is critical for preserving independence and quality of life due to lower extremity impairment. The purpose of this study was to report the revision rate, as well as clinical and radiological outcome in wheelchair-dependent patients treated with reverse total shoulder arthroplasty (RTSA) and to compare them to an ambulating population.MethodsProspectively obtained data of 21 primary RTSAs in 17 wheelchair-dependent patients (5 male, 12 female) with a median age of 72.4 years (range: 49-80) and a minimum follow-up of 2 years were analyzed retrospectively. Revision rate, clinical (Subjective Shoulder Value = SSV, relative Constant-Murley Score = rCS, wheelchair user’s shoulder pain index = WUSPI) and radiological (glenoid loosening, scapular notching, glenoid inclination) outcome, as well as implant-related parameters (baseplate peg length, glenosphere size, bony augmentation), were compared with a 2:1 matching cohort of 42 ambulating patients (10 male, 32 female) with a median age of 72.5 years (range: 56-78).ResultsThe revision rate was 9.5% in both cohorts. In the wheelchair cohort, two shoulders had to be revised due to a complete baseplate dislocation. In the matching cohort, four shoulders had to be revised due to one prosthetic dislocation, one traumatic and one atraumatic scapular spine fracture with glenoid baseplate dislocation, and one fracture of the greater tuberosity. Median preoperative SSV and rCS did not differ significantly between cohorts. Postoperative SSV was also comparable (wheelchair: median 70 (range: 10-99) vs. matching: median 70 (30-100), p = n.s.). Relative CS was significantly lower in the wheelchair cohort (65% vs. 81.4%, P = .004). Median postoperative WUSPI was 35 points (range: 13-40) for difficulty and 0 points for pain (range: 0-29). The highest difficulty and pain were found for ‘hygiene behind the back’ and ‘propulsion of wheelchair up a ramp or on uneven surface’. Glenoid loosening, scapular notching, and postoperative baseplate inclination did not differ significantly between cohorts. In the wheelchair cohort, glenoid autograft augmentation (38.1% vs. 7.1%, P = .002) and implantation of baseplates with longer pegs were performed more often (≥ 25mm: 38.1% vs. 7.1%, P = .004).ConclusionRTSA is a valuable therapeutic option for the treatment of advanced OA or irreparable rotator cuff tears in wheelchair-bound patients with high patient satisfaction. Postoperatively, poorer function and a higher rate of baseplate dislocations might be anticipated compared to ambulating patients.     

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     

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.