The effect of body mass index on functional outcome,pain, and postoperative complications in shoulder arthroplasty after a proximal humerus fracture

BackgroundAlthough shoulder arthroplasty often gives a reliable improvement in shoulder pain and function after proximal humeral fractures (PHFs), one must consider the risk of complications. The purpose of this study was to investigate whether body mass index (BMI) is associated with an increased risk of complications or worse postoperative shoulder function after reverse shoulder arthroplasty (RSA) or hemiarthroplasty (HA) in patients with PHF.MethodsThis study included 233 patients who underwent HA or RSA after PHF in the Ryhov Teaching Hospital between 2006 and 2018. Data collected include age, gender, BMI, preoperative and postoperative Constant score, preoperative and postoperative visual analogue scale (VAS) score during rest and activity, postoperative complications, and patient satisfaction.ResultsAnalysis was made in HA and RSA patients separately. The HA and RSA patients were divided into three groups based on their BMI. Group I consisted of patients with a BMI <25 kg/m², group II consisted of patients with a BMI between 25 and 29.9 kg/m², and group III consisted of patients with a BMI > 30 kg/m². We found no statistically significant difference between BMI groups regarding postoperative Constant score, postoperative VAS score during rest, postoperative VAS score during activity, postoperative complications, and patient satisfaction in neither HA patients nor RSA patients.ConclusionThis study showed that BMI did not affect the risk of postoperative complications or bad functional outcome after treatment of PHF with HA or RSA.     

Difference in clinical outcome between total shoulder arthroplasty and reverse shoulder arthroplasty used in hemiarthroplasty revision surgery

Introduction:The increase of shoulder replacements will lead to a higher revision rate of shoulder arthroplasties. The aim of this study is to evaluate the clinical results of revision surgery performed in our hospital, distinguish the differences in clinical outcome according to revision indication and differences between total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) in hemiarthroplasty (HA) revision surgery.Results:From July 1994 to July 2008, 39 patients (40 shoulders) underwent revision arthroplasty. Of 19 patients (19 shoulders) we obtained a complete follow-up. The mean age at revision surgery 69 ± 10 years (range: 46-83) and the mean follow-up 41 ± 31 months (range: 10-113). In 7 cases TSA was used for revision when the cuff was intact, 12 times RSA was performed. The indications for the revision were glenoid erosion (n = 4), humeral component malposition (n = 2), cuff-pathology (n = 12) and infection (n = 1). Postoperative constant score 51.7 ± 11.4 for TSA and 31.1 ± 18.7 for RSA (P = 0.008). The DASH was 48.3 ± 25.1 and 68.7 ± 17.5, respectively (P = 0.09). DSST showed 6 ± 4 and 4 ± 4 (P = 0.414). OSS 41.3 ± 10.1 and 28.1 ± 10.3 (P = 0.017). SF-36 43.3 ± 22.1 and 24.5 ± 12.8 (P = 0.072). Four shoulders (21%) presented four complications.Conclusions:In this study, revision surgery showed poor to reasonable postoperative results and better clinical outcome for TSA. When a revision after HA was needed, and the soft-tissue component of the shoulder was intact, a TSA proved to be a preferable solution.     

Clinical application of intraoperative O-arm navigation in reverse shoulder arthroplasty

BackgroundInaccurate fixation and positioning of the glenoid component using conventional techniques are problematic in reversed shoulder arthroplasty (RSA). Our objective was to investigate the accuracy of O-arm navigation of the glenoid component in RSA.MethodsThis retrospective case–control study comprised 2 groups of 25 patients who underwent reversed shoulder arthroplasty with or without intraoperative O-arm navigation. The intraoperative goal was to place the component neutrally in the glenoid in the axial plane and 10° inferiorly tilted in the scapular plane. Glenoid version angle and inclination were measured by computed tomography obtained preoperatively and a year postoperatively. Operative time, intraoperative bleeding, and the presence of postoperative complications were recorded.ResultsCompared with the ideal, the range of error for version was 7.3° (SD 3.6°) in the control group and 5.6° (SD 3.6°) in the navigated group (P = 0.278), and the range of error for inclination was 18.3° (SD 11.7°) in the control group and 4.9° (SD 3.8°) in the navigated group (P = 0.0004). The mean operative time was 164.6 (SD 21.2) min in the control group and 192.0 (SD 16.2) min in the navigated group (P = 0.001). The mean intraoperative bleeding was 201.0 (SD 37.0) mL in the control group and 185.3 (SD 35.6) mL in the navigated group (P = 0.300). There were no complications reported related to the intraoperative O-arm navigation.ConclusionO-arm navigation may be a useful tool for the placement with inferior tilt of the glenoid procedure in reversed shoulder arthroplasty.     

Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty

Introduction

Fracture sequelae (FS) of the proximal humerus is a challenging scenario in shoulder surgery. Despite they have been traditionally treated with hemiarthroplasty (HA), the use of reverse shoulder arthroplasty (RSA) has been recently introduced. However, there are no studies comparing the results of HA and RSA in FS. The purpose of this study was to compare the functional and quality of life-related outcomes, and complications in the treatment of proximal humeral FS between HA and RSA.

Materials and methods

A therapeutic prospective non-randomized comparative study was conducted. All consecutive patients with diagnosis of FS after non-operative treatment of proximal humeral fractures and no previous shoulder surgery were considered for this study. A total of 32 patients (24 females, 8 males) with a mean (SD) age at the time of surgery of 80.1 (4.9) years were finally included: 12 in the HA group, and 20 in the RSA group. FS were treated with shoulder arthroplasty by the implantation of either HA or RSA. Constant score (total and specific items), quality of life (assessed through SF-36), and complications requiring revision surgery were compared between groups.

Results

All parameters of the Constant score significantly improved in the postoperative compared to preoperative period when considering the entire sample. The RSA group demonstrated a higher improvement in total Constant score (p = 0.06) and Constant activity level (p = 0.02) compared to the HA group. The HA demonstrated a higher number of complications compared to the RSA (p = 0.05). There were no differences in SF-36 scores between both groups.

Conclusions

The shoulder arthroplasty is an effective treatment for FS with significant improvement in pain and function. The RSA may be a better option than HA for FS given the trend towards better total Constant score and a significantly lower number of complications requiring revision surgery.

Level of evidence

Therapeutic level II evidence.     

Survivorship of a Medialized Glenoid and Lateralized Onlay Humerus Reverse Shoulder Arthroplasty Is High at Midterm Follow-up

Background

Reverse shoulder arthroplasty (RSA) is a common treatment of a variety of disabling shoulder conditions. The purpose of this study was to determine revision-free survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus implant and to identify etiologies of revision.

Methods

All RSAs performed using the Comprehensive^® Reverse Shoulder System (Zimmer Biomet, Inc.; Warsaw, IN, USA) at one institution from 2008 to 2014 were identified through a retrospective review. Charts were reviewed to determine whether the RSA was a primary or revision surgery. Patients were contacted by telephone, and survivorship was defined as no subsequent surgery after RSA. Of the 526 RSAs performed, responses were obtained from 403 patients (77%). A Kaplan–Meier analysis was performed to determine survivorship over time. A χ² test was used to determine differences between revision rates after RSA.

Results

Minimum follow-up was 3 years, and average follow-up was 4.83 ± 1.60 years. Survivorship was 96% at 2 years and 93% at 5 years after RSA. Revisions were performed for instability (n = 8), humeral tray-taper junction failure (n = 5), acute fracture (n = 4), infection (n = 3), glenoid loosening (n = 3), osteolysis (n = 1), or notching (n = 1). Fourteen of the 151 patients (9.2%) who had surgery prior to RSA required revision after RSA. Having shoulder surgery prior to RSA was associated with higher rates of subsequent revision after RSA.

Conclusion

Overall, survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus RSA is high, and prostheses implanted in native shoulders have lower rates of revision at midterm follow-up. Instability (1.9%) was the most common reason for revision.

     

Is distal peripheral neuropathy common after shoulder arthroplasty?

BackgroundNeurologic injury after shoulder arthroplasty has been reported in previous outcome studies. However, the incidence and development of distal peripheral neuropathy (DPN) after shoulder arthroplasty requiring surgical intervention has not been previously described.HypothesisThe authors report on the incidence of DPN requiring surgical intervention following shoulder arthroplasty.MethodsA retrospective review was conducted of a prospectively collected shoulder arthroplasty registry at a single institution from a single surgeon from April 2006 to April 2017. Patients were included in the series if they had primary surgical intervention for ipsilateral or contralateral peripheral neuropathy following primary shoulder arthroplasty. Patients were excluded if they had known peripheral neuropathy or cervical radiculopathy prior to surgery. DPN was defined for the study as symptoms or diagnostic testing consistent with cubital tunnel or carpal tunnel syndrome. Demographics, patient reported outcome measures, and preoperative and postoperative shoulder range of motion were collected and analyzed with paired t-tests and multivariate regression models.ResultsOne thousand three hundred eighty-seven total shoulder arthroplasties were performed in this period. During the study period, 16 patients (1.2%) underwent surgery for ipsilateral DPN while 6 patients (0.4%) underwent surgery for contralateral DPN. ASES scores, SANE scores, and shoulder flexion improved significantly from pre- to postoperatively for both groups. There was no significant difference in postoperative scores between groups. Finally, the multivariate linear analysis did not yield any statistically significant regression equations for ASES, SANE VAS, AFE, and AER.ConclusionShoulder arthroplasty resulted in increased ipsilateral distal peripheral neuropathy. Emergence of DPN symptoms following arthroplasty is multifactorial and may be related to a form of the double crush syndrome.Level of evidenceLevel IV; Case series     

Glenoid baseplate migration with subsequent stabilization after reverse shoulder arthroplasty using a through-growth cage: a matched cohort study

BackgroundFew studies have evaluated the outcomes of glenoid baseplate migration after reverse shoulder arthroplasty (RSA). The question is whether an ingrowth central cage implant that has undergone early migration can restabilize due to cage ingrowth. The primary purpose of this study is to evaluate the radiographic factors associated with glenoid baseplate migration after RSA using a through-growth cage implant and secondarily evaluate their clinical outcomes with nonoperative management.MethodsA retrospective review of a single institution database was performed from January 1,2008 to June 30, 2017 for all shoulders using a single implant system (Equinoxe, Exactech, Inc., Gainesville, FL, USA). All RSAs with a documented complication of glenoid loosening were evaluated. Chart and radiograph review was performed to identify shoulders with confirmed glenoid loosening undergoing revision (revision group, n = 10) and those with migration that stabilized over time and avoided revision surgery (stable migration group, n = 10). The stable migration group was matched to an age-, sex-, and follow-up matched control group (1:3) (control group, n = 30). Demographic factors, preoperative and immediate postoperative radiographic factors, active range of motion (ROM), and patient-reported outcomes (PROMs) were compared. Radiographic factors evaluated included preoperative alpha/beta angles, humeral lengthening, glenosphere overhang, prosthesis-scapular neck angle, glenosphere inclination, and postoperative alpha/beta angles.ResultsA total of 50 RSA patients were evaluated at a mean follow-up of 38 months. Immediate postoperative inferior glenoid overhang was significantly less in the stable migration group compared to the control group (6.2 vs. 8.6 mm, P = .03). Preoperative ROM and PROMs were similar amongst all 3 groups. The stable migration group demonstrated improved ROM and PROMs compared preoperatively with all ROM and PROM values exceeding the minimally clinically important difference (MCID). The control group demonstrated greater improvements in ROM and PROMs compared to the stable migration group, with a majority exceeding the MCID. When compared to the revision group, the stable migration group had significantly greater improvements in forward flexion, ASES score, and Constant score as well as improvements above the MCID in abduction, external rotation, and SST score.ConclusionRSA patients with glenoid migration and secondary stabilization still achieve improved ROM above the MCID, but the results are inferior to those RSA patients without glenoid migration. Approximately half of the shoulders with baseplate loosening using a through-growth cage implant will restabilize and have better ROM and function compared to those that are ultimately revised.Level of EvidenceLevel III; Treatment Study     

Quantitative in vivo assessment of bone allograft viability using 18F-fluoride PET/CT after glenoid augmentation in reverse shoulder arthroplasty: a pilot study

Background

Success after glenoid bone augmentation in total shoulder arthroplasty depends on osseous integration and non-resorption. Standard imaging techniques, such as computed tomography (CT) and X-rays, cannot quantify bone viability. Therefore, we introduce a new technique to assess graft viability using ¹⁸F-sodium fluoride (¹⁸F-NaF) PET–CT for femoral allografts in reverse total shoulder arthroplasty (RSA).

Materials and methods

Patient charts were reviewed following glenoid augmentation using femoral allografts in reverse total shoulder arthroplasty. A total of seven patients were included in this study. ¹⁸F-NaF PET–CT was used to assess graft viability and graft fusion. Semiquantitative assessment of ¹⁸F-NaF uptake was performed by means of a standardized uptake value (SUV). Radiographs were used to assess fusion. The mean age of the patients at the time of follow-up was 83.4 years (range 79–92), and the mean follow-up was 44.4 months.

Results

Viability and fusion were confirmed in all allografts using semiquantitative analysis of ¹⁸F-NaF PET–CT by means of standardized uptake value (SUVmax). Metabolic activity of medullary region of a vertebral spine was defined as a reference background. The mean value of maximum tracer activity in the allograft was not statistically different from native bone in the reference vertebrae (p = 0.14).

Conclusions

¹⁸F-NaF PET–CT is a practicable tool to quantitatively assess viability in large bone allografts after glenoid augmentation in RSA. The study shows viability and fusion in all allografts.

Level of Evidence

Level IV, treatment study.

     

Function after closed reduction from early unstable reverse shoulder arthroplasty

BackgroundOptimizing deltoid tension during reverse shoulder arthroplasty (RSA) remains a challenge for the shoulder surgeon. Ideal tension likely differs based on patient age, anatomy, size, preoperative diagnosis, and deltoid strength. Excess tension might overstuff the joint and limit range of motion. The aim of this study was to compare the function of patients with early postoperative instability (as a proxy for deltoid tension) and those without instability.MethodsA retrospective cohort study comparing two groups of patients with primary RSA operated on over a 5-year period by a single fellowship-trained shoulder and elbow surgeon using a combination of lateralized and medialized glenoid prosthesis with a 135-degree neck-shaft angle on the humeral side was conducted. The main exposure was shoulder dislocation that did not require revision arthroplasty compared with all other patients in the study period who underwent uneventful primary RSA. Chart review was performed for patient demographics, preoperative diagnosis, operative details, preoperative and postoperative range of motion and pain, reoperation, and instability events. The primary outcome was final clinic visit forward elevation. Outcomes included preoperative, postoperative, and difference in forward elevation and external rotation, as well as pain level.ResultsA total of 79 shoulders treated with primary RSA from 2015 to 2019 were identified. The average follow-up was 9 months (range, 3-47 months). Sixty-seven patients (72 shoulders) underwent uneventful primary RSA. Seven patients (7 shoulders) in the treatment cohort presented to a postoperative visit with complaint of shoulder dislocation that was able to be self-reduced and/or presented with a dislocated shoulder requiring closed reduction without sedation. At the final follow-up, average postoperative forward elevation was 121 ± 27 degrees in stable shoulders versus 145 ± 15 degrees in the unstable group (P = .003). No significant difference in external rotation was shown between stable and unstable RSA (39 ± 12 degrees and 36 ± 14 degrees, respectively). Overall average forward elevation and external rotation improved from 71 to 123 degrees and 19 to 39 degrees, respectively. More than 95% of patients (69/72 uneventful RSA and 6/7 unstable RSA) reported improvement in shoulder pain postoperatively.ConclusionIn the absence of other reasons for instability, early dislocation after RSA is a potential marker of relatively loose deltoid tension. In this study, patients with instability demonstrated higher forward elevation. Patients without instability are likely a mix of those with optimal and suboptimal deltoid tension.Level of evidenceLevel III, Retrospective Comparative Treatment Study     

Clinical and radiological outcome of the Total Evolutive Shoulder System (TESS®) reverse shoulder arthroplasty: a prospective comparative non-randomised study

Purpose

The aims of this study were to assess the function and quality of life after the Total Evolutive Shoulder System (TESS) reverse shoulder arthroplasty (RSA), to evaluate the radiological stability of the stemless version and to address the effect of arm lengthening and scapular notching (SN) on the outcome.

Methods

This was a prospective comparative non-randomised study. A total of 37 consecutive patients (40 shoulders) underwent TESS RSA between October 2007 and January 2012; 16 were stemless and 26 were stemmed. At a mean follow-up of 39 months (15–66), we evaluated range of motion (ROM), pain and functional outcome with QuickDASH and quality of life with EQ-5D score. Radiologically, component positioning, signs of loosening, SN and arm length difference were documented.

Results

We found a significant improvement in functional outcome and reduction of pain in both stemmed and stemless groups. No humeral loosening was evident, but there were four glenoid loosenings. In 12 shoulders that developed SN, seven already had scapular bone impression (SBI) evident on initial post-operative radiographs. Glenoid overhang seemed to decrease the risk of SN. Arm lengthening was associated with better EQ-5D but did not influence ROM or functional outcome.

Conclusions

Reverse shoulder arthroplasty markedly improved shoulder function. SN is of concern in RSA, but proper positioning of the glenoid component may prevent its development.     

Effect of reverse total shoulder arthroplasty humeral inclination on glenohumeral range of motion,deltoid force,and glenoid strain: a biomechanical study

BackgroundReverse total shoulder arthroplasty (RSA) primarily varies between 2 implant design options: a 135 humeral stem inclination that closely resembles anatomic orientation, versus the Grammont-style 155 humeral stem inclination that further medializes and distalizes the center of rotation (COR). The purpose of this study was to compare deltoid force, glenoid strain, and simulated glenohumeral range of motion (ROM) between RSA 135 and RSA 155 designs, with a series of standardized permutations of glenosphere offset and rotator cuff pathology.MethodsTwelve fresh-frozen cadaveric shoulder specimens were studied using a shoulder simulator. Native shoulder motion profiles for reproducible abduction range of motion were established using a customized testing device. Optical 3-dimensional tracking and pressure sensors were used to accurately record glenohumeral range of motion (ROM), deltoid force, and glenoid strain for RSA 135 and RSA 155 designs. For each cohort, all combinations of glenosphere offsets and rotator cuff tendon involvement were evaluated.ResultsThere was no significant difference in the overall abduction ROM between the 155 and the 135 humeral stem implants (P = .75). Resting abduction angle and maximum abduction angle were significantly greater with a 155 + STD (standard offset) construct than with a 135 + STD construct (P < .001 and P = .01, respectively). Both stem inclinations decreased combined deltoid force requirements as compared the native shoulder with a massive cuff tear. Effective glenoid strain did not vary significantly between 135 + STD and 155 + STD constructs (P = .66).ConclusionOverall, range of motion between the 135 and the 155 humeral stem inclinations was not significantly different. The cumulative deltoid force was lower in RSA shoulders when compared to native shoulders with massive rotator cuff tears, highlighting the utility of both implant designs. The Grammont-style 155 stem coupled with a 2.5 mm inferior offset glenosphere required less deltoid force to reach maximum abduction than did the more anatomic, lateralized 135 stem coupled with a 4 mm lateral offset glenosphere.Level of EvidenceBasic Science, Biomechanics Controlled Laboratory Study     

Return to golf after shoulder arthroplasty: golf performance and outcome scores

BackgroundGolf is an increasingly popular sport in the United States, especially among the age group of patients undergoing joint replacement. Return to golf after hip and knee arthroplasty has been previously studied. However, the quality and level of play after total shoulder arthroplasty (TSA) are less defined, especially after reverse shoulder arthroplasty (RSA). We hypothesize that shoulder pain and performance will improve during golf similarly after both anatomic and reverse total shoulder arthroplasties.MethodsThis is a retrospective cohort study of 69 patients identified as playing golf recreationally before undergoing either anatomic or RSA. All patients were cleared to return to golf activities 3 months after surgery. A golf-specific questionnaire was emailed to patients focusing on their experience returning to golf after shoulder arthroplasty. Results after TSA were compared with RSA. Patient-reported and functional outcome scores were evaluated.ResultsThe median age at surgery was 70 (62-73) years with 47 (68.1%) total shoulder replacements and 22 (31.9%) reverse shoulder replacements. Thirty-six (52.1%) patients returned to playing golf within 6 months and sixty (87.0%) patients returned to playing golf within 12 months after surgery. Enjoyment of golf either improved or stayed the same in 51 patients (91.0%). There was no significant change in the handicap score after shoulder replacement. Pain experienced during golf improved significantly from a median visual analog score pain of 6 to 1 (P < .001), with slightly greater improvement in pain for patients who underwent TSA (P = .025). Driving distance improved for 52.2% of patients, with patients who underwent TSA reporting significantly greater improvements in distance (P = .014). For all other questions, patients treated with anatomic shoulder arthroplasty and RSA reported similar experiences. American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, Single Assessment Numerical Evaluation score, visual analog score function, active flexion, and external rotation all significantly improved at the most recent follow-up (P < .001).ConclusionReturn to golf after both reverse and anatomic total shoulder arthroplasties is a realistic expectation, with significant improvements in pain and function while playing golf. Enjoyment playing golf, golf performance, and average length of drive improve in approximately half of all patients. Patients treated with anatomic shoulder arthroplasty and RSA can expect similar golf experiences after surgery, with patients who underwent TSA experiencing a better improvement in driving distance.     

Glenosphere inclination and clinical outcomes after reverse shoulder arthroplasty

BackgroundThe relationship of numerous implant design and positioning-related variables with range of motion and clinical outcomes have been investigated for reverse shoulder arthroplasty (RSA). While glenosphere inclination has been investigated with regards to implant fixation and scapular notching, little research has been done on the association between glenosphere inclination and clinical outcomes. Therefore, the primary objective of this study was to investigate the relationship between preoperative glenoid inclination, postoperative glenosphere inclination and inclination change (∆INC) from pre- to postoperative on clinical outcomes after RSA.MethodsA multicenter retrospective study was conducted of RSAs with minimum 2-year clinical follow-up. All included patients had the same RSA prosthesis. Preoperative, postoperative, and ∆INC from pre-to postoperatively were measured for each patient. The primary study outcome was the minimum 2-year ASES score. Secondary outcomes were active range of motion, Constant-Murley score and Western Ontario Ostearthritis Shoulder (WOOS) score at a minimum of 2 years postoperatively. Receiver-operator characteristic curve analyses were performed to determine if any significant thresholds in inclination existed. Univariate analyses were performed with ANOVA to compare subgroup means. Finally, a multivariate logistic regression was performed to examine each inclination variable as a predictor of clinical outcome while controlling for patient and implant-related variables.ResultsEighty seven patients were included in the study. The mean age was 70 years and 53% of patients were male. The examiners had excellent reliability determined by intraclass correlation coefficients for all 3 measurements. There was no apparent correlation between preoperative inclination, postoperative inclination or ∆INC with minimum 2-year ASES scores. This was confirmed in the receiver-operator characteristic analyses, where no significant thresholds were found for each of the 3 assessed measurements (P> .05 for all analyses). A subgroup analysis comparing patients with low preoperative inclination (<10°) and patients with high preoperative inclination (>10°) stratified by the ∆INC demonstrated no significant association with inclination (P > .05 for all comparisons). In the multivariate regression analysis, inclination had no significant association with the minimum 2-year ASES scores.ConclusionFor the studied implant system, preoperative inclination, postoperative inclination and ∆INC did not have a significant association with postoperative clinical outcomes after RSA.Level of evidenceLevel III; Retrospective Comparison Study     

Changes in deltoid muscle tension after reverse shoulder arthroplasty as quantified by shear wave elastography: relationship with radiographic parameters and functional outcomes

IntroductionImplantation of a reverse shoulder arthroplasty (RSA) impacts deltoid length, shape and tension. Quantification of changes in deltoid muscle tension with implantation of RSA has remained elusive. The purpose of this study was to use shear wave elastography (SWE) to quantify deltoid muscle stiffness preoperatively, intraoperatively and postoperatively in patients undergoing RSA.MethodsTwenty patients scheduled to undergo RSA (ReUnion, Stryker) were prospectively enrolled in this study. A single observer trained in SWE quantified deltoid stiffness preoperatively, intraoperatively, and postoperatively. Clinical evaluation included pain, motion, quickDASH, ASES, Oxford, and subjective shoulder value scores. Preoperative and postoperative radiographs were measured by an independent observer to determine the lateralization and distalization shoulder angles (LSA and DSA). A statistical analysis was then performed to determine whether changes in deltoid muscle stiffness correlated with any of these parameters.ResultsImplantation of a RSA lead to an increase SWE deltoid stiffness value from 22.4 ± 4.2 kPa preoperatively to 29.9 ± 5.23 kPa (P˂ .0001) immediately after surgery, and 26.6 ± 6.6kPa (P= .03) at most recent follow-up. Preoperative SWE deltoid stiffness values did not differ when measured in the office or under anesthesia. Reverse arthroplasty did not significantly change the LSA (P= .051), but did increase the DSA (P< .0001). Greater SWE deltoid stiffness values correlated with better active elevation (P= .0128) better external rotation (P= .0247), and larger DSA (P= .0026). Elevation and external rotation showed a positive correlation with the DSA and a negative correlation with the LSA.ConclusionAfter implantation of one RSA design incorporating glenoid and humeral lateralization, deltoid stiffness as measured with SWE increased significantly. Deltoid stiffness seems to correlate with joint distalization, elevation and external rotation. SWE seems to be reliable to quantify deltoid stiffness after reverse shoulder arthroplasty.Level of EvidenceLevel IV; Diagnostic Study     

Revision to reverse total shoulder arthroplasty: do short stem and stemless implants reduce the operative burden compared to convertible stems?

BackgroundRevision of prior hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) to reverse shoulder arthroplasty (RSA) is a technically challenging procedure with high complication rates. The purpose of this study was to compare intraoperative complications between convertible humeral stems and nonconvertible humeral stems stratified by stem length for conversion of TSA or HA to RSA.Materials and methodsA multicenter retrospective analysis of patients undergoing revision of a primary TSA or HA to RSA was conducted. Patients were divided into 2 groups based on convertible or nonconvertible humeral stem design from the index surgery. The primary outcome measures were the following intraoperative variables and complications: total operative time, blood loss, intraoperative fracture, overall complication rate, and blood transfusions. Rates were compared between groups and analyzed according to primary stem length for the nonconvertible group.ResultsA total of 279 patients were included in the study, 70 with convertible stems and 209 with nonconvertible stems. About 70% of convertible stems were successfully retained. Operative time was similar between the 2 groups overall. Patients with nonconvertible stems had higher intraoperative blood loss (P = .0001), higher overall complication rate (P = .009), and greater risk of intraoperative fracture (P = .002). Revising stemless and short stems to RSA had significantly reduced operative time compared to standard length stems (97 and 116 minutes vs. 141 minutes, P < .0001 and P = .035, respectively). When revising stemless implants, there was a significantly lower rate of intraoperative fracture (3.6%) compared to short stems (24%, P = .004) and standard stems (23.4%, P = .001). When revising stemless implants to RSA, there was shorter operative time (P= .0001) and similarly low rate of intraoperative fracture (P= .820) compared to convertible stems.ConclusionIn revision of anatomic TSA to RSA, convertible stems lead to lower blood loss and intraoperative fracture rate compared to nonconvertible stems when broadly including all stem types. However, differences appear to be based on stem type. Among nonconvertible stems, revision of short stem and stemless implants are associated with reduced operative time compared to standard length stems. Revision of stemless implants to RSA is associated with the shortest operative time of all implant types as well as a similar rate of intraoperative fracture compared to convertible stems.Level of EvidenceLevel III; Retrospective Cohort Comparative Study     

Bone preserving technique for reverse arthroplasty: The preferred management option for osteoarthritis with glenoid bone loss in patients 70 and older

Elderly patients with shoulder arthritis and glenoid bone loss represent a challenging patient population. Surgical treatment options include hemiarthroplasty, anatomic total shoulder arthroplasty (TSA) with bone grafting or augmentation, and reverse total shoulder arthroplasty (RSA). The RSA has multiple advantages compared to anatomic TSA, particularly in an older patient population with glenoid bone loss.RSA with an augmented glenoid baseplate is ideal for the treatment of patients who have glenoid bone loss. The augmented base plate has many advantages including bone preservation, longer central and peripheral screws, ability to dial the augment to match the region of bone deficiency, and lateralization to improve tensioning on the deltoid and rotator cuff. Additionally, a bone preserving RSA is possible with an augmented glenoid baseplate in patients with no glenoid bone loss.     

Utilization of reverse shoulder arthroplasty for the treatment of glenohumeral arthritis among American Board of Orthopaedic Surgery (ABOS) Part II candidates, 2008-2019

BackgroundDespite advances in shoulder arthroplasty, treatment options for advanced glenohumeral osteoarthritis (GHOA) remain limited. Surgical management includes total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), and hemiarthroplasty. The rates of TSA and RSA for the treatment of GHOA in the United States has increased in recent years. Trends in shoulder arthroplasty in recently trained surgeons have not been explored. The purpose of the study was to examine the trends in arthroplasty use (TSA, RSA, and hemiarthroplasty) for primary GHOA among American Board of Orthopedic Surgeons (ABOS) Part II examinees, and to identify patterns based on geographic region or fellowship training.MethodsABOS Part II examinees with at least 1 shoulder arthroplasty in the examination years 2008-2019 were collected. Hemiarthroplasty, TSA, and RSA performed from 2007-2018 for a diagnosis of primary GHOA were included. Arthroplasty for primary or secondary diagnoses of fracture, infection, tumor, rotator cuff arthropathy or tear, revision, and non-arthroplasty procedures were excluded. Proportion and volume of cases were evaluated, with sub-analyses of geographic region and fellowship training. Univariate logistic regression determined statistical significance (P< .05).ResultsA total of 946,946 cases from 8609 ABOS Part II examinees were submitted, with 8733 shoulder arthroplasties performed. Overall, 3923 arthroplasties for primary GHOA were included (44.9% of all shoulder arthroplasties). TSA was used in 50.9% of cases. The proportion of RSA performed for primary GHOA has increased over the past 11 years, with RSA surpassing TSA as the most common procedure for primary GHOA over the last 4 years (P< .001). Hemiarthroplasty is less commonly. TSA and RSA were performed in similar proportions across regions, with the largest volume in the Midwest. Most procedures (91.5%) were completed by surgeons in sports medicine, shoulder and elbow, and those completing multiple fellowships. From 2008-2019 the number of RSA procedures performed for primary GHOA by sports medicine and shoulder and elbow surgeons has increased approximately 1100% and 800%, respectively (P< .001).ConclusionUtilization of RSA for treatment of primary GHOA by ABOS Part II examinees has increased significantly over the past twelve years. Among ABOS Part II examinees, RSA has recently surpassed TSA as the most common arthroplasty utilized for treatment of primary GHOA. Examination of early-career surgical practice allows for consideration of training influence in treatment of GHOA. As volume of shoulder arthroplasty continues to increase, trends and procedure volume have implications for clinical practice and patient outcomes.Level of EvidenceLevel IV; Case-series Database Study     

Shoulder arthroplasty in patients with ipsilateral hemiparesis: a safe and durable procedure? A case series

HypothesisShoulder arthroplasty is a safe and durable procedure that provides pain relief, improved range of motion (ROM), and minimal complications for shoulder pain and dysfunction in patients with ipsilateral hemiparesis.MethodsThis is a retrospective review of all adult patients who underwent primary reverse total shoulder arthroplasty (RSA) or total shoulder arthroplasty (TSA) in the hemiparetic upper extremity at a single quaternary care academic medical center from 1988 to 2019. Patients were excluded if their neurologic insult was secondary to a spinal-cord injury, cerebral palsy, or inflammatory arthritis, if they underwent a hemiarthroplasty, if they exhibited mild hemiparesis (Medical Research Council Scale of ≥4), or if they had less than 30 days of radiographic follow-up. The primary clinical outcome was revision surgery for any reason. The secondary clinical outcomes included pain using the visual analog scale, ROM via active-assisted manual muscle testing (AAROM), and postoperative complications. The primary radiographic outcome was implant lucency using a standard scale.ResultsA total of 5 shoulders in 5 patients were included, 4 RSAs and 1 TSA with a mean clinical follow-up of 6.2 years (range: 1.42-14.2 years) and mean radiographic follow-up of 3.7 years (range: 31 days-13.5 years). No patient underwent revision surgery. The mean visual analog scale score significantly improved from 7.6 to 1.4 at the last follow-up (P = .005). The mean forward elevation AAROM improved from 27° preoperatively to 88° at the last follow-up (P = .015). There was no significant difference in external rotation at the last follow-up (P = .105). One patient had asymptomatic grade 1 glenoid component lucency with superior subluxation of the humerus after undergoing TSA at a final follow-up of 4.5 years. No other complications were reported.ConclusionShoulder arthroplasty is a durable procedure that provides pain relief, improved AAROM, and minimal complications in patients with ipsilateral hemiparesis. The increase in active-assisted forward elevation ROM can improve caregiver ease with hygiene and dressing. Patients in this study who underwent RSA did not have subsequent glenohumeral dislocation. Larger numbers of patients would be required for adequate power analysis regarding instability in this cohort of patients who may be at risk; our small series did not identify any instability events.Level of evidenceLevel IV; Treatment Study     

Comparison of radiographs and computed tomography (CT) imaging for preoperative evaluation and planning for shoulder arthroplasty

BackgroundThe purpose of this study was to determine if addition of CT to axillary radiographs (AXR) alters preoperative decision making for shoulder arthroplasty.MethodsPreoperative deidentified images (XR alone and XR with CT) of 50 patients with glenohumeral arthritis were reviewed independently by 3 reviewers in a blinded fashion. Each reviewer graded images for glenoid wear pattern as simple (Walch A1 or B1) or advanced [A2, B2, C]), adequacy of AXR and need for advanced imaging. The reviewers determined a preoperative plan for all patients based on XR alone vs. XR and CT including the arthroplasty type (anatomic or reverse total shoulder) and their plan for treating glenoid wear (eccentric or standard reaming vs. bone graft or augment). Kappa values (κ) were calculated to determine inter-rater agreement and consistency among multiple reviewers. Fisher's exact test was used to assess any difference in preoperative plan once the shoulders were separated into simple and advanced glenoid wear patterns.ResultsThe 3 reviewers agreed that quality of AXRs was significantly inadequate (P < .001) for assessing glenoid wear in advanced glenoid wear patterns compared to simple wear patterns. Following evaluation on AXRs alone, the need for CT imaging was significantly higher in advanced glenoid wear patterns compare to simple ones (81% vs. 31%; P < .001). The addition of CT images did not result in a significant change to the preoperative plan in simple glenoid wear patterns but in advanced glenoid wear, addition of CT can change the preoperative plan with respect to arthroplasty type and/or strategy for addressing glenoid wear.ConclusionAxillary radiographs are often inadequate for preoperative planning in shoulder arthritis with advanced glenoid wear patterns (Walch A2, B2, C types). Addition of CT imaging to radiographs in shoulder arthritis with advanced glenoid wear can affect the preoperative decision with respect to type of shoulder arthroplasty and/or plan for addressing glenoid wear (reaming, bone graft or augmented glenoids).Level of evidenceLevel IV     

Hip-inspired implant for revision of failed reverse shoulder arthroplasty with severe glenoid bone loss: Improved clinical outcome in 11 patients at 3-year follow-up

Background and purpose

Glenoid reconstruction and inverted glenoid re-implantation is strongly advocated in revisions of failed reverse shoulder arthroplasty (RSA). Nevertheless, severe glenoid deficiency may preclude glenoid reconstruction and may dictate less favorable solutions, such as conversion to hemiarthropasty or resection arthropasty. The CAD/CAM shoulder (Stanmore Implants, Elstree, UK), a hip arthroplasty-inspired implant, may facilitate glenoid component fixation in these challenging revisions where glenoid reconstruction is not feasible. We questioned (1) whether revision arthroplasty with the CAD/CAM shoulder would alleviate pain and improve shoulder function in patients with failed RSA, not amenable to glenoid reconstruction, (2) whether the CAD/CAM hip-inspired glenoid shell would enable secure and durable glenoid component fixation in these challenging revisions.

Patients and methods

11 patients with failed RSAs and unreconstructable glenoids underwent revision with the CAD/CAM shoulder and were followed-up for mean 35 (28–42) months. Clinical outcomes included the Oxford shoulder score, subjective shoulder value, pain rating, physical examination, and shoulder radiographs.

Results

The average Oxford shoulder score and subjective shoulder value improved statistically significantly after the revision from 50 to 33 points and from 17% to 48% respectively. Pain rating at rest and during activity improved significantly from 5.3 to 2.3 and from 8.1 to 3.8 respectively. Active forward flexion increased from 25 to 54 degrees and external rotation increased from 9 to 21 degrees. 4 patients required reoperation for postoperative complications. No cases of glenoid loosening occurred.

Interpretation

The CAD/CAM shoulder offers an alternative solution for the treatment of failed RSA that is not amenable to glenoid reconstruction.Reverse shoulder arthroplasty (RSA) has become an established treatment for painful and debilitating shoulder pathologies associated with rotator-cuff insufficiency (Boileau et al. 2005, 2006, Frankle et al. 2005). The preoperative condition of shoulders requiring RSA and the technically demanding nature of the procedure make RSA challenging, with an overall complication rate of 15–50% in recently reported series (Guery et al. 2006, Gerber et al. 2009, Kempton et al. 2011). Complications related to the glenoid component (e.g. loosening, mechanical baseplate failure, dissociation) have been reported in 4–16% of cases (Gurey et al. 2006, Fevang et al. 2009, Farshad and Gerber 2010). Aseptic loosening is the most common glenoid-sided complication requiring revision following RSA (Fevang et al. 2009), and is often associated with considerable scapular bone loss (e.g. inferior scapular notching, glenoid deficiency after implant removal), which further complicates surgical revision (Antuna et al. 2001, Boileau et al. 2005, Elhassan et al. 2008, Gerber et al. 2009).Re-implantation of a glenoid component has been found to provide better clinical results than conversion to hemiarthroplasty or resection arthroplasty in revisions of both anatomical (Antuna et al 2001, Elhassan et al. 2008) and reverse shoulder arthroplasties (Farshad et al. 2012, Favard 2013), and it is strongly advocated. However, achievement of secure fixation of a glenoid implant may not be feasible in the presence of severe glenoid bone loss. Glenoid reconstruction with bone graft has been used to facilitate glenoid implant fixation in poor glenoid bone stock in primary shoulder arthroplasty (Hill and Norris 2001) and revision shoulder arthroplasty (Holcomb et al. 2009, Patel et al. 2012). The inconsistent clinical results and durability of fixation achieved with this technique have led to increasing interest in more reliable surgical alternatives for this challenging problem.The CAD/CAM (computer-assisted design/computer-assisted manufacture) shoulder (Stanmore Implants, Elstree, UK) is a constrained hip arthroplasty-inspired shoulder implant that was designed to facilitate glenoid implant fixation by securing a large glenoid shell to the scapula around the deficient glenoid, rather than to the deficient glenoid itself. Unlike Grammont-type implants, the CAD/CAM shoulder has an increased glenohumeral offset (less medialized implant), which has been shown to improve rotational movements of the shoulder (by recruiting anterior and posterior deltoid fibers and re-tensioning of the remaining rotator cuff) and to minimize scapular notching (Holcomb et al. 2009, Valenti et al. 2011)The purpose of this study was (1) to determine whether revision arthroplasty with the CAD/CAM shoulder would alleviate pain and improve shoulder function in patients with failed RSA and severe glenoid deficiency that is not amenable to reconstruction and inverted glenoid re-implantation; and (2) to determine whether the CAD/CAM hip-inspired glenoid shell would enable secure and durable glenoid component fixation in these challenging revisions. To our knowledge, no previous study has evaluated the use of such implants in revision surgery for failed glenoid-deficient RSA.