Return to golf and golf-specific performance after anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty

BackgroundGolf is a common sporting activity that patients continue to participate into older age, including after joint replacement surgery. The influence of shoulder replacement on golf performance remains unclear. We hypothesized that patients undergoing anatomic total shoulder arthroplasty (TSA) would have significantly better return to play rates and better performance metrics, including handicap, driving distance, and 7-iron distance, after shoulder replacement relative to those treated with reverse total shoulder arthroplasty (RTSA).MethodsPatients were retrospectively surveyed after anatomic TSA and RTSA with regards to return to golf and golf performance before and after shoulder replacement. Patients reported if they were able to return to golf after shoulder replacement, timing of return to golf, and driving distance, 7-iron distance, handicap, and difficulty with specific shot types upon returning to golf. Significance was defined as P < .05.ResultsThe survey was completed by 31 patients with a total of 37 replaced shoulders (68.0 ± 8.1 years; 87% male) out of 44 patients who indicated they played golf. The overall return to golf rate was 74%. Patients undergoing anatomic TSA returned at a significantly higher rate relative to patients treated with RTSA (93% [14 of 15] vs. 56% [9 of 16], P= .037). There was no difference between groups with regards to drive distance, 7-iron distance, and handicap. There were also no differences between preoperative and postoperative values for patients who were able to return to golf. Overall, patients played golf less frequently afterward than they did prior to shoulder replacement (P= .013).ConclusionPatients are able to return to golf after shoulder replacement, at an overall rate of 74%, including a rate of 93% for patients with anatomic TSA and 56% for patients with RTSA. Golf performance was similar before and after shoulder replacement surgery for both groups among those who were able to return to play, though overall frequency was decreased after shoulder replacement.Level of EvidenceLevel III; Retrospective Cohort Comparative Study     

Anatomic vs. reverse shoulder arthroplasty for glenohumeral osteoarthritis with intact rotator cuff: a retrospective comparison of patient-reported outcomes using the systems outcomes database with up to 5-year follow-up

BackgroundThe growing enthusiasm for the use of reverse shoulder arthroplasty (RSA) in the treatment of primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff is based on data derived from single-center studies with limited generalizability and follow-up. This study compared patient-reported outcomes (PROs) between RSA and total shoulder arthroplasty (TSA) for the treatment of primary GHOA with up to 5-year follow-up and examined temporal trends in the treatment of GHOA between 2012 and 2021.MethodsA retrospective review was performed on patients with primary GHOA undergoing primary arthroplasty surgery from the Surgical Outcomes System global registry between 2012 and 2021. PROs including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and visual analog scale (VAS) for pain were compared between RSA and TSA at 1, 2, and 5 years postoperatively.ResultsA total of 4451 patients were included, with 2693 (60.5%) undergoing TSA and 1758 (39.5%) undergoing RSA. Both RSA and TSA provided clinically excellent outcomes at 1 year postoperatively (ASES: 80.8 ± 17.9 vs. 85.9 ± 15.2, respectively; SANE: 74.8 ± 24.7 vs. 79.5 ± 22.9; VAS pain: 1.3 ± 2.0 vs. 1.1 ± 1.7; all P < .05) that were maintained at 2 years (ASES: 81.3 ± 19.3 vs. 87.3 ± 14.9; SANE: 74.8 ± 26.2 vs. 79.7 ± 24.7; VAS pain: 1.3 ± 2.1 vs. 1.0 ± 1.6; all P < .05) and 5 years (ASES: 81.7 ± 16.5 vs. 86.9 ± 15.3; SANE: 71.6 ± 28.5 vs. 78.2 ± 25.9; VAS pain: 1.0 ± 1.7 vs. 1.0 ± 1.7; all P < .05), with statistical significance favoring TSA. After controlling for age and sex, there was an adjusted difference of 4.5 units in the ASES score favoring TSA (P = .005) at 5 years postoperatively but no differences in adjusted SANE (P = .745) and VAS pain (P = .332) scores. The use of RSA for GHOA grew considerably over time, from representing only 17% of all replacements performed for GHOA in 2012 to nearly half (47%) in 2021 (P < .001).ConclusionRSA as a treatment for GHOA with an intact rotator cuff seems to yield PROs that are largely clinically equivalent to TSA extending to 5 years postoperatively. The observed statistical significance favoring TSA appears to be of marginal clinical benefit based on established minimal clinically important differences and may be a result of the large sample size. Further research using more granular clinical data and examining differences in range of motion and complications is warranted as it may change the value analysis.     

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.     

Prevalence and predictors of persistent pain 2 years after total shoulder arthroplasty

BackgroundElective total shoulder arthroplasty is highly successful, but there is a subset of patients who continue to experience pain after this procedure. The purposes of this study were to elucidate the prevalence and patient characteristics predictive of persistent pain after shoulder arthroplasty.MethodsWe identified patients who had received an elective primary shoulder arthroplasty (anatomic or reverse) between 2016 and 2017 from our prospectively maintained, single-surgeon registry. Patients were stratified by the presence or absence of persistent pain at 2 years postoperatively, as defined by a Visual Analog Pain score of ≥2. This value was chosen in accordance with previously reported values for minimal clinically important differences. Multivariable logistic regression was used to identify factors associated with persistent pain.ResultsOf the 244 patients included for analysis, 46(18.9%) had persistent pain at 2 years postoperatively. The average pain score in this group was found to be significantly greater than the patients without pain (3.6 ± 1.6 vs 0.14 ± 0.35, P< .001). Patients with persistent pain had a higher incidence of preoperative opioid use (26.1% vs 13.6%, P= .038), diabetes (28.3% vs 11.6%, P= .004), number of self-reported allergies (3 ± 4.8 vs 1.9 ± 2.3,P= .03), peak postoperative inpatient pain (8.1 ± 1.9 vs 6.9 ± 2.1,P< .001), incidence of prior ipsilateral shoulder surgery (50% vs 30%, P= .011), and a higher percentage received a reverse shoulder arthroplasty (87% vs 70.7%, P= .024). The patient characteristics that were independently predictive of persistent pain were history of prior ipsilateral shoulder surgery (odds ratio 2.44; 95% confidence interval 1.21-4.91; P = .013) and greater postoperative inpatient pain intensity (odds ratio, 1.26 per 1 unit increase; 95% confidence interval 1.03-1.55; P = .024).ConclusionAbout 1 in 5 patients report persistent pain after elective primary shoulder arthroplasty. Prompt identification of at-risk patients (eg, those with severe postoperative inpatient pain and a history of prior shoulder surgery) may prove effective in optimizing the pain experience after shoulder arthroplasty.Level of evidenceLevel III; Cohort Study with Prospective Data and Retrospective Study Design.     

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     

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     

Is there a threshold of preoperative function that predicts failure to achieve clinically significant outcomes after total and reverse shoulder arthroplasty?

BackgroundThe purpose of this study was to determine if there is a threshold of preoperative function that is predictive of postoperative outcomes and the likelihood of achieving clinically significant outcomes following shoulder arthroplasty (SA).MethodsWe retrospectively identified patients who underwent a primary SA at our institution. Patients with preoperative and postoperative American Shoulder and Elbow Surgeons scores (ASES) were included in our analysis. A receiver operating characteristic (ROC) analysis was utilized to reach a preoperative ASES threshold correlated with achievement of the following clinically significant outcomes: minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state. This analysis was performed for our entire SA cohort and subanalyzed for total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). Fischer exact tests were used to analyze categorical data while continuous data were analyzed using t-tests. For the ROC, area under the curve (AUC) was calculated, along with bootstrap 95% confidence intervals and P values, with <0.05 as significant.ResultsA total of 516 patients were included (164 TSA and 352 RSA). ROC analysis yielded a preoperative ASES above 54 as predictive of failure to achieve MCID for all SAs (AUC, 0.77; P < .001), above 49 for TSA (AUC 0.74, P < .001), and above 56 for RSA (AUC 0.79, P < .001). Patients with preoperative ASES scores above 54 were significantly less likely to achieve MCID (odds ratio 5.1, P < .001) and SCB (odds ratio 7.2, P < .001); however, they had higher postoperative ASES scores (84 vs. 78, P < .001). A preoperative ASES score of 73 corresponded to a 50% chance of achieving MCID. ROC analysis also yielded a preoperative ASES score above 51 as predictive of failure to achieve SCB for all SA, TSA, and RSA (AUC: 0.79, 0.78, and 0.80, respectively, all P < .001). A preop ASES score of 52 corresponded to a 50% chance of achieving SCB.ConclusionPreoperative ASES scores above 49-56 are predictive of failure to achieve MCID and SCB following TSA and RSA. Although patients above these preoperative thresholds achieve higher absolute ASES scores at the final follow-up, they experienced less relative improvement from baseline. This will help surgeons counsel individual patients about appropriate expectations after arthroplasty.     

Preoperative risk factors for lower physical therapy compliance rates after shoulder arthroplasty

BackgroundParticipation in postoperative rehabilitation is thought to be an important step in achieving a good outcome after total shoulder arthroplasty. The effects of common preoperative risk factors on physical therapy compliance are not well defined. This study compared physical therapy compliance rates in patients with and without a history of smoking, mood disorders, and preoperative opioid pain medication use.MethodsA retrospective chart review of primary anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) completed at a single institution from 2010 to 2015 was carried out. Postoperative physical therapy was conducted using a standardized 12-week shoulder arthroplasty program. Preoperative risk factors captured in the electronic medical record were a history of mood disorder, chronic preoperative opioid use, and tobacco use. Compliance rates in the 90-day global period after surgery were calculated by identifying attendance at physical therapy appointments. Compliance rates were then compared by the presence or absence of these risk factors. Two-tailed t-tests and analysis of variance were used to determine the significance of any differences in compliance between groups.ResultsA total of 214 shoulder arthroplasties (92 RTSAs, 122 TSAs) performed by a single surgeon were identified. In the global period after surgery, 82% of all physical therapy visits were attended. There were no statistically significant differences between groups regarding laterality. The overall compliance rates for the RTSA and TSA groups were similar at 83% and 82%, respectively, (P = .66). Patients with a history of mood disorder had a significantly lower compliance rate (76%) than those without (85%, P = .004), patients with a history of smoking had significantly lower compliance rates at 79% vs. 83% (P = .05), and patients with a history of chronic preoperative opioid use showed a statistically insignificant trend toward lower compliance at 78% vs. 84% (P = .06). Forty-two patients had multiple concurrent comorbidities, with a compliance rate of 72%. Patients with multiple comorbidities were significantly less compliant than patients with a single comorbidity (82%, P = .017) or patients with no comorbidities (85% P = .001).ConclusionPatients with mood disorders and a history of tobacco use were significantly less compliant with postoperative physical therapy programs after shoulder arthroplasty. Our data also suggest that the effects of these risk factors may be additive, with patients diagnosed with multiple comorbid conditions having the lowest therapy compliance rate of any group. Patients with the identified comorbidities may benefit from preoperative counseling and management of these risk factors to achieve optimal results after shoulder arthroplasty.Level of evidenceLevel III, Retrospective Prognostic 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     

Revision to Reverse Total Shoulder Arthroplasty Restores Stability for Patients With Unstable Shoulder Prostheses

Background

Instability after shoulder arthroplasty remains a complication with limited salvage options. Reoperation for instability with anatomic designs has led to high rates of persistent instability, therefore we aimed to evaluate the use of RSA for treatment of prosthetic instability.

Questions/purposes

(1) After revision shoulder arthroplasty to a reverse prosthesis (RSA), what is the survivorship free from dislocations at 2 and 5 years? (2) What factors are associated with dislocations? (3) What is the survivorship free from revision after revision to RSA? (4) From preoperation to postrevision to RSA, what are the clinical outcomes—the proportion of patients with moderate to severe pain, shoulder elevation and external rotation ROM, American Shoulder and Elbow Surgeons scores, and Simple Shoulder Test scores?

Methods

All shoulder arthroplasties revised for prosthetic instability using RSA components between January 2004 and July 2014 were retrospectively studied. During the period in question, we performed 82 revisions for instability of an anatomic total shoulder arthroplasty (TSA) (n = 62), hemiarthroplasty (n = 13), or reverse TSA (n = 7). We typically used a reverse TSA to treat this problem, but we identified 12 treated in other ways, including revision of a TSA to hemiarthroplasty (n = 3), revision of a reverse TSA to hemiarthroplasty (n = 2), revision of hemiarthroplasty to a hemiarthroplasty (n = 1), and revision of an anatomic TSA to another anatomic TSA (n = 6). This left 70 patients for evaluation; of those, 65 (93%) were available for analysis at a mean of 3 years (range, 2–10 years). A total of seven patients died. Eight of the 65 shoulders were not evaluated during the last 5 years, including three in patients who died earlier. The mean age of the patients at the time of revision RSA was 65 years (range, 40–89 years). Data were obtained from a longitudinally maintained institutional joint registry. Instability was defined as severe subluxation confirmed on clinical and radiographic examinations. We evaluated pain and ROM, and Kaplan-Meier curves were used to estimate survivorship.

Results

The survivorship free from dislocation at 2 and 5 years was 87% (95% CI, 80%–94%) and 79% (95% CI, 67%–91%) respectively, with 10 of 65 (15%) patients having an episode of dislocation after revision surgery. Persistent instability was more common in those with a BMI greater than 35 kg/m² (hazard ratio [HR], 5; 95% CI, 2–16; p = 0.008) and prior hemiarthroplasty (HR, 5; 95% CI, 2–16; p = 0.005), whereas patients who had undergone a previous TSA were less likely to have persistent instability (HR, 0.08; 95% CI, 0.0–0.30; p < 0.001) The survival free from rerevision for any indication at 2 and 5 years was 85% (95% CI, 76%–94%) and 78% (95% CI, 66%–90%) respectively; with the numbers available, we were not able to find associated factors. Fewer patients had moderate or severe pain after revision to RSA (preoperative: 48 of 65 [74%]; postoperative: nine of 65 [14%]; p < 0.001). After surgery, patients showed improvement in shoulder elevation (preoperative: 42° [± 30°], postoperative: 112° [42°]; mean difference, 70° [95% CI, ? 83^o to 57°]; p < 0.001) and external rotation (preoperative: 20° [± 22°], postoperative: 42° [± 23°]; mean difference, 22° [95% CI, ? 30° to ? 14°]; p < 0.001). American Shoulder and Elbow Surgeons scores improved (preoperative: 21 [± 10], postoperative: 68 [± 14], mean difference, 46 [95% CI, ? 58 to ? 35]; p < 0.001); where a higher score is better. Simple Shoulder Test scores also improved (preoperative: 2/12 [± 2], postoperative: 7/12 [± 3]; mean difference, 5 [95% CI, ? 7 to ? 2.17]; p < 0.001); where a higher score is better.

Conclusions

Revision RSA for prosthetic instability after shoulder arthroplasty is associated with reasonable implant survival and few complications. Approximately one in seven patients will have a recurrent dislocation. In patients with persistent instability or with risk factors for instability, consideration should be given for use of larger glenospheres and increasing the lateral offset at the time of RSA.

Level of Evidence

Level IV, therapeutic study.

     

Rationalizing routine postoperative blood testing following elective shoulder arthroplasty

BackgroundImprovements in perioperative care have decreased complication rates following arthroplasty surgery and enabled outpatient surgery. Although studies have suggested selective routine postoperative blood tests for lower limb arthroplasty, there is currently a paucity of research into its utility for shoulder arthroplasty. Our aim was to define an algorithm based on Charlson Comorbidity Index (CCI) value as part of a predictive algorithm to identify low-risk patients undergoing elective anatomic and reverse shoulder arthroplasty that can safely do without routine postoperative blood tests.MethodsElectronic medical records were retrospectively reviewed for patients who underwent elective primary shoulder arthroplasty at our institution, both anatomic and reverse, between January 2009 and October 2020. Inclusion criteria included patients who underwent reverse or anatomic shoulder arthroplasty for glenohumeral joint osteoarthritis or rotator cuff arthropathy and had documented preoperative and postoperative blood tests including full blood count and serum electrolytes. Exclusion criteria included patients who had revision and trauma indications for surgery because of the increased complication rates associated with these indications. Variables recorded included age, gender, body mass index, indication for surgery, comorbidities, American Society of Anesthesiologists score, CCI score, preoperative blood test values from preadmission assessment, postoperative day one blood test values, and interventions required based on blood results.ResultsA total of 140 patients were included in the study. Eighteen patients (12.85%) required intervention based on postoperative blood tests, the most common indications being anemia and hyponatremia. Patients that required intervention had higher CCI (P = .001) and lower preoperative hemoglobin (P = .014). With the application of cutoff values of hemoglobin of ≥106 g/L, and CCI score of less than 4, only one patient in our study required intervention.ConclusionRoutine postoperative blood test following primary elective shoulder arthroplasty is not required in low-risk patients, defined as those with a CCI score of <4 and a preoperative hemoglobin of >106 g/L.     

How does gout impact outcomes following primary shoulder arthroplasty?: Gout and shoulder arthroplasty

IntroductionStudies have shown that the overall prevalence of gout has increased. Data shows that patients with gout have worse outcomes following total joint arthroplasty, however studies investigating the effects of gout following primary total shoulder (TSA) and reverse shoulder arthroplasty (RSA) are limited. The purpose of this study was to compare outcomes of patients with and without gout undergoing primary shoulder arthroplasty, evaluating (1) in-hospital length of stay (LOS); (2) medical complications; (3) cost of care.MethodsA retrospective query using a nationwide administrative claims database was performed from January 2005 to March 2014 for all patients who underwent primary TSA and RSA for the treatment of glenohumeral osteoarthritis, yielding a total of 11,414 patients to be included. For the TSA cohort, 7702 patients were identified within the study (n = 1,185) and control (n = 6417) cohorts. Similarly, 3712 patients were identified within the RSA cohorts (gout n = 621 and control n = 3,091). Primary endpoints were in-hospital LOS, 90-day medical complications, and total global 90-day episode of care (EOC) costs. Multivariate logistic regression analyses were used to calculate the odds (OR) of medical complications, whereas Welch's t-tests were used to compare LOS and costs of care. A P value less than .05 was considered statistically significant.ResultsPatients with gout undergoing primary TSA (3- vs. 2-days, P < .0001) and RSA (3- vs. 2-days, P < .0001) had significantly longer in-hospital LOS. Gout patients undergoing either TSA (41.2 vs. 11.3%; OR: 3.30, P < .0001) or RSA had significantly higher incidence and odds (50.6 vs. 17.9%; OR: 2.10, P < .0001) of developing 90-day medical complications compared to their counterparts. Study group patients incurred significantly higher total global 90-day episode of care costs following both TSA ($15,007.84 vs. $13,447.06, P < .0001) and RSA ($19,659.27 vs. $16,783.70, P< .0001).ConclusionThis study demonstrates that patients with gout undergoing primary shoulder arthroplasty have longer in-hospital LOS, in addition to higher rates of complications, and increased costs of care. The study can be used by orthopedic surgeons to educate patients who have gout on complications which may occur following their surgical procedure.Level of EvidenceLevel III, retrospective comparative study.     

Perioperative complications and outcomes in patients with paraplegia following anatomic and reverse total shoulder arthroplasty

BackgroundPatients with lower extremity paraplegia utilize their upper extremities for mobilization and propulsion, which can lead to painful shoulder degeneration. Anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) are utilized for patients with paraplegia in an attempt to decrease pain and increase mobility and function of the shoulder joint. The optimal treatment and associated risks of shoulder arthroplasty surgery in patients with paraplegia are unknown. The purpose of this study is to evaluate the perioperative outcomes, length of hospital stay, and readmissions in patients with paraplegia compared to a control group without paraplegia who underwent aTSA and rTSA.MethodsThe United States Nationwide Readmission Database (NRD) was utilized for this study. To ensure that the perioperative outcomes were attributable to the total shoulder arthroplasty (TSA), patients were excluded if they had any additional invasive procedure(s) during the same hospitalization as the original TSA as long as the procedure was not an adverse outcome of interest. Seventy-nine patients with paraplegia who underwent a TSA were isolated and matched to controls without paraplegia based on arthroplasty type (aTSA vs. rTSA), sex, age, obesity status, insurance type, and median household income. Comparative differences in patient demographics, comorbidities, perioperative complications, length of stay and readmission rates were analyzed.ResultsPatients with paraplegia undergoing TSA had an increased prevalence of the following preoperative comorbidities: deficiency anemia (P < .01), congestive heart failure (P < .03), fluid and electrolyte disorders (P < .03), and depression (P < .05). They were also significantly more likely to develop a urinary tract infection or at least 1 perioperative complication (both P < .01). The median length of stay for patients with paraplegia (3 days) following TSA was significantly longer than for patients without paraplegia (1 day; P = .01), and 26.6% of patients with paraplegia were readmitted for any reason following the TSA compared to 8.9% of those without paraplegia (P < .03). Additionally, patients with paraplegia were not at an increased risk of developing an infection or receiving a revision of the TSA within the calendar year of their surgery (both P = 1).ConclusionTSA successfully relieves shoulder pain and addresses pathology in patients with paraplegia, however this study demonstrates that patients with paraplegia undergoing a TSA experience higher medical complication rates in the perioperative period, a longer hospital stay, and higher readmission rates following discharge compared to their able-bodied matched controls. These findings highlight the importance of providing special consideration for patients with paraplegia when opting for surgical interventions.Level of Evidence: Level III; Retrospective Cohort; Treatment Study     

Predictors of blood transfusion in patients undergoing total shoulder arthroplasty

BackgroundAnatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty are major surgeries that may result in significant blood loss and the need for transfusion. The purpose of this study was to identify predictors for blood transfusion in patients undergoing TSA.MethodsThe American College of Surgeons National Surgical Quality Improvement Program was used to identify 12,982 patients who underwent TSA (anatomic or reverse) from January 1, 2011 to December 31, 2016. We compared patients who underwent intraoperative or postoperative blood transfusion with those who did not receive a blood transfusion. Multivariable logistic regression was used to determine independent factors associated with blood transfusion.ResultsThe rate of intraoperative and postoperative blood transfusion was 3.5% during the study period. Compared with patients who did not receive a blood transfusion, those who did were older (73.4 vs. 68.9 years, P < .001), had longer operative times (137.8 vs. 110.7 minutes, P < .001), had longer hospital stays (3.9 vs. 1.9 days, P < .001), and were more likely to be female (74% vs. 55%, P < .001). Patients who received a blood transfusion had higher mean American Society of Anesthesiologists (ASA) classification score (2.8 vs. 2.5, P < .001). The following factors were independently associated with greater odds of blood transfusion: ASA class 4 (odds ratio [OR] 8.4, 95% confidence interval [CI] 2.0-36), dialysis (OR 2.5, 95% CI 1.0-5.9), bleeding disorders (OR 2.4, 95% CI 1.6-3.5), female sex (OR 1.8, 95% CI 1.4-2.3), and smoking (OR 1.4, 95% CI 1.0-2.0). Patients with independent functional status before surgery were least likely to require blood transfusion (OR 0.5, P < .001).ConclusionIn patients undergoing shoulder arthroplasty, preoperative factors such as ASA classification, smoking, and functional status can be used to identify patients at increased risk for requiring blood transfusion.Level of evidenceLevel III.     

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     

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     

A comparison of patient same-day discharge selection after shoulder arthroplasty before and after the COVID-19 pandemic

BackgroundEarly discharge has been a target of cost control efforts, given the growing demand for joint replacement surgery. Select patients are given the choice for same-day discharge (SDD) or overnight stay after shoulder arthroplasty. The COVID-19 pandemic changed patient perspectives regarding hospital visitation and admission. The purpose of this study was to determine if the COVID-19 pandemic impacted the utilization of SDD after shoulder arthroplasty. We hypothesize that patients undergoing shoulder arthroplasty after the start of the COVID-19 pandemic will have higher rates of SDD.MethodsA retrospective continuous review was performed on 370 patients who underwent a primary anatomic (total shoulder arthroplasty) or reverse shoulder arthroplasty between August 2019 and December 2020 by a single surgeon. This group of patients represent the 185 arthroplasty cases completed before the COVID-19 pandemic and the first 185 patients after the start of the pandemic. April 1, 2020, was chosen as the cutoff for pre-COVID patients, as this represents the date a statewide ban on elective surgery was declared. All patients were counseled preoperatively regarding SDD and given the choice to stay overnight, unless medically contraindicated. Demographics, medical history, length of stay, 30- and 90-day readmissions, and 90-day emergency room (ER) and urgent care visits were obtained from medical records and compared. Two-tailed student t-tests, chi-square tests, and Fischer’s exact were performed where appropriate.ResultsThe 2 groups were similar in age, body mass index, gender distribution, and Outpatient Arthroplasty Risk Assessment score. During the collection period, there were more anatomic shoulder arthroplasties performed after (54%) than before (44%) the COVID-19 pandemic (P = .029). Patients treated after the start of the COVID-19 pandemic were almost 3 times more likely to have an SDD (P < .001), with 85.4% (158/185) of patients being discharged the same day after COVID-19, compared with 34.6% (64/185) before COVID-19. Discharge disposition (location of discharge) was significantly different, as 99% (183/185) of patients undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared with 94% (174/185) of patients before COVID-19. There was no difference in 30-day readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the 2 groups.ConclusionOur study suggests that the COVID-19 pandemic has dramatically impacted patient choices for SDD within a single surgeon’s practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe alternative for patients after total shoulder arthroplasty and reverse shoulder arthroplasty.Level of evidenceLevel III; Retrospective Comparative Study