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

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

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.     

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.     

Acromial fracture after reverse shoulder arthroplasty

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

Correlation of patient-reported outcome measurement information system-upper extremity with American Shoulder and Elbow Surgeons scores in shoulder arthroplasty

BackgroundMultiple outcome measure surveys are available to assess preoperative and postoperative outcomes for a variety of orthopedic procedures such as shoulder arthroplasty. Although legacy instruments such as American Shoulder and Elbow Surgeons (ASES) remain popular, there remains no singular gold standard survey instrument for shoulder arthroplasty patients, and alternative instruments have been developed to better capture clinical outcomes. The goal of this study is to compare the efficacy of Patient-Reported Outcome Measurement Information System-Upper Extremity (PROMIS-UE) using computer adaptive technology with ASES scores both preoperatively and postoperatively in shoulder arthroplasty patients. Our hypothesis is that there would be a strong correlation between PROMIS-UE and ASES scores both preoperatively and postoperatively in total shoulder arthroplasty patients.MethodsPatients who underwent total shoulder arthroplasty and agreed to complete baseline and 1-year follow-up of ASES and PROMIS-UE scores were included. Patients also completed PROMIS-Physical Function (PROMIS-PF) as a third point comparison. Responses to these instruments were statistically analyzed and compared using Pearson correlation coefficients. Floor and ceiling effects were then calculated.ResultsNinety patients were included in this study, all of whom completed the PROMIS-UE, PROMIS-PF, and ASES surveys both preoperatively and 12 months postoperatively. The mean age in this cohort was 68.9 years (standard deviation [SD] 8.4 years, range 39-89). The mean preoperative and postoperative PROMIS-UE scores were 26.6 (SD 6.7, range 14.7-44.6) and 41.8 (SD 10.3, range 20.2-56.4) respectively. Mean preoperative and postoperative PROMIS-PF computer adaptive technology scores were 35.7 (SD 9.54, range 34.2-64) and 44.3 (SD 9.22, range 23.5-73.3) respectively. The mean ASES score was 37.5 preoperatively (SD 18.0, range 5-99.5) and 77.5 postoperatively (SD 20.5, range 25.0-100.0). PROMIS-UE demonstrated a moderate correlation with ASES preoperatively and a strong correlation postoperatively (r = 0.52, confidence interval 0.27-0.60; r = 0.70, confidence interval 0.55-0.78, respectively). PROMIS-UE demonstrated a minor floor effect preoperatively (7.8%) but significant ceiling effect postoperatively (24.4%) and ASES demonstrated a mild ceiling effect at final follow-up (8.9%). There were otherwise no other floor or ceiling effects at all other time points across each survey.ConclusionPROMIS-UE correlates well with ASES at both baseline and 1-year postoperation for patients undergoing total shoulder replacement. In addition, the change seen between both baseline and 1 year outcome scores for both scoring systems also correlates strongly, suggesting that PROMIS-UE may be a suitable alternative to ASES for this patient population.     

The effect of humeral stem alignment in reverse shoulder arthroplasty

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

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     

术前肩关节功能训练对合并冻结肩的肩袖损伤患者手术效果的影响

背景:目前对合并冻结肩的肩袖损伤患者的手术时机有一定争议,部分研究认为应先通过肩关节功能训练在一定程度上缓解冻结肩后再手术,也有研究认为推迟修复肩袖的手术可能会导致肩袖损伤进一步扩大,影响修复效果.目的:探讨合并冻结肩的肩袖损伤患者术前肩关节功能训练后行关节镜下肩袖修复关节松解术与入院后一期行关节镜手术的临床疗效差别....     

Humeral resurfacing hemiarthroplasty with meniscal allograft in a young patient with glenohumeral osteoarthritis

STUDY DESIGN: Case report. BACKGROUND: Management of glenohumeral joint osteoarthritis in young, active patients is challenging due to the significant functional limitations and progression of the disease, coupled with the limited lifespan of prosthetic implants presently in use. The purpose of this report is to present the detailed rehabilitation program and outcome of a patient who suffered an initial glenohumeral dislocation and, following multiple surgical interventions, required shoulder hemiarthroplasty and biologic glenoid resurfacing to return to function. CASE DESCRIPTION: An objectively based rehabilitation protocol was used for this patient following shoulder hemiarthroplasty. Data collected included passive and active range of motion, isometric rotational strength, and functional outcome scores to include the Single Assessment Numeric Evaluation (SANE) and American Shoulder Elbow Surgeons (ASES) outcome measures. OUTCOMES: Progressive improvements in active and passive range of motion were documented at numerous points during postoperative rehabilitation, including 1 and 2 years postoperatively. The patient's initial functional outcome scores improved from 2/100 to 90/100 in the SANE and from 17/100 to 85/100 for the ASES rating scales. At 2 years postsurgery the SANE score was 60/100 and ASES 68/100. DISCUSSION: Early postoperative range of motion exercises performed in a range protecting the subscapularis, coupled with a progressive program of rotator cuff and scapular strengthening exercises, resulted in decreased pain, improved range of motion, and return to work in a limited capacity following hemiarthroplasty with biologic glenoid resurfacing. Further research in series of patients following this procedure will help to establish optimal treatment guidelines and prognosis for young active patients with severe glenohumeral joint osteoarthritis. LEVEL OF EVIDENCE: Therapy, level 4.     

Prognostic factors of shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder for patient with diabetes mellitus: A retrospective cohort study

IntroductionShoulder manipulation under ultrasound-guided cervical nerve root block (MUC) gives good clinical results in patients with frozen shoulder 1 week after the procedure. However, some patients are refractory to MUC. The present study was performed to investigate the prognostic factors of MUC for frozen shoulder.MethodsWe evaluated 73 frozen shoulders (70 patients) to investigate the prognostic factors of MUC. The patients' mean age was 56.6 years, and 60% were female. The mean duration of symptoms before MUC was 8.6 months. We assessed pain using a numeric rating scale (NRS), range of motion (ROM), and the American Shoulder and Elbow Surgeons (ASES) score before and 1 year after MUC. We compared patients with an ASES score of <80 (defined as a poor clinical result) with those with an ASES score of ≥80 (good clinical result). To identify the risk factors for a poor clinical result, multiple logistic regression analysis was performed using the following variables: age, sex, duration of symptoms before MUC, diabetes mellitus (DM), initial NRS score, and initial ROM.ResultsThe initial NRS score and the prevalence of DM were significantly greater in the poor clinical results group. Multiple logistic regression analysis revealed that DM was the only independent risk factor for a poor clinical result after MUC (odds ratio, 51; 95% confidence interval, 10.9–237; p = .01).ConclusionsDM is a negative prognostic factor of MUC for frozen shoulder, and patients with DM should be informed of this before they undergo treatment for frozen shoulder.     

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     

Does Margin Convergence Reverse Pseudoparalysis in Patients with Irreparable Rotator Cuff Tears?

BackgroundMargin convergence has been shown to restore muscle tension in a cadaveric model of a rotator cuff tear. However, the clinical utility of this technique remains uncertain for patients with pseudoparalysis caused by an irreparable rotator cuff tear.Questions/purposes(1) For patients with massive irreparable rotator cuff tears, in what proportion of patients does margin convergence reverse pseudoparalysis? (2) In patients with massive irreparable rotator cuff tears, does margin convergence improve American Shoulder and Elbow Surgeons (ASES) scores? (3) What is the survivorship free from MRI evidence of retear after margin convergence?MethodsBetween 2000 and 2015, we treated 203 patients for pseudoparalysis with a rotator cuff tear. Pseudoparalysis was defined as active elevation less than 90° with no stiffness, which a physical therapist evaluated in the sitting position using a goniometer after subacromial injection of 10 cc lidocaine to eliminate pain. Of those, we considered patients who underwent at least 3 weeks of unsuccessful nonoperative treatment in our hospital as potentially eligible. Twenty-one percent (43 of 203) who either improved or were lost to follow-up within 3 weeks of nonoperative treatment were excluded. A further 12% (25 of 203) were excluded because of cervical palsy, axillary nerve palsy after dislocation or subluxation, and development of severe shoulder stiffness (passive shoulder elevation < 90°). Repair was the first-line treatment, but if tears were considered irreparable with the torn tendon unable to reach the original footprint after mobilizing the cuff during surgery, margin convergence was used. When margin convergence failed, the procedure was converted to hemiarthroplasty using a small humeral head to help complete the repair. Therefore, 21% (42 of 203) of patients treated with regular repair (18% [36 of 203]) or hemiarthroplasty (3% [6 of 203]) were excluded. That left 93 patients eligible for consideration. Of those, 13 patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, and 86% (80 of 93) were analyzed (49 men and 31 women; mean age 68 ± 9 years; mean follow-up 26 ± 4 months). Seventy-six percent (61 of 80) were not evaluated in the last 5 years. We considered reversal of pseudoparalysis as our primary study outcome of interest; we defined this as greater than 90° active forward elevation; physical therapists in care measured this in the sitting position by using goniometers. Clinical outcomes were evaluated based on the ASES score from chart review, active ROM in the shoulder measured by the physical therapists, and the 8-month Kaplan-Meier survivorship free from MRI evidence of retear graded by the first author.ResultsPseudoparalysis was reversed in 93% (74 of 80) patients, and improvement in ASES scores was observed at the final follow-up (preoperative 22 ± 10 to postoperative 62 ± 21, mean difference 40 [95% CI 35 to 45]; p < 0.01). The 8-month Kaplan-Meier survivorship free from MRI evidence of retear after surgery was 72% (95% CI 63% to 81%). There were no differences in clinical scores between patients with and without retears (intact ASES 64 ± 24, re-tear ASES 59 ± 10, mean difference 6 [95% CI -5 to 16]; p = 0.27).ConclusionMargin convergence can be a good option for treating patients with pseudoparalysis and irreparable rotator cuff tears despite the relatively high retear rates. The proportion of pseudoparalysis reversal was lower in patients with three-tendon involvement. Further studies will be needed to define the appropriate procedure in this group.Level of EvidenceLevel IV, therapeutic study.     

Subscapularis integrity and patient-reported outcomes after total shoulder arthroplasty: does time to mobilization matter?

BackgroundMaintaining subscapularis integrity may be a significant variable in optimizing patient outcomes following total shoulder arthroplasty. Multiple factors have been reported in orthopedic literature as a contributor to subscapularis failure. Most surgeons follow a protocol that calls for some period of immobilization. However, time of mobilization and rehabilitation is still a point of discussion, as no consensus currently exists. Our study aimed to compare postoperative outcomes of patients who followed a traditional immobilization protocol to those who underwent rapid mobilization.MethodsA single-blinded, randomized controlled clinical trial was conducted between December 2015 and May 2018. Patients were prospectively enrolled and randomized using a 1:1 random allocation into 2 groups: prolonged immobilization for 4 weeks or rapid mobilization at 1 week. All cases were performed by a single, fellowship-trained shoulder and elbow surgeon with standard pre- and intra-operative protocols. Metallic markers were used to mark the musculotendinous junction of the subscapularis tendon. Postoperatively, patients were notified of their randomization assignment and provided detailed instructions on when to begin mobilization. Patient-reported outcome measures, physical examination, and radiologic assessments were evaluated preoperatively and at 6 weeks, 3 months, 6 months, 12 months, and 32 months postoperatively. Our primary outcome was clinical and radiographic subscapularis failure.ResultsForty-three patients consented with 40 procedures randomized to the 2 cohorts. Among these 40 procedures, there were up to 235 follow-up visits over 32 months. Of the 40 procedures, 2 (5.0%) were complicated with a postoperative tear, both associated with a weak belly test and radiographically confirmed with medialization of the surrogate markers on plain radiographs. No statistically significant difference was seen between the prolonged immobilization and rapid mobilization groups for American Shoulder and Elbow Surgeons shoulder score, Constant Shoulder Score, Visual Analog Scale Score, Simple Shoulder Test Score, and Short-Form Surveys at any follow-up point (all P > .05). On evaluating active forward flexion and external rotation, no statistically significant difference was also appreciated between the 2 groups at any time point (all P > .05).DiscussionOur randomized control trial compared currently accepted protocols to immobilize for 4 weeks following total shoulder arthroplasty using a peel to early mobilization at 1 week and found no statistical and clinical difference in outcomes. However, further study is necessary before a consensus recommendation can be made.     

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.     

Hill-Sachs Remplissage手术治疗骨缺损性复发性肩关节前脱位

目的 探讨关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术治疗存在明显骨缺损的复发性肩关节前脱位的疗效.方法 回顾性分析随访2年以上的应用关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术治疗的复发性肩关节前脱位49例患者的病例资料,男42例,女7例;接受手术时年龄16.7～54.7岁,平均28.4岁.49例均为单向不稳定,合并明显的肩盂骨性损伤及巨大的Hill-Sachs损伤.术中采用金属缝合锚钉行Bankart修补,辅助后方冈下肌腱固定填充Hill-Sachs损伤.全部病例随访24～35个月,平均29.0个月,随访时采用ASES评分、Constant-Murley评分、Rowe评分进行功能评估,观察肩关节活动度变化.结果 术前及终末随访时肩关节平均前屈上举162.9°±17.1°和170.9°±7.4°(P=0.007),平均体侧外旋56.0°±17.6°和54.1°±17.1°(P=0.511);ASES评分为(84.7±11.3)分和(96.0±3.4)分(P=0.000),Constant-Murley评分为(93.3±8.7)分和(97.8±3.6)分(P=0.005),Rowe评分为(36.8±8.5)分和(89.8±12.5)分(P=0.000).终末随访时1例患者出现复发脱位,3例患者出现半脱位,失效率8.2%(4/49).此4例患者恐惧试验阳性.结论 肩关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术是治疗存在明显骨缺损的复发性肩关节前脱位的有效方法之一.手术适应证的正确选择、熟练的关节镜下操作技术以及术后长期、严格的功能康复锻炼是手术成功的关键.

Abstract：

Objective The purpose of our study was to report the results of using arthroscopic Remplissage and Bankart repair in patients who had an engaging Hill-Sachs lesion with significant glenoid bone loss. Methods We retrospectively reviewed 49 consecutive patients who underwent arthroscopic Remplissage and Bankart repair for anterior shoulder instability with a mean duration of follow-up of 29.0 months (24-35 months). At the time of surgery the mean age of 42 men and 7 women was 28.4 years. All patients were diagnosed as recurrent anterior shoulder dislocation with a bony lesion of glenoid and an engaging HillSachs lesion. An arthroscopic Remplissage and Bankart repair using metal anchor was performed in all cases.ASES score, Constant-Murley score and Rowe score were used to evaluate the stability and the function of the shoulder. Results Patients' active forward elevation significantly(P=0.007) improved from 162.9°±17.1°preoperatively to 170.9°±7.4° at final follow-up. The external rotation was 56.0°±17.6° before the surgery compared with the 54.1°±17.1° postoperatively(P=0.511 ). The ASES score, Constant-Murley score and Rowe score was 84.7±11.3, 93.3±8.7 and 36.8±8.5 preoperatively compared with 96.0±3.4, 97.8±3.6 and 89.8±12.5 postoperatively. Significant difference could be found with regard to ASES score (P=0.000), ConstantMurley score (P=0.005) and Rowe score (P=0.000). One redislocation happened and a subluxation was noticed in three patients (8.3%). Conclusion Arthroscopic Remplissage combined with Bankart repair can achieve satisfactory for recurrent anterior shoulder dislocation accompany with engaging Hill-Sachs lesion.     

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     

Predictors of patient satisfaction and outcomes following reverse total shoulder arthroplasty

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

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     

The influence of computed tomography preoperative planning on clinical outcomes after anatomic total shoulder arthroplasty: a matched cohort analysis

BackgroundEvaluation, characterization, and correction of glenoid deformity are an important part of performing anatomic total shoulder arthroplasty (TSA). Three-dimensional computed tomography (3D CT) planning has been shown to improve implant position, but the impact on clinical outcomes is less clear. The purpose of the current study is to compare clinical outcomes of TSA performed with 3D CT preoperative planning with matched controls performed without CT-based planning.MethodsUtilizing a multicenter shoulder arthroplasty registry, patients who underwent a TSA with 2-year clinical follow-up were retrospectively identified. These patients were divided into two cohorts based on technique for glenoid guide pin placement based on surgeon preference: 1) those who utilized 3D preoperative templating with or without patient-specific instrumentation (PSI) and 2) a control group of TSAs performed without 3D CT preoperative planning. The two groups were matched 1:1 based on age, sex, and baseline American Shoulder and Elbow Surgeons (ASES) score. Patient-reported outcomes and active range of motion (ROM) obtained at 2 years postoperatively were assessed and compared between the two cohorts. A subgroup analysis was also performed comparing outcomes in patients with 3D CT preoperative planning with and without PSI.ResultsData collection was performed on 84 study patients with 3D CT preoperative planning (51 with PSI and 33 without) and 84 matched control patients without CT-based planning (168 patients in total). Baseline characteristics were similar between the groups. Improvement from baseline for the ASES score (study group: 45.4, controls: 39.0, P = .029) and external rotation at 90^° of abduction (study group: 42^° vs. 29^°, P = .009) was significantly greater in the CT-based planning group than that in matched controls. There were no other significant differences in improvement in outcomes or ROM between the two groups. Within the 3D CT cohort, there were no significant differences in patient-reported outcomes or ROM between TSAs performed with or without PSI. A significantly greater percentage of patients with 3D CT planning achieved a patient acceptable symptomatic state than controls (89% vs. 75%, P = .016).ConclusionTSAs performed with 3D CT preoperative glenoid planning with or without utilization of PSI were associated with statistically significantly greater improvement from baseline in ASES scores and external rotation at 90^° of abduction than TSA performed without 3D CT planning. The clinical significance of this finding is unclear, as the differences failed to meet a clinically significant threshold.