Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures

PurposeUnsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.MethodsWe include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed.ResultsOf 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 – 79 years) and mean follow-up was 58.7 months (range 18 – 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000).ConclusionSuccessful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.     

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

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

Going forward with reverse shoulder arthroplasty

Rotator cuff is a vital structure of glenohumeral joint, the dysfunction of which leads to debilitating pain and restricted movement. Arthroplasty using unconstrained anatomical prosthesis for treating these conditions have not been successful in the past. Reverse Shoulder Arthroplasty (RSA) is a novel technique specifically designed to address end stage glenohumeral arthritis in rotator cuff deficient joint. Short and mid-term studies have demonstrated a significant improvement in pain and range of motion of the shoulder joint. However there is a very high complication rate in comparison to total and hemiarthroplasty of shoulder joint. Over the years, there has been a steady increase in RSAs performed, both in volume and the indications for its use. This article discusses the biomechanical aspects, indications and critically reviews the clinical outcome following Reverse Shoulder Arthroplasty.     

反肩置换在老年肱骨近端内固定失败翻修术中的疗效观察

目的：探讨反肩置换术在老年肱骨近端骨折内固定失败后翻修中的应用价值和效果。方法 ：回顾性分析2014年5月至2020年3月肱骨近端骨折内固定失败的患者8例,其中男3例,女5例;年龄65～75岁。8例均行反式肩关节置换术,病程8～16个月。记录并比较手术前和末次随访的关节活动度（range of motion,ROM）、加州大学（University of California at Los Angeles,UCLA）肩关节评分、肩关节视觉模拟评分（visual analogue scale,VAS）、焦虑自评量表（self-rating anxiety scale,SAS）评分、肩关节功能Constant-Murley评分,并分析手术并发症情况。结果：术后8例均获得随访,时间16～28个月。患肩关节活动度（前屈、外旋、外展、内旋）术后明显改善,术后VAS、SAS和UCLA评分也得到改善。肩关节功能Constant-Murley评分中末次随访疼痛、日常活动、活动范围、力量测试评分比术前均有明显提升,且总分比术前提高。1例发生肩胛盂切迹,影像学显示分级为1级,其余患者未发生相关特异性和非特...     

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.     

Effect of stress-shielding-induced bone resorption on glenoid loosening in reverse total shoulder arthroplasty

Aseptic loosening of the glenoid component is one of the main reasons for the high revision rates of reverse total shoulder arthroplasty (RTSA). It has been reported that the bulky implant designs may lead to stress shielding. However, it is uncertain whether the shielding effect is severe enough to lead to bone resorption and glenoid loosening. The purpose of this study was to evaluate the level of stress-shielding and assess whether bone resorption plays a role in aseptic glenoid loosening following RTSA. A cadaveric in vitro test model was used to validate a finite element model (FEM) of the scapula. The FEM of the scapula, incorporating adaptive bone remodeling algorithms, was used to predict changes in postoperative bone density after RTSA. Changes in bone strength after implantation were also analyzed. The strain values predicted from the FEM of the scapula were in agreement with the in vitro measurements. Analysis of postoperative bone adaptation revealed that strain-induced bone resorption began at the peg of the implant and around the resected bone surface and then gradually expended to the peripheral regions. The bone strength also reduced postoperatively and appeared particularly around the implant peg. Strain-induced bone resorption is a likely source of the bone loss commonly observed in RTSA. The finite element glenoid bone remodeling simulation may be used as a tool to evaluate glenoid implant design.     

Comparing bone resorption after anatomical shoulder arthroplasty between various surgical procedures using a single-stem model

BackgroundIn shoulder arthroplasty, bone resorption around the stem can lead to stem loosening and makes surgery difficult at the time of revision. Proximal bone resorption after reverse shoulder arthroplasty can cause instability because of a decrease of deltoid wrapping effect. As factors of the stem itself, such as stem coating, shape, length, and use of bone cement, may also affect bone resorption, a single-stem model should be used to compare bone resorptions between different pathologies and surgical procedures. However, to date, a few reports have compared these differences in detail using a single-stem model. Therefore, we investigated the prevalence and location of humeral bone resorption in a single-stem model.MethodsThe study included 100 shoulders that underwent anatomical total shoulder arthroplasty (TSA) or humeral head replacement (HHR) with a single uncemented humeral stem from 2008 to 2018. The patients were 31 men and 69 women. The mean age at surgery was 72.9 years (range, 41-86 years). The patients were divided into three groups: especially, 25, 61, and 14 shoulders received TSA for primary osteoarthritis without rotator cuff tears (TSA group), HHR using an anatomical head with rotator cuff repair for cuff tear arthropathy (CTA) (HHR group), and HHR using a CTA head without rotator cuff repair (CTA group), respectively. Patients were monitored for a mean of 56 months (range, 12-98 months). The location of bone resorption was divided into seven zones as follows: zone 1, greater tuberosity; zone 2, lateral diaphysis; zone 3, lateral diaphysis beyond the deltoid tuberosity; zone 4, tip of the stem; zone 5, medial diaphysis beyond the deltoid tuberosity; zone 6, medial diaphysis; and zone 7, calcar region. The degree of bone resorption was classified from grade 0 to 4.ResultsBone resorption of grade 3 or higher was significantly more frequent at the greater tuberosity in the HHR and CTA groups (P < .001 and P < .001, respectively) than that in the TSA group. Grade 4 bone resorption was significantly more frequent in the CTA than that in the TSA and HHR groups in zone 1 (P = .016 and P = .041, respectively).ConclusionThe state of attachment of the rotator cuff to the greater tuberosity might affect bone resorption at the greater tuberosity, such as the greater tuberosity after shoulder arthroplasty. In cases of shoulder arthroplasty for arthropathy with rotator cuff tear, performing rotator cuff repair might prevent bone resorption.Level of evidenceLevel IV; Prognosis Study     

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

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