Comparison of complication rates in reverse total shoulder arthroplasty performed for degenerative conditions versus proximal humerus fractures

BackgroundIndications for reverse total shoulder arthroplasty (RTSA) have been expanding. In addition to degenerative joint disease (DJD), RTSA is now being used to treat proximal humerus fractures (PHF). The purpose of this study was to compare postoperative complications in RTSA performed for DJD versus PHF.MethodsA retrospective analysis of the PearlDiver National Database was performed. International Classification of Diseases 10 codes were used to identify RTSA patients from 2015-2018 and separate them into DJD and PHF cohorts. Demographics, comorbidities, and hospital data were identified and compared using a two-sample t-test and chi-squared test. Systemic complications at 90 days and surgical complications at 90 days, 1 year, and 2 years were compared using multivariable logistic regression.ResultsFifteen thousand six hundred seventy eight patients (92.6% DJD, 7.4% PHF) were identified. PHF patients were more likely to be older (70.3 vs. 69.7 years, P = .026), female (83.5% vs. 62.2%, P < .001), and have more medical comorbidities (Charlson Comorbidity Index 3.42 vs. 3.17, P = .006) than DJD patients. After controlling for patient factors, PHF patients were more likely than DJD patients to develop urinary tract infection (odds ratio [OR] 1.65, P < .001), deep vein thrombosis (OR 1.76, P = .024), and hematoma (OR 3.83, P < .001) within 90 days of RTSA. At 90 days, 1 year, and 2 years postoperatively, RTSA for PHF patients were also more likely than RTSA for DJD patients to sustain a periprosthetic fracture (OR 2.57, P < .001) and instability (OR 2.02, P < .001).ConclusionsPatients with DJD and PHF undergoing RTSA represent different patient populations with distinct postoperative clinical outcomes. RTSA for PHF has inferior outcomes, which is significant in an era of bundled payments.     

Reverse shoulder arthroplasty for proximal humerus fractures

A reverse shoulder arthroplasty is a consideration for the treatment of comminuted four-part proximal humerus fractures in elderly patients. While a reverse TSA should not replace other treatment modalities, it is indicated in elderly patients with fractures that are not amenable to fixation. Immediate stability and relative independence from tuberosity healing are clear advantages, but the complication rate is substantially higher. Larger studies are necessary to clarify appropriate indications.     

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.     

Surgical treatment for acute and displaced proximal humerus fractures in elderly patients: hemiarthroplasty vs. reverse shoulder arthroplasty

BackgroundProximal humerus fractures (PHFs) are the third most common fractures in elderly patients. The best treatment option on this population is still a topic of discussion. Reverse shoulder arthroplasty (RSA) has increased popularity as a viable treatment option for these fractures. Yet, few studies demonstrate the risk factors for mortality after this procedure.MethodsThe authors present a retrospective study including patients older than 75 y with acute and displaced PHFs primarily treated with RSA or hemiarthroplasty in a public hospital between January 2004 and January 2020. The exclusion criteria were pathologic fractures and more than 6 weeks to surgery. Survival curves were obtained using the Kaplan-Meier method and the log-rank test was performed to compare survival rates.ResultsA total of 73 patients met the inclusion criteria. The mean age at the time of fracture and surgery was 78 y old, 10 males and 63 females, with a median clinical follow-up of 64 months (standard deviation 34). Forty-one patients (56%) had an American Society of Anesthesiologists score of 2. Twenty-eight patients were submitted to hemiarthroplasty and 45 to RSA. Regarding hemiarthroplasty, only one patient with hemiarthroplasty died within a year, and the 5 y survival rate was 70%. Concerning to RSA group, five patients died within a year, and the survival rate at 5 y was 66.2 %. The American Society of Anesthesiologists score (P < .001) was the only risk factor identified for mortality at 5 y. Hemiarthroplasties had more prosthetic loosening compared with RSA (P = .024). Three hemiarthroplasties were converted to RSA, and we verified 1 RSA infection. In the group of hemiarthroplasties, 56% returned to their normal daily living activities, while in the RSA 92% did that, representing a significant difference (P = .007).ConclusionRSA as a primary treatment for displaced PHFs had a high survival rate (88.9% at 1 year and 66.2% at 5 y) and better functional results comparing to patients treated with hemiarthroplasty. With proper patient selection, RSA is a safe procedure for the treatment of PHF, especially in an elderly population.     

Three- and four-part proximal humerus fractures in the elderly: Eminence versus evidence

The majority of proximal humerus fractures are minimally displaced and good outcomes can be achieved with nonoperative treatment strategies. However, controversy exists regarding the best management of highly comminuted and displaced proximal humerus fractures that occur in elderly patients with poor bone quality. Although surgical options including open reduction and internal fixation or hemiarthroplasty can restore excellent function, the rate of catastrophic failure remains high measuring between 20% and 40%. Reverse total shoulder arthroplasty has recently been introduced as a means for treatment of these fractures with intermediate results demonstrating improved range of motion, functional outcomes, and lower rates of revision.     

Management of proximal humerus fractures in adults

The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.     

Prior surgical fixation of proximal humerus fractures is associated with increased complications following subsequent reverse shoulder arthroplasty

BackgroundThe objective of this study was to compare complication rates between patients undergoing reverse shoulder arthroplasty (RSA) after a prior open reduction and internal fixation (ORIF) for proximal humerus fracture (PHF) to those undergoing RSA as a primary treatment for PHFs, glenohumeral osteoarthritis, or rotator cuff tear arthropathy (CTA).MethodsPatients who underwent RSA between 2015 and 2020 were identified in the Mariner database. Patients were separated into 3 mutually exclusive groups: (1) RSA for osteoarthritis, rotator cuff tear, or CTA (Control-RSA); (2) RSA as a primary treatment for PHF (PHF-RSA); and (3) RSA for patients with prior ORIF of PHFs (ORIF-RSA). Ninety-day medical and 2-year postoperative surgical complications were identified. In addition, patients in the PHF-RSA group were subdivided into those undergoing RSA for PHF within 3 months of the fracture (acute) vs. those treated greater than 3 months from diagnosis (delayed). Multivariate regression was performed to control for differences in comorbidities and demographics.ResultsA total of 30,824 patients underwent primary RSA for arthritis or CTA, 5389 patients underwent RSA as a primary treatment for a PHF, and 361 patients underwent RSA after ORIF of a PHF. ORIF before RSA was associated with an increased risk of overall revision (odds ratio [OR] 2.45, P = .002), infection (OR 2.40, P < .001), instability (OR 2.43, P < .001), fracture (OR 3.24, P = .001), minor medical complications (OR 1.59, P = .008), and readmission (OR 2.55, P = .001) compared with the Control-RSA cohort. RSA as a primary treatment for PHF was associated with an increased risk of 2-year revision (OR 1.60, P < .001), infection (OR 1.51, P < .001), instability (OR 2.84, P < .001), and fracture (OR 2.54, P < .001) in addition to major medical complications (OR 2.02, P < .001), minor medical complications (OR 1.92, P < .001), 90-day emergency department visits (OR 1.26, P < .001) and 90-day readmission (OR 2.03, P < .001) compared with the Control-RSA cohort. The ORIF-RSA group had an increased risk of periprosthetic infection (OR 1.94, P = .002) when compared with the PHF-RSA cohort. There were no differences in medical or surgical complications in the RSA-PHF cohort between patients treated in an acute or delayed fashion.ConclusionRSA following ORIF of a PHF is associated with increased complications compared with patients undergoing RSA for nonfracture indications. Prior ORIF of a PHF is also an independent risk factor for postoperative infection after RSA compared with patients who undergo RSA as a primary operation for fracture. The timing of RSA as a primary operation for PHF does not appear to impact the rates of postoperative medical and surgical complications.     

Proximal humerus fractures should be treated with a reverse shoulder replacement

Historically, fractures of the proximal humerus not amendable to closed treatment or internal fixation have been treated with hemiarthroplasty. Clinical outcomes following hemiarthroplasty have been variable and difficult to predict. Results are often correlated with increasing age, tuberosity healing, and tuberosity position. Reverse shoulder arthroplasty has demonstrated effectiveness in elderly patients with rotator cuff arthropathy and has been increasingly employed for complex fractures in older patients. Several small trials have compared the reverse arthroplasty and hemiarthroplasty for acute fractures, and reverse shoulder arthroplasty has demonstrated more reproducible results in elderly patients.     

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.     

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.     

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     

Primary reverse shoulder arthroplasty for acute proximal humerus fractures: A 5-year long term retrospective study of elderly patients

BackgroundReverse shoulder arthroplasty (RSA) in complex shoulder fractures is ever more frequently. This study compares clinical and radiologic results of patients with comminuted proximal humeral fractures (PHFs) treated with RSA, with and without tuberosities grafting.MethodsBetween January 2009 and June 2014, 55 patients aged ≥65 years with 3- and 4-part PHFs were treated surgically. Patients’ files and the hospital’s digital database were reviewed retrospectively with at least 5-year of follow up. We constituted three groups according to the tuberosity consolidation: patients in whom the tuberosities showed anatomic consolidation (Group I) and patients either with secondary displacement of the tuberosities (Group II) or without tuberosity repair (Group III).ResultsThe 74% of the repaired tuberosities consolidated in anatomic position. Among range of motion (ROM), we reported that forward elevation, abduction and external rotation were significantly better in Group I than those in Group II-III. Furthermore, quick Dash score and Constant score showed more satisfied results in Group I. Regarding complications, not infection or instability were found in group I. On the other hand, in group II, we reported one patient with deep infection, leading to two steps surgery. In group III, we recorded two patients with instability required implant revision and one with deep infection treated by revision.ConclusionRSA showed satisfied results even at 5 year follow up. Preservation of the tuberosities in anatomic position improves active forward elevation and external rotation as well as patient satisfaction with less complications.     

Trends in Medicare physician reimbursement and utilization for proximal humerus fixation and shoulder arthroplasty

BackgroundFixation and arthroplasty remain the mainstays of surgical treatment of degenerative and traumatic shoulder pathology. They also constitute an appreciable sum of Medicare expenditure. With continued concern for declines in Medicare reimbursement across orthopedic surgery, it is important to understand how trends in reimbursement correlate with relative procedure volumes. Our aims were to describe temporal changes in procedure volumes, physician payment, and patient charges for proximal humerus open reduction internal fixation (ORIF) and shoulder arthroplasty.MethodsUsing Medicare's Physician Fee Schedules from 2012 to 2017, we examined procedure volumes, number of unique surgeons performing, actual submitted patient charges, and surgeon payments from 2012 to 2017 for six shoulder procedures: proximal humerus ORIF (CPT-23615), traumatic hemiarthroplasty (HEMI) (CPT-23616), degenerative HEMI (CPT-23470), primary total shoulder arthroplasty (TSA) (CPT-23472), partial TSA revision (humeral or glenoid component, CPT-23473), and total TSA revision (CPT-23474). The reimbursement ratio was calculated by dividing surgeon payment by patient charges. Growth rates of charges and payment were adjusted for inflation using annual consumer price index inflation rates over the same time period.ResultsThe total number of traumatic and degenerative HEMI cases fell over ?60%. Similarly, the number of unique surgeons performing traumatic and degenerative HEMI fell over ?53%. In contrast, the number of TSA procedures rose by +70%, whereas partial and total revision TSA rose by +62% and +88%, respectively. The number of unique surgeons rose +28% and over +73% for primary and revision TSA, respectively. There was a large gap (between 3.4 and 4.4 times) between submitted charges and surgeon payment for all years analyzed. After adjusting for inflation, Medicare payment to surgeons decreased for all types of surgery (?6% to ?9%) other than ORIF, which increased +10%. Submitted patient charges during this period increased +14% and +9.7% for ORIF and revision TSA (total), respectively, but decreased by ?6% for traumatic HEMI. The reimbursement ratio was ≤29% for all procedures analyzed across all years and fell the most for revision TSA (partial and total).ConclusionFrom 2012 to 2017, there was a sharp decline in the use of shoulder HEMI with a correspondingly high increase in TSA. After accounting for inflation, HEMI and TSA showed appreciable declines in surgeon payment over time, whereas ORIF was the only surgery with increased surgeon payment. Revision TSA saw the largest declines in the reimbursement rate. Physicians and health care policy makers must be aware of these trends to ensure both a sustainable payment infrastructure for surgeons as well as to maintain access to care for these procedures.Level of evidenceLevel III; Economic Study     

Arthroplasty costs excluding implants: anatomic total shoulder versus reverse shoulder arthroplasty

BackgroundThe incidence of reverse total shoulder arthroplasty (rTSA) has been rising exponentially in recent years. Compared to anatomic total shoulder arthroplasty (aTSA), rTSA incurs higher total hospital costs, largely due to implant prices. However, rTSA typically requires less operating room (OR) time and is a cementless procedure, potentially representing important cost savings. Our aim is (1) to evaluate the difference in total hospital costs for rTSA and aTSA excluding implant costs and (2) to identify cost factors between the two procedures. Our hypothesis is that rTSAs and aTSAs will have similar costs excluding implants due to offsetting personnel and supply costs.MethodsTime-driven activity-based costing was utilized to determine the costs of rTSAs and aTSAs at our single-specialty hospital from January 2018 to 2020. Implant costs were subtracted from total hospital costs to determine costs excluding implants. Other demographic and cost parameters were also compared.ResultsNine hundred twenty-one primary shoulder procedures were analyzed (577 rTSAs and 344 aTSAs). Patients undergoing rTSA were significantly older, had a larger American Society of Anesthesiologists classification, had a longer length of stay, and were more likely to have Medicare as the primary insurance. Additionally, patients undergoing rTSA had significantly less OR time and fewer home discharges (P < .05). However, excluding implants, supply costs and overall hospital costs were 0.86× and 1.01× the cost of aTSA, respectively (P < .001 and P = .560), indicating that there was no significant difference between rTSA and aTSA overall hospital costs when omitting implant costs. Implants accounted for 97% of the difference in overall hospital costs between rTSA and aTSA.ConclusionExcluding implants, rTSA and aTSA have similar hospital costs. The savings with rTSA attributed to decreased OR time and supplies (excluding implants) are offset by personnel costs and length of stay from the postanesthesia care unit through discharge. Decreasing rTSA implant prices to the level of aTSA would equate the costs for these two procedures. As the incidence of rTSA rises, strategies to decrease implant costs are important for decreasing overall health expenditures.     

Reverse shoulder arthroplasty in acute fractures of the proximal humerus: A systematic review

The indications for surgical intervention in complex fractures of the proximal humerus are disputed. In elderly patients with poor bone stock it may be impossible to obtain satisfactory fixation of the tuberosities to a hemiarthroplasty (HA). In such cases primary insertion of a reverse shoulder arthroplasty (RSA) has been suggested. We aimed to review clinical studies reporting benefits and harms of RSA in acute fractures. A systematic review. We included 18 studies containing 430 RSA in acute fractures. We found no randomized clinical trials. Four studies compared outcome after RSA with a historical control group of HA. The median constant score was 58 (range 44-68) which is comparable to previous reviews of HA in 4-part fractures. Complications included dislocation, infection, hematoma, instability, neurological injury, reflex sympathetic dystrophy, intraoperative fractures, periprosthetic fractures, and baseplate failure. Scapular notching was reported in 11 studies with a median value of 25% (range 0-94). Heterogeneity of study designs and lack of primary data precluded statistical pooling of data. No high quality evidence was identified. Based on the available evidence the use of RSA in acute fractures is questionable. The complication rate was high and the clinical implications of long term scapular notching are worrying. Randomized studies with long term follow up using the latest techniques of tubercular reinsertion in RSA toward HA should be encouraged.