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     

Prospective observational study of anatomic and reverse total shoulder arthroplasty using a single implant system with long-term follow-up

BackgroundBoth anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) are the standard of care for various end-stage degenerative conditions of the glenohumeral joint. The purpose of this prospective study was to compare clinical outcomes of aTSA and rTSA using the same platform total shoulder arthroplasty system at a minimum follow-up of 8 years.MethodsAn international multicenter data registry was used to identify patients undergoing primary aTSA or rTSA with a minimum of 8-year follow-up. Patients were scored preoperatively and at latest follow-up using 6 outcome and 4 range of motion metrics. Patients graded global shoulder function on a 0-10 scale. Patient satisfaction was classified as much better, better, unchanged, or worse. Pain was graded using the Visual Analog Scale. A student’s 2-tailed paired t-test, Chi-squared test, or Wilcoxon rank-sum test were used when appropriate, where P < .05 indicates significant differences.ResultsA total of 364 aTSA patients and 278 rTSA patients were included. rTSA had greater mean age (aTSA 65.1, rTSA 71.2, P < .0001) and shorter mean follow-up (aTSA 115.2 months, rTSA 109.7 months; P = .0002). Postoperatively, all patients demonstrated significant improvements in pain and function. Preoperatively, aTSA patients had greater active abduction and forward elevation, global function, Constant Score, and the University of California, Los Angeles score. At latest follow-up, aTSA had greater active abduction, forward elevation, external rotation, and Simple Shoulder Test scores. There were no postoperative differences in patient satisfaction, shoulder function, pain, or any other outcome measure between the groups. aTSA patients had a greater revision rate (aTSA 5.8%, rTSA 1.8%; P = .0114), with no difference in complication rates. Humeral radiolucent lines were present in 20.9% of aTSA patients and 37.1% of rTSA patients (P = .0011). Glenoid radiolucent lines were present in 48.0% of aTSA patients (average score of 1.5). Scapular notching was present in 14.5% of rTSA patients (average grade of 0.26).ConclusionThis study is one of the largest to date that compares aTSA and rTSA with a minimum follow-up of 8 years. Significant improvements are seen in both aTSA and rTSA. For both groups, the complication rate was lower than previously reported in the literature. At the latest follow-up, pain relief and global function were significantly improved with high patient satisfaction in both groups, with no statistical differences found. This study provides physicians with information to help guide them when advising patients as to what they can expect at a minimum of 8 years after aTSA and rTSA.     

Impact of tobacco use on perioperative complications and readmission rates following primary anatomic and reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to investigate the relationship between tobacco use and outcomes following both aTSA and rTSA, with the hypothesis being that tobacco users will have inferior postsurgical outcomes compared to nontobacco users.MethodsThe Nationwide Readmission Database (NRD) was queried from 2016 to 2018 to identify qualifying cases of aTSA (n = 16,241) and rTSA (n = 23,975). These groups were further subdivided based on tobacco use status. Demographic and hospital characteristics were first compared between groups. The unadjusted incidence of postoperative medical and shoulder-specific complications, mortality, revisions, and readmissions were then compared. Finally, the groups were assessed for the same variables after controlling for demographic factors and comorbidities.ResultsFor both aTSA and rTSA, statistically significant differences exist in regard to age, sex, primary expected payer, median household income, hospital region, hospital teaching status, and total number of comorbidities between tobacco users and nonusers (all P < .05). Tobacco users undergoing aTSA experienced higher rates of gastrointestinal complications (0.07% vs. 0.01%, P = .021) and readmissions (15.3% vs. 13.6%, P = .007), while tobacco users undergoing rTSA experienced higher rates of acute renal failure (2.5% vs. 1.9%, P = .005), acute respiratory distress (1.3% vs. 0.9%, P = .002), and the need for ventilator assistance (1.2% vs. 0.7%, P < .001). Adjusted analysis showed that tobacco users were more likely to develop acute respiratory distress syndrome (OR = 1.292, P = .036) and require ventilator assistance (OR = 1.376, P = .008), and are more likely to have at least one readmission (P = .026).ConclusionThe results of this study demonstrate that tobacco users undergoing primary aTSA and rTSA are at an increased risk for several perioperative complications and are more likely to be readmitted following surgery compared to nontobacco users. These findings highlight the importance of determining a patient's tobacco use status as consideration should be given to not performing a TSA until tobacco use has stopped.Level of evidenceLevel III; Retrospective Cohort Treatment 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.     

Treatment of massive irreparable rotator cuff tears without arthritis: a comparison of superior capsular reconstruction,partial rotator cuff repair,and reverse total shoulder arthroplasty

BackgroundTo compare outcomes of superior capsular reconstruction (SCR), partial rotator cuff repair (PR), and reverse total shoulder arthroplasty (rTSA) for massive irreparable rotator cuff tear (MIRCT) without arthritis at more than 2 years follow-up.MethodsA retrospective analysis of prospectively collected data of consecutive patients undergoing surgical treatment for intraoperatively confirmed MIRCT without arthritis using SCR, PR, or rTSA. Preoperative and postoperative data were collected and multivariate analysis performed.ResultsThirty two patients met inclusion criteria for SCR, 24 for PR, and 42 for rTSA (mean follow-up years: SCR 3.2; PR 4.0; rTSA 3.5; P = .02). The rTSA patients were older (66.2 years; SCR 57.3; PR 59.0; P = .0001) and more likely to be female (61.9%; SCR 12.5%; PR 25.0%; P < .001). Intraoperative evaluation demonstrated full thickness subscapularis tear in 37.5% for SCR, 4.2% for PR, and 21.4% for rTSA (P = .01). Pseudoparalysis was present in 18.8% of SCR, 0% of PR, and 14.3% of rTSA patients (P = .08). All groups saw postoperative improvement in strength and patient-reported outcomes (P < .036). SCR and rTSA demonstrated an improved forward elevation range of motion (ROM) postoperatively while PR did not (P = .96). No group experienced improvement in rotation ROM (P > .12). rTSA had worse postoperative ROM in all planes compared to SCR and PR (P < .003). There were no differences between groups in postoperative strength (P > .16) or patient-reported outcomes (American Shoulder and Elbow Surgeons P = .14; visual analog scale P = .86; single assessment numeric evaluation P = .61). Patients were satisfied in 81.2% of SCR cases, 87.5% of PR, and 95.3% of rTSA (P = .33). Three of 32 (9.4%) SCR patients required conversion to rTSA, while 3 of 24 (12.5%) PR patients required reoperation (2 revision repairs; 1 conversion to rTSA). There were 3 additional surgical complications among 42 rTSA patients (7.1%). There were 4 nonsurgical complications in the SCR group and 1 in the rTSA group. One SCR patient and 3 rTSA patients were deceased. Multivariate analysis demonstrated no independent predictors of revision surgery. An increased acromiohumeral interval distance was an independent predictor of improved postoperative strength for all groups (P < .02).ConclusionSCR, PR, and rTSA for the treatment of MIRCT without arthritis all significantly improved postoperative strength and outcomes scores with >80% patient satisfaction but with rTSA having worse postoperative motion and a higher complication rate. There were no independent predictors for revision surgery. SCR, PR and rTSA are all viable operations for MIRCT without arthritis with satisfactory results maintained at 2 years postoperatively.     

Outcomes after anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty in patients with long-term disability claims

BackgroundStudies have shown that patients with workers' compensation claims have worse clinical outcomes after various orthopedic procedures. This study aimed to determine the influence of disability status on 2-year clinical outcomes after reverse total shoulder arthroplasty (RTSA) and anatomic total shoulder arthroplasty (ATSA).MethodsReview of an institutional database identified patients on disability with a minimum of 2-year follow-up and compared them to a comorbidity-matched cohort of patients without disability claims. Assessments between patients included preoperative and postoperative Visual Analog Scale (VAS) pain scores, American Shoulder and Elbow Surgeons (ASES) scores, strength, range of motion (ROM), and postoperative complications.ResultsForty-eight shoulders (45 patients) were in the ATSA cohort (24 with disability, 24 without disability) and 46 shoulders (45 patients) in the RTSA cohort (23 with disability, 23 without disability). Patients in the ATSA cohort with disability claims had higher 3-month and 2-year VAS scores (4 vs. 1, P = .003; 4 vs. 1, P = .02, respectively), lower 2-year ASES scores (58 vs. 87, P = .015), and decreased forward elevation ROM and internal rotation ROM (150 vs. 170, P = .017; 60 vs. 62.5, P = .024, respectively) compared to the cohort without disability. Significant differences in baseline values also were noted between cohorts (lower preoperative ASES: 31.7 vs. 40.5, P = .033; higher VAS: 7 vs. 6, P = .03; decreased forward elevation ROM: 90 vs. 110, P = .02). Patients in the RTSA cohort with disability claims had higher 3-month and 2-year VAS (5 vs. 1, P = .02; 3 vs. 0.5, P = .04, respectively) scores than those without claims. The baseline values for the disability cohort with RTSA demonstrated lower ASES (22.1 vs. 43.6, P = .005) and higher VAS (8 vs. 4, P = .004) scores. No significant differences were noted in improvement for the ATSA or RTSA cohorts in any parameter. The ATSA with disability cohort had a higher complication rate (45% vs. 16.6%, P = .0299). No differences were noted in complication rates in the RTSA group.ConclusionPatients who have reported disability status demonstrated worse outcomes after ATSA and RTSA compared to patients without disability claims. However, there was no significant difference in the amount of change in outcomes between groups, indicating that patients on disability can still realize significant improvements after shoulder arthroplasty.     

Arthroscopic glenoid removal for symptomatic component loosening in anatomic total shoulder arthroplasty: can it work?

BackgroundGlenoid loosening is a common cause of failure in anatomic total shoulder arthroplasty (aTSA). Arthroscopic evaluation and removal of the loose glenoid component is a treatment option, but data on this technique is limited. The purpose of this study was to evaluate the outcomes following arthroscopic glenoid removal for aTSA patients with symptomatic glenoid loosening.MethodsA retrospective case series was performed to identify aTSA patients with symptomatic glenoid component loosening, who underwent arthroscopic evaluation and glenoid removal from 2005-2019. Date of index shoulder arthroplasty, culture results, and any subsequent revision shoulder procedures were documented. All patients were contacted via telephone to obtain American Shoulder and Elbow Surgeons, Simple Assessment Numeric Evaluation, satisfaction scores (0-100), reoperation performed at an outside facility, and whether they would undergo the operation again.ResultsTwenty-three patients were identified who underwent arthroscopic glenoid removal, of which 20 (87%) were available for a follow-up. Patients had a mean age of 65.6 ± 11.9 years, body mass index of 29.4 ± 6.2 kg/m², and 12/20 were females (60%). The average time from index aTSA to arthroscopic glenoid removal was 7.0 ± 3.6 years (range, 1.9-11.9 years). All patients had loose glenoids at the time of arthroscopic evaluation and 5 patients (25%) had concurrent rotator cuff tears. All patients had cultures obtained at the time of arthroscopy and none were positive. Five patients (25%) underwent revision to reverse total shoulder arthroplasty at a mean 7.4 ± 4.2 months, for a survival of 75% at final follow-up. Comparing patients who underwent revision to those who did not, there was no difference in age (61.0 ± 9.2 vs. 67.1 ± 12.6 years, P = .34), body mass index (29.8 ± 9.5 vs. 29.2 ± 5.1 kg/m², P = .86), sex (100% vs. 47% female, P = .06), time from index aTSA to glenoid removal (63.0 ± 38.4 vs. 91.4 ± 43.9 months, P = .34), or presence of rotator cuff tear (20% vs. 27%, P = 1.0). Of the 15 patients (75%) who did not undergo reoperation, the average American Shoulder and Elbow Surgeons, Simple Assessment Numeric Evaluation, and Satisfaction scores were 54.3 ± 29.2, 53.5 ± 27.6, and 65.9 ± 37.9 respectively, at an average follow-up of 36.0 ± 19.5 months (range, 12-67 months). No patient (0%) who underwent reoperation would undergo the arthroscopic glenoid removal again, whereas 12 patients (60%) who did not undergo reoperation would choose to have an arthroscopic glenoid removal again.ConclusionsGlenoid loosening is an unfortunate complication of aTSA. Survival was 75% for patients who underwent arthroscopic glenoid removal with modest patient reported outcomes. In appropriately selected patients, arthroscopic glenoid removal is a reasonable treatment option to consider for symptomatic glenoid component loosening.     

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.     

Can the reverse total shoulder arthroplasty provide as good of an outcome as an anatomic shoulder arthroplasty

BackgroundReverse total shoulder arthroplasty (RTSA) is an excellent treatment option for a variety of shoulder pathologies. Anatomic total shoulder arthroplasty (TSA) remains an excellent treatment for patients with glenohumeral arthritis and a functioning rotator cuff. RTSA has become a much more common procedure than TSA in recent times. It is currently unclear if patients who have a good outcome following TSA outperform patients who have a good outcome following RTSA. The purpose of this study was to compare the 2-year outcomes of patients with good outcomes, defined as having forward flexion of >130° and American Shoulder and Elbow Surgeons score of >70, following TSA and RTSA.MethodsAll patients who underwent TSA or RTSA between 2015 and 2019 with minimum 2-year follow-up were eligible for inclusion. Patients were included if their postoperative forward flexion was >130° and American Shoulder and Elbow Surgeons score was >70. Patients were excluded if they were a revision surgery, were treated with an arthroplasty for fracture, or had a latissimus transfer. Demographic variables were analyzed between groups. Range of motion (ROM), strength, and patient-reported outcome (PRO) scores were compared between groups.ResultsOverall, 318 TSAs were included; 155 (49%) met the criteria for a “good” outcome. Among RTSAs, 428 were included; 154 (36%) met the criteria for a “good” outcome. When comparing PROs between groups, RTSA patients had worse preoperative and postoperative PRO scores (all P < .05). When comparing preoperative physical examination findings, RTSA patients had worse ROM and strength (all P < .05) and worse Constant Power scores and Constant scores (P < .001 in both cases). Postoperatively, RTSA patients had worse ROM and strength (all P < .05) and worse Constant scores (P = .028). The magnitude of change (delta) from preoperative to postoperative function was often greater following RTSA than TSA. There were no significant differences in whether expectations were met or exceeded between RTSA and TSA patients in regards to pain control (99% vs. 98%; P = .177), motion and strength (93% vs. 96%; P = .559), ability to return to activities of daily living (98% vs. 99%; P = .333), or return to sporting activities (95% vs. 91%; P = .268).ConclusionPatients do well following both TSA and RTSA. In patients who have a good outcome following either TSA or RTSA, those patients who underwent TSA have superior outcomes to patients following RTSA. However, the change in outcome scores from pre- to post-surgery is often more significant with RTSA, as they often start out with worse motion and clinical scores.     

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.     

A Prospective Randomized Controlled Trial Comparing Medial-Pivot versus Posterior-Stabilized Total Knee Arthroplasty

BackgroundThe medial-pivot (MP) design for total knee arthroplasty (TKA) aims to restore more natural “ball-and-socket” knee kinematics compared to the traditional posterior-stabilized (PS) implants for TKA. The objective of this study is to determine if there was any difference in functional outcomes between patients undergoing MP-TKA vs PS-TKA.MethodsThis prospective randomized controlled trial consisted of 43 patients undergoing MP-TKA vs 45 patients receiving a single-radius PS-TKA design. The primary outcome was postoperative range of motion (ROM). Secondary outcomes included the Western Ontario and McMaster Universities Arthritis Index, Oxford Knee Score, Knee Society Score (KSS), and radiological outcomes. All study patients were followed-up for 2 years after surgery.ResultsPatients undergoing MP-TKA had comparable ROM at 1 year (114.6° ± 16.3° vs 111.3° ± 17.8° respectively, P = .88) and 2 years after surgery (114.9° ± 15.5° vs 114.9° ± 16.4° respectively, P = .92) compared to PS-TKA. There were also no differences in Western Ontario and McMaster Universities Arthritis Index (26.8 ± 19.84 vs 22.0 ± 12.03 respectively, P = .14), Oxford Knee Score (42.7 ± 8.1 vs 42.3 ± 6.7 respectively, P = .18), KSS clinical scores (82.9 ± 16.96 vs 81.42 ± 10.45 respectively, P = .12) and KSS functional scores (76.2 ± 18.81 vs 73.93 ± 8.53 respectively, P = .62) at 2-year follow-up. There was no difference in postoperative limb alignment or complications.ConclusionThis study demonstrated excellent results in both the single-radius PS-TKA design and MP-TKA design. No differences were identified at 2-year follow-up with respect to postoperative ROM and patient-reported outcome measures.     

The association of elevated body mass index (BMI) with complications and outcomes following anatomic total shoulder arthroplasty: a systematic review

PurposeObesity has been associated with increased perioperative complications following shoulder arthroplasty, though this finding has not been consistently reported. The purpose of this systematic review is to summarize the correlation between elevated body mass index (BMI) and the prevalence of perioperative complications and clinical outcomes following anatomic total shoulder arthroplasty (aTSA).MethodsAn extensive literature search of PubMed, Embase, ScienceDirect, and Google Scholar was conducted up until October 2020. Clinical studies that specifically examined the association between BMI and/or various categories of obesity with perioperative complications and functional outcomes following aTSA were included. Public databases (NIS, ACS-NSQIP, PearlDiver, and statewide databases) were largely excluded from the analysis unless procedural codes allowed for differentiation between reverse total shoulder arthroplasty (rTSA) and aTSA.ResultsEleven studies were included in this systematic review - 9 studies reported solely on perioperative complications, 1 study solely on functional outcomes, and 1 study on both complications and outcomes following aTSA. Seven papers had a MINORS (Methodological Index for Non-Randomized Studies) score of <16, indicating low methodological quality. There was no association found between elevated BMI and overall perioperative medical and surgical complications, surgical site infection (SSI), re-operation without revision, aseptic revision, periprosthetic fracture, intraoperative blood loss, need for blood transfusion, 90-day re-admission, absolute hospital LOS or short-term mortality. There is an increased risk for overall revision following aTSA and need for extended hospital LOS in patients with elevated BMI. Range of motion of the operative shoulder, pain, and patient reported outcome measures (PROMs) have generally demonstrated significant improvement following unconstrained arthroplasty.DiscussionIncreasing BMI was not found to be associated with an elevated risk for the majority of perioperative complications following aTSA. Range of motion and patient reported functional outcomes can be expected to improve, even amongst morbidly obese patients.Level of EvidenceLevel IV; Review Article     

Midterm outcomes of revision shoulder arthroplasty

BackgroundSince the introduction of shoulder arthroplasty, the indications have been expanding. Because of the increasing number of arthroplasty procedures, revision surgeries are also inevitable. The purpose of our study is to delineate a large number of revision shoulder arthroplasty cases treated in different ways, including antibiotic spacer placement (ABX), hemiarthroplasty (HA), anatomic total shoulder arthroplasty (aTSA), and reverse total shoulder arthroplasty (rTSA), and to analyze the relationship between preoperative factors and clinical outcomes.MethodsWe reviewed our institution's records of revision shoulder arthroplasty between January 1, 2000, and October 1, 2017. Preoperative information included age at the time of surgery, gender, body mass index, and infection status. Pre- and postoperatively, we gathered 6 patient-reported clinical outcomes and 3 range-of-motion parameters (elevation, abduction, and external rotation). Postoperative complications were also assessed. Then, we examined the differences between the pre- and postoperative outcomes. As a secondary analysis, we performed multivariable regression analysis on the same outcomes, accounting for age at the time of surgery, infection status, and previous surgery type.ResultsAmong the 341 revisions performed, 138 cases met inclusion criteria of at least a 2-year follow-up with pre- and postoperative functional outcome scores. The majority of our revision procedures were to a rTSA (92 cases, 67%), followed by aTSA (28 cases, 20%), and ABX/HA (18 cases, 13%). The mean age at the time of our index surgery was 66 years old. In aTSA and rTSA, all the postoperative outcomes (ie, ASES, Constant, UCLA, SST, SPADI, SF-12 scores, and 3 AROMs) were significantly improved beyond the minimal clinically important difference (MCID) except SF-12 scores in aTSA (P = .25) and active external rotation in rTSA (P = .73). None of the ABX/HA's postoperative outcomes achieve significant improvement or MCID. Multivariable regression analysis showed that older age at the time of surgery was significantly associated with better outcomes in 3 of the 6 patient-reported outcomes (ASES, SST, and SPADI; P = .023, .023, and .028, respectively).ConclusionRevision aTSA and rTSA showed statistically and clinically significant improvement postoperatively. ABX and HA did not achieve meaningful postoperative improvement. Overall, patients getting revision shoulder arthroplasty at an older age had better patient-reported outcomes.Level of evidenceLevel III; Retrospective Cohort Study     

Failed prior rotator cuff repair is associated with worse clinical outcomes after reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to determine the comparative risk profile and clinical outcomes for patients undergoing reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy (CTA) without failed prior rotator cuff repair (RCR) compared with RTSA for CTA with prior RCR.MethodsFrom 2006 to 2014, all patients who underwent RTSA by two surgeons after failed RCR with minimum 2-year follow-up were identified. Patients who underwent RTSA with failed prior RCR were matched in a 1:1 ratio to patients undergoing primary RTSA, while controlling for demographic factors, prosthesis design, and surgeon. Postoperative active forward elevation and active external rotation were recorded. Outcome measures included American Shoulder and Elbow Surgeons score, Visual Analog Scale (VAS), and Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were noted, and comparative multivariate analysis was performed.ResultsOf 262 patients, 192 (73.3%) were available at minimum 2-year follow-up. The prior RCR group had a significantly higher complication rate (17.4%, n = 15) than the primary RTSA group (3.8%, n = 4) (P = .001), although no significant difference in periprosthetic infection (P = .469) or secondary revision rate (P = .136) was observed. At mean 36.3 ± 26.1-month follow-up, the prior RCR group had statistically worse American Shoulder and Elbow Surgeons score (P < .001), VAS (P = .001), Simple Shoulder Test (P < .001), and active forward elevation (P = .006). Patients with multiple failed RCR attempts (n = 38) before RTSA demonstrated no significant differences versus isolated failed RCR (n = 48; P > .05).ConclusionThis study demonstrated that patients with RTSA after prior failed RCR have significantly worse patient-reported outcomes and greater rate of perioperative complications than patients undergoing primary RTSA for CTA.     

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     

Acute versus delayed reverse total shoulder Arthroplasty for the management of Proximal Humerus Fractures

ObjectivesProximal humerus fractures (PHF) are common, yet their optimal management remains debated. Reverse total shoulder arthroplasty (rTSA) is an increasingly popular option, particularly for non-reconstructible or osteoporotic fractures. Despite this trend, current literature provides limited guidance with regards to surgical timing and patient selection for rTSA. A trial of non-operative management might be beneficial for many patients who are not clearly indicated for surgery, provided this does not have a major negative impact on results for those who ultimately require rTSA. The purpose of this study was to investigate whether delayed reverse shoulder arthroplasty for fracture (>28 days from injury) is associated with any difference in complication rates or functional outcomes relative to acute surgery.DesignRetrospective cohort studyPatients/Participants114 consecutive patients who underwent rTSA as the primary management of a PHF at two Level 1 trauma centers and one academic community hospital between 2004 and 2016.InterventionrTSA as primary management of proximal humerus fractureMain Outcome MeasurementsComplications, range of motion, and patient-reported functional outcomes scores (DASH, PROMIS physical function, and EQ-5D)ResultsEighty-two of 114 patients (72%) underwent early surgery. Complex (4-part, head-split, dislocated) fractures were significantly more common in the acutely treated group. There was no significant difference in complications. Overall complication rate was 11.4%. There was a significant difference in DASH score favoring early surgery, with an average score of 22.4 in acutely treated patients versus 35.1 in delayed patients (p = 0.034). There was a non-statistically significant trend towards better PROMIS physical function scores and ROM in the acutely treated group.ConclusionDelay in performing primary rTSA for management of PHF does not lead to an increase in complication rates but it may come at the cost of worse functional outcomes in patients who ultimately require rTSA.     

What are the Outcomes After Primary Total Hip and Knee Arthroplasty in Patients With Prior Cerebrovascular Accidents?

BackgroundFor patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes.MethodsOur total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12).ResultsFor CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients.ConclusionComplications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.     

Development of a predictive model for a machine learning–derived shoulder arthroplasty clinical outcome score

BackgroundWe use machine learning to create predictive models from preoperative data to predict the Shoulder Arthroplasty Smart (SAS) score, the American Shoulder and Elbow Surgeons (ASES) score, and the Constant score at multiple postoperative time points and compare the accuracy of each algorithm for anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA).MethodsClinical data from 2270 patients who underwent aTSA and 4198 patients who underwent rTSA were analyzed using 3 supervised machine learning techniques to create predictive models for the SAS, ASES, and Constant scores at 6 different postoperative time points using a full input feature set and the 2 different minimal feature sets. Mean absolute errors (MAEs) quantified the difference between actual and predicted outcome scores for each model at each postoperative time point. The performance of each model was also quantified by its ability to predict improvement greater than the minimal clinically important difference (MCID) and the substantial clinical benefit (SCB) patient satisfaction thresholds for each outcome measure at 2-3 years after surgery.ResultsAll 3 machine learning techniques were more accurate at predicting aTSA and rTSA outcomes using the SAS score (aTSA: ±7.41 MAE; rTSA: ±7.79 MAE), followed by the Constant score (aTSA: ±8.32 MAE; rTSA: ±8.30 MAE) and finally the ASES score (aTSA: ±10.86 MAE; rTSA: ±10.60 MAE). These prediction accuracy trends were maintained across the 3 different model input categories for each of the SAS, ASES, and Constant models at each postoperative time point. For patients who underwent aTSA, the XGBoost predictive models achieved 94%-97% accuracy in MCID with an area under the receiver operating curve (AUROC) between 0.90-0.97 and 89%-94% accuracy in SCB with an AUROC between 0.89-0.92 for the 3 clinical scores using the full feature set of inputs. For patients who underwent rTSA, the XGBoost predictive models achieved 95%-99% accuracy in MCID with an AUROC between 0.88-0.96 and 88%-92% accuracy in SCB with an AUROC between 0.81-0.89 for the 3 clinical scores using the full feature set of inputs.DiscussionOur study demonstrated that the SAS score predictions are more accurate than the ASES and Constant predictions for multiple supervised machine learning techniques, despite requiring fewer input data for the SAS model. In addition, we predicted which patients will and will not achieve clinical improvement that exceeds the MCID and SCB thresholds for each score; this highly accurate predictive capability effectively risk-stratifies patients for a variety of outcome measures using only preoperative data.Level of evidenceLevel III; Retrospective Comparative Study