The effect of subscapularis management technique on outcomes and complication rates following reverse total shoulder arthroplasty

BackgroundRepair of the subscapularis tendon following rTSA has been shown to decrease postoperative dislocations in some studies, but the effect of repair on other outcomes has not been defined. We proposed to assess differences in postoperative pain, function, range of motion, strength, complications, and reoperations after three types of management of the subscapularis tendon—primary repair (tendon-to-tendon), transosseous repair, and no repair—at a minimum of two years of follow-up after rTSA.MethodsReview of an institutional database identified patients with primary rTSA treated by a single surgeon using the same operative technique and implant (medial glenoid with lateral humeral implant) except for subscapularis repair (tendon-to-tendon repair, transosseous repair, no repair). Patients with revision rTSA, anatomic TSA, hemiarthroplasty, or surgery for proximal humeral fracture, nonunion, or malunion were excluded.ResultsOf 210 patients meeting inclusion criteria, 82 (39%) had primary tendon repair of the subscapularis (PTR), 88 (41.9%) had transosseous repair (TOR), and 40 (19%) did not have the subscapularis repaired (NR). Of all demographics and comorbidities measured, the only significant differences among treatments groups were in gender (54.9% female in PTR, 43.2% in TOR, and 72.5% in NR, p = 0.008) and subscapularis status before surgery (89% intact in PTR, 80.7% in TOR, and 38.5% in NR, p < 0.001). There were significantly more patients in the NR group whose operative indication was massive rotator cuff tear compared to the TO and PR groups. Similarly, there were significantly more patients whose operative indication was primary osteoarthritis in the TR group over the PR group, and the PR group over the NR group. There were no significant differences in complication rates (11% PTR, 13.6% TOR, 15% NR, p = 0.79) or reoperation rates (PTR 2.4%, TOR 2.3%, NR 5.0%, p = 0.66) or associations between subscapularis management technique and reoperation or complication rates.ConclusionSubscapularis management technique in rTSA did not affect complication or reoperation rates, and the procedure led to improvements in pain, function, range of motion, and strength in all three treatment groups. Repair of the subscapularis, regardless of technique, led to greater improvements in pain compared to no repair, although this may be partially attributable to better preoperative subscapularis status in the repair groups. Both repair techniques led to equal improvements in all measured outcomes, with the exception of primary tendon repair producing more improvement in ER strength compared to transosseous repair.Level of evidenceLevel III; Case Control Study     

Stable glenoid component of reverse total shoulder arthroplasty at 2 years as measured with model-based radiostereometric analysis (RSA)

Background and purpose — Reverse total shoulder arthroplasty (TSA) is used for treating cuff arthropathy, displaced proximal humeral fractures (PHF), and in revision shoulder surgery, despite sparse evidence on long-term results. We assessed stability of the glenoid component in reverse TSA, using model-based RSA.Patients and methods — 20 patients (mean age 76 years, 17 female), operated on with reverse TSA at Oslo University Hospital, in 2015–2017 were included. Indications for surgeries were PHFs, malunion, cuff arthropathy, and chronic shoulder dislocation. RSA markers were placed in the scapular neck, the coracoid, and the acromion. RSA radiographs were conducted postoperatively, at 3 months, 1 year, and 2 years. RSA analysis was performed using RSAcore with Reversed Engineering (RE) modality, with clinical precision < 0.25 mm for all translations (x, y, z) and < 0.7° for rotations (x, z). Scapular “notching” was assessed in conventional radiographs.Results — 1 patient was excluded due to revision surgery. More than half of the patients displayed measurable migration at 2 years: 6 patients with linear translations below 1 mm and 8 patients who showed rotational migration. Except for one outlier, the measured rotations were below 2°. The migration pattern suggested implant stability at 2 years. 10 patients showed radiolographic signs of “notching”, and the mean Oxford Shoulder Score (OSS) at 2 years was 29 points (15–36 points).Interpretation — Stability analysis of the glenoid component of reversed total shoulder arthroplasty using reversed engineering (RE) model-based RSA indicated component stability at 2 years.

Reverse total shoulder arthroplasty (TSA) is a widely used procedure. It was originally intended for cuff arthropathy in elderly patients (Grammont and Baulot 1993), but is presently used for several indications, including acute proximal humeral fractures (PHFs) in the elderly, fracture malunions, chronic dislocations, and revision surgery (Clavert et al. 2019, Rugg et al. 2019, Malahias et al. 2020). For operative treatment of displaced 3- and 4-part PHFs in the elderly, reversed TSA has become the treatment of choice (Critchley et al. 2020), presently down to 60 years of age (Goldenberg et al. 2020).The increased use of reverse TSA has occurred despite sparse evidence concerning long-term clinical outcomes for the implant. However, short-term RSA may predict the longevity of implants (Valstar et al. 2005). For hips and knees, continuous micro-migration over 2 years has shown to be indicative of increased risk of implant loosening (Kärrholm et al. 1994, de Vries et al. 2014). To our knowledge, RSA stability analysis of the glenoid component of reverse TSA in patients has not previously been published.Much concern has been placed on the subject of “notching,” where the polyethylene liner of a reverse TSA over time erodes into the inferior scapular neck (Levigne et al. 2011). Several studies have related notching to poorer outcomes (Mollon et al. 2017, Simovitch et al. 2019), while others have voiced concerns about this causing instability and loosening of the glenoid component (Roche et al. 2013c, Huri et al. 2016).Model-based RSA has the advantage over traditional marker-based RSA of not having to alter implants by attaching markers, and the clinical precision of model-based RSA on the glenoid component is known (Fraser et al. 2018). With increased use, sparse long-term evidence, and with “notching” as the backdrop, we performed a stability analysis of the glenoid component of reversed TSA, using model-based RSA.     

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.     

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     

Complications and readmissions following reverse total shoulder arthroplasty with same-day discharge

Background: Recent studies have demonstrated the safety of anatomic total shoulder arthroplasty (TSA) in an outpatient setting. No clinical studies to date have specifically analyzed complication and readmission rates following RTSA with same-day discharge. The purpose of this study was to compare the 90-day complication and readmission rates of patients undergoing reverse total shoulder arthroplasty (RTSA) who were discharged to home on the same day with those of patients who were admitted to the inpatient setting for at least one night.Methods: 135 consecutive patients who underwent 144 RTSA between were analyzed. Suitability for same-day discharge was determined preoperatively using standardized criteria. Operative time, 90-day readmission and complication rates, as well as ASA class and Charlson Comorbidity Index scores were recorded and compared between groups. Differences between the patients undergoing inpatient RTSA (Group 1) versus RTSA with same-day discharge (Group 2) were evaluated with student's t-test, Mann–Whitney, or Chi square as statistically appropriate, and reported as p-values.Results: Group 1 was significantly older than Group 2 when analyzed as a whole (74.3 years vs. 67.5 years, p < 0.001) and when stratified by ASA score. Group 1 had significantly higher ASA and CCI scores than Group 2 (p < 0.001). Average total operating room (OR) time was significantly longer in Group 1 than Group 2 (183 ± 45 min versus 153 ± 30 min, respectively; p < 0.001). There were 7 postoperative complications (7.6%) in Group 1 (2 postoperative seromas, 1 stress fracture, 1 dissociation of prosthesis, 1 brachial plexopathy, 1 episode of syncope, and 1 C acnes reinfection) within the 90-day postoperative period. There were 4 postoperative complications (7.7%) in Group 2 (2 postoperative seromas, 1 periprosthetic fracture, and 1 dislocation). One patient (1.1%) in Group 1 (C. Acnes infection) and 1 patient (1.9%) in Group 2 (periprosthetic fracture) required readmission within 90 days. There were no significant differences in postoperative complications or readmissions between the groups.Conclusion: RTSA with same-day discharge is a safe option for appropriately selected patients. Same-day discharge does not increase 90-day readmission and complication rates following RTSA.Level of Evidence: Level III     

Convertible implants: Simplifying the revision from anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty

Modern shoulder arthroplasty techniques include hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse shoulder arthroplasty (RSA). Out of all arthroplasty procedures, total shoulder arthroplasty produces more satisfactory outcomes for osteoarthritis and inflammatory arthropathy (Sanchez-Sotelo, 2011 [1]). As shoulder arthroplasty procedures continue to increase in popularity, so do revision surgeries (revision TSAs and revision RSAs). Implants used in shoulder arthroplasty procedures have been transformed substantially from generation to generation, going from 1st to 4th generation implants. We propose 5th generation convertible implants that enable a more patient-specific, anatomic reconstruction with the potential to solve major issues that exist with implants from previous years.