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Patients who sustain fragility fractures prior to total shoulder arthroplasty have significantly higher risk for bone health-related complications within 8 years of procedure. Identification of these high-risk patients with an emphasis on preoperative, intraoperative, and postoperative bone health optimization may help minimize these preventable complications. PURPOSE: As the population ages, more patients with osteoporosis are undergoing total shoulder arthroplasty (TSA), including those who have sustained a prior fragility fracture. Sustaining a fragility fracture before TSA has been associated with increased risk of short-term revision rates, periprosthetic fracture (PPF), and secondary fragility fractures but long-term implant survivorship in this patient population is unknown. Therefore, the purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision TSA, periprosthetic fracture, and secondary fragility fracture. METHODS: Patients aged 50 years and older who underwent TSA were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to TSA. Patients who had a prior fragility fracture (7631) were matched 1:1 to patients who did not based on age, gender, Charlson Comorbidity Index (CCI), smoking, obesity, diabetes mellitus, and alcohol use. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, periprosthetic fracture, and secondary fragility fracture within 8 years of index surgery. RESULTS: The 8-year cumulative incidence of revision TSA (5.7% vs. 4.1%), periprosthetic fracture (3.8% vs. 1.4%), and secondary fragility fracture (46.5% vs. 10.1%) were significantly higher for those who had a prior fragility fracture when compared to those who did not. On multivariable analysis, a prior fragility fracture was associated with higher risks of revision (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.24-1.74; p < 0.001), periprosthetic fracture (HR, 2.98; 95% CI, 2.18-4.07; p < 0.001) and secondary fragility fracture (HR, 8.39; 95% CI, 7.62-9.24; p < 0.001). CONCLUSIONS: Prior fragility fracture was a significant risk factor for revision, periprosthetic fracture, and secondary fragility fracture within 8 years of primary TSA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications. LEVEL OF EVIDENCE: III.
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OBJECTIVES: A new ultrasound-based device is proposed to non-invasively measure the orientation of the scapula in the standing position to consider this parameter for Total Shoulder Arthroplasty. The aim of this study was to assess the accuracy and reliability of this device. METHODS: Accuracy was assessed by comparing measurements made with the ultrasound device to those acquired with a three-dimensional (3D) optical localization system (Northern Digital, Canada) on a dedicated mechanical phantom. Three users performed 10 measurements on three healthy volunteers with different body mass (BMI) indices to analyze the reliability of the device by measuring the intra and interobserver variabilities. RESULTS: The mean accuracy of the device was 0.9°± 0.7 (0.01-3.03), 1.3°± 0.8 (0.03-4.55), 1.9°± 1.5 (0.05-5.76), respectively, in the axial, coronal, and sagittal planes. The interobserver and intraobserver variabilities were excellent whatever the BMI and the users experience. CONCLUSIONS: The device is accurate and reliable enough for the measurement of the scapula orientation in the standing position.
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Articulación del Hombro , Posición de Pie , Humanos , Reproducibilidad de los Resultados , Escápula/diagnóstico por imagen , Variaciones Dependientes del Observador , Canadá , Articulación del Hombro/diagnóstico por imagen , Rango del Movimiento Articular , Fenómenos BiomecánicosRESUMEN
BACKGROUND: The two major reverse shoulder arthroplasty (RSA) designs are the Grammont design and the lateralized design. Even if the lateralized design is biomechanically favored, the classic Grammont prosthesis continues to be used. Functional and subjective patient scores as well as implant survival described in the literature so far are comparable to the lateralized design. A pure comparison of how the RSA design influences outcome in patients has not yet been determined. The aim of this study was a comparison focused on patients with cuff tear arthropathy (CTA). METHODS: We analyzed registry data from 696 CTA patients prospectively collected between 2012 and 2020 in two specialized orthopedic centers up to 2 years post-RSA with the same follow-up time points (6,12 24 months). Complete teres minor tears were excluded. Three groups were defined: group 1 (inlay, 155° humeral inclination, 36 + 2 mm eccentric glenosphere (n = 50)), group 2 (inlay, 135° humeral inclination, 36 + 4 mm lateralized glenosphere (n = 141)) and group 3 (onlay, 145° humeral inclination, + 3 mm lateralized base plate, 36 + 2 mm eccentric glenosphere (n = 35)) We compared group differences in clinical outcomes (e.g., active and passive range of motion (ROM), abduction strength, Constant-Murley score (CS)), radiographic evaluations of prosthetic position, scapular anatomy and complications using mixed models adjusted for age and sex. RESULTS: The final analysis included 226 patients. The overall adjusted p-value of the CS for all time-points showed no significant difference (p = 0.466). Flexion of group 3 (mean, 155° (SD 13)) was higher than flexion of group 1 (mean, 142° (SD 18) and 2 (mean, 132° (SD 18) (p < 0.001). Values for abduction of group 3 (mean, 145° (SD 23)) were bigger than those of group 1 (mean, 130° (SD 22)) and group 2 (mean, 118° (SD 25)) (p < 0.001). Mean external rotation for group 3 (mean, 41° (SD 23)) and group 2 (mean, 38° (SD 17)) was larger than external rotation of group 1 (mean, 24° (SD 16)) (p < 0.001); a greater proportion of group 2 (78%) and 3 (69%) patients reached L3 level on internal rotation compared to group 1 (44%) (p = 0.003). Prosthesis position measurements were similar, but group 3 had significantly less scapular notching (14%) versus 24% (group 2) and 50% (group 1) (p = 0.001). CONCLUSIONS: Outcome scores of different RSA designs for CTA revealed comparable results. However, CTA patients with a lateralized and distalized RSA configuration were associated with achieving better flexion and abduction with less scapular notching. A better rotation was associated with either of the lateralized RSA designs in comparison with the classic Grammont prosthesis. LEVEL OF EVIDENCE: Therapeutic study, Level III.
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Artroplastía de Reemplazo de Hombro , Artropatía por Desgarro del Manguito de los Rotadores , Articulación del Hombro , Prótesis de Hombro , Humanos , Artroplastía de Reemplazo de Hombro/métodos , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugía , Manguito de los Rotadores/cirugía , Diseño de Prótesis , Rango del Movimiento Articular , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has increased at a greater rate than other shoulder procedures. In general, clinical and functional outcomes after RTSA have been favorable regardless of indication. However, little evidence exists regarding patient specific factors associated with clinical improvement after RTSA. Predicting postoperative outcomes after RTSA may support patients and physicians to establish more accurate patient expectations and contribute in treatment decisions. The aim of this study was to determine predictive factors for postoperative outcomes after RTSA for patients with degenerative shoulder disorders. METHODS: EMBASE, PubMed, Cochrane Library and PEDro were searched to identify cohort studies reporting on predictive factors for postoperative outcomes after RTSA. Authors independently screened publications on eligibility. Risk of bias for each publication was assessed using the QUIPS tool. A qualitative description of the results was given. The GRADE framework was used to establish the quality of evidence. RESULTS: A total of 1986 references were found of which 11 relevant articles were included in the analysis. Risk of bias was assessed as low (N = 7, 63.6%) or moderate (N = 4, 36.4%). According to the evidence synthesis there was moderate-quality evidence indicating that greater height predicts better postoperative shoulder function, and greater preoperative range of motion (ROM) predicts increased postoperative ROM following. CONCLUSION: Preoperative predictive factors that may predict postoperative outcomes are: patient height and preoperative range of motion. These factors should be considered in the preoperative decision making for a RTSA, and can potentially be used to aid in preoperative decision making. LEVEL OF EVIDENCE: Level I; Systematic review.
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Artroplastía de Reemplazo de Hombro , Rango del Movimiento Articular , Articulación del Hombro , Humanos , Artroplastía de Reemplazo de Hombro/efectos adversos , Resultado del Tratamiento , Articulación del Hombro/cirugía , Articulación del Hombro/fisiopatologíaRESUMEN
PURPOSE: This systematic review aims to provide an overview of the current knowledge on the role of the metaverse, augmented reality, and virtual reality in reverse shoulder arthroplasty. METHODS: A systematic review was performed using the PRISMA guidelines. A comprehensive review of the applications of the metaverse, augmented reality, and virtual reality in in-vivo intraoperative navigation, in the training of orthopedic residents, and in the latest innovations proposed in ex-vivo studies was conducted. RESULTS: A total of 22 articles were included in the review. Data on navigated shoulder arthroplasty was extracted from 14 articles: seven hundred ninety-three patients treated with intraoperative navigated rTSA or aTSA were included. Also, three randomized control trials (RCTs) reported outcomes on a total of fifty-three orthopedics surgical residents and doctors receiving VR-based training for rTSA, which were also included in the review. Three studies reporting the latest VR and AR-based rTSA applications and two proof of concept studies were also included in the review. CONCLUSIONS: The metaverse, augmented reality, and virtual reality present immense potential for the future of orthopedic surgery. As these technologies advance, it is crucial to conduct additional research, foster development, and seamlessly integrate them into surgical education to fully harness their capabilities and transform the field. This evolution promises enhanced accuracy, expanded training opportunities, and improved surgical planning capabilities.
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Artroplastía de Reemplazo de Hombro , Realidad Aumentada , Realidad Virtual , Humanos , Artroplastía de Reemplazo de Hombro/métodos , Cirugía Asistida por Computador/educación , Cirugía Asistida por Computador/métodos , Articulación del Hombro/cirugíaRESUMEN
BACKGROUND: Reverse shoulder arthroplasty (RSA) is a valuable treatment for rotator cuff arthropathy (RCA) in developed regions. Socioeconomic issues impact access to specialized care and there is a lack of data on RSA outcomes in developing regions. We present our 24-month follow-up on RSA surgeries to treat RCA in our low-income population. METHODS: Prospective evaluation of 26 patients subjected to RSA at Hospital Geral de Fortaleza-CE, Brazil, between January 2018 and December 2020. Literacy [>/≤ 8 school years(SY)] and income were documented. Outcomes considered pain (visual analogue scale; VAS) as well as SSV, SPADI, ASES, and UCLA scoring, and range of motion [forward flexion (FF); external rotation (ER)]. RESULTS: Patients were 68.5 ± 7.6 years-old with 16(61.5%) females; 65% had hypertension and 7 (26.9%) had diabetes. Over 90% declared < 900.00 US$ monthly family earnings and 10 (38.4%) patients declared ≤8 SY with > 80% exerting blue-collar jobs. Pain showed a significant reduction from baseline (8 ± 2) to 24 months (2.1 ± 2.3; p < 0.001). UCLA (10.3 ± 5.6 and 28.6 ± 7.2), ASES (16.7 ± 10.8 and 63.1 ± 28.4), SSV (326 ± 311 and 760 ± 234), and SPADI (98.3 ± 26.5) scores significantly improved from baseline to 24 months, achieving minimal clinically important difference. FF (89.2° ± 51.2° to 140.6 ± 38.3°) and ER (19.2° ± 22.5 to 33.4° ± 20.6°) significantly improved from baseline to 24 months (p = 0.004 and 0.027, respectively). There were 5 non-serious adverse events with one surgical revision. All patients returned to daily life activities. CONCLUSION: This is the first outcome report 2 years following RSA in a low-income population. Data indicate this procedure is justifiable regardless of socioeconomic issues.
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Artroplastía de Reemplazo de Hombro , Artropatías , Lesiones del Manguito de los Rotadores , Articulación del Hombro , Femenino , Humanos , Persona de Mediana Edad , Anciano , Masculino , Manguito de los Rotadores/cirugía , Artroplastía de Reemplazo de Hombro/efectos adversos , Artroplastía de Reemplazo de Hombro/métodos , Lesiones del Manguito de los Rotadores/diagnóstico por imagen , Lesiones del Manguito de los Rotadores/cirugía , Resultado del Tratamiento , Artropatías/cirugía , Rango del Movimiento Articular , Dolor , Pobreza , Articulación del Hombro/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: The current study aimed to determine the changes in pre-and post-operative Pittsburg sleep quality index (PSQI) and Tampa scale of kinesiophobia (TSK) values ââaccording to the Hamada classification in patients who underwent reverse shoulder arthroplasty (RSA) for rotator cuff tear arthropathy (RCTA). METHODS: One hundred and eight patients who underwent RSA for RCTA were reviewed retrospectively. The patients were divided into two groups with low grade (stages 1-2-3) (n = 49) and high grade (stages 4a-4b-5) (n = 59) according to the Hamada classification, which is the radiographic evaluation of RCTA. PSQI and TSK values ââwere calculated preoperatively, and post-operatively at the 6th week, 6th month, and 1st year. The change in PSQI and TSK values ââbetween the evaluations and the effect of staging according to the Hamada classification on this change was examined. RESULTS: When compared in preoperative evaluations, PSQI and TSK scores were found to be lower in low-grade group 1 (7.39 ± 1.56, 51.88 ± 4.62, respectively) than in high-grade group 2 (10.47 ± 2.39, 57.05 ± 3.25, respectively) according to Hamada classification (both p < 0.001). In the postoperative evaluations, PSQI and TSK results decreased gradually compared to the preoperative evaluations, and there was a severe decrease in both parameters between the 6th-week and 6th-month evaluations (both p < 0.001). Preoperatively, 102 (95%) patients had sleep disturbance (PSQI ≥ 6), and 108 (100%) patients had high kinesiophobia (TSK > 37). In the 1st year follow-ups, sleep disturbance was observed in 5 (5%) patients and kinesiophobia in 1 (1%) patient. When the Hamada stages were compared, it was seen that there was a significant difference before the operation (both p < 0.001), but the statistically significant difference disappeared in the PSQI value in the 1st year (p = 0.092) and in the TSK value in the 6th month (p = 0.164) post-operatively. It was observed that Hamada staging caused significant differences in PSQI and TSK values ââin the preoperative period but did not affect the clinical results after treatment. CONCLUSIONS: RSA performed based on RCTA improves sleep quality and reduces kinesiophobia. RCTA stage negatively affects PSQI and TSK before the operation but does not show any effect after the treatment.
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Artroplastía de Reemplazo de Hombro , Artropatías , Lesiones del Manguito de los Rotadores , Artropatía por Desgarro del Manguito de los Rotadores , Articulación del Hombro , Humanos , Artroplastía de Reemplazo de Hombro/efectos adversos , Artroplastía de Reemplazo de Hombro/métodos , Manguito de los Rotadores/cirugía , Estudios Retrospectivos , Kinesiofobia , Resultado del Tratamiento , Artropatía por Desgarro del Manguito de los Rotadores/cirugía , Artropatías/cirugía , Sueño , Lesiones del Manguito de los Rotadores/complicaciones , Lesiones del Manguito de los Rotadores/diagnóstico por imagen , Lesiones del Manguito de los Rotadores/cirugía , Articulación del Hombro/cirugía , Rango del Movimiento ArticularRESUMEN
BACKGROUND: Various surgical techniques and conservative therapies are useful tools for treating proximal humerus fractures (PHFs), but it is important to understand how to properly utilize them. Therefore, we performed a systematic review and network meta-analysis to compare and rank the efficacy and safety of medical treatments for PHF. METHODS: PubMed, Embase, the Cochrane Library, and the ClinicalTrials.gov databases were systematically searched for eligible randomized controlled trials (RCTs) from inception until June 2022. Conservative therapy-controlled or head-to-head RCTs of open reduction internal fixation (ORIF), intramedullary nailing (IMN), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (RTSA) used for the treatment of adult patients with PHF were included. The surface under the cumulative ranking (SUCRA) probabilities were applied to compare and rank the effects of medical treatments for PHF. RESULTS: Eighteen RCTs involving 1,182 patients with PHF were selected for the final analysis. Mostly baseline characteristics among groups were well balanced, and the imbalanced factors only included age, injury type, medial comminution, blood loss, and cognitive function in single trial. The SUCRA probabilities found that RTSA provided the best effect on the Constant-Murley score (SUCRA: 100.0%), and the disabilities of the arm, shoulder and hand (DASH) score (SUCRA: 99.0%). Moreover, HA (SUCRA: 85.5%) and RTSA (SUCRA: 68.0%) had a relatively better effect on health-related quality of life than the other treatment modalities. Furthermore, conservative therapy (SUCRA: 84.3%) and RTSA (SUCRA: 80.7%) were associated with a lower risk of secondary surgery. Finally, the best effects on the risk of complications are varied, including infection was observed with conservative therapy (SUCRA: 94.2%); avascular necrosis was observed in HA (SUCRA: 78.1%), nonunion was observed in RTSA (SUCRA: 69.6%), and osteoarthritis was observed in HA (SUCRA: 93.9%). CONCLUSIONS: This study found that RTSA was associated with better functional outcomes, while the comparative outcomes of secondary surgery and complications varied. Optimal treatment for PHF should consider patient-specific factors.
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Artroplastía de Reemplazo de Hombro , Hemiartroplastia , Fracturas del Húmero , Fracturas del Hombro , Adulto , Humanos , Hemiartroplastia/efectos adversos , Fracturas del Húmero/cirugía , Húmero/cirugía , Metaanálisis en Red , Fracturas del Hombro/cirugía , Fracturas del Hombro/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: We compared the rate of all-cause revision of 2 classes of primary anatomic shoulder arthroplasty, stemmed (stTSA) and stemless (slTSA), undertaken with cemented all-polyethylene glenoid components. METHODS: A large national arthroplasty registry identified 2 cohort groups for comparison, stTSA and l undertaken for all diagnoses between January 1, 2011, and December 31, 2021. A subanalysis from January 1, 2017, allowed capturing of additional patient demographics including American Society of Anesthesiologists score, body mass index, and glenoid morphology. The cumulative percent revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age and gender. RESULTS: Of the 7995 stTSA procedures, the CPR at 9 years was 5.6% (95% confidence interval [CI]: 5.0, 6.4), and for 3156 slTSA procedures, the CPR was 4.4% (95% CI: 3.6, 5.5). There was no significant difference in the rate of revision between the study groups (HR = 0.76 [95% CI: 0.51, 1.14], P = .189, adjusted for age, gender, humeral head size, humeral fixation, bearing surface, glenoid design, and mean surgeon volume [MSV]). There was an increased rate of revision for stTSA and slTSA undertaken with humeral head sizes <44 mm (stTSA <44 mm vs. 44-50 mm, HR = 1.56 [CI: 1.18, 2.08], P = .001; slTSA <44 mm vs. 44-50 mm, HR = 2.08 [CI: 1.32, 3.33], P = .001). MSV as a continuous predictor was not a revision risk to stTSA vs. slTSA, but categorically, a low MSV (<10 stTSA + slTSA cases per annum) was associated with a higher revision rate for stTSA (10-20 cases/yr vs. <10 cases/yr, HR = 0.72 [CI: 0.55, 0.95], P = .019) but was not in slTSA. Revision rates were increased for stTSA with non-crosslinked polyethylene (XLPE) glenoids vs. XPLE after 2 years (HR = 2.20 [CI: 1.57, 3.08], P < .001) but did not significantly differ for slTSA. Metal/XPLE (humeral/glenoid) bearing surface of stTSA rate of revision was not different from each combination of slTSA bearing surface. Instability/dislocation was a revision risk for slTSA vs. stTSA (HR = 1.93 [CI: 1.28, 2.91], P = .001), but from 2017, neither of American Society of Anesthesiologists score, body mass index, and glenoid morphology changed the rate of revision. CONCLUSIONS: Revision rates of stTSA and slTSA did not significantly differ and were associated with humeral head size but not patient characteristics. Surgeon inexperience of anatomic shoulder arthroplasty and non-XLPE glenoids were risk factors for stTSA revision but not slTSA. The metal/XLPE stTSA rate of revision was not found to differ significantly from slTSA regardless of polyethylene or humeral head bearing type. Revision for instability/dislocation was more common for slTSA.
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Artroplastía de Reemplazo de Hombro , Luxaciones Articulares , Ortopedia , Articulación del Hombro , Humanos , Artroplastía de Reemplazo de Hombro/efectos adversos , Polietileno , Diseño de Prótesis , Australia , Luxaciones Articulares/cirugía , Sistema de Registros , Resultado del Tratamiento , Articulación del Hombro/cirugía , ReoperaciónRESUMEN
BACKGROUND: Prior research has shown that industry funding can impact the outcomes reported in medical literature. Limited data exist on the degree of bias that industry funding may have on shoulder arthroplasty literature outside of the Journal of Shoulder and Elbow Surgery. The purpose of this study is to characterize the type and frequency of funding for recently published shoulder arthroplasty studies and the impact of industry funding on reported outcomes. We hypothesized that studies with industry funding are more likely to report positive outcomes than those without. MATERIALS AND METHODS: We performed a retrospective study searching all articles with the term "shoulder arthroplasty," "reverse shoulder arthroplasty," "anatomic total shoulder arthroplasty," or "total shoulder arthroplasty" on PubMed from the years January 2020 to December 2022. The primary outcome of studies was coded as either positive, negative, or neutral. A positive result was defined as one in which the null hypothesis was rejected. A negative result was defined as one in which the result did not favor the group in which the industry-funded implant was used. A neutral result was defined as one in which the null hypothesis was confirmed. Article funding type, subcategorized as National Institutes of Health funding or industry funding was recorded. Author disclosures were recorded to determine conflicts of interest. Statistical analysis was conducted using the χ2 test and Fisher exact test. RESULTS: A total of 750 articles reported on either conflict of interest or funding source and were included in the study. Of the total number of industry-funded studies, the majority were found to have a positive primary endpoint (58.1%, 104 of 179), as compared to a negative (7.8%, 14 of 179) or neutral endpoint (33.5%, 60 of 179) (P = .004). Overall, 363 articles reported an author conflict of interest, and the majority of these studies had positive primary endpoint (55.6%, 202 of 363) as compared to negative (9.1%, 33 of 363) or neutral endpoints (34.4%, 125 of 363) (P = .002). CONCLUSION: The results of this study suggest that there is a significant relationship between conflicts of interest and the primary outcome of shoulder arthroplasty studies, beyond the overall positive publication bias. Studies with industry funding and author conflicts of interest both report positive outcomes more frequently than negative outcomes. Shoulder surgeons should be aware of this potential bias when choosing to base clinical practice on published data.
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Artroplastía de Reemplazo de Hombro , Humanos , Artroplastía de Reemplazo de Hombro/economía , Estudios Retrospectivos , Investigación Biomédica/economía , Conflicto de Intereses , Apoyo a la Investigación como AsuntoRESUMEN
BACKGROUND: Inflammatory arthritis (IA) represents a less common indication for anatomic and reverse total shoulder arthroplasty (TSA) than osteoarthritis (OA). The safety and efficacy of anatomic and reverse TSA in this population has not been as well studied compared to OA. We analyzed the differences in outcomes between IA and OA patients undergoing TSA. METHODS: Patients who underwent primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) from 2016-2020 were identified in the Premier Healthcare Database. Inflammatory arthritis (IA) patients were identified using International Classification of Diseases, Tenth Revision, diagnosis codes and compared to osteoarthritis controls. Patients were matched in a 1:8 fashion by age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, and patient comorbidities were compared. Multivariate regression was performed following matching to account for any residual confounding and 90-day complications were compared between the 2 cohorts. Descriptive statistics and regression analysis were employed with significance set at P < .05. RESULTS: Prior to matching, 5685 IA cases and 93,539 OA controls were identified. Patients with IA were more likely to be female, have prolonged length of stay and increased total costs (P < .0001). After matching and multivariate analysis, 4082 IA cases and 32,656 controls remained. IA patients were at increased risk of deep wound infection (OR 3.14, 95% CI 1.38-7.16, P = .006), implant loosening (OR 4.11, 95% CI 1.17-14.40, P = .027), and mechanical complications (OR 6.34, 95% CI 1.05-38.20, P = .044), as well as a decreased risk of postoperative stiffness (OR 0.36, 95% CI 0.16-0.83, P = .002). Medically, IA patients were at increased risk of PE (OR 2.97, 95% CI 1.52-5.77, P = .001) and acute blood loss anemia (OR 1.27, 95% CI 1.12-1.44, P < .0001). DISCUSSION AND CONCLUSION: Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients with multiple increased surgical and postoperative medical complications in patients undergoing aTSA and rTSA. Surgeons should consider these potential complications and employ a multidisciplinary approach in preoperative risk stratification of IA undergoing shoulder replacement.
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Artroplastía de Reemplazo de Hombro , Artroplastia de Reemplazo , Osteoartritis , Articulación del Hombro , Humanos , Femenino , Masculino , Artroplastía de Reemplazo de Hombro/efectos adversos , Artroplastia de Reemplazo/efectos adversos , Complicaciones Posoperatorias/etiología , Osteoartritis/complicaciones , Estudios de Cohortes , Estudios Retrospectivos , Resultado del Tratamiento , Articulación del Hombro/cirugíaRESUMEN
BACKGROUND: Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. METHODS: A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. RESULTS: A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. CONCLUSIONS: There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.
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Artroplastía de Reemplazo de Hombro , Humanos , Estudios Retrospectivos , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Pacientes Ambulatorios , Selección de Paciente , Algoritmos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: Patients who rely on their upper extremities for ambulation, or upper extremity ambulators (UEAs), place considerable stress on their shoulders through the use of assistive devices like walkers, crutches, canes, and wheelchairs. It has been postulated that UEAs may be at increased risk for complications following shoulder arthroplasty. This study aimed to systematically review the literature related to (1) patient-reported outcomes measures (PROMs), (2) functional outcomes, and (3) complications in UEAs who undergo shoulder arthroplasty. METHODS: A systematic review of the PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify studies reporting clinical outcomes of shoulder arthroplasty in UEAs. Patient demographics, clinical characteristics, PROMs, radiographic outcomes, and postoperative range of motion were collected and compared to control patients (i.e. bipedal ambulators) from the constituent studies. RESULTS: A total of eight studies evaluating 248 UEA cases and 206 control cases were included for review. Ambulatory assistive devices utilized by UEAs included walkers (39%), wheelchairs (38%), canes (22%), and a crutch (<1%). Among UEA cases, 197 (79%) reverse total shoulder arthroplasty, 37 (15%) anatomic total shoulder arthroplasty, and 14 (6%) hemiarthroplasty were performed. Overall, patients exhibited significant improvements in mean American Shoulder and Elbow Surgeons (ASES) scores, Constant-Murley scores, Simple Shoulder Test (SST) scores, and Visual Analog Scale (VAS) scores postoperatively. Among 3 studies that included comparison with control groups of bipedal ambulators, no significant differences in outcomes were identified. The overall clinical complication rate was 17% for UEAs compared to 9.1% for controls. The rate of revision surgery was 7.7% for UEAs and 4.9% for bipedal ambulators. CONCLUSIONS: UEAs experience satisfactory pain relief, functional improvements, and good subjective outcomes following shoulder arthroplasty. However, complication and revision rates are higher compared to those for bipedal ambulators, and the majority of UEAs undergo reverse shoulder arthroplasty (RSA) compared to anatomic total shoulder arthroplasty (aTSA).
RESUMEN
BACKGROUND: Elderly patients and their surgeons may eschew shoulder arthroplasty due to concerns over patient safety and longevity. The purpose of this study was to review the current literature evaluating the clinical and radiographic outcomes of shoulder arthroplasty performed in patients 80 years and older. METHODS: A literature search of the Embase, PubMed, Medline, and Cochrane databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating the outcomes of primary and revision anatomic (aTSA) and reverse (RSA) total shoulder arthroplasty in patients 80 years and older were included for analysis. RESULTS: A total of 15 studies evaluating 1685 primary aTSAs, 1170 primary RSAs, 69 RSAs performed for fracture, and 45 revision RSAs were included for review. The postoperative active forward flexion and external rotation ranged from 138° to 150° and 45° to 48° after aTSA and from 83° to 139° and 16° to 47° after RSA, respectively. Postoperative visual analog scale pain scores ranged from 0 to 1.8 after aTSA and from 0 to 1.4 after RSA. Ninety-day mortality ranged from 0% to 3%, and perioperative complications ranged from 0% to 32%. Late complications ranged from 5.6% to 24% for aTSA patients and 3.5% to 29% for patients undergoing RSA for all indications. Common complications included glenoid loosening (0%-18%) and rotator cuff tear (5.6%-10%) after aTSA and scapular notching (0%-40%) and scapular fracture (4%-9.4%) after RSA. Reoperation rates ranged from 0% to 6% after aTSA and from 0% to 13% after RSA. CONCLUSIONS: aTSA and RSA in this population are safe and effective, demonstrating low rates of perioperative mortality and reoperation, durability that exceeds patient longevity, satisfactory postoperative range of motion, and excellent pain relief. Late complication rates appear to be similar for aTSA and RSA.
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Artroplastía de Reemplazo de Hombro , Humanos , Artroplastía de Reemplazo de Hombro/efectos adversos , Dolor/etiología , Rango del Movimiento Articular , Fracturas del Hombro/cirugía , Articulación del Hombro/cirugía , Resultado del Tratamiento , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Baseplate failure in reverse shoulder arthroplasty (RSA) is a rare but potentially catastrophic complication owing to poor patient outcomes and significant glenoid bone loss. The purpose of this study was to report on the prevalence, causes, and outcomes of revision RSA (rRSA) for baseplate failure or loosening. METHODS: A retrospective review of our institutional database was performed to identify all patients treated for a failed RSA from 2006 to 2021 who required revision to another RSA (rRSA) performed by a single surgeon. A total of 676 failed RSA procedures were identified, and further analysis identified 46 patients (6.8%) who underwent rRSA for baseplate failure with a confirmed loose baseplate at the time of rRSA. The primary outcome was repeated failure of the reimplanted baseplate following rRSA. The mode of failure associated with baseplate failure was stratified into 1 of 3 groups: aseptic, septic, or traumatic. Twenty-four patients underwent primary revision, and 22 had undergone >1 previous arthroplasty prior to undergoing re-revision. Five patients underwent previous rRSA for baseplate failure performed by an outside surgeon. The criteria for secondary outcome analysis of final American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and range of motion were met by 32 patients and 23 patients at 1- and 2-year follow-up, respectively. RESULTS: Three patients (6.5%) had repeated baseplate failure requiring re-revision; 2 had baseplate failure at <1 year with associated periprosthetic infections and underwent conversion to hemiarthroplasty. The third patient experienced traumatic failure at 10 years and underwent successful rRSA. The mean American Shoulder and Elbow Surgeons scores at 1 and 2 years were 62.3 and 61.7, respectively. There was no significant difference in outcomes based on mode of baseplate failure (P = .232) or total arthroplasty burden (P = .305) at 1 year. There were 13 total complications in 11 patients, 5 of which required reoperation for reasons other than baseplate failure. CONCLUSION: In this study, rRSA for baseplate failure constituted 6.8% of all revisions performed over a period of 15 years. Re-revision for recurrent baseplate failure was required in 3 of 46 patients (6.5%). Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty.
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Artroplastía de Reemplazo de Hombro , Hemiartroplastia , Articulación del Hombro , Humanos , Artroplastía de Reemplazo de Hombro/efectos adversos , Articulación del Hombro/cirugía , Falla de Prótesis , Estudios Retrospectivos , Hemiartroplastia/efectos adversos , Reoperación/métodos , Resultado del Tratamiento , Rango del Movimiento ArticularRESUMEN
BACKGROUND: Postoperative scapular stress fractures (SSFs) are a formidable problem after reverse shoulder arthroplasty (RSA). Less is known about patients who have these fractures preoperatively. The primary aim of this study was to examine postoperative satisfaction in patients undergoing primary RSA who have preoperative SSF and compared to a matched cohort without preoperative fracture. The secondary aim was to examine the differences in patient-reported outcomes between and within study cohorts. METHODS: A retrospective chart review of primary RSAs performed by a single surgeon from 2000 to 2020 was conducted. Patients diagnosed with cuff tear arthropathy (CTA), massive cuff tear (MCT), or rheumatoid arthritis (RA) were included. Five hundred twenty-five shoulders met inclusion criteria. Fractures identified on preoperative computed tomography scans were divided into 3 groups: (1) os acromiale, (2) multifragments (MFs), and (3) Levy types. Seventy-two shoulders had an occurrence of SSF. The remaining 453 shoulders were separated into a nonfractured cohort. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and visual analog scale (VAS) scores were compared pre- and postoperatively in the total fracture group and the nonfractured group cohort. The multifragment subgroup was also compared to the pooled Os/Levy subgroup. RESULTS: The total incidence of SSF in all shoulders was 13.7%. There was a difference in satisfaction scores at all time points between the nonfracture (7.9 ± 2.8) and total fracture group (5.4 ± 3.6, P < .001, at last visit). There was also a greater ASES total score in the nonfractured group vs the total fracture group at the final visit (69.4 ± 23.4 and 62.1 ± 24.2; P = .02). The MF group had worse ASES functional or VAS functional scores than the Os/Levy group at all time points: at 1 year, ASES function: MF 24.2 ± 14.5 and Os/Levy 30.7 ± 14.2 (P = .045); at 2 years, ASES function: MF 21.4 ± 14.4 and Os/Levy 35.5 ± 10.6 (P < .001); and at last follow-up, VAS function: MF 4.8 ± 2.8 and Os/Levy 6.4 ± 3.2 (P = .023). DISCUSSION: Scapular fractures were proportionally most common in patients diagnosed with CTA (16.3%) compared with a 9.2% and 8.6% incidence in patients diagnosed with MCT and RA, respectively. Patients with preoperative SSF still see an improvement in ASES scores after RSA but do have lower satisfaction scores compared with the nonfractured cohort. The multifragment fracture group has lower functional and satisfaction scores at all postoperative time points compared with both the nonfracture and the Os/Levy fracture group.
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Artroplastía de Reemplazo de Hombro , Escápula , Humanos , Artroplastía de Reemplazo de Hombro/efectos adversos , Masculino , Femenino , Estudios Retrospectivos , Anciano , Escápula/lesiones , Escápula/cirugía , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Fracturas Óseas/cirugía , Satisfacción del Paciente , Medición de Resultados Informados por el PacienteRESUMEN
BACKGROUND: Anatomic and reverse total shoulder arthroplasty (TSA) are effective treatment options for end-stage glenohumeral osteoarthritis. However, consideration for pre-existing conditions must be taken into account. Factor V Leiden (FVL), the most common inherited thrombophilia, is one such condition that predisposes to a prothrombotic state and may affect perioperative and longer-term outcomes following TSA. METHODS: Adult patients undergoing primary TSA for osteoarthritis indication were identified in the 2010 through October 2021 PearlDiver M157 database. Patients with or without FVL were matched at a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and 5-year revision rates were assessed and compared with multivariable logistic regression and rank-log tests, respectively. Finally, the relative use and bleeding/clotting outcomes were assessed based on venous thromboembolic (VTE) prophylactic agents used, with categories defined as (1) warfarin, heparin, or direct oral anticoagulant (DOAC) or (2) aspirin/no prescription found. RESULTS: Of 104,258 TSA patients, FVL was identified for 283 (0.27%). Based on matching, 1081 patients without FVL and 272 patients with FVL were selected. Multivariable analyses demonstrated that those with FVL displayed independently greater odds ratios (ORs) of deep vein thrombosis (DVT, OR = 9.50, P < .0001), pulmonary embolism (PE, OR = 10.10, P < .0001), and pneumonia (OR = 2.43, P = .0019). Further, these events contributed to the increased odds of aggregated minor (OR = 1.95, P = .0001), serious (OR = 6.38, P < .0001), and all (OR = 3.51, P < .0001) adverse events. All other individual 90-day adverse events, as well as 5-year revision rates, were not different between the study groups. When compared to matched patients without FVL on the same anticoagulant agents, FVL patients on warfarin, heparin, or DOAC agents demonstrated lesser odds of 90-day DVT and PE (OR = 4.25, P < .0001, and OR = 2.54, P = .0065) than those on aspirin/no prescription found (OR = 7.64 and OR = 21.95, P < .0001 for both). Interestingly, those on VTE prophylactic agents were not at greater odds of bleeding complications (hematoma or transfusion). DISCUSSION AND CONCLUSIONS: TSA patients with FVL present a difficult challenge to shoulder reconstruction surgeons. The current study highlights the strong risk of VTE that was reduced but still significantly elevated for those with stronger classes of VTE chemoprophylaxis. Acknowledging this risk is important for surgical planning and patient counseling, but also noted was the reassurance of similar 5-year revision rates for those with vs. without FVL.
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BACKGROUND: Reverse total shoulder arthroplasty (RSA) has been increasingly utilized for a variety of shoulder pathologies that are difficult to treat with anatomical total shoulder arthroplasty (TSA). Few studies have compared the outcomes of TSA vs. RSA in patients with cuff intact glenohumeral osteoarthritis and poor preoperative forward elevation. This study aimed to determine whether there is a difference in functional outcomes and postoperative range of motion (ROM) between TSA and RSA in these patients. METHODS: This retrospective cohort study included 116 patients who underwent RSA or TSA between 2013 and 2022 for the treatment of rotator cuff intact primary osteoarthritis with restricted preoperative forward flexion (FF) and a minimum 1-year follow-up. Each arthroplasty group was divided into 2 subgroups: patients with preoperative FF between 91° and 120° or FF lower than or equal to 90°. Patients' clinical outcomes, including active ROM, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective shoulder value were collected. Clinical and radiographic complications were evaluated. RESULTS: There was no significant difference between RSA and TSA in terms of sex (58.3% male vs. 62.2% male, P = .692), or follow-up duration (20.1 months vs. 17.7 months, P = .230). However, the RSA cohort was significantly older (72.0 ± 8.2 vs. 65.4 ± 10.6, P = .012) and weaker in FF and (ER) before surgery (P < .001). There was no difference between RSA (57 patients) and TSA (59 patients) in visual analog scale pain score (1.2 ± 2.3 vs. 1.3 ± 2.3, P = .925), subjective shoulder value score (90 ± 15 vs. 90 ± 15, P = .859), or American Shoulder and Elbow Surgeons score (78.4 ± 20.5 vs. 82.1 ± 23.2, P = .476). Postoperative active ROM was statistically similar between RSA and TSA cohorts in FF (145 ± 26 vs. 146 ± 23, P = .728) and ER (39 ± 15 vs. 41 ± 15, P = .584). However, internal rotation was lower in the RSA cohort (P < .001). This was also true in each subgroup. RSA led to faster postoperative FF and ER achievement at 3 months (P < .001). There was no statistically significant difference in complication rates between cohorts. CONCLUSION: This study demonstrates that patients with glenohumeral osteoarthritis who have a structurally intact rotator cuff but limited preoperative forward elevation can achieve predictable clinical improvement in pain, ROM, and function after either TSA or RSA. Reverse arthroplasty may be a reliable treatment option in patients at risk for developing rotator cuff failure.
Asunto(s)
Artroplastía de Reemplazo de Hombro , Osteoartritis , Rango del Movimiento Articular , Recuperación de la Función , Articulación del Hombro , Humanos , Masculino , Femenino , Artroplastía de Reemplazo de Hombro/métodos , Estudios Retrospectivos , Osteoartritis/cirugía , Osteoartritis/fisiopatología , Anciano , Persona de Mediana Edad , Articulación del Hombro/cirugía , Articulación del Hombro/fisiopatología , Resultado del TratamientoRESUMEN
BACKGROUND: Regional anesthesia is a valuable component of multimodal pain control in total shoulder arthroplasty (TSA), and multiple interscalene block anesthetic options exist, including non-liposomal interscalene bupivacaine (NLIB) and liposomal interscalene bupivacaine (LIB). The purpose of the current of study was to compare pain control and opioid consumption within 48 hours postoperative in those undergoing TSA with either LIB or NLIB. METHODS: This was a retrospective cohort study at a single academic medical center including consecutive patients undergoing inpatient (>23-hour hospitalization) primary anatomic or reverse TSA from 2016 to 2020 who received either LIB or a NLIB for perioperative pain control. Perioperative patient outcomes were collected including pain levels and opioid usage, as well as 30- and 90-day ED visits or readmissions. The primary outcome was postoperative pain and opioid use. RESULTS: Overall, 489 patients were included in this study (316 LIB and 173 NLIB). Pain scores at 3, 6, 12, and 48 hours postoperatively were not statistically significantly different (p>0.05 for all). However, the LIB group had improved pain scores at 24- and 36-hours postoperative (p<0.05 all). There was no difference in the incidence of severe postoperative pain, defined as a 9 or 10 NRS-11 score, between the two anesthesia groups after adjusting for preoperative pain and baseline opioid use (OR: 1.25; 95% CI: 0.57-2.74; p=0.57). Overall, 99/316 (31.3%) of patients receiving LIB did not require any postoperative opioids compared with 38/173 (22.0%) receiving NLIB; however, this difference was not statistically significant after adjusting for prior opioid use and preoperative pain (p=0.33). No statistically significant differences in postoperative total morphine equivalents or mean daily morphine equivalents consumed between the groups were found during their hospital stays (p>0.05 for both). Finally, no significant differences in 30- and 90-day ED visits or readmission rates were found (all p>0.05). CONCLUSION: LIB and NLIB demonstrated differences in patient reported pain scores at 24- and 36-hours post operation, although these did not reach clinical significance. There were no statistically significant differences in opioid consumption during the hospital stay, including opioid use, total morphine equivalents and daily mean morphine equivalents consumed during the hospital stay. Additionally, no differences were observed in 30- and 90-day ED visits or readmission rates.
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BACKGROUND: Clinical significance, as opposed to statistical significance, has increasingly been utilized to evaluate outcomes after total shoulder arthroplasty (TSA). The purpose of this study was to identify thresholds of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for TSA outcome metrics and determine if these thresholds are influenced by prosthesis type (anatomic or reverse TSA), sex, or preoperative diagnosis. METHODS: A prospectively collected international multicenter database inclusive of 38 surgeons was queried for patients receiving a primary aTSA or rTSA between 2003 and 2021. Prospectively, outcome metrics including ASES, shoulder function score (SFS), SST, UCLA, Constant, VAS Pain, shoulder arthroplasty smart (SAS) score, forward flexion, abduction, external rotation, and internal rotation was recorded preoperatively and at each follow-up. A patient satisfaction question was administered at each follow-up. Anchor-based MCID, SCB, and PASS were calculated as defined previously overall and according to implant type, preoperative diagnosis, and sex. The percentage of patients achieving thresholds was also quantified. RESULTS: A total of 5851 total shoulder arthroplasties (TSAs) including aTSA (n = 2236) and rTSA (n = 3615) were included in the study cohort. The following were identified as MCID thresholds for the overall (aTSA + rTSA irrespective of diagnosis or sex) cohort: VAS Pain (-1.5), SFS (1.2), SST (2.1), Constant (7.2), ASES (13.9), UCLA (8.2), SPADI (-21.5), and SAS (7.3), Abduction (13°), Forward elevation (16°), External rotation (4°), Internal rotation score (0.2). SCB thresholds for the overall cohort were: VAS Pain (-3.3), SFS (2.9), SST 3.8), Constant (18.9), ASES (33.1), UCLA (12.3), SPADI (-44.7), and SAS (18.2), Abduction (30°), Forward elevation (31°), External rotation (12°), Internal rotation score (0.9). PASS thresholds for the overall cohort were: VAS Pain (0.8), SFS (7.3), SST (9.2), Constant (64.2), ASES (79.5), UCLA (29.5), SPADI (24.7), and SAS (72.5), Abduction (104°), Forward elevation (130°), External rotation (30°), Internal rotation score (3.2). MCID, SCB, and PASS thresholds varied depending on preoperative diagnosis and sex. CONCLUSION: MCID, SCB, and PASS thresholds vary depending on implant type, preoperative diagnosis, and sex. A comprehensive understanding of these differences as well as identification of clinically relevant thresholds for legacy and novel metrics is essential to assist surgeons in evaluating their patient's outcomes, interpreting the literature, and counseling their patients preoperatively regarding expectations for improvement. Given that PASS thresholds are fragile and vary greatly depending on cohort variability, caution should be exercised in conflating them across different studies.