International trends in shoulder replacement: a meta-analysis from 11 public joint registers.

BACKGROUND AND PURPOSE: International variation exists in the types of shoulder replacement used for treatment of specific diseases. Implant choice continues to evolve without high-quality evidence. Our aim was to evaluate trends in incidence rates of shoulder replacement and assess any recent changes in practice between countries by using registry data. METHODS: Patient characteristics, indication and year of surgery, type of replacement, and collection methods of patient-reported outcomes (PROMs) was extracted from 11 public joint registries. Meta-analyses examined use of reverse total shoulder replacement (RTSR) for osteoarthritis, cuff tear arthropathy, and acute fracture; use of anatomical total shoulder replacement (TSR) for osteoarthritis; and use of humeral hemiarthroplasty for fracture. RESULTS: The annual growth rate of shoulder replacements performed is 6-15% (2011-2019). The use of RTSR has almost doubled (93%). RTSR is now universally performed for cuff tear arthropathy (97.3%, 95% confidence interval [CI] 96.0-98.1). Its use for avascular necrosis, trauma, and inflammatory arthropathy is increasing. The use of RTSR was similar (43.1%, CI 30.0-57.2) versus TSR (44.7%, CI 31.1-59.1) for osteoarthritis. The types of PROMs used, collection time points, and response rates lack standardization. COVID-19 had a varying inter-registry impact on incidence rates. CONCLUSION: The incidence of shoulder replacements has grown. Use of RTSR has increased for all disease indications despite limited high-quality evidence driving this change in indications outside of cuff arthropathy. Consequently, less variation is observed in international practice. Existing differences now relate to use of newer implant types and methodology of PROMs collection, which prevents international comparison and outcome analysis.

Clinical and structural outcome 20 years after repair of massive rotator cuff tears.

BACKGROUND: Short- and mid-term outcomes after massive cuff tear repair are well reported, but there is no documentation of the clinical and structural outcomes at 20 years of follow-up. The hypothesis of the present study was that at 20 years, deterioration of the shoulder would have occurred and led to a substantial number of reoperations. METHODS: The authors retrospectively recalled all 127 patients operated for massive rotator cuff tears in 1994 at 6 different centers. At the 20-year follow-up, 26 patients died and 35 were lost to follow-up. Thirteen (10.2%) had been reoperated. This left 53 patients for personal clinical assessment. Forty-nine consented to standardized radiographic evaluation for assessment of osteoarthritis, 36 patients underwent magnetic resonance imaging, allowing assessment of tendon healing, atrophy, and fatty infiltration (FI) of the cuff muscles. RESULTS: The final Constant-Murley score (CS) was 68 ± 17.7 (range, 8-91) vs. 44 ± 15.3 (range, 13-74) preoperatively (P < .05). The final Subjective Shoulder Value (SSV) was 73% ± 23% (range, 0-100). Retears (Sugaya IV and V) were found in 17 cases (47%). Nine patients (17%) had cuff tear arthropathy (Hamada stage 4). The CS and SSV for the shoulders with FI stages III or IV were significantly inferior (53 ± 19 points and 65% ± 14% respectively) than for those with FI stages 0-II (respectively, 71.6 ± 6 points and 73% ± 4%) (P < .05). CONCLUSIONS: Twenty years after surgical repair of massive rotator cuff tears, the functional scores remain satisfactory, and the rate of revision is low.

Rotator Cuff Degeneration: The Role of Genetics.

BACKGROUND: The literature is certain regarding the multifactorial etiology of rotator cuff degeneration. However, it remains unclear if rotator cuff degeneration exclusively depends on intrinsic and extrinsic factors or if it is also genetically determined. We compared the health status of cuff tendons, evaluated with a magnetic resonance imaging (MRI) study, between elderly monozygotic and dizygotic twins with the aim of separating the contributions of genetics from shared and unique environments. METHODS: The rotator cuff tendon status was assessed using the Sugaya classification by MRI. Heritability, defined as the proportion of total variance of a specific characteristic in a particular population due to a genetic cause, was calculated as twice the difference between the intraclass correlation coefficients for monozygotic and dizygotic pairs. The influence of shared environment, which contributes to twin and sibling similarity, was calculated as the difference between the monozygotic correlation coefficient and the heritability index. RESULTS: We identified 33 pairs of elderly twins: 17 monozygotic pairs and 16 dizygotic pairs, with a mean age (and standard deviation) of 64.62 ± 3.32 years. The polychoric correlation was 0.62 in monozygotic twins and 0.53 in dizygotic twins. The calculated heritability index was 0.18 (18%), and the contribution was 0.44 (44%) for the shared environment and 0.38 (38%) for the unique environment. CONCLUSIONS: The role of genetics in rotator cuff degeneration is quantified by our study on elderly monozygotic and dizygotic twins; however, it is only partial with respect to the contribution of shared and unique environments.

Poor patient-reported outcome after shoulder replacement in young patients with cuff-tear arthropathy: a matched-pair analysis from the Danish Shoulder Arthroplasty Registry.

Background and purpose - Reverse shoulder arthroplasty (RSA) has become the treatment of choice for cuff-tear arthropathy. There are, however, concerns about the longevity and the outcome of an eventual revision procedure. Thus, resurfacing hemiarthroplasty (RHA) with extended articular surface has been suggested for younger patients. We compared the patient-reported outcome of these arthroplasty designs for cuff-tear arthropathy. Patients and methods - We included patients operated on because of cuff-tear arthropathy and reported to the Danish Shoulder Arthroplasty Registry (DSR) from January 1, 2006 to December 31, 2013. 117 RHA cases were matched by age and sex with 233 RSA controls. 34 of the RHAs were conventional and 67 were RHAs with extended articular surface. The Western Ontario Osteoarthritis of the Shoulder (WOOS) Index at 1 year was used as primary outcome. The score was converted to a percentage of a maximum score. Revision, defined as removal or exchange of any component or the addition of a glenoid component, was used as secondary outcome. Results - Median WOOS was 49 (30-81) for RHA and 77 (50-92) for RSA (p < 0.001). For patients younger than 65 years, median WOOS was 58 (44-80) after RHA, similar to the 54 after RSA (37-85). For patients older than 65 years, median WOOS was 48 (28-82) after RHA and 79 (55-92) after RSA (p < 0.001). Interpretation - In all patients RSA had a clinically and statistically better patient-reported outcome than RHA. However, in patients younger than 65 years the functional outcome was similar and poor for either arthroplasty type. The optimal treatment of CTA in young patients remains a challenge.

Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up.

BACKGROUND: Treatment options for irreparable cuff tears include synthetic interposition grafts, but whether such grafts can maintain acceptable shoulder function and prevent cuff tear arthropathy in the long-term is unknown. METHOD: This was a retrospective case series of 13 consecutive patients treated with a synthetic interposition graft made of Dacron (DuPont, Wilmington, DE, USA). Patients were examined with bilateral ultrasonography, bilateral x-ray imaging, Constant-Murley score, and Western Ontario Rotator Cuff score. RESULTS: After a mean of 18 years (range, 17-20 years), 1 patient had died, and 12 were available for x-ray imaging and 10 also for ultrasonography and clinical scores. Cuff tear arthropathy (Hamada grade ≥2) had developed in 9 of 12 (75%; 95% confidence interval, 43%-95%), including 3 patients operated on with arthroplasty in the follow-up period. The mean absolute Constant-Murley score was 46 (standard deviation, 26), and the mean Western Ontario Rotator Cuff score was 59 (standard deviation, 20). In 7 of 10 patients (70%) with available ultrasonography, the graft was interpreted as not intact. All patients had a contralateral full-thickness tear, and 7 of 12 patients (58 %; 95% confidence interval, 28%-85%) had contralateral cuff tear arthropathy. The number of patients with cuff tear arthropathy was not significantly different between the shoulder repaired with a Dacron graft and the contralateral shoulder (P = .667). CONCLUSION: These results indicate that a synthetic interposition graft with screw fixation could not prevent cuff tear arthropathy and preserve cuff integrity in a long-term perspective.