Augmented baseplates yield optimum outcomes when compared with bone graft augmentation for managing glenoid deformity during reverse total shoulder arthroplasty: a retrospective comparative study.

PURPOSE: The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using glenoid bone grafting (BG rTSA) with primary rTSA using augmented glenoid baseplates (Aug rTSA) with a minimum 2-year follow-up. METHODS: A total of 520 primary rTSA patients treated with 8° posterior glenoid augments (n = 246), 10° superior glenoid augments (n = 97), or combined 10° superior/8° posterior glenoid augments (n = 177) were compared with 47 patients undergoing glenoid bone grafting for glenoid bone insufficiency. The mean follow-up was 37.0(±16) and 53.0(±27) months, respectively. Outcomes were analyzed preoperatively and at the latest follow-up using conventional statistics and stratification by minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds where applicable. Radiographs were analyzed for baseplate failure, and the incidences of postoperative complications and revisions were recorded. RESULTS: The glenoid Aug rTSA cohort had greater improvements in patient-reported outcome measures (PROMs) and range of motion when compared with the BG rTSA group at a minimum of 2-year follow-up, including Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles score, Shoulder Pain and Disability Index score, shoulder function, Shoulder Arthroplasty Smart score, abduction, and external rotation (P < .05). Patient satisfaction was higher in the Aug rTSA group compared with the BG rTSA group (P = .006). The utilization of an augmented glenoid component instead of glenoid bone grafting resulted in approximately 50% less total intraoperative time (P < .001), nearly 33% less intraoperative blood loss volume (P < .001), approximately 3-fold less scapular notching (P < .01), and approximately 8-fold less adverse events requiring revision (P < .01) when compared with the BG rTSA cohort. Aside from SCB for abduction, the Aug rTSA cohort achieved higher rates of exceeding MCID and SCB for every PROM compared with BG rTSA. More specifically, 77.6% and 70.2% of the Aug rTSA achieved SCB for American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index vs. 55% and 48.6% in the BG rTSA, respectively (P = .003 and P = .013). CONCLUSION: The present midterm clinical and radiographic study demonstrates that the utilization of an augmented baseplate for insufficient glenoid bone stock is superior as judged by multiple PROMs and range of motion metrics when compared with bone graft augmentation at minimum 2-year follow-up. In addition, when analyzed according to MCID and SCB thresholds, the use of augmented baseplates outperforms the use of glenoid bone grafting. Complication and revision rates also favor the use of augmented glenoid baseplates over glenoid bone grafting. Long-term clinical and radiographic follow-up is necessary to confirm that these promising midterm results are durable.

Development and validation of a predictive model for outcomes in shoulder arthroplasty: a multicenter analysis of nearly 2000 patients.

BACKGROUND: Guiding expectations following shoulder arthroplasty is important in improving patient satisfaction. The purpose of this study was to develop a predictive model to calculate 2-year American Shoulder and Elbow Surgeons (ASES) scores in shoulder arthroplasty patients from a comprehensive set of preoperative patient factors and types of arthroplasty performed. METHODS: This retrospective multicenter study included 1947 shoulder arthroplasties performed from 2010 to 2015 at 3 high-volume centers. Twenty-six variables were evaluated for an association with 2-year ASES scores, and variables with P < .20 in our pair-wise analysis were used to develop a predictive model. The prediction root-mean-square error was calculated. External validation was performed using data from 233 patients who underwent shoulder arthroplasty performed by a separate shoulder surgeon at a center not involved with creation of the predictive model. RESULTS: A total of 1947 patients were analyzed, and their data were used to construct the predictive model. Variables most associated with 2-year ASES scores were patient age, preoperative ASES score, disability, chronic obstructive pulmonary disease, alcohol use, anatomic vs. reverse total shoulder arthroplasty, and primary vs. revision shoulder arthroplasty. By use of cross validation, the prediction error was 20.1, the proportion of variance explained was 25.3%, the mean absolute error was 15.9, and the C statistic for the linear regression model was 0.66. After external validation, the mean difference between predicted and actual 2-year ASES scores was 12.7 points, within the accepted minimal clinically important difference after shoulder arthroplasty. DISCUSSION: Data from nearly 2000 shoulder arthroplasties allowed the development and validation of a model to predict 2-year ASES scores following shoulder arthroplasty. The model was accurate within the minimal clinically important difference in 85% of patients.

Opioid requirement after rotator cuff repair is low with a multimodal approach to pain.

BACKGROUND: Current practices may aim to blunt rather than understand postoperative pain. Perhaps the most common serious complication of arthroscopic rotator cuff repair (ARCR) is persistence of opiate medication intake. Patients still receive upwards of 80 oxycodone 5 mg pills, or 600 morphine milligram equivalents (MMEs), leading more than 20% of opioid-naïve subjects to continue to fill opioid prescriptions beyond 180 days after surgery. Developing evidence-based guidelines for narcotic prescription after ARCR presents an opportunity for orthopedic surgeons to address the opioid epidemic. PURPOSE: The purpose of this study was (1) to prospectively determine the requirements for opiate medications after ARCR, and (2) to create an evidence-based guideline for postoperative prescription, in contrast to the anecdotal or expert panel recommendations that currently exist. We further investigated whether a liposomal bupivacaine (LB) interscalene never block (ISNB) would reduce pain and opiate consumption compared with standard bupivacaine ISNB (control) for ARCR. METHODS: The study enrolled 100 patients who underwent primary ARCR surgery. Patients were provided with postoperative "pain journals" to document their daily pain on a numerical rating scale, satisfaction with pain management using the Likert scale, and track their daily oxycodone 5 mg pill consumption during the 14-day postoperative period. Enrolled patients were further randomized to receiving an LB (experimental) or standard bupivacaine (control) ISNB. RESULTS: A total of 77% of all patients required fewer than 15 pills postoperatively. The LB group consumed an average of 1.7 fewer pills (13.0 MMEs) on postoperative day (POD) 1 (P = .02) and reported statistically lower pain during PODs 1 and 2 (P = .01 and P = .006), as well as cumulatively throughout the study period (P = .03). In addition, LB patients remained opioid-free at a higher rate (44% vs. 15% in controls, P = .03). CONCLUSION: With a multimodal approach, the majority of patients undergoing ARCR can manage postoperative pain with 15 or fewer oxycodone 5 mg tablets (112.5 MMEs) and maintain a high degree of satisfaction. The addition of an LB ISNB may further reduce the consumption of postoperative narcotics compared with a standard ISNB. This study provides evidence that may be used for surgeon guidelines in the effort to reduce opioid prescriptions after ARCR.

Patient-reported outcomes of reverse total shoulder arthroplasty: a comparative risk factor analysis of improved versus unimproved cases.

BACKGROUND: The purpose of this study was to compare characteristics of patients who reported to be subjectively unimproved vs. improved after reverse total shoulder arthroplasty. METHODS: Data were derived from a prospective registry of patients who underwent reverse total shoulder arthroplasty with a minimum 2-year follow-up. Patients were asked to rate their subjective satisfaction and then divided into those who were unchanged or worse (unimproved group [UG]) vs. better or much better (improved group [IG]). The groups were compared for differences in demographic characteristics, preoperative factors, functional outcomes, and complications. RESULTS: There were 1425 patients in the IG and 134 patients in the UG. Patients in the IG were more likely to have a diagnosis of osteoarthritis. Patients in the UG were more likely to have coronary artery disease and diabetes and to have undergone prior surgery. No differences in implant configuration were found between groups. Preoperative measures for patients in the UG were worse for pain and function but not for range of motion. The outcomes in patients in the UG were worse for all postoperative measures, as well as for preoperative-to-postoperative improvement. Of the patients in the UG, 48% continued to have moderate to severe pain postoperatively. The complication rate was significantly higher in the UG. DISCUSSION: Up to 8.5% of patients rate themselves as unimproved after surgery. These patients are more likely to have certain comorbidities and to have undergone prior surgery. Although outcomes were significantly worse for all measures in the UG, improvement occurred in all measures despite patients subjectively being worse or unchanged. Residual pain and difficulty sleeping play a substantial role in subjective assessment of overall outcome.

Effect of Tuberosity Healing on Clinical Outcomes in Elderly Patients Treated With a Reverse Shoulder Arthroplasty for 3- and 4-Part Proximal Humerus Fractures.

OBJECTIVES: To evaluate tuberosity union rate and clinical outcome after 3- and 4-part proximal humerus fractures in the elderly. DESIGN: Retrospective, multicenter database cohort study. SETTING: Level I and Level II trauma centers. PATIENTS: Fifty-five patients older than 65 years had insertion of reverse shoulder arthroplasty (RTSA) for OTA/AO 11-B and 11-C proximal humerus fractures. INTERVENTION: Treatment with RTSA using a dedicated low profile onlay fracture stem using variable tuberosity fixation. MAIN OUTCOME MEASURES: Constant score, the American Shoulder and Elbow Surgeons score, Shoulder Pain and Disability Index score, University of California at Los Angeles score, Simple Shoulder Test score, visual analog pain score, shoulder function score, active range of motion, external rotation (ER)-specific tasks and position, rate of greater tuberosity healing, effect of tuberosity healing on overall clinical metrics, incidence of humeral lucency, and scapular notching. RESULTS: Eighty-three percent of the greater tuberosities that were repaired united. Greater tuberosity union resulted in greater active ER (P = 0.0415). There was a statistically significant difference in the ability to do ER-type activities between the 2 cohorts reflected in the ability to position one's hand behind their head with the elbow forward (P = 0.002) and comb their hair (P < 0.001). CONCLUSION: The use of a low profile onlay fracture stem in RTSA for acute 3- and 4-part proximal humerus fractures in the elderly can result in a high tuberosity union rate. Greater tuberosity healing significantly influences ER and ER-type activities that are not apparent by analysis of the overall metrics studied. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Subscapularis-Sparing Approaches to Total Shoulder Arthroplasty: Ready for Prime Time?

To minimize the risk of subscapularis failure after shoulder replacement, a method of preserving the subscapularis while allowing access to the glenohumeral joint was developed. Only the inferior 30% to 50% of the subscapularis tendon is detached from the humerus, leaving the superior aspect attached to the lesser tuberosity. This subscapularis-sparing, minimally invasive approach to the glenohumeral joint was evaluated in 43 subjects with a minimum 2-year follow-up and subscapularis strength equal to the opposite side. The approach provided adequate exposure for shoulder replacement surgery and decreased risk of postoperative failure of the subscapularis tendon.

Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty.

BACKGROUND: Alternative techniques have been developed to address pain after shoulder arthroplasty and are well documented. We evaluated the effect of adding intraoperative liposomal bupivacaine and intravenous dexamethasone during shoulder arthroplasty. METHODS: We retrospectively reviewed 2 consecutive cohorts undergoing elective shoulder arthroplasty. The 24 patients in cohort 1 and the 31 patients in cohort 2 received perioperative multimodal management with preoperative and postoperative intravenous and oral narcotics, gabapentin, nonsteroidal anti-inflammatory drugs, acetaminophen, and single-injection interscalene block. Cohort 2 also received 8 to 10 mg of intravenous dexamethasone intraoperatively after the skin incision and liposomal bupivacaine injected at surgery. Patients who did and did not use preoperative narcotics were analyzed together and separately. We evaluated hospitalization length of stay, narcotic use, and visual analog scale pain before and after the change in the perioperative protocol. RESULTS: Cohort 1 was hospitalized longer (2 vs. 1 day; P < .001), required more narcotics on postoperative day 1 (21.0 vs. 10.0 mg; P < .001) and days 0 and 1 cumulatively (30.5 vs. 17.5 mg; P = .001), and had more pain on postoperative days 0 (6.5 vs. 3.5; P < .001) and 1 (7.5 vs. 3.5; P < .001) than cohort 2. In patients using preoperative narcotics, cohort 2 had less pain on postoperative day 1 (3.5 vs. 7.0; P = .006), less cumulative narcotic use (20 vs. 58.5 mg; P = .03), and shorter hospitalization (1 vs. 2 days; P = .052) than cohort 1. CONCLUSION: These changes to the perioperative shoulder arthroplasty protocol decreased hospitalization length of stay, narcotic requirement, and pain.

Stemless and Short Stem Humeral Components in Shoulder Arthroplasty.

Humeral-sided arthroplasty design evolution continues to be supported by the published literature in the transition away from traditional stemmed devices. Early studies have shown not only absence of failure with these newer shorter and stemless designs but also equivalence in terms of early outcomes compared to traditional stemmed devices with the benefits of shorter operative time, less blood loss, easier revision, and the potential to reduce stress shielding and periprosthetic fractures. We will review the literature available on the different designs of both short stem and stemless humeral devices.

The incidence of radiographic aseptic loosening of the humeral component in reverse total shoulder arthroplasty.

BACKGROUND: The reverse total shoulder arthroplasty (RTSA) has been used in the treatment of complex shoulder problems. The incidence of aseptic loosening of the humeral component has not been previously reported. METHODS: This is a multicenter, retrospective, blinded, case-control radiographic review of 292 patients to determine the rate of humeral stem loosening. There were 177 cemented and 115 press-fit humeral components. Radiographs were critiqued for radiolucent lines adjacent to the humeral stem based on the method described by Gruen et al. RESULTS: The overall rate of loosening was 0.74%. No radiographic loosening occurred in the press-fit group (115 stems). In the cemented group (177 stems), 2 shoulders (1.18%) were identified with radiographically loose stems. No loosening occurred in the press-fit group. No statistically significant difference was found in humeral stem loosening when the press-fit group and the cemented group were compared (P = .198). DISCUSSION: Our study indicates the cemented or press-fit RTSA system will result in a low incidence of radiolucent lines and radiographic loosening. Compared with historical survivorship of conventional anatomic total shoulder arthroplasty, RTSA shows a lower rate of radiographic stem loosening at a mean of 38.46 months. CONCLUSIONS: The RTSA has a low incidence of humeral stem loosening at midterm. These results underscore the importance of careful selection of patients to provide the benefits of this surgical technique. Press-fit fixation may provide a lower risk to stem loosening.

Scapular notching in reverse shoulder arthroplasty: validation of a computer impingement model.

PURPOSE: The purpose of this study is to validate a reverse shoulder computer impingement model and quantify the impact of implant position on scapular impingement by comparing it to that of a radiographic analysis of 256 patients who received the same prosthesis and were followed postoperatively for an average of 22.2 months. METHODS: A geometric computer analysis quantified anterior and posterior scapular impingement as the humerus was internally and externally rotated at varying levels of abduction and adduction relative to a fixed scapula at defined glenoid implant positions. These impingement results were compared to radiographic study of 256 patients who were analyzed for notching, glenoid baseplate position, and glenosphere overhang. RESULTS: The computer model predicted no impingement at 0° humeral abduction in the scapular plane for the 38 mm, 42 mm, and 46 mm devices when the glenoid baseplate cage peg is positioned 18.6 mm, 20.4 mm, and 22.7 mm from the inferior glenoid rim (of the reamed glenoid) or when glenosphere overhang of 4.6 mm, 4.7 mm, and 4.5 mm was obtained with each size glenosphere, respectively. When compared to the radiographic analysis, the computer model correctly predicted impingement based upon glenoid base- plate position in 18 of 26 patients with scapular notching and based upon glenosphere overhang in 15 of 26 patients with scapular notching. CONCLUSIONS: Reverse shoulder implant positioning plays an important role in scapular notching. The results of this study demonstrate that the computer impingement model can effectively predict impingement based upon implant positioning in a majority of patients who developed scapular notching clinically. This computer analysis provides guidance to surgeons on implant positions that reduce scapular notching, a well-documented complication of reverse shoulder arthroplasty.