Hemiarthroplasty for proximal humerus fractures and for fracture sequelae: did not differ in their outcomes.

Background: The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae. Methods: Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk. Results: The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P = .102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P = .004), lower rate of previous procedure (4.3% vs. 51.9%; P < .001), lower bone graft use (28.6% vs. 59.6%; P < .001), and a longer length of stay (5.9 vs. 3.0 days; P < .001) in the acute HA group. Additionally, no differences were observed between the acute and sequalae cohort in pain (2.0 vs. 2.5; P = .523), forward elevation (98° vs. 93°; P = .627), external rotation (30° vs. 23°; P = .215), internal rotation score (4.0 vs. 4.5; P = .589), satisfaction (P = .592), ASES scores (64.4 vs. 57.1; P = .168), complications (27.1% vs. 28.8%; P = .836), or reoperations (11.4% vs. 19.2%; P = .229). When comparing acute fractures and sequalae, the 15-year complication rates were 32.4% and 43.3%, respectively (P = .172), with 15-year reoperation rates of 13.7% and 24%, respectively (P = .098). Conclusions: HA, whether performed acutely for a PHF or in a delayed fashion for fracture sequalae, demonstrated no statistically significant differences in outcomes for all examined parameters. HA in this setting may provide reasonable pain relief. However, limited motion, marginal ASES scores, and elevated rates of complications and reoperations can be expected up to 15 years postoperatively.

Shoulder arthroplasty in patients with upper extremity lymphedema may result in transient or permanent lymphedema worsening.

INTRODUCTION: Upper extremity lymphedema can complicate mastectomy, lymph node dissection, and radiation. The purpose of this study is to present the outcomes of shoulder arthroplasty in patients with lymphedema. METHODS: The 19 shoulders with a shoulder arthroplasty and lymphedema on the surgical side (6 anatomic, 12 reverse, 1 hemiarthroplasty) were followed for four years (1-10 years). There were 2 males and 17 females; average age was 67.8 (48-86) years. Breast carcinoma was the most common reason for lymphedema (75%). A dedicated lymphedema questionnaire could be completed for 14 shoulders. RESULTS: Pain improved from moderate or severe preoperatively to no or mild in 18 shoulders. Motion improved in elevation (55° preoperatively, 107° at last follow-up), external rotation (14°, 43°), and internal rotation (sacrum, L5). Complications included an acromion stress fracture with a deep infection (1), deep infection (1), superficial infection (1), and glenoid loosening (1). Lymphedema worsened in nine cases, but worsening was permanent in only four. Currently, lymphedema treatment is being performed by 93% of survey respondents. No patients reported lymphangitis or lymphangiosarcoma. CONCLUSION: Shoulder arthroplasty for an upper extremity with lymphedema provides substantial improvements in pain and motion; however, infection is a concerning complication. Fifty percent of the patients will experience worsening of their lymphedema and in 20% worsening may be permanent.

Correlation between hemolytic profile and phylotype of Cutibacterium acnes (formerly Propionibacterium acnes) and orthopedic implant infection.

INTRODUCTION: Cutibacterium acnes is a recognized culprit for implant-associated infections, but positive cultures do not always indicate clinically relevant infection. Studies have shown a correlation between the ß-hemolytic phenotype of C. acnes and its infectious capacity, but correlation with genetic phylotype has not been performed in literature. The purpose of this study is to evaluate ß-hemolysis phenotype, genetic phylotype, and mid-term clinical outcomes of C. acnes isolated from orthopedic surgical sites. METHODS: Fifty-four C. acnes isolates previously obtained from surgical wounds of patients undergoing hip, knee, shoulder, or spine implant removal were re-cultured. There were 21 females and 33 males with an average age of 59 years (range, 18-84). Twenty-four were from clinically infected sites whereas 30 were considered contaminants. De novo ß-hemolysis was analyzed and a retrospective chart review was performed to evaluate clinical outcomes at 7.1 years (range, 0.1-12.8). RESULTS: On Brucella agar with 5% rabbit blood, 46% of contaminant and 43% of infectious isolates were hemolytic. Type II phylotype was significantly more nonhemolytic regardless of infectious or contaminant status (p < 0.05). Type 1B correlated with a hemolytic-infectious phenotype and Type 1A with a hemolytic-contaminant phenotype but was not statistically significant. CONCLUSION: The ß-hemolytic profile of C. acnes did not correlate with phylotype or clinically relevant orthopedic infection.

Cost analysis and complication profile of primary shoulder arthroplasty at a high-volume institution.

BACKGROUND: Paralleling the increased utilization of shoulder arthroplasty, bundled-payment reimbursement is becoming increasingly common. An understanding of the costs of each element of care and detailed information on the frequency of and reasons for readmission and reoperation are keys to developing bundled-payment initiatives. The purpose of this study was to perform a comprehensive analysis of complications, readmission rates, and costs of primary shoulder arthroplasty at a high-volume institution. METHODS: Between 2012 and 2016, 2 shoulder surgeons from a single institution performed 1794 consecutive primary shoulder arthroplasties: 636 anatomic total shoulder arthroplasties (TSAs), 1081 reverse shoulder arthroplasties (RSAs), and 77 hemiarthroplasties. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation. RESULTS: The 90-day complication, reoperation, and readmission rates were 2.3%, 0.6%, and 1.8%, respectively. The 90-day readmission risk was higher among patients with an American Society of Anesthesiologists score of 3 or greater; a 1-unit increase in the American Society of Anesthesiologists score was associated with a $429 increase in index cost. Of the hospital readmissions, 10 were directly related to the index arthroplasty whereas 21 were not. The median standardized costs were as follows: preoperative evaluation, $481; index surgical hospitalization, $15,758; and postoperative care, $183. The median standardized costs for index surgical hospitalization were different for each procedure: TSA, $14,010; RSA, $16,741; and hemiarthroplasty, $12,709. CONCLUSION: In this study, primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. The median standardized costs inclusive of preoperative workup and 90-day postoperative recovery were $14,675 and $17,407 for TSA and RSA, respectively.

Primary reverse shoulder arthroplasty: how did medialized and glenoid-based lateralized style prostheses compare at 10 years?

BACKGROUND: The purpose of this study was to compare long-term outcomes, complications, and reoperation rates of primary reverse total shoulder arthroplasty (RTSA) performed at a single institution using 2 implant designs: a Grammont medialized prosthesis (medialized [M] group) and a Frankle glenoid-based lateralized prosthesis (glenoid-lateralized [GL] group). METHODS: Between 2004 and 2008, 100 consecutive single-institution primary RTSAs were performed by reconstructive shoulder surgeons who were not design consultants, with the aim of obtaining 10-year follow-up: 56 in the M group and 44 in the GL group. Patients were followed up until death, until revision surgery, or for a minimum of 10 years. RESULTS: Of 100 patients, 87 had more than 2 years' follow-up (mean, 77 months). A subset analysis of 41 patients with an average of 10.2 years' follow-up showed sustained long-term outcomes. RTSA provided clinical improvements without significant differences between the M and GL groups, except for improved active forward elevation in the M group (144° in M group vs. 115° in GL group, P = .002). Reoperation was required in 6 shoulders (10-year cumulative incidence of 3 [5%] in M group vs. 3 [8%] in GL group) for a total of 16 complications (10-year cumulative incidence of 8 [14%] in M group vs. 8 [20%] in GL group). Notching rates were significantly higher in the M group (77% in M group vs. 47% in GL group, P = .013); differences in severe notching (grade 3 or 4) were clinically relevant but did not reach statistical significance (23% in M group vs. 9% in GL group, P = .22). CONCLUSION: Primary RTSA using these first 2 prosthesis designs was associated with good outcomes and low reoperation (5%-8%) and complication (14%-20%) rates at 10 years. The M group had higher rates of notching. These results may provide a benchmark for comparison with newer implants, especially considering that these results include the early RTSA implantation learning curve.

The effect of patient-reported metal allergies on the outcomes of shoulder arthroplasty.

BACKGROUND: Although literature exists regarding hip and knee arthroplasty outcomes in patients with skin allergy to metals, there is minimal information about skin allergy implications on shoulder arthroplasty outcomes. The purpose of this study was to determine the results, complications, and failure rate among patients with a self-reported metal allergy undergoing shoulder arthroplasty. METHODS: Fifty-two shoulder arthroplasties were performed at our Institution in 43 patients with self-reported metal allergies. Forty primary and 12 revision shoulder arthroplasties were performed using anatomic (30) and reverse (22) components. Retrospective chart review was performed to determine metal allergy history, implant composition, pain, motion, and complications. Radiographs were reviewed to determine mechanical failure rates. Average follow-up time was 65 months. RESULTS: Allergies reported included nickel (37), cobalt chrome (4), copper (2), zinc (1), titanium (1), gold (1), and nonspecific metal allergy (8); 8 patients reported multiple metal allergies. All components implanted in patients with nickel allergies contained nickel. At most recent follow-up, pain was rated as none or mild in 88% of shoulders. Active elevation improved from 80° to 141° and external rotation from 24° to 52°. Two revisions were performed for glenoid loosening (3.8%); both were revision cases with substantial glenoid bone loss. One patient with mild pain had a radiographically loose glenoid component 12 years after anatomic shoulder arthroplasty. CONCLUSION: Results from this study suggest that shoulder arthroplasty in patients with self-reported metal allergy provides satisfactory pain relief and improved range of motion with low revision rates.

Shoulder arthroplasty in patients with immunosuppression following solid organ transplantation.

BACKGROUND: The purpose was to determine the risk and outcomes of primary shoulder arthroplasties in patients with immunosuppression who had undergone solid organ transplantation. METHODS: Using a single institution's total joint registry, we reviewed 30 primary shoulder arthroplasties in 25 post-transplantation patients, including 12 total shoulder arthroplasties, 10 hemiarthroplasties, and 8 reverse shoulder arthroplasties, between 1985 and 2012. Therapy and patient variables were recorded, including immunosuppressive therapy protocols, the date of preceding solid organ transplantation, and specific medications taken in the perioperative period. We matched a cohort of control patients for age, sex, type of implant, and year of surgery at a ratio of 4:1. Two groups were compared regarding mortality risk, complications, and clinical outcomes (pain score, range of motion, and American Shoulder and Elbow Surgeons score). RESULTS: No periprosthetic infections occurred in the post-transplantation group at a mean follow-up of 39 months. However, the post-transplantation group showed an increased risk of periprosthetic fractures compared with the control group (hazard ratio, 8.18; 95% confidence interval, 1.22-70.98; P = .03). Despite the increase in fractures, the overall number of complications did not differ between the groups. Furthermore, postoperative shoulder function and outcome scores were not significantly different between patients who had a prior transplant and those who did not. CONCLUSION: Primary shoulder arthroplasty in patients with immunosuppression who underwent solid organ transplantation is a successful procedure to treat glenohumeral arthritis. In contrast, there may be an increased risk of periprosthetic fractures in patients with a history of a solid organ transplant.

Shoulder arthroplasty in patients with cerebral palsy: a matched cohort study to patients with osteoarthritis.

BACKGROUND: Patients with cerebral palsy (CP) often experience shoulder impairment via spasticity, muscle contractures, and joint instability. Currently, few studies investigate shoulder arthroplasty (SA) in patients with CP. This study reviewed the outcomes of both anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) in patients with CP. METHODS: Over a 30-year-period, 5 patients undergoing SA (2 TSA, 3 RSA) with a diagnosis of CP were identified. The cohort included 4 male patients with a mean age of 50.4 years (range, 44-58 years). CP patients were matched 1:2 based on age, sex, body mass index, and year of surgery with a group of patients undergoing SA for osteoarthritis (OA). RESULTS: Survival from implant revision for both TSA and RSA in CP was 100% at both 2 and 5 years postoperatively. Clinical complications were only observed in 2 patients after TSA, with 1 patient requiring revision at 14 years postoperatively. Collectively, there was no difference in the rate of complications and implant survival between patients with CP vs. OA. Prior to the surgical procedure, all CP patients had severe or moderate pain, with no moderate or severe pain postoperatively. Notable postoperative increases from preoperative baselines were noted in forward elevation (57°-106°), abduction (48°-84°), and external rotation (30°-64°). RSA had significantly improved postoperative abduction compared to TSA (97° vs. 64°, P < .01). CONCLUSIONS: SA is a safe, durable procedure in patients with CP to clinically improve pain, function, and satisfaction. RSA was associated with better function and fewer complications than TSA.

Primary reverse shoulder arthroplasty in patients older than 80 years of age: survival and outcomes.

AIMS: Reverse shoulder arthroplasty (RSA) reliably improves shoulder pain and function for a variety of indications. However, the safety and efficacy of RSA in elderly patients is largely unknown. The purpose of this study was to report the mortality, morbidity, complications, reoperations, and outcomes of primary RSA in patients aged > 80 years. PATIENTS AND METHODS: Between 2004 and 2013, 242 consecutive primary RSAs were performed in patients aged > 80 years (mean 83.3 years (sd 3.1)). Of these, 53 were lost to follow-up before two years and ten had died within two years of surgery, leaving 179 for analysis of survivorship, pain, motion, and strength at a minimum of two years or until revision surgery. All 242 patients were considered for the analysis of 90-day, one-year, and overall mortality, medical complications (90-day and overall), surgical complications, and reoperations. The indications for surgery included rotator cuff arthropathy, osteoarthritis, fracture, the sequela of trauma, avascular necrosis, and rheumatoid arthritis. A retrospective review of the medical records was performed to collect all variables. Survivorship free of revision surgery was calculated at two and five years. RESULTS: One patient (0.4%) died within the first 90 days. A total of 45 patients (19%) were known to have died at the time of the final follow-up, with a median time to death of 67.7 months (interquartile range 40.4 to 94.7) postoperatively. Medical complications occurred in six patients (3%) and surgical complications occurred in 21/179 patients (12%). Survivorship free from revision was 98.9% at two years and 98.3% at five years; survivorship free from loosening was 99.5% at final follow-up. The presence of peripheral vascular disease correlated with a higher complication rate. CONCLUSION: Primary RSA was safe and effective in patients aged > 80 years, with a relatively low rate of medical and surgical complications. Thus, age alone should not be a contraindication to primary RSA in patients aged > 80 years. However, a careful evaluation of comorbidities is required in this age group when considering primary RSA. Cite this article: Bone Joint J 2019;101-B:1520-1525.

Reverse shoulder arthroplasty for patients with glenohumeral osteoarthritis secondary to glenoid dysplasia.

The purpose is to report the clinical and radiographic outcomes, complications and reoperations of reverse shoulder arthroplasty (RSA) for glenoid dysplasia. All patients who had undergone RSA for osteoarthritis secondary to underlying glenoid dysplasia were retrospectively identified. The study included twelve shoulders (11 patients), with a mean (SD) patient age of 62.2 (13.2) years and median (range) clinical follow-up of 28 (24-34) months. RSA resulted in substantial improvements in pain and function. At most recent follow-up, there was a significant improvement in forward flexion range of motion (ROM), a non-significant improvement in internal rotation ROM, and no changes in external rotation ROM. The mean (SD) SST and ASES scores were 7.8 (3.7) and 73.5 (20.4), respectively. There were no reoperations or radiographic loosening. The results were excellent in 1 case, satisfactory in 8, and unsatisfactory in 3. RSA provides acceptable function and good pain relief, though patients should be advised that shoulder rotation may be somewhat limited.

Symptomatic Thromboembolic Complications After Shoulder Arthroplasty: An Update.

BACKGROUND: Venous thromboembolism (VTE) complications, including deep vein thrombosis and pulmonary embolism, are dreaded complications of orthopaedic surgical procedures that can result in substantial morbidity and mortality. There is a paucity of data examining risk factors for VTE in shoulder arthroplasty. The purpose of the present study was to review the rate of symptomatic VTE, determine patient and operative risk factors for VTE, and report on complications associated with VTE following shoulder arthroplasty. METHODS: Over a 16-year period, 5,906 patients underwent primary anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. Symptomatic VTE events were identified in 24 shoulders within 90 days of surgery. Patient records were reviewed for surgical indication, patient and operative risk factors, and management of VTE. RESULTS: The rate of symptomatic VTE following shoulder arthroplasty was 0.41%. There were no deaths resulting from VTE events. Compared with patients who did not have VTE, those with symptomatic VTE events were found to be older (74.75 versus 68.51 years; p = 0.0028) and more likely to have had arthroplasty for a traumatic indication (3.31% versus 0.33%; p < 0.001). Age of >70 years and arthroplasty for a traumatic indication were found to be independent risk factors on multivariate nominal logistic regression analysis, whereas body mass index, sex, operative time, and type of arthroplasty performed were not found to be independent risk factors. There were 11 readmissions resulting directly from the VTE events, and patients diagnosed with VTE as inpatients had longer hospital stays than outpatients (13.71 versus 1.94 days; p = 0.0002). CONCLUSIONS: The risk of VTE following shoulder arthroplasty is low, and routine use of pharmacologic VTE prophylaxis may not be necessary. However, VTE complications can lead to substantial morbidity, longer hospital stays, readmission to the hospital, and further complications. Therefore, patients with multiple risk factors for VTE such as prior history of VTE, active malignancy, age of >70 years, or arthroplasty for traumatic indications should be considered for pharmacologic VTE prophylaxis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Anatomic Intraoperatively Prepared Antibiotic Spacer in Two-Stage Shoulder Reimplantation for Deep Infection: The Potential for Early Rehabilitation.

Molded antibiotic shoulder spacers allow for intraoperative customization of antibiotics and multiple size options. The purpose of this study was to evaluate the efficacy of an anatomic intraoperatively molded spacer in the two-stage treatment of infection and to assess the safety of early rehabilitation when the capsule and rotator cuff are present. During 2014 and 2015, 27 shoulders were treated with a molded antibiotic cement spacer as part of a two-stage treatment. Indications included periprosthetic joint infection (n=18), native shoulder infection (n=8), and infection after internal fixation (n=1). All patients were followed for a minimum of 2 years. Mean follow-up time was 29.6 months. Patients were allowed to perform motion exercises (group I; n=16) or were instructed to avoid motion (group II; n=11) after spacer implantation, depending on the condition of their rotator cuff. Infection was eradicated in 23 of the 27 shoulders (85%). At most recent follow-up, pain scores were lower in group I. Mean final elevation was 115° in group I compared with 93° in group II. Mean final active external rotation was 36°, with no difference between the groups. In 3 (4%) shoulders with significant proximal humeral bone loss, the spacer became rotationally unstable. An anatomic intraoperatively molded spacer can be implanted safely in two-stage treatment for deep infection and has a reasonable rate of eradication. When adequate capsule and rotator cuff tissue is present, early motion in between stages can be safely recommended with a trend toward improved forward elevation at final follow-up and may facilitate the second stage reimplantation. [Orthopedics. 2019; 42(4):211-218.].

Reverse shoulder arthroplasty for rheumatoid arthritis since the introduction of disease-modifying drugs.

PURPOSE: Rheumatoid arthritis has been associated with poor clinical outcomes in hemiarthroplasty and unconstrained total shoulder arthroplasty. The reverse shoulder arthroplasty can be utilized to address the shortcomings of hemiarthroplasty and unconstrained total shoulder arthroplasty in the inflammatory arthritis patient population. The objective of the present study was to retrospectively review clinical and radiographic outcomes of patients who underwent reverse shoulder arthroplasty for rheumatoid arthritis and other inflammatory arthropathies and provide a comprehensive analysis to identify factors that may alter patient outcomes. METHODS: We identified 91 primary reverse shoulder arthroplasties performed between 2006 and 2013 in patients with inflammatory arthritis. Seventy-five had at least two years of follow up with an average follow-up of 4.0 years. The average age at the time of surgery was 70 years old. Peri-operative use of steroids, biologics, and methotrexate were reviewed. Outcomes evaluated included revision and reoperation rates, complications, American Shoulder and Elbow Surgeons (ASES) scores, simple shoulder test (SST) scores, component loosening, and scapular notching. RESULTS: The two and five year implant revision-free survival was 99%. The two and five year re-operation-free survival was 97%. Eighteen (24%) glenoid components required augmentation with corticocancellous autograft from the humeral head. There were two cases of glenoid loosening with gross changes in position. Patients experienced significant pain relief with a 92% satisfaction rate. Shoulder elevation and external rotation improved from 65 and 21 degrees pre-operatively to 138 and 45 degrees post-operatively, respectively (p < .01). Average ASES and SST scores were 72 and 7.0, respectively. The use of prednisone, DMARDs, or biologic medications had no significant impact on outcomes.

Primary reverse shoulder arthroplasty using contemporary implants is associated with very low reoperation rates.

BACKGROUND: The early results of reverse shoulder arthroplasty (RSA) were influenced to some extent by the use of first-generation implants and surgeons' learning curves, resulting in relatively high reoperation rates. The purpose of this study was to quantify the burden of and identify the indications for reoperation after primary RSA using contemporary implants and techniques. METHODS: A retrospective review of 1649 primary RSAs implanted consecutively between 2009 and 2015 at a single institution was conducted. All arthroplasties were performed by 5 fellowship-trained shoulder surgeons at a tertiary referral center. Demographic characteristics, indications for primary RSA, and reoperations were analyzed and categorized for trends associated with each type of reoperation performed. RESULTS: A total of 39 reoperations (2.37%) were performed for a variety of indications. Overall, only a few patients with infection or instability required reoperation (0.55%). The most common indications for reoperation were related to the humeral component (1.03%); the majority of humeral component complications were related to a specific design flaw of 1 implant system. RSAs performed for proximal humeral fracture sequelae more commonly underwent reoperation owing to instability or humeral component-related issues; all 4 cases of aseptic humeral stem loosening occurred in the setting of proximal humeral fracture sequela treatment. Only 0.36% of all primary RSAs required reoperation because of glenoid complications. CONCLUSIONS: Primary RSA performed with contemporary implants and surgical techniques seems to be associated with a very low rate of reoperation. The most common reasons for reoperation were humeral component fracture for 1 particular implant, humeral loosening, dislocation, infection, and glenoid failure, each occurring at a rate under 1%.

Intraobserver and interobserver reliability of the modified Walch classification using radiographs and computed tomography.

BACKGROUND: The Walch classification was introduced to classify glenoid morphology in primary glenohumeral osteoarthritis. A modified Walch classification was recently proposed, with 2 additional categories, B3 (monoconcave glenoid with posterior bone loss leading to retroversion > 15° or subluxation > 70%) and D (excessive anterior subluxation), as well as a more precise definition of subtypes A2 and C. The purpose of this study was to evaluate the intraobserver and interobserver agreement of the modified Walch classification system using both plain radiographs and computed tomography (CT). METHODS: Three fellowship-trained shoulder surgeons blindly and independently evaluated radiographs and CT scans of 100 consecutive shoulders (98 patients) with primary glenohumeral osteoarthritis and classified all shoulders according to the modified Walch classification in 4 separate sessions, each 4 weeks apart. Statistical analysis with the κ coefficient was used to evaluate reliability. RESULTS: The first reading by the most senior observer on the basis of CT scans was used as the gold standard (distribution: A1, 18; A2, 12; B1, 20; B2, 25; B3, 22; C, 1; and D, 2). The average intraobserver agreement for radiographs and CT scans was 0.73 (substantial; 0.72, 0.74, and 0.72) and 0.73 (substantial; 0.77, 0.69, and 0.72), respectively. The average interobserver agreement was 0.55 (moderate; 0.61, 0.51, and 0.53) for radiographs and 0.52 (moderate; 0.63, 0.50, and 0.43) for CT scans. CONCLUSION: Intraobserver agreement of the modified Walch classification was substantial both for axillary radiographs and for CT scans. Interobserver agreement was fair. Although the modified Walch classification represents an improvement over the original classification, automated computer-based analysis of CT scans may be needed to further improve the value of this classification.

Patient-reported activities after bilateral reverse total shoulder arthoplasties.

PURPOSE: Reverse shoulder arthroplasty (RSA) improves pain and function with very good satisfaction. Concerns exist about some activities of daily living (ADLs) involving internal rotation. The purpose of this study was to report how patients with bilateral RSA perform various ADLs. METHODS: Thirty-one primary bilateral RSA patients (average age 76 years; 21 women and 10 men) completed a survey to assess various outcomes. The average time between the second arthroplasty and the survey was 2.7 years (range 1.0-7.8 years). RESULTS: All clinical parameters were favorable. All patients reported being able to easily manage toileting and 87% reaching their back pocket. However, 29% found difficulty and 39% were unable to wash their back or put on bra. In comparison with various unilateral arthroplasty types, there was no statistical difference in overall activities ( p < 0.05). CONCLUSION: Bilateral RSA can provide good functional outcome and high satisfaction. Patients manage most ADLs easily with some limitations in activities requiring extreme internal rotation.

Significance of Perioperative Tests to Diagnose the Infection in Revision Total Shoulder Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the value of perioperative tests for the diagnosis of infection in revision shoulder arthroplasty. METHODS: A retrospective analysis was performed on 537 shoulder arthroplasties (429 patients) that underwent revision shoulder arthroplasty at our institution. Periprosthetic tissue cultures were positive in 169/537 surgeries. RESULTS: White-blood cell count (WBC) was elevated in 3.8% revision arthroplasties. Erythrocyte sedimentation rate (ESR) was elevated in 23.1% revision arthroplasties. The C-reactive protein (CRP) was elevated in 20.8% revision arthroplasties. Bone scans (technetium, indium) were performed on 9.9% patients and it was positive for osteomyelitis in just one revision arthroplasty. Intra-operative pathology was read as consistent with acute inflammation in 11.9% revision arthroplasties. The positive and negative predictive values for intra-operative pathology were 56.7% and 71.6% respectively. CONCLUSION: All of the perioperative tests had a high specificity and negative predictive value, but low sensitivity and positive predictive value.

Revision anatomic shoulder arthroplasty with posterior capsular plication for correction of posterior instability.

BACKGROUND: Revision of failed anatomic total shoulder arthroplasty or hemiarthroplasty is a challenging procedure. Restoring adequate soft tissue balance in the revision setting can be particularly problematic. When persistent posterior instability is encountered in the revision setting, options include changing component position or size, posterior capsular plication (PCP), or conversion to a reverse arthroplasty. The purpose of this study was to report the clinical and radiographic outcomes, complications, and reoperations of PCP performed in the setting of revision anatomic shoulder arthroplasty. PATIENTS AND METHODS: Between 1975 and 2013, 15 patients (16 shoulders) had PCP during revision anatomic shoulder arthroplasty. Indications for revision arthroplasty included posterior instability in 15, glenoid loosening in 3, polyethylene wear in 2, and glenoid erosion in 1 shoulder. The mean (standard deviation (SD)) age was 60.1 (12.6) years, and the median (range) follow-up was 68 (2-228) months. A retrospective chart review was conducted to obtain all data. RESULTS: At the last follow-up, nine shoulders (56%) had absence of posterior radiographic subluxation. Five (31%) cases underwent reoperation due to persistent posterior instability. Complications were observed in seven (44%) cases. Complete pain relief was achieved in four (25%) shoulders. The mean (SD) postoperative forward flexion, external rotation, and the American Shoulder and Elbow Surgeons score were 110° (41°), 40° (29°), and 62.1 (21.9), respectively. Results were excellent in two (13%), satisfactory in seven (44%), and unsatisfactory in seven (44%) shoulders. CONCLUSIONS: PCP to correct posterior instability during revision anatomic shoulder arthroplasty had an unacceptably high failure rate. In these circumstances, consideration should instead be given to conversion to a reverse shoulder arthroplasty.