The effect of cuff arthropathy stage on sleep disturbance and kinesiophobia in reverse shoulder arthroplasty patients.

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 ​​according 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 ​​were calculated preoperatively, and post-operatively at the 6th week, 6th month, and 1st year. The change in PSQI and TSK values ​​between 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 ​​in 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.

Managing rotator cuff tear arthropathy: a role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty.

BACKGROUND: Disabling cuff tear arthropathy (CTA) is commonly managed with reverse shoulder arthroplasty (RSA). However, for patients with CTA having preserved active elevation, cuff tear arthropathy hemiarthroplasty (CTAH) may offer a cost-effective alternative that avoids the complications unique to RSA. We sought to determine the characteristics and outcomes of a series of patients with CTA managed with these procedures. MATERIALS AND METHODS: We retrospectively reviewed 103 patients with CTA treated with shoulder arthroplasty, the type of which was determined by the patient's ability to actively elevate the arm. Outcome measures included the change in the Simple Shoulder Test (SST), the percent maximum improvement in SST (%MPI), and the percentage of patients exceeding the minimal clinically important difference for the change in SST and %MPI. Postoperative x-rays were evaluated to assess the positions of the center of rotation and the greater tuberosity for each implant. RESULTS: Forty-four percent of the 103 patients were managed with CTAH while 56% were managed with RSA. Both arthroplasties resulted in clinically significant improvement. Patients having RSA improved from a mean preoperative SST score of 1.7 (interquartile range [IQR], 0.0-3.0) to a postoperative score of 6.3 (IQR, 2.3-10.0) (P < .01). Patients having CTAH improved from a preoperative SST score of 3.1 (IQR, 1.0-4.0) to a postoperative score of 7.6 (IQR, 5.0-10.) (P < .001). These improvements exceeded the minimal clinically important difference. Instability accounted for most of the RSA complications; however, it did not account for any CTAH complications. The postoperative position of the center of rotation and greater tuberosity on anteroposterior radiographs did not correlate with the clinical outcomes for either procedure. CONCLUSION: For 103 patients with CTA, clinically significant improvement was achieved with appropriately indicated CTAH and RSA. In view of the lower cost of the CTAH implant, it may provide a cost-effective alternative to RSA for patients with retained active elevation.

The long-term results of shoulder hemiarthroplasty in irreducible four-part fracture-dislocation of the proximal humerus without rotator cuff tear arthropathy.

PURPOSE: Although there are concerns about nonunion of the greater tuberosity or shoulder weakness, hemishoulder arthroplasty (HSA) is a viable treatment option for irreducible four-part proximal humerus fractures-dislocation without rotator cuff tear arthropathy. This study aims to analyze the long-term radiological and functional outcomes of HSA. METHODS: This study enrolled 36 patients who underwent HSA due to irreducible four-part proximal humerus fracture-dislocation without rotator cuff tear arthropathy between March 2005 and May 2020. The exclusion group included 10 reverse total shoulder arthroplasty patients. The mean age and mean follow-up period were 68.6 years old and 48.6 months, respectively. Radiological assessments, such as vertical and horizontal greater tuberosity position, greater tuberosity healing, and implant position, were evaluated. Clinically, American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion were evaluated. RESULTS: The greater tuberosity union rate was 55.6% (n = 20), with 44.4% (n = 16) experiencing nonunion, malunion, and bone resorption. The mean vertical and horizontal greater tuberosity positions showed significant difference at last follow-up compared to immediate postoperation. The retroversion of the implant was 23.8 ± 4.61°, and the acromio-humeral interval was 7.6 ± 1.34 mm. The mean last follow-up ASES and CMS were 39.5 ± 4.03 and 55.4 ± 10.41, respectively. The mean active forward flexion, abduction, internal rotation, and external rotation were 100.9 ± 15.04°, 92.5 ± 14.47°, 44.2 ± 12.83°, and 42.5 ± 15.32°, respectively. CONCLUSION: In long-term follow-up, the greater tuberosity was superiorly migrated and externally rotated. Active forward flexion and abduction in the last follow-up were significantly limited. However, in terms of pain relief, a satisfactory result was seen.

Lateralization and distalization shoulder angles do not predict outcomes in reverse shoulder arthroplasty for cuff tear arthropathy.

BACKGROUND: In reverse shoulder arthroplasty (RSA), there are a plethora of measurements regarding implant lateralization and distalization to optimize the center of rotation. Two specific measurements known as the "lateralization shoulder angle" (LSA) and "distalization shoulder angle" (DSA) have been the recent focus of studies to assess their association with RSA and postoperative function. The aim of this study was to evaluate the prognostic clinical value of the LSA and DSA in a large cohort of patients with cuff tear arthropathy (CTA) who were treated with different RSA systems. METHODS: Two local shoulder arthroplasty registries were reviewed for all RSA patients documented to have undergone a radiologic assessment and complete 2-year follow-up examination. The main inclusion criterion was primary RSA in patients with CTA. Patients with either a complete teres minor tear, os acromiale, or acromial stress fracture reported between the time of surgery and the 24-month follow-up were excluded. Five RSA implant systems with 4 neck-shaft angles (NSAs) were assessed. The Constant score, Subjective Shoulder Value, and range of motion at 2 years were correlated with both the LSA and DSA assessed on 6-month anteroposterior radiographs. Linear and parabolic univariable regressions were calculated for both shoulder angles, for each prosthesis system, and for the entire patient cohort. RESULTS: Between May 2006 and November 2019, there were a total of 630 CTA patients who had undergone primary RSA. Of this large cohort of patients, 270 were treated with the Promos Reverse prosthesis system (NSA, 155°); 44, Aequalis Reversed II (NSA, 155°); 62, Lima SMR Reverse (NSA, 150°); 25, Aequalis Ascend Flex (NSA, 145°); and 229, Univers Revers (NSA, 135°). The mean LSA was 78° (standard deviation [SD], 10°; range, 6°-107°), and the mean DSA was 51° (SD, 10°; range, 7°-91°). The average Constant score at 24 months' follow-up was 68.1 points (SD, 13 points; range, 13-96 points). Neither the linear nor parabolic regression calculations for the LSA or DSA revealed significant associations with any of the clinical outcomes. CONCLUSION: Different patients may achieve different clinical outcomes despite having identical LSA and DSA values. There is no association between angular radiographic measurements and 2-year functional outcomes after RSA.

Short- to medium-term outcomes and future direction of reverse shoulder arthroplasty: Current concepts.

Reverse shoulder arthroplasty is typically indicated for patients with severe shoulder osteoarthritis, rotator cuff tear arthropathy, or proximal humerus fractures that have failed to heal properly. The primary goal of reverse shoulder arthroplasty is to improve shoulder function and reduce pain, while also restoring the ability to perform daily activities. There is a growing body of evidence supporting the effectiveness of reverse shoulder arthroplasty in improving shoulder function and reducing pain in patients with severe shoulder osteoarthritis or rotator cuff tear arthropathy. Reverse shoulder arthroplasty is associated with significant improvements in shoulder function and pain reduction compared to non-surgical treatments. This paper aims to summarize current knowledge, practices and present a summary of the long-term effects of reverse shoulder arthroplasty (RSA) on patient outcomes, including how these outcomes are defined and what measures are typically used to assess them. It will also cover newer definitions of outcomes for RSA that have been developed in recent years in order to better understand the long-term effects of the procedure on patient-reported outcomes and functional ability, as well as information on revision surgery and implant survivorship, and the future of RSA (3D-navigation, patient-specific instrumentation, robotics and artificial intelligence) and its effects on outcomes.

Spontaneous Deltoid Tear in Cuff Tear Arthropathy and Its Effect on the Outcome of Reverse Total Shoulder Arthroplasty: A Comparison Using Propensity Score Matching.

Background: Deltoid function critically influences the results of reverse total shoulder arthroplasty (RTSA), and spontaneous deltoid attrition tears are frequently detected in cuff tear arthropathy (CTA) patients; however, the clinical impacts of these tears on RTSA outcomes are undetermined. Our aim was to determine the effect of spontaneous deltoid attrition tears on postoperative outcomes after RTSA without an additional deltoid procedure. Methods: Seventy-two patients who underwent RTSA for CTA with preoperative magnetic resonance imaging (MRI) and a minimum clinical follow-up of 1 year (mean, 32 months) were retrospectively reviewed in the study. Patients with a history of previous shoulder surgery or injury were excluded. The presence and location of deltoid attrition tears were determined in preoperative MRI. Propensity score matching (1:1) was performed to construct tear and no-tear groups. Finally, 21 patients, matched with respect to age, sex, hand dominance, symptom duration, medical comorbidity (obesity, diabetes mellitus, and coronary artery disease), Hamada grade, and implant type, were assigned to each group. Clinical outcomes (functional scores, isometric power, and range of motion) in the two groups were compared. Results: Deltoid attrition tears were detected in 21 of the 72 enrolled cases (29.1%). Anterolateral deltoid was the most frequent location and no tear was detected in the posterior deltoid. The tear rate increased with disease severity (Hamada G2, 4.8%; G3, 23.8%; > G4, 71.4%). No pre- or postoperative clinical variables differed significantly between the tear and no tear groups. Conclusions: Deltoid attrition tears were detected in 29% of CTA patients who underwent RTSA. The most common site was the anterolateral region and tear prevalence tended to increase with CTA progression. However, RTSA was found to provide satisfactory outcomes regardless of the presence of a deltoid attrition tear.

Reverse shoulder arthroplasty: State-of-the-art.

The reverse shoulder arthroplasty conceived by Paul Grammont in 1985 has gradually gained popularity as a treatment for multiple shoulder diseases. Unlike previous reverse shoulder prosthesis characterized by unsatisfactory results and a high glenoid implant failure rate, the Grammont design has immediately shown good clinical outcomes. This semi constrained prosthesis solved the issues of the very first designs by medializing and distalizing the center of rotation with an increased stability of the replacement of the component. The indication was initially limited to cuff tear arthropathy (CTA). It has then been expanded to irreparable massive cuff tears and displaced humeral head fractures. The most frequent problems of this design are a limited postoperative external rotation and scapular notching. Different modifications to the original Grammont design have been proposed with the aim of decreasing the risk of failure and complications and improving the clinical outcomes. Both the position and version/inclination of the glenosphere and the humeral configuration (e.g. neck shaft angle) influence the RSA outcomes. A lateralized glenoid (whether with bone or metal) and a 135° Inlay system configuration leads to a moment arm which is the closest to the native shoulder. Clinical research will focus on implant designs reducing bone adaptations and revision rate, strategies to prevent more effectively infections. Furthermore, there is still room for improvement in terms of better postoperative internal and external rotations and clinical outcomes after RSA implanted for humeral fracture and revision shoulder arthroplasty.

Disparities in arthroplasty utilization for rotator cuff tear arthropathy.

BACKGROUND: Rotator cuff tear arthropathy (CTA) carries a significant symptomatic burden for patients. Reverse shoulder arthroplasty (RSA) is an effective treatment intervention for CTA. Disparities in musculoskeletal medicine are well documented; however, there is a paucity of literature on how social determinants of health affect utilization rates. The purpose of this study is to determine how social determinants of health affect the utilization rates of RSA. METHODS: A single-center retrospective review was conducted for adult patients diagnosed with CTA between 2015 and 2020. Patients were divided by those who underwent RSA and those who were offered RSA but did not undergo surgery. Each patient's zip code was used to determine the most specific median household income in the US Census Bureau database and compared to the multistate metropolitan statistical area median income. Income levels were defined by the US Department of Housing and Urban Development's (HUD's) 2022 Income Limits Documentation System and the Federal Reserve's (FED's) Community Reinvestment Act. Because of numeric restrictions, patients were grouped into racial cohorts of Black, White, and all other races. RESULTS: Patients of other races had significantly lower odds of continuing to surgery compared with White patients in models controlled for median household income (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.18-0.81, P = .01), HUD's 3 income levels (OR 0.36, 95% CI 0.18-0.74, P = .01), and FED's income levels (OR 0.37, 95% CI 0.17-0.79, P = .01). There was no significantly different odds of going on to surgery between FED income levels and median household income levels, but when compared with those with low HUD income, those below median had significantly lower odds of going on to surgery (OR 0.43, 95% CI 0.23-0.80, P = .01). CONCLUSION: Although contradictory to reported health care utilization for Black patients, our study supports reported disparities in utilization for other ethnic minorities. These findings may suggest that improvements in utilization efforts targeted Black-identifying patients but not necessarily other ethnic minorities. The findings of this study can help providers understand how social determinants of health play a role in the utilization of care for CTA and direct mitigation efforts to reduce disparities in access to adequate orthopedic care.

Comparison of Clinical Performance of Inlay versus Onlay Humerus Implants in Reverse Total Shoulder Arthroplasty.

Background: Reverse total shoulder arthroplasty (RTSA) has become the treatment of choice for the management of massive rotator cuff tears combined with cuff tear arthropathy, and many novel designs have been proposed to overcome the shortcomings of classic RTSA. This study sought to evaluate and compare RTSA outcomes among patients with cuff tear arthropathy treated by a medialized inlay humerus implant with a neck shaft angle of 155° or a lateralized onlay implant with a neck shaft angle of 145°. Methods: A retrospective review of 32 inlay implants and 32 onlay implants was performed. The active range of motion (ROM), visual analog scale (VAS) for pain, motor power for elevation and external rotation, and functional scores including the American Shoulder and Elbow Surgeons score, Constant score, and Korean Shoulder Scoring system were assessed before surgery, at 3, 6, and 12 months after surgery, and at the last follow-up at least 24 months after surgery. Scapular notching, lateral humeral offset, and deltoid wrapping offset were assessed for radiographic evaluation. Results: The preoperative demographic data of both groups showed no significant differences (p > 0.05). The mean follow-up period was 24.9 months. Significant improvements in forward flexion, functional scores, and pain VAS score were observed in both groups at the last follow-up. No significant differences in ROM or functional scores were found between two groups at each time point, except that the onlay implant group exhibited a significantly greater range of external rotation at 3 and 12 months after surgery and at the last follow-up. The rate of scapular notching and the final power improvement did not show significant differences between the groups. Conclusions: Primary RTSA using inlay or onlay humerus implants was associated with recovery from pseudoparalysis and good clinical outcomes. However, RTSA with onlay humerus implantation led to clinically superior results in terms of external rotation.

How common is nerve injury after reverse shoulder arthroplasty? A systematic review.

BACKGROUND: Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature. METHODS: A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms "reverse shoulder," "reverse total shoulder," "inverted shoulder," and "inverted total shoulder" with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected. RESULTS: After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases. CONCLUSION: Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.

Glenoid wear after humeral head replacement with using a single implant in patients with cuff tear arthropathy more than five years.

BACKGROUND: The aim of this study was to investigate glenoid wear in patients with humeral head replacement with a smaller humeral head, who were observed for >5 years, and to examine the relationship between radiographic changes and clinical outcome. METHODS: In this study, 41 shoulders of 41 patients (13 men, 28 women) were followed up for >5 years. The mean patient age at the time of surgery was 70.5 years. The average follow-up period at short-term was 26.0 months, and intermediate-term was 66.5 months. We classified glenoid wear into four grades (i.e., Grade 0 to Grade 3). Age, sex, clinical scores, and range of motion were investigated in relation to the grade of glenoid wear. Radiographs of glenoid wear evaluated in the short-term were subsequently compared to radiographs obtained in the intermediate-term period. RESULTS: At the final follow-up, 16 (39%) patients had Grade 0 wear, 11 (27%) patients had Grade 1 wear, 10 (24%) patients had Grade 2 wear, and 4 (10%) patients had Grade 3 wear. The University of California-Los Angeles score, Japanese Orthopaedic Association score, and active forward flexion were significantly lower in the Grade 3 patients; however, Grade 3 patients did not have significant pain. No significant difference in age, sex, Constant score, active external rotation, and active internal rotation in relation to the grade of glenoid wear was observed. In total, 25 (61%) patients showed a progression of glenoid wear. Cases in which glenoid wear progressed after 4 years after surgery were rare. Two patients of Grade 3 underwent total shoulder arthroplasty revision at 16 months and 38 months, respectively. CONCLUSIONS: Glenoid wear occurred in 61% of patients at 5 years follow-up. Pain of Grade 3 patients was mild, therefore, if pain is not severe, revision surgery may not be necessary.

Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty.

BACKGROUND: Previous studies have indicated an increased risk of periprosthetic joint infection (PJI) in patients treated with reverse shoulder arthroplasty (RSA) compared with patients treated with anatomic total shoulder arthroplasty. The reason for this is unclear but may be related to a high prevalence of previous rotator cuff repair in patients who are treated with RSA. The purpose of this study was to determine previous non-arthroplasty surgery as a risk factor for revision owing to PJI after RSA for cuff tear arthropathy, massive irreparable rotator cuff tears, or osteoarthritis. METHODS: Data were retrieved from the Danish Shoulder Arthroplasty Registry and medical records. We included 2217 patients who underwent RSA for cuff tear arthropathy, massive irreparable rotator cuff tears, or osteoarthritis between 2006 and 2019. PJI was defined as ≥3 of 5 tissue samples positive for the same bacteria or as definite or probable PJI evaluated based on criteria from the International Consensus Meeting. The Kaplan-Meier method was used to illustrate the unadjusted 14-year cumulative rates of revision. A Cox regression model was used to report hazard for revision owing to PJI. Results were adjusted for previous non-arthroplasty surgery, sex, diagnosis, and age. RESULTS: Revision was performed in 88 shoulders (4.0%), of which 40 (1.8%) underwent revision owing to PJI. There were 272 patients (12.3%) who underwent previous rotator cuff repair, of whom 11 (4.0%) underwent revision owing to PJI. The 14-year cumulative rate of revision owing to PJI was 14.1% for patients with previous rotator cuff repair and 2.7% for patients without previous surgery. The adjusted hazard ratio for revision owing to PJI for patients with previous rotator cuff repair was 2.2 (95% confidence interval, 1.04-4.60) compared with patients without previous surgery. CONCLUSION: There is an increased risk of revision owing to PJI after RSA for patients with previous rotator cuff repair. We recommend that patients with previous rotator cuff repair be regarded as high-risk patients when considering RSA.

Editorial Commentary: Rotator Cuff Repairs Fail at an Alarmingly High Rate During Long-Term Follow-Up: Graft Augmentation and Biologics May Improve Future Outcomes.

Rotator cuff repairs (RCR) frequently fail to heal, particularly those with advanced fatty infiltration, supraspinatus and infraspinatus atrophy, narrowed acromiohumeral distance, and large-to-massive tear size. Unfortunately, the longer the follow up, the more sobering the statistics, with some reported retear rates ranging up to 94%. Importantly, recent long-term radiographic assessments after primary RCR reveal direct correlations between failure and patient-reported outcomes, functional deterioration, and ultimately, progression of glenohumeral arthritis and/or frank cuff tear arthropathy. As shoulder surgeons, we must continue to seek out novel approaches to improve tendon to bone healing and recapitulate the native rotator cuff enthesis. In doing so, we hope to engender more sustained subjective and objective results for our patients over time. Investigations are ongoing into several biomechanical and biological or structural adjuncts, from platelet-rich plasma and bone marrow aspirate concentrate to autograft or allograft structural augments. We must continue to push the envelope and refuse to settle for the current reality and alarmingly high failure rates following RCR.

Glenoid wear and its impact on clinical results after humeral head replacement using a single prosthesis in cuff tear arthropathy with more than 8 years of follow-up.

BACKGROUND: Glenoid wear (GW) is a long-term complication after humeral head replacement (HHR) and is one of the major reasons for revision surgery. This study aimed to evaluate GW at >8 years of follow-up after HHR in patients with cuff tear arthropathy (CTA) by use of a modified classification of GW, to examine the relationship between GW and clinical outcomes, and to identify risk factors for GW progression. METHODS: This retrospective case-series study included 34 shoulders that were monitored for >8 years after HHR in patients with CTA (13 men and 21 women; mean age at surgery, 70.9 years [range, 55-82 years]). Patients were monitored for a mean of 10.3 years (range, 8.1-13.2 years). GW was classified using plain radiographs as follows: grade 0, no remarkable postoperative changes; grade 1, postoperative glenohumeral joint space narrower than preoperative glenohumeral joint space; grade 2, contact between glenoid and humeral head prosthesis; and grade 3, glenoid erosion. Grade 3 cases were further classified into the following subtypes: grade 3A, partial erosion of anterior glenoid; grade 3B, partial erosion of superior glenoid; and grade 3C, concentric erosion of glenoid. Clinical outcomes including range of motion (active flexion and active external rotation) and postoperative pain (Constant score) were compared between grade 0-2 shoulders and grade 3 shoulders, as well as between the grade 3 subtypes. Age, sex, preoperative range of motion, preoperative pain, and number of ruptured tendons were analyzed as possible risk factors for progression to grade 3. RESULTS: The final GW grade was grade 0 in 3 shoulders, grade 1 in 10, grade 2 in 6, and grade 3 in 15 (grade 3A in 2, grade 3B in 6, and grade 3C in 7). The grade 3 group had lower pain scores (10.7 ± 6.2 vs. 14.2 ± 1.9, P = .044) and limited active flexion (108.2° ± 42.3° vs. 140.6° ± 26.7°, P = .041) compared with the grade 0-2 group. Subtype comparison showed that the grade 3B group had lower pain scores (7.0 ± 6.7 vs. 15.0 ± 0.0, P = .007) and limited active flexion (80.0° ± 26.2° vs. 140.8° ± 27.5°, P = .010) compared with the grade 3C group. Limited preoperative active external rotation was an individual risk factor for grade 3 GW (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .009). CONCLUSIONS: In the long term (>8 years) after HHR with tendon transfer in patients with CTA, patients with the development of grade 3C GW ultimately achieve pain relief even without revision surgery whereas grade 3B GW is associated with persistent pain and might require revision surgery.

Drivers of inpatient hospitalization costs, joint-specific patient-reported outcomes, and health-related quality of life in shoulder arthroplasty for cuff tear arthropathy.

BACKGROUND: Cuff tear arthropathy (CTA) can be successfully treated with various types of shoulder arthroplasty. While reverse total shoulder arthroplasty (RSA) is commonly used to treat CTA, CTA hemiarthroplasty (CTA-H, hemiarthroplasty with an extended humeral articular surface) can also be effective in patients with preserved glenohumeral elevation and an intact coracoacromial (CA) arch. As the value of arthroplasty is being increasingly scrutinized, cost containment has become a priority. The objective of this study was to assess hospitalization costs and improvements in joint-specific measures and health-related quality of life for these two types of shoulder arthroplasty in the management of CTA. METHODS: Seventy-two patients (39 CTA-H and 33 RSA) were treated during the study time period using different selection criteria for each of the two procedures: CTA-H was selected in patients with retained active elevation, an intact CA arch, and an intact subscapularis, while RSA was selected in patients with pseudoparalysis or glenohumeral instability. The Simple Shoulder Test (SST) was used as a joint-specific patient-reported outcome measure. Improvement in quality-adjusted life years was measured using the Short Form 36. Costs associated with inpatient care were collected from hospital financial records. Univariate and multivariate analyses focused on determining predictors of hospitalization costs and improvements in patient-reported outcomes. RESULTS: Significant improvements in SST and Short Form 36 physical component scores were seen in both groups. Inpatient hospitalization costs were significantly higher in the RSA group than that in the CTA-H group ($15,074 ± $1614 vs. $10,389 ± $1948, P < .001), driven primarily by supplies including the cost of the prosthesis ($9005 ± $2521 vs. $4715 ± $2091, P < .001). The diagnosis of diabetes was an independent predictor of higher inpatient hospitalization costs for both groups. There were no independent predictors for quality-adjusted life year improvements. SST improvement in the CTA-H group was significantly higher in patients with lower preoperative SST scores. CONCLUSION: Using a standard algorithm of CTA-H for shoulders with retained active elevation and an intact CA arch and RSA for poor active elevation or glenohumeral instability, both procedures led to significant improvements in health-related quality of life and joint-specific measures. Costs were significantly lower for patients meeting the selection criteria for CTA-H. Further value analytics are needed to compare the relative cost effectiveness of RSA and CTA-H for patients with CTA having retained active elevation, intact CA arch, and intact subscapularis.

Recall Bias in Retrospective Assessment of Preoperative American Shoulder and Elbow Surgeons Scores After Reverse Total Shoulder Arthroplasty.

INTRODUCTION: Although reverse total shoulder arthroplasty (RTSA) has been shown to be effective for the treatment of cuff tear arthropathy (CTA), the patient's inability to accurately recall their preoperative shoulder condition could skew their perception of the effectiveness of the procedure. Identifying patients who are susceptible to notable recall bias before surgery can help surgeons counsel patients regarding expectations after surgery. The purpose of this study was to evaluate whether patients who undergo RTSA are susceptible to recall bias and, if so, which factors are associated with poor recollection. METHODS: Patients who underwent RTSA for CTA by the senior author between September 2016 and September 2018 were identified. All patients completed the American Shoulder and Elbow Surgeons (ASES scores) Standardized Assessment Form at the time of preoperative assessment. Patients were contacted at a minimum of 24 months after surgery to retrospectively assess their preoperative condition. RESULTS: A total of 72 patients with a mean age of 72.2 ± 7.65 years completed a retrospective shoulder assessment at 28.3 ± 7.3 months postoperatively. Patient assessment of shoulder condition showed poor reliability (intraclass correlation coefficient = 0.453, confidence interval, 0.237-0.623). Greater preoperative shoulder ASES scores were associated with a greater difference between preoperative ASES scores and recall ASES scores (ß = 0.275, P < 0.001). CONCLUSION: Patients who undergo RTSA for CTA are susceptible to clinically significant recall bias. Patients with better preoperative condition recall worse preoperative shoulder conditions compared with patients with worse preoperative conditions and are susceptible to a higher degree of recall bias. This patient population should be identified preoperatively and have notable counseling before and after surgery to help them better understand their disease burden and what to expect after surgical intervention. LEVEL OF EVIDENCE: III, diagnostic cohort study.

Clinical and radiographic outcomes following reverse total shoulder arthroplasty in patients 60 years of age and younger.

BACKGROUND: Although initially indicated for use in older patients, reverse total shoulder arthroplasty (rTSA) is being increasingly used in younger patients. The purpose of this study is to compare the clinical and radiographic outcomes of patients aged <60 years to those aged 60-79 years following primary rTSA. METHODS: 154 patients aged <60 years and 1763 patients aged 60-79 years were identified from an international multi-institutional Western Institutional Review Board-approved registry with a minimum 2 years' follow-up. All patients were evaluated and scored preoperatively and at latest follow-up using 5 outcome scoring metrics and 4 active range of motion (ROM) measurements. RESULTS: Patients aged <60 years were more often male (P = .023), had a higher body mass index (P = .001), higher rates of previous surgery (57% vs. 27%, P < .001), higher rates of post-traumatic arthritis (11% vs. 5%, P < .001) and inflammatory arthropathy (13% vs. 4%, P < .001), and lower rates of rotator cuff tear arthropathy (25% vs. 38%, P = .006). There were no differences in ROM between the groups but patients aged <60 years had significantly lower function and outcome metric scores and higher pain scores at latest follow-up. Adverse event rates were similar between the 2 groups, but patients aged <60 years were more likely to require revision (5.2% vs. 1.8%, P = .004). Patients aged <60 years also had lower satisfaction scores (much better/better 86% vs. 92%, P = .006). CONCLUSION: At a mean follow-up of 47 months, primary rTSA patients aged <60 years had worse clinical outcomes compared with those aged 60-79 years, with lower outcome scores, increased pain, lower function scores, and less patient satisfaction. Patients aged <60 years had higher rates of previous surgery, inflammatory arthropathy, and post-traumatic arthritis, whereas those aged 60-79 years had higher rates of rotator cuff tear arthropathy. Although complications were similar, younger patients had 3 times the risk of revision rTSA.

Predictors of poor and excellent outcomes after reverse total shoulder arthroplasty.

BACKGROUND: Favorable clinical and functional outcomes can be achieved with reverse total shoulder arthroplasty (RSA). Given the expanding utilization of RSA in the United States, understanding the factors that influence both excellent and poor outcomes is increasingly important. METHODS: A single-surgeon prospective registry was used to identify patients who underwent RSA from 2015 to 2018 with a minimum of 2 years' follow-up. An excellent postoperative clinical outcome was defined as a final American Shoulder and Elbow Surgeons (ASES) score in the top quartile of ASES scores. A poor outcome was defined as an ASES score in the bottom quartile. Logistic regression was used to determine preoperative characteristics associated with both excellent and poor outcomes. RESULTS: A total of 338 patients with a mean age of 71.5 years (standard deviation [SD], 6.4 years) met the inclusion and exclusion criteria. The average preoperative ASES score for the entire cohort was 35.3 (SD, 16.4), which improved to 82.4 (SD, 16.1) postoperatively (P < .001). Univariate analysis demonstrated that a diagnosis of primary osteoarthritis (OA), private insurance, and higher preoperative ASES scores were significantly associated with achieving excellent outcomes (P < .01 for all). Variables predictive of poor outcomes were workers' compensation status (P = .03), depression (P = .02), a preoperative diagnosis of rotator cuff tear arthropathy (P < .01), preoperative opioid use (P < .01), a higher number of allergies (P < .01), and prior ipsilateral shoulder surgery (P < .01). Multivariate regression analysis demonstrated that OA (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.2-26.5; P = .03) and private insurance (OR, 2.7; 95% CI, 1.12-6.5; P = .02) correlated with excellent outcomes whereas a higher number of reported allergies (OR, 0.83; 95% CI, 0.71-0.97; P = .02), self-reported depression (OR, 0.39; 95% CI, 0.16-0.99; P =.04), a history of ipsilateral shoulder surgery (OR, 0.36; 95% CI, 0.15-0.87; P =.02), and preoperative opioid use (OR, 0.26; 95% CI, 0.09-0.76; P = .01) were predictive of poor outcomes. CONCLUSIONS: A preoperative diagnosis of primary OA is the strongest predictor of excellent clinical outcomes following RSA. Patients with an increasing number of reported allergies, self-reported depression, a history of ipsilateral shoulder surgery, and preoperative opioid use are significantly more likely to achieve poor outcomes after RSA. Given the increasing utilization of RSA, this information is important to appropriately counsel patients regarding postoperative expectations.

Treating cuff tear arthropathy by reverse total shoulder arthroplasty: do the inclination of the humeral component and the lateral offset of the glenosphere influence the clinical and the radiological outcome?

PURPOSE: Reverse total shoulder arthroplasty is widely used for the treatment of cuff tear arthropathy. Standard implants consist of a humeral component with an inclination angle of 155° and a glenosphere without lateral offset. Recently, lower inclination angles of the humeral component as well as lateralized glenospheres are implanted to provide better rotation of the arm and to decrease the rate of scapular notching. This study investigates the clinical and radiological results of a standard reverse total shoulder in comparison with an implant with an inclination angle of 135° in combination with a 4 mm lateralized glenosphere in context of cuff tear arthropathy. MATERIAL AND METHODS: For this retrospective comparative analysis 42 patients treated by reverse total shoulder arthroplasty for cuff tear arthropathy were included. Twenty-one patients (m = 11, f = 10; mean age 76 years; mean follow-up 42 months) were treated with a standard 155° humeral component and a standard glenosphere with caudal eccentricity (group A), while twenty-one patients (m = 5, f = 16; mean age 72 years; mean follow-up 34 months) were treated with a 135° humeral component and 4 mm lateral offset of the glenosphere (group B). At follow-up patients of both groups were assessed with plain X-rays (a.p. and axial view), Constant Score, adjusted Constant Score, the subjective shoulder value and the range of motion. RESULTS: The clinical results were similar in both groups concerning the Constant Score (group A = 56.3 vs. group B = 56.1; p = 0.733), the adjusted CS (group A = 70.4% vs. group B = 68.3%; p = 0.589) and the SSV (group A = 72.0% vs. group B = 75.2%; p = 0.947). The range of motion of the operated shoulders did not differ significantly between group A and group B: Abduction = 98° versus 97.9°, p = 0.655; external rotation with the arm at side = 17.9° versus 18.7°, p = 0.703; external rotation with the arm positioned in 90° of abduction = 22.3° versus 24.7°, p = 0.524; forward flexion = 116.1° versus 116.7°, p = 0.760. The rate of scapular notching was higher (p = 0.013) in group A (overall: 66%, grade 1: 29%, grade 2: 29%, grade 3: 10%, grade 4: 0%) in comparison to group B (overall: 33%, grade 1: 33%, grade 2: 0%, grade 3: 0%, grade 4: 0%). Radiolucency around the humeral component was detected in two patients of group B. Stress shielding at the proximal humerus was observed in six patients of Group A (29%; cortical thinning and osteopenia in zone M1 and L1) and two patients of group B (10%; cortical thinning and osteopenia in zone M1 and L1). Calcifications of the triceps origin were observed in both groups (group A = 48% vs. group B = 38%). CONCLUSION: Theoretically, a lower inclination angle of the humeral component and an increased lateral offset of the glenosphere lead to improved impingement-free range of motion and a decreased rate of scapular notching, when compared to a standard reverse total shoulder implant. This study compared two different designs of numerous options concerning the humeral component and the glenosphere. In comparison to a standard-fashioned implant with a humeral inclination of 155° and a standard glenosphere, implants with a humeral inclination angle of 135° and a 4 mm lateralized glenosphere lead to comparable clinical results and rotatory function, while the rate of scapular notching is decreased by almost 50%. While the different implant designs did not affect the clinical outcome, our results indicate that a combination of a lower inclination angle of the humeral component and lateralized glenosphere should be favored to reduce scapular notching. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Reverse Shoulder Arthroplasty After Prior Rotator Cuff Repair: A Matched Cohort Analysis.

INTRODUCTION: Rotator cuff repair (RCR) is commonly performed before reverse shoulder arthroplasty (RSA) with conflicting evidence on the effect on arthroplasty outcomes. The purpose of this investigation was to evaluate the effect of a prior RCR on the outcomes and complications of primary RSA. METHODS: Between 2007 and 2017, 438 RSAs performed in patients with a prior RCR and 876 case-matched controls were identified from a multicenter database. Patients were grouped based on a preoperative diagnosis of glenohumeral osteoarthritis (GHOA) and rotator cuff tear arthropathy (CTA). Data collected included range of motion, strength, complications, and revisions. Additional clinical metrics included American Shoulder and Elbow Society score, Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test, and the University of California Los Angeles shoulder score. RESULTS: Compared with controls, both GHOA and CTA study groups demonstrated lower postoperative forward elevation (FE) (133° versus 147°, P < 0.001; 133° versus 139°, P = 0.048) and FE trength (6.5 versus 8.2, P = 0.004; 6.1 versus 7.3, P = 0.014). In addition, inferior improvements were observed in the GHOA and CTA study groups with respect to abduction (38° versus 52°, P = 0.001; 36° versus 49°, P = 0.001), FE (41° versus 60°, P < 0.001; 38° versus 52°, P = 0.001), ER (16° versus 25°, P < 0.001; 10° versus 17°, P = 0.001), and Constant score (28.4 versus 37.1, P < 0.001; 26.2 versus 30.9, P = 0.016). Compared with controls, no differences were observed in the GHOA and CTA study groups with respect to notching (11.2% versus 5.6%, P = 0.115; 5.8% versus 7.9%, P = 0.967), complications (4.3% versus 1.6%, P = 0.073; 2.5% versus 2.7%, P = 0.878), and revision surgery (3.1% versus 0.9%, P = 0.089; 1.1% versus 1.3%, P = 0.822). CONCLUSION: RSA after a prior RCR improves both pain and function, without increasing scapular notching, complications, or revision surgery. However, compared with patients without a prior RCR, postoperative shoulder function may be slightly decreased. LEVEL OF EVIDENCE: III; Retrospective Cohort Study.