Complication rates following reverse and anatomic shoulder replacement in treatment of glenohumeral arthritis: a 10-year Medicare review study.

BACKGROUND: We sought to compare the complication rates after anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) for primary glenohumeral arthritis in a Medicare population. METHODS: Patients who underwent a shoulder arthroplasty were identified from the 5% subset of Medicare parts A/B between 2009 and 2019. Patients with less than 1-year follow-up were excluded. A total of 8846 patients with a diagnosis of glenohumeral arthritis were then subdivided into those who received aTSA (5935 patients) and RSA (2911 patients). A multivariate Cox regression analysis was then performed comparing complication rates at 3 months, 6 months, 1 year, 2 years, and 5 years. RESULTS: Statistically significant increased rates of instability (hazard ratio [HR] = 1.46), fracture of the scapula (HR = 7.76), infections (HR = 1.45), early revision (HR = 1.79), and all complications (HR = 1.32) were seen in the RSA group. There was no significant difference in revision rate at 5 years between the 2 groups. There was no difference in patient characteristics or comorbid conditions (smoking status, diabetes, Charlson score, etc.) or hospital characteristics (location, teaching status, public vs. private, etc.) between the 2 groups. CONCLUSION: An increased rate of early complications was observed with the use of RSA compared with aTSA for the treatment of primary glenohumeral arthritis, including instability, scapula fracture, infection, and all cause complication. No difference in revision rate between RSA and aTSA at 5 years was observed.

Massive rotator cuff tears without arthropathy: when to consider reverse shoulder arthroplasty.

Massive rotator cuff tears often present a challenge for the treating orthopaedic surgeon. A multitude of surgical approaches have been described to manage this condition, ranging from biceps tenotomy to complex muscle transfers to reverse shoulder arthroplasty. Among these procedures, reverse shoulder arthroplasty is increasingly advocated to relieve pain and restore function; however, the exact role of this arthroplasty procedure continues to be defined, particularly in patients without any evidence of associated glenohumeral arthritis. In this patient population, the reverse shoulder prosthesis is used primarily to address the instability associated with massive rotator cuff tears, as opposed to the more common application of arthroplasty to manage cartilage disease. Currently accepted indications for reverse shoulder arthroplasty include patients with pseudoparalysis and irreparable rotator cuff tears, with or without anterosuperior escape. Surgeons must be aware of conditions that may clinically mimic pseudoparalysis caused by a rotator cuff tear, such as axillary nerve injury, deltoid dehiscence, or cervical radiculopathy. These conditions produce deltoid insufficiency and are unlikely to benefit from a reverse shoulder arthroplasty. Caution is also warranted when considering this procedure in patients with massive rotator cuff tears in whom active forward elevation greater than 90° is preserved. These patients may achieve little benefit in range of motion and pain relief with a reverse shoulder arthroplasty.

Reverse Shoulder Arthroplasty in the Management of Irreparable Rotator Cuff Tears without Arthritis.

INTRODUCTION: The ability to provide reliable outcomes in treatment of patients with degenerative rotator cuff tears has become increasingly complicated, as a result of more advanced disease and the increased array of treatment choices. STEP 1 PREOPERATIVE PLANNING: Develop and communicate with a consistent team of interdisciplinary physicians both preoperatively and postoperatively; utilize advanced imaging modalities to evaluate muscle atrophy as well as glenoid and humeral bone stock. STEP 2 PATIENT POSITIONING: Place the patient in a beach-chair position, check the abdominal strap, and position yourself facing the axilla. STEP 3 SURGICAL APPROACH: Develop the subdeltoid and subacromial spaces and take care to avoid vigorous over-retraction of the deltoid. STEP 4 HUMERAL EXPOSURE AND PREPARATION: Perform the head cut utilizing the 135° resection guide, broach the humerus, and ream the humeral socket. STEP 5 GLENOID EXPOSURE AND PREPARATION GLENOSPHERE INSERTION: Ream the inferior surface to bleeding subchondral bone; bleeding subchondral bone on the inferior 50% of the prepared glenoid surface indicates a sufficient depth. STEP 6 FINAL HUMERAL PREPARATION: At final reaming, the edge of the reamer should sit flush with the cut surface of the humerus. STEP 7 TRIALING: Proper soft-tissue balance is frequently achieved by positioning the humeral component so that the rim of the socket lies just above the humeral osteotomy site at the anatomic neck. STEP 8 COMPONENT IMPLANTATION AND CLOSURE: When cementing the humeral component, the socket should match the reamed proximal part of the humerus. RESULTS: Initially, reverse shoulder arthroplasty was primarily used to treat osteoarthritis of the glenohumeral joint resulting from chronic rotator cuff deficiency or for true rotator cuff tear arthropathy. WHAT TO WATCH FOR: Indications Contraindications Pitfalls & Challenges.

Lunate-lunate facet ratio and variance to predict articular gap after distal radius fracture.

PURPOSE: Intra-articular gap is a well-defined prognosticator of outcome after distal radius fracture. However, it is often difficult to assess on plain radiographs, particularly in the sagittal plane, as visualized on the lateral view. The purposes of this study were to establish normal values for the lunate-lunate facet ratio (LLFR) and to evaluate whether the LLFR and lunate-lunate facet variance (LLFV) are reliable plain film measures of sagittal articular gap in distal radius fractures compared with sagittal reconstructions of computed tomography (CT) scans. METHODS: We studied 35 uninjured, skeletally mature wrist radiographs to establish the normal LLFR value. The LLFR was defined as the ratio of the maximum width of the lunate (A) to the width of a line spanning the maximum distance from dorsal to volar across the articular surface of the lunate facet, defined by the end point of the radiographically thickened line representing the subchondral bone (B). The LLFV was determined as measurement B minus measurement A. Interobserver and intraobserver reliability for 2 observers were examined by the intraclass correlation coefficient (ICC) for measurements of the uninjured wrists and for the same measurements of 20 intra-articular distal radius fractures. For 12 of the subjects with fractures, the LLFR and LLFV were correlated with the intra-articular gap as measured on CT scan using simple linear regression. RESULTS: The mean value of the LLFR in the normal subjects was 1.00 +/- 0.04 for observer 1 and 1.00 +/- 0.02 for observer 2. There was significant intraobserver reliability for both uninjured (ICC = 0.83, p < .001) and fractured wrists (ICC = 0.87, p < .001), as well as significant interobserver reliability for uninjured (ICC = 0.69, p < .001) and fractured wrists (ICC = 0.64, p = .015). The LLFR was significantly associated with articular gap on sagittal CT reconstructions (R(2) = -0.81, p < .01). The LLFV correlated highly with articular gap on sagittal CT reconstructions (R(2) = 0.83, p < .01). CONCLUSIONS: The LLFR, measured on the lateral radiograph of the wrist, exhibits high intraobserver and interobserver reliability, with a normal value of 1.0. Both the LLFR and the LLFV are significantly related to articular gap on sagittal CT reconstruction images. The LLFR decreases with increasing intra-articular gap formation. The LLFV allows a direct estimation of articular gap size. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Small-diameter percutaneous decompression for osteonecrosis of the shoulder.

Core decompression of the humeral head has previously been used as a joint-preserving procedure for treatment of symptomatic osteonecrosis of the shoulder. In this article, we describe a new decompression technique, which involves multiple small-diameter (3-mm) percutaneous perforations. In our study population (early-stage disease), shoulder arthroplasty was avoided in all 15 patients (26 shoulders) for a mean follow-up of 32 months (range, 24-41 months). Of the 26 shoulders, 25 had successful clinical and functional outcomes (University of California Los Angeles shoulder score, >24 points), and 1 showed radiographic progression of the disease but has not needed further operative treatment. We compared our decompression results with those of a nonoperative historical control group, identified through a literature search. There was a 48% (143/299) rate of progression to arthroplasty in the control group at a follow-up ranging from 2 to 4.5 years. This outpatient, percutaneous perforations technique appears to be a low-morbidity method for relieving symptoms and deferring shoulder arthroplasty in patients with symptomatic osteonecrosis of the humeral head.

Osteonecrosis of the humeral head.

Osteonecrosis of the humeral head is considerably less common than osteonecrosis of the hip. However, as in the hip, the interaction between a genetic predisposition and certain risk factors may lead to increased intraosseous pressure, loss of circulation, and eventual bone death. The most common risk factor remains corticosteroid use, which accounts for most reported cases. Radiographic staging and measurement of lesion size are predictive of disease progression and can be used to determine appropriate intervention. Recent studies have reported the use of various treatment modalities such as pharmacologics, core decompression with small-diameter drilling, arthroscopic-assisted core decompression, and bone grafting. Prospective, randomized studies are needed to determine the efficacy of these joint-preserving procedures. Newer resurfacing techniques have a role in treating articular surface loss. Hemiarthroplasty and total shoulder arthroplasty are recommended for patients with end-stage disease.