Functional assessment and quality of life of patients after reverse total shoulder arthroplasty in the late follow-up period.

BACKGROUND: Due to the systematically increasing number of shoulder replacement procedures among older people, the need to assess their quality of life is becoming more and more important. OBJECTIVE: The aim of the study was to functionally assess the shoulder joint and the quality of life of patients before and after reverse total shoulder arthroplasty (rTSA). METHODS: The observational study included 15 patients after the rTSA procedure (randomly selected). The quality of life and shoulder joint function before and after rTSA were assessed using the following scales: SF-36, Constant-Murley Score, Disabilities of the Arm, Shoulder and Hand Scale (DASH) and the University of California-Los Angeles Shoulder Rating Scale (UCLA scale) and Simple Shoulder Test (SST). RESULTS: There were statistically significant differences (p< 0.001) between measurements in the overall scores of the SF-36 questionnaire. Statistically significant differences (p< 0.001) were found between measurements in terms of the Constant-Murley, DASH, UCLA and SST scales results. CONCLUSIONS: Reverse total shoulder arthroplasty significantly improved the patients' quality of life and the functional condition of the operated limb.

Do patient outcomes and follow-up completion rates after shoulder arthroplasty differ based on insurance payor?

BACKGROUND: Disparities associated with socioeconomic status (SES) and insurance coverage have been shown to affect outcomes in different medical conditions and surgical procedures. We hypothesized that patients insured by Medicaid will be associated with lower follow-up rates and inferior outcomes relative to those with Medicare or private insurance. METHODS: Patients undergoing shoulder arthroplasty, including anatomic total shoulder arthroplasty, reverse arthroplasty, and hemiarthroplasty, were enrolled preoperatively in an institutional database. Preoperative demographics, payor (Medicaid, Medicare, or private insurance), and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores were recorded. Postoperatively, patients completed ASES scores at multiple time points. Follow-up completion rate was calculated as the number of follow-up visits completed relative to possible visits. Continuous variables were compared between groups with 1-way analyses of variance, and chi-squared tests were used for categorical variables. Significance was defined as P < .05. RESULTS: There were 491 shoulder replacements performed for 438 patients from 2012-2017. The mean follow-up completed percentage was significantly lower (P < .001) for Medicaid patients (62.6% ± 33.7%) relative to Medicare patients (80.2% ± 26.7%; P < .001) and private insurance patients (77.8% ± 22.1%; P = .001). The ASES Composite score increased significantly for all patients from baseline to final follow-up. At each time point, including before surgery and each postoperative time point, patients with Medicaid insurance had significantly lower ASES Composite scores. The final ASES Composite score was significantly lower in the Medicaid patients (66.1 ± 28.7) relative to private insurance patients (78.3 ± 20.8; P = .023). Medicaid patients had significantly lower preoperative (P < .001) and postoperative (P = .018) ASES Pain subscores. In multivariate regression analysis, Medicaid insurance was associated with both inferior preoperative and postoperative ASES scores relative to patients with Medicare or private insurance. CONCLUSIONS: We observed that all patients, regardless of insurance payor, improved by similar magnitudes after shoulder arthroplasty, though patients with Medicaid insurance had significantly lower preoperative and postoperative ASES scores, primarily because of the ASES Pain subscore. Patients with Medicaid insurance also have lower follow-up rates than other payors.

Total Shoulder Arthroplasty Utilizing the Subscapularis-Sparing Approach.

Traditionally, total shoulder arthroplasty is performed through the deltopectoral approach with violation of the subscapularis tendon. In order to reduce the incidence of postoperative subscapularis dysfunction, the subscapularis-sparing approach, performed entirely through the rotator interval, was developed. This technique allows earlier rehabilitation and may potentially prevent subsequent subscapularis insufficiency and clinical failures.

The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation for anatomic total shoulder arthroplasty.

Anatomic total shoulder arthroplasty is the gold standard shoulder replacement procedure for patients with an intact rotator cuff and sufficient glenoid bone to accommodate prosthetic glenoid implant and offers reliable patient satisfaction, excellent implant longevity, and a low incidence of complications. Disparity exists in the literature regarding rehabilitation strategies following anatomic total shoulder arthroplasty. This article presents a consensus statement from experts in the field on rehabilitation following anatomic total shoulder arthroplasty. The goal of this consensus statement is to provide a current evidence-based foundation to inform the rehabilitation process after anatomic total shoulder arthroplasty. These guidelines apply to anatomic total shoulder arthroplasty (replacement of the humeral head and glenoid), hemiarthroplasty (replacing only the humeral head), and hemiarthroplasty with glenoid reaming or resurfacing. The consensus statement integrates an extensive literature review, as well as survey results of the practice patterns of members of the American Society of Shoulder and Elbow Therapists and the American Shoulder and Elbow Surgeons. Three stages of recovery are proposed, which initially protect and then gradually load soft tissue affected by the surgical procedure, such as the subscapularis, for optimal patient outcomes. The proposed guidelines should be used in collaboration with surgeon preferences and patient-specific factors.

Rehabilitation After Anatomic and Reverse Total Shoulder Arthroplasty: A Critical Analysis Review.

Postoperative rehabilitation is believed to be essential in optimizing clinical outcome and function following shoulder arthroplasty. Despite this long-held notion, there is a paucity of high-quality evidence to guide rehabilitation protocols and practice. For patients undergoing anatomic total shoulder arthroplasty (ATSA), there are insufficient comparative data regarding type or duration of sling utilization. Based on current evidence, there is no appreciable benefit to early motion compared with a delayed-motion protocol following ATSA. There is insufficient literature to support the use of formal physical therapy over a physician-directed program following ATSA. At the present time, no high-quality evidence exists to guide the postoperative rehabilitation of patients undergoing reverse total shoulder arthroplasty (RTSA). Prospective randomized controlled trials evaluating postoperative management and rehabilitation following ATSA and RTSA are needed to guide best practices and optimize clinical outcomes.

Predicting Postoperative Course After Total Shoulder Arthroplasty Using a Medical-Social Evaluation Model.

INTRODUCTION: The ability to predict successful outcomes is important for patient satisfaction and optimal results after shoulder arthroplasty. We hypothesize that a medical-social scoring tool will predict resource requirements in doing total shoulder arthroplasty (TSA). METHODS: A retrospective analysis of 453 patients undergoing TSA was undertaken. Preoperatively, medical and social surveys were completed by each patient. Demographics, comorbidity scores, hospital course, postdischarge disposition, and readmissions were collected. RESULTS: The average length of stay was 1.6 days (0 to 7). There was an association with utilization of home care or inpatient rehabilitation and both the medical (7.3 versus 3.9; P = 0.0002) and social (7.1 versus 3.4; P < 0.0001) components of the survey. There was a weak correlation between hospital length of stay and the social component of the survey (R = 0.29; P < 0.001), but not the medical component (R = 0.04; P = 0.38). No variable was predictive of readmission. Social score of eight was found to be predictive of postoperative requirement of home care or rehabilitation. CONCLUSION: This study found that Medical and Social Survey Scores can stratify patients who are at risk of requiring more advanced postdischarge care and/or a longer hospital stay. With this, we can match patients to the most appropriate level of postoperative care.

A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) does not have a standard postoperative protocol. Although instability is a worrisome complication, prolonged immobilization may also be disabling in the elderly population. This study aimed to determine if early vs. delayed range of motion (ROM) after RTSA affected postoperative ROM, patient-reported outcomes, and the dislocation rate. METHODS: A single-blinded, randomized controlled trial was performed enrolling patients from 2013 to 2017. Patients were randomly assigned to either a delayed-rehabilitation group (no ROM for 6 weeks) or early-rehabilitation group (immediate physical therapy for passive and active ROM) and followed up for a minimum of 1 year. Demographic characteristics, ROM, American Shoulder and Elbow Surgeons (ASES) scores, and complications were recorded. RESULTS: Of an initial enrollment of 107 shoulders, 80.3% completed 1-year follow-up: 44 shoulders in the delayed-therapy group and 42 shoulders in the immediate-therapy group. Both groups had significantly improved forward flexion (32° improvement) and abduction (22° improvement) by 3 months. Both groups showed significant improvements in ASES scores by 6 weeks (9.4-point improvement in composite score) with continued improvement through 6 months (35.1 points). No significant differences were found between groups for any postoperative measure, with the exception of the ASES functional score favoring the delayed-therapy group at 6 months (26.3-point improvement vs. 16.7-point improvement). No differences in complications, notching, or narcotic use were noted between groups. CONCLUSIONS: Both early- and delayed-ROM protocols after RTSA demonstrated significant, similar improvements in ROM and outcomes. Early initiation of postoperative rehabilitation may benefit the elderly population by avoiding the limitations of prolonged immobilization postoperatively.

Anterior Capsular Reconstruction with Dermal Allograft in Combination With Anatomic Glenohumeral Arthroplasty: A Case Report.

CASE: A 43-year-old man with chronic right shoulder pain and dysfunction due to recurrent anterior instability, irreparable subscapularis tear, and glenohumeral arthritis presented to our practice. After workup and counseling, he was treated with anatomic total shoulder arthroplasty augmented by anterior capsular reconstruction using human acellular dermal allograft. At 15 months postoperatively, his forward elevation, external rotation, and internal rotation were 160, 45, and T12, nearly equal to contralateral values. His glenohumeral joint remained reduced, and no complications were encountered. CONCLUSION: We report the first known anterior capsular reconstruction performed in combination with anatomic shoulder arthroplasty.

Enhanced Recovery After Surgery: Concepts and Application to Total Shoulder Replacement.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) focuses on optimizing each element on a treatment pathway and encouraging the patient to actively engage in his or her recovery and rehabilitation. It requires collaboration across a multidisciplinary team and has been successful in improving patient outcomes, length of stay (LOS), and costs for a wide range of surgical procedures, including musculoskeletal surgeries such as total hip and total knee replacement. PURPOSE: To examine the application of ERAS concepts to total shoulder replacement (TSR) surgery. METHODS: Hospital Episode Statistics (HES) in England on LOS for TSR surgery were examined, and a review of literature on the use of ERAS concepts in TSR was undertaken. RESULTS: Analysis of HES data suggested scope for improvement in reducing LOS. A review of the literature found some evidence of the use of ERAS concepts, particularly in multimodal pain management. CONCLUSIONS: Future research is now required for ERAS procedure-specific components for TSR surgery.

A Systematic Review of Proposed Rehabilitation Guidelines Following Anatomic and Reverse Shoulder Arthroplasty.

BACKGROUND: Total shoulder arthroplasty (TSA) is indicated for patients with glenohumeral arthritis. In this procedure, the humeral head and glenoid surface are replaced with prosthetic components. Reverse total shoulder arthroplasty (RTSA) is indicated for patients with glenohumeral arthritis and a poorly functioning rotator cuff. In this procedure, a glenosphere articulates with a humerosocket. While those surgeries are commonly performed, a thorough review of the literature is required to determine the areas of agreement and variations in postoperative rehabilitation. OBJECTIVES: To describe the literature on rehabilitation protocols following anatomic TSA and RTSA. METHODS: For this systematic review, a computerized search was conducted in medical databases from inception to May 21, 2018 for relevant descriptive studies on TSA and RTSA rehabilitation protocols. The methodological index for nonrandomized studies tool and the modified Downs and Black tool for randomized controlled trials were used for assessment of the individual studies. RESULTS: Sixteen studies met the inclusion criteria, of which 1 provided level I evidence, 1 provided level III evidence, 2 provided level IV evidence, and 12 provided level V evidence. Ten of the studies described rehabilitation guidelines for TSA and 6 described those for RTSA. Following TSA, the use of a sling was recommended for a duration that varied from 3 to 8 weeks, and 4 of the 10 published protocols included resisted exercise during the initial stage of healing (the first 6 weeks after surgery). Seven of 10 published protocols recommended limiting shoulder external rotation to 30° and that passive range of motion be fully restored by 12 weeks post surgery. Suggested use of a sling post RTSA varied from "for comfort only" to 6 weeks, motion parameters varied from no passive range of motion to precautionary range limits, and all protocols agreed on performing deltoid isometric exercises early post surgery. There was a high level of heterogeneity for the rehabilitation guidelines and associated precautions for both TSA and RTSA. CONCLUSION: The majority of published protocols were descriptive in nature. Published rehabilitation strategies following TSA and RTSA are based on biomechanical principles, healing time frames, and exercise loading principles, with little consistency among protocols. There is a need to determine optimal rehabilitation approaches post TSA and RTSA based on clinical outcomes. LEVEL OF EVIDENCE: Therapy, level 5. J Orthop Sports Phys Ther 2019;49(5):337-346. doi:10.2519/jospt.2019.8616.

Reverse shoulder arthroplasty for fracture sequelae: Clinical outcome and prognostic factors.

BACKGROUND: The reverse total shoulder arthroplasty (RTSA) is a common therapy for the fracture sequelae (FS) of the proximal humerus. The aim of this study was to show the short and midterm clinical outcome of the RTSA for FS and to identify prognostic factors. METHODS: Data from 46 patients with chronic FS who underwent RTSA were analysed. The clinical follow-up included the Constant score and radiographic examination. Patients were divided into groups based on the Boileau classification of FS, and the degree of metaphyseal bone loss was measured (Boileau type I 9 patients; type II 3 patients; type III 8 patients and type IV 16 patients). Scapular notching was assessed according to the classification of Sirveaux. RESULTS: The mean postoperative Constant score was 57. Clinical outcomes were similar among the various FS groups, as defined according to the Boileau classification, but patients who had undergone revision arthroplasty had a significantly inferior mean Constant score than patients with type IV FS. There were no significant differences between patients who were initially managed with conservative therapy and those treated surgically. Patients with metaphyseal bone loss >3 cm showed inferior clinical scores. Inferior scapular notching was seen in 25 patients, and had a negative effect on the clinical outcome. Complications included five infections and one dislocation. CONCLUSION: Metaphyseal bone loss was unfavourable prognostic factors in patients with FS treated with RTSA. However, the Boileau classification did not serve as a prognostic criterion. Previous operative or conservative treatment had no influence on the outcome and scapular notching was associated with inferior clinical results.

High pain intensity after total shoulder arthroplasty.

BACKGROUND: As reimbursement becomes increasingly tied to quality and patient experience, there is growing interest in alleviation of postoperative pain combined with optimal opioid stewardship. We characterized predictors of severe inpatient pain after elective total shoulder arthroplasty and evaluated its association with opioid use, operative time, hospital length of stay, discharge disposition, and cost. METHODS: We identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017 from our registry. Severe postoperative pain was defined as peak pain intensity ≥75th percentile. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with severe pain, including demographics, emotional health, comorbidities, and American Shoulder and Elbow Surgeons score. Opioid consumption was expressed as oral morphine equivalents (OMEs). Costs were calculated using time-driven activity-based costing. RESULTS: In decreasing order of magnitude, the predictors of severe postoperative pain were greater number of self-reported allergies, preoperative chronic opioid use, lower American Shoulder and Elbow Surgeons score, and depression. Patients reporting severe pain took more opioids (202 vs. 84 mg OMEs), stayed longer in the hospital (2.9 vs. 2.0 days), used postacute inpatient rehabilitation services more frequently (28% vs. 10%), and were more likely to be high-cost patients (23% vs. 5%; all P < .001), but they did not have longer operations (166 vs. 165 minutes, P = .86). CONCLUSIONS: Efforts to address psychological and social determinants of health might do as much or more than technical improvements to alleviate pain, limit opioid use, and contain costs after shoulder arthroplasty. These findings are important in the redesign of care pathways and bundling initiatives.

Care and rehabilitation after a total shoulder replacement.

Pierre's grandmother, Mrs. Peck, receives a reverse total shoulder joint replacement in an orthopaedic centre. It's a scheduled operation, made necessary by osteoarthritis. Pierre likes looking after his grandmother, so he won't be travelling this summer.

Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up.

INTRODUCTION: Reverse shoulder arthroplasty shifts the rotational center of the shoulder joint caudally and medially to restore shoulder function in a rotator cuff deficient shoulder. Despite promising results in early- and mid-term follow-up, long-term loss in shoulder function has been described in the literature. A lack of exercise in elderly patients may be one reason for this loss in function. This study examines the functional benefits of physical therapy in the mid-term to long-term follow-up regarding the subjective and objective shoulder function. MATERIALS AND METHODS: Twenty patients with a mean age of 73 years were included in this series. The study was performed as a single-center, prospective study. Initial indications for reverse shoulder arthroplasty were cuff tear arthropathy, failed anatomical shoulder arthroplasty, and fracture sequelae. The patients were clinically examined at a mean follow-up of 62 months using the Constant score (CS) and the DASH score for the operated and the non-operated shoulder. They were reevaluated using the same scores following a standardized physical therapy program of 6 weeks' duration. RESULTS: The mean CS as well as the mean age- and gender-adjusted CS of the affected shoulder improved significantly from 53.5 to 59.3 points, and 72.7-80.8%, respectively. The subcategories activities of daily living (ADL) and range of motion (ROM) of the CS improved significantly, whereas no significant improvement was observed for the subcategories pain and strength. Evaluating the contralateral shoulder, no significant change was observed for the age- and gender-adjusted CS and the CS as well as its subcategories. We found no significant difference in the CS comparing the different etiologies prior to physical therapy. DISCUSSION: Physical therapy plays an important role subsequent to reverse shoulder arthroplasty. It also has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. However, physical therapy seems to have limited effect on the strength and the residual pain level. LEVEL OF EVIDENCE: Level III.

Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up.

INTRODUCTION: Reverse shoulder arthroplasty shifts the rotational center of the shoulder joint caudally and medially to restore shoulder function in a rotator cuff deficient shoulder. Despite promising results in early- and mid-term follow-up, long-term loss in shoulder function has been described in the literature. A lack of exercise in elderly patients may be one reason for this loss in function. This study examines the functional benefits of physical therapy in the mid-term to long-term follow-up regarding the subjective and objective shoulder function. MATERIALS AND METHODS: Twenty patients with a mean age of 73 years were included in this series. The study was performed as a single-center, prospective study. Initial indications for reverse shoulder arthroplasty were cuff tear arthropathy, failed anatomical shoulder arthroplasty, and fracture sequelae. The patients were clinically examined at a mean follow-up of 62 months using the Constant score (CS) and the DASH score for the operated and the non-operated shoulder. They were reevaluated using the same scores following a standardized physical therapy program of 6 weeks' duration. RESULTS: The mean CS as well as the mean age- and gender-adjusted CS of the affected shoulder improved significantly from 53.5 points to 59.3 points, and 72.7-80.8%, respectively. The subcategories activities of daily living and range of motion of the CS improved significantly, whereas no significant improvement was observed for the subcategories pain and strength. Evaluating the contralateral shoulder, no significant change was observed for the age- and gender-adjusted CS and the CS as well as its subcategories. We found no significant difference in the CS comparing the different etiologies prior to physical therapy. DISCUSSION: Physical therapy plays an important role subsequent to reverse shoulder arthroplasty. It also has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. However, physical therapy seems to have limited effect on the strength and the residual pain level. LEVEL OF EVIDENCE: Level III.

The Utilization of Formal Physical Therapy After Shoulder Arthroplasty.

BACKGROUND: It is widely believed that structured rehabilitation programs by professional therapists help guide patients through the various recovery periods after shoulder arthroplasty, speeding up their recovery and improving their final functional gains. However, to our knowledge, there are no studies providing information about the current state of physical rehabilitation use after shoulder arthroplasty. OBJECTIVES: To describe the variation in physical rehabilitation utilization after total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), and to identify differences in utilization based on type of insurance (private versus public), sex, age, and region of the country. METHODS: This epidemiological retrospective database study utilized a commercially available database, PearlDiver, with longitudinal patient tracking linking all patients' Current Procedural Terminology and International Classification of Diseases-Ninth Revision codes to their specific records to analyze patterns of physical rehabilitation usage after TSA and RSA in the United States. Two main patient populations were analyzed within the PearlDiver database, the Humana private insurance population and the Medicare insurance population. The period analyzed was 2010 to 2015. RESULTS: There was significantly higher utilization of physical rehabilitation in the Humana population when compared to the Medicare population (P<.001, Cramer's V = 0.270). In the Humana population, 36% of patients had 5 or fewer physical rehabilitation visits in the 6 months following their operation, while in the Medicare population, 56% of patients had 5 or fewer physical rehabilitation visits in the same period. Those with TSA had a higher utilization rate than those with RSA in the Humana (P<.001, V = 0.104; TSA, 31% had 5 or fewer physical rehabilitation visits; RSA, 40% had 5 or fewer physical rehabilitation visits within 6 months) and Medicare populations (P<.001, V = 0.135; TSA, 51% had 5 or fewer physical rehabilitation visits; RSA, 61% had 5 or fewer physical rehabilitation visits within 6 months). CONCLUSION: Postoperative utilization of physical rehabilitation after anatomic TSA and RSA is markedly higher in privately insured patients than in patients with Medicare, regardless of age, sex, diagnosis, or region of country. These findings have important implications, from the individual patient's experience and outcomes to system-wide resource utilization. LEVEL OF EVIDENCE: Economic and decision analyses, level 4. J Orthop Sports Phys Ther 2018;48(11):856-863. Epub 8 May 2018. doi:10.2519/jospt.2018.8176.

Discharge Destination After Shoulder Arthroplasty: An Independent Risk Factor for Readmission and Complications.

INTRODUCTION: Postdischarge disposition after shoulder replacement lacks uniform guidelines. The goal of this study was to identify complication and readmission rates by discharge disposition and determine whether disposition was an independent risk factor for adverse events, using a statewide database. METHODS: Data from the California Office of Statewide Health Planning and Development discharge database were used. Patient information was assessed, and 30- and 90-day complication rates were identified. Univariate and multivariate analyses were used to determine the complication risk. RESULTS: From 2011 to 2013, 10,660 procedures were identified, with 7,709 patients discharged home, 1,858 discharged home with home health support, and 1,093 discharged to postacute care (PAC) facilities. Patients discharged to PAC facilities or to home with health support tended to be older, female, and using Medicare. After controlling for confounders, at 30 and 90 days, patients discharged to PAC facilities were found to be more likely to experience a complication. DISCUSSION: Discharge to a PAC facility was an independent risk factor for complications and readmission. LEVEL OF EVIDENCE: Level III, retrospective cohort design, observational study.

Return to sport after shoulder arthroplasty: a systematic review and meta-analysis.

PURPOSE: With increasing incidence and indications for shoulder arthroplasty, there is an increasing emphasis on the ability to return to sports. The main goal of this study was to determine the rate of return to sport after shoulder arthroplasty. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review and meta-analysis. A search was performed on MEDLINE, Scopus, EMBASE, and the Cochrane Library. The quality of the included studies was evaluated according to the Methodological Index for Nonrandomized Studies checklist. The main judgement outcome was the rate of return to sports activity after shoulder arthroplasty and the level of play upon return (identical or higher/lower level). RESULTS: Thirteen studies were reviewed, including 944 patients (506 athletes), treated with shoulder arthroplasty at an average follow-up of 5.1 years (range, 0.5-12.6 years). The most common sports were swimming (n = 169), golf (n = 144), fitness sports (n = 71), and tennis (n = 63). The overall rate of return to sport was 85.1% (95% CI, 76.5-92.3%), including 72.3% (95% CI, 60.6-82.8%) returning to an equivalent or improved level of play, after 1-36 months. Patients undergoing anatomic total shoulder arthroplasty returned at a significantly higher rate (92.6%) compared to hemiarthroplasty (71.1%, p = 0.02) or reverse total shoulder arthroplasty (74.9%, p = 0.003). CONCLUSION: Most patients are able to return to one or more sports following shoulder arthroplasty, with anatomic total shoulder arthroplasty having the highest rate of return. LEVEL OF EVIDENCE: IV.