Functional Composite Spacer (Antibiotic Cement around a Hemiarthroplasty) for the Treatment of Shoulder Infections: Minimum 5-Year Outcomes.

BACKGROUND: Periprosthetic infections remain a challenging complication following shoulder arthroplasty and an ideal treatment protocol has yet to be established. Two-stage revision is a common approach. Historically, the first stage entails placement of an all-cement antibiotic spacer. While prior studies have reported on cement spacers as definitive management, persistent pain and inadequate function often lead many to later request a second stage procedure. The functional composite spacer consists of a humeral hemiarthroplasty implant with antibiotic cement coated around the stem alone to preserve the metallic humeral head-glenoid articulation. Functional composite spacers have demonstrated improvements in function and motion with high patient satisfaction at 25 months, but longer-term follow-up is needed to better understand the role it may play in the management of shoulder infections. The purpose of this study is to evaluate outcomes at a minimum of 5 years in patients who initially planned to undergo two-stage revision but elected to retain the functional spacer. METHODS: A retrospective review of a single institution's shoulder surgery repository from 2007 to 2018 identified 30 patients who underwent placement of a composite spacer. Overall, 5 patients underwent second stage reimplantation and 12 patients did not have 5-year follow-up (6 lost to follow-up and 6 deceased). A total 13 patients were included who maintained a functional composite spacer and had minimum 5-year follow-up. Patient-reported outcome measures (ASES, SST, SANE, VAS F and VAS P), satisfaction, range of motion, and radiographic estimation of glenoid wear were evaluated. RESULTS: Two of 13 patients (15%) required additional surgery: one secondary closure for early superficial wound dehiscence and one revision spacer for pain. There were no re-infections. At most recent follow-up patient satisfaction was high and significant improvements were noted for ASES (45.4; p<0.001), SST (5.3; p=0.003), SANE (47.3; p=0.002), VAS F (4.9; p=0.004), and VAS P (-4.4; p=0.007) as well as range of motion including abduction (39.2˚; p=0.005) and elevation (65.9˚; p=0.005). There was no significant change in humeral head medialization (p=0.11). CONCLUSIONS: Patients who do not undergo an early revision and retain a functional composite spacer maintain good function and range of motion with minimal pain at mid-term follow-up.

Improvement in Sleep Disturbance Following Arthroscopic Rotator Cuff Repair.

BACKGROUND: Approximately 90% of patients express concerns with sleep shortly after developing shoulder-related symptoms. Previous small cohort studies have demonstrated the impact of rotator cuff repair on sleep, but none have characterized the observed benefits. The purpose of this study is to evaluate sleep improvement after rotator cuff repair including the speed of sleep recovery, the time at which improvement plateaus, and the longer-term maintenance of improved sleep. METHODS: A retrospective review of our institution's shoulder and elbow repository identified patients who underwent primary arthroscopic rotator cuff repair from 2012 - 2021 and reported sleep disturbance preoperatively. Patients were evaluated using sleep-related questions from the Simple Shoulder Test and American Shoulder and Elbow Surgeons score. Sleep outcomes were compared from a preoperative visit to 3-month, 6-month, 12-month, and most recent follow-ups to evaluate efficacy of treatment, speed of recovery and improvement plateaus. RESULTS: Among 677 RCR patients, 95.7% (648/677) reported sleep disturbance preoperatively. A total of 474 met inclusion criteria with median follow-up of 4.1 years (IQR, 2.1-6.1). At most recent follow-up, 81.8% were able to sleep comfortably and 65.7% were able to sleep on the affected side. A plateau in the ability to sleep comfortably was seen at 6 months while no plateau was observed in the ability to sleep on the affected side. More rapid improvement in the ability to sleep comfortably occurred during the first 3 months and from 3 - 6 months for the ability to sleep on the affected side. CONCLUSION: The majority of patients with sleep disturbance who undergo RCR, report significant, rapid, and lasting improvement in the ability to sleep comfortably and the ability to sleep on the affected side.

Correlation Between Patient-Reported and Clinician-Measured Shoulder Range of Motion in Patients Undergoing Shoulder Surgery.

INTRODUCTION: There has been increasing interest in remote measures of patients' health, both in the clinical and research settings. This study sought to evaluate correlations between patient-reported and clinician-measured (CM) shoulder range of motion (ROM). METHODS: ROM measures including elevation, abduction, and internal rotation were recorded by a patient-reported picture-based survey and clinician measurement during each patient visit. A total of 13,842 visits over a 16-year period met inclusion criteria. Spearman correlation was performed to determine the correlation between patient-reported and CM elevation, abduction, and internal rotation. A subgroup analysis was conducted to evaluate motion in patients who underwent arthroplasty and arthroscopy. RESULTS: Patients were 52.4% male with a median age of 67 years (range, 18 to 96). PR and CM shoulder ROM were gathered at 13,842 patient visits. Strong correlations between PR and CM elevation (r = 0.70) and internal rotation (r = 0.66) were found, as well as a moderate correlation between PR and CM abduction (r = 0.59). Strong correlations were found between all three PR and CM measures of motion in the arthroplasty subgroup (elevation r = 0.74, abduction r = 0.63, and internal rotation r = 0.64). CONCLUSIONS: There is a strong correlation between patient-reported and CM shoulder elevation and internal rotation, as well as a moderate correlation between PR and CM abduction. This allows for a method of assessing patient motion without requiring an in-person visit. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Acromion fractures after reverse shoulder arthroplasty occur in predictable clusters.

BACKGROUND: Acromion and scapular spine fractures (ASFs) following reverse total shoulder arthroplasty (RSA) have been reported at a rate of 3.9%. The location of the fracture has been shown to be an important factor in determining the outcomes of nonoperative treatment, with medial fractures having worse outcomes than lateral fractures. As the debate between operative and nonoperative treatment continues, a more precise understanding of the location of the fracture is necessary for effective management. The purpose of this study was to use 3-dimensional computed tomography (CT) reconstruction to characterize the exact location of ASFs after RSA. METHODS: A retrospective review of 2 separate institutional shoulder and elbow repositories was performed. Patients with post-RSA ASFs documented by post-fracture CT scans were included. The query identified 48 patients who sustained postoperative ASFs after RSA between July 2008 and September 2021. CT scans of patients with ASFs were segmented using Mimics software. Eight patients were excluded because of poor image quality. Each bone model was manipulated using 3-Matic Medical software to align the individual scapula with an idealized bone model to create a view of scapular fracture locations on a normalized bone model. This model was used to classify the fractures using the modified Levy classification. RESULTS: The study cohort consisted of 40 patients with a diagnosis of postoperative ASF after RSA. The median age at the time of surgery was 76 years (interquartile range, 73-79 years). The cohort comprised 32 women (80%) and 8 men (20%), with a median body mass index of 27.8. Only 10 patients (25%) had a previous diagnosis of osteoporosis and 6 (13%) had a diagnosis of inflammatory arthritis; 53% of patients underwent RSA owing to rotator cuff tear arthropathy. The distribution of fracture locations was similar within the cohort. However, lateral fractures were slightly more prevalent. The most common fracture location was the type I zone, with 12 fracture lines (29%). There were 11 fracture lines (26%) in the type IIa zone, 10 (23%) in the type IIb zone, 0 in the type IIc zone, and 9 (21%) in the type III zone. CONCLUSION: ASFs after RSA occur in 4 predictable clusters. No fractures appeared to distinctly cluster in the type IIc zone, which may not represent a true fracture zone. Understanding the distribution of these fractures will help to enable the future design of implants and devices to stabilize the fractures that require fixation.

Impact of humeral stem length on calcar resorption in anatomic total shoulder arthroplasty.

BACKGROUND: Use of standard-length anatomic total shoulder (TSA) humeral stems has been associated with high rates of medial calcar bone loss. Calcar bone loss has been attributed to stress shielding, debris-induced osteolysis, and undiagnosed infection. Short stem and canal-sparing humeral components may provide more optimal stress distribution and thus lower rates of calcar bone loss related to stress shielding. The purpose of this study is to determine whether implant length will affect the rate and severity of medial calcar resorption. METHODS: A retrospective review was performed on TSA patients treated with three different-length humeral implants (canal-sparing, short, and standard-length designs). Patients were matched 1:1:1 based on both gender and age (±4 years), resulting in 40 patients per cohort. Radiographic changes in medial calcar bone were evaluated and graded on a 4-point scale, from the initial postoperative radiographs to those at 3 months, 6 months, and 12 months. RESULTS: The presence of any degree of medial calcar resorption demonstrated an overall rate of 73.3% at one year. At 3 months, calcar resorption was observed in 20% of the canal-sparing cohort, while the short and standard designs demonstrated resorption in 55% and 52.5%, respectively (P = .002). At 12 months, calcar resorption was seen in 65% of the canal-sparing design, while both the short and standard designs had a 77.5% rate of resorption (P = .345). The severity of calcar resorption for the canal-sparing cohort was significantly lower at all time points when compared to the short stem (3 months, P = .004; 6 months, P = .003; 12 months, P = .004) and at 3 months when compared to the standard-length stem (P = .009). CONCLUSION: Patients treated with canal-sparing TSA humeral components have significantly lower rates of early calcar resorption with less severe bone loss when compared to patients treated using short and standard-length designs.