Reverse Total Shoulder Arthroplasty Within 6 Weeks of Proximal Humerus Fracture is Associated with the Lowest Risk of Revision.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHF). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals. METHODS: A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2-years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF). RESULTS: In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified two timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6 week cohort, the 7-52 week cohort was more likely to undergo revision surgery within 2-years (OR: 1.93, P < 0.001). Moreover, the 7-52 week cohort had significantly higher odds of revision indicated for dislocation (OR: 2.24, P < 0.001), mechanical loosening (OR: 1.71, P < 0.001), PJI (OR: 1.74, P < 0.001), and PPF (OR: 1.96, P < 0.001). CONCLUSIONS: Using SSLR, we were successful in identifying two data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4 to 6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

Iatrogenic Excessive Clavicle Resection as a Complication of Arthroscopic Distal Clavicle Excision.

Arthroscopic distal clavicle excision (DCE) is a reliable procedure to treat acromioclavicular joint arthritis. Typically, only 1 to 2 cm of distal clavicle should be removed. Resection of too much bone can lead to instability of the joint or lack of support to the shoulder. We describe 2 patients who had excessive clavicular bone removed arthroscopically, leading to irreparable clavicular pain and dysfunction. The 2 female patients, ages 56 and 60 years, presented to our clinic with continued pain after DCE. Both had pain intractable with nonoperative treatment and loss of range of motion of the shoulder. Radiographs revealed a distal clavicle defect of 7.5 cm in 1 patient. The second patient had a 2-cm distal clavicular defect with an adjacent 2-cm clavicle bone fragment between the defect and residual clavicle shaft. Both underwent surgery with subtotal claviculectomy for pain control. During surgery, 1 patient had a subclavian vein requiring vascular repair. After 1 year of follow-up, both patients had reduced but residual pain and restricted range of motion. Only 1 patient could rejoin her preinjury occupation. Neither patient could continue with preinjury recreational sports. Excessive removal of the distal clavicle during DCE can result in continued pain and disability of the shoulder. Methods to visualize the anatomy of the distal clavicle and its articulation to the acromion should be considered when performing this operation arthroscopically. Reoperation to remove subtotal clavicle has good clinical outcomes but may lead to serious complications due to the proximity to major neurovascular structures. [Orthopedics. 2024;47(1):e57-e60.].

Narrative review of influence of prosthesis lateralization on clinical outcomes in reverse shoulder arthroplasty: glenoid vs. humerus vs. combined.

Background and Objective: Reverse shoulder arthroplasty has become a common orthopaedic procedure, with a growing number of cases annually for multiple indications, such as rotator cuff arthropathy, osteoarthritis, or fractures of the proximal humerus, to reduce pain and restore shoulder mobility. Prosthesis design and various recent improvements aim to enhance range of motion (ROM) and stability and to limit component loosening and other potential complications. Many of these well-known issues could theoretically be improved by glenoid, humeral, or combined component lateralization. The objective of this article is to provide an up-to-date literature overview, present available options, and discuss the rationale behind lateralization of certain components, as well as their combined impact on outcomes of reverse shoulder arthroplasty. Methods: PubMed and Scopus databases from 2003 to 2023 were searched and screened for studies, including systematic reviews, on the influence of glenoid, humeral, and combined component lateralization that served for narrative review of rationale behind such design. Key Content and Findings: Currently, a number of computer simulations, anatomic studies, and limited clinical references aim to support the rationale behind glenoid augmentation, variable humeral neck-shaft angle (NSA), or humeral tray design. Conclusions: The utility of lateralization has not yet been clinically established. Randomized, long-term clinical outcome studies are still needed to reach a verdict going beyond surgeon preference and case-specific indications.

Use of custom glenoid components for reverse total shoulder arthroplasty.

BACKGROUND: Our purpose was to evaluate a custom reverse total shoulder arthroplasty glenoid baseplate for severe glenoid deficiency, emphasizing the challenges with this approach, including short-term clinical and radiographic outcomes and complications. METHODS: This was a single-institution, retrospective series of 29 patients between January 2017 and December 2022 for whom a custom glenoid component was created for extensive glenoid bone loss. Patients were evaluated preoperatively and at intervals for up to 5 years. All received preoperative physical examinations, plain radiographs, and computed tomography (CT). Intra- and postoperative complications are reported. RESULTS: Of 29 patients, delays resulted in only undergoing surgery, and in three of those, the implant did not match the glenoid. For those three, the time from CT scan to implantation averaged 7.6 months (range, 6.1-10.7 months), compared with 5.5 months (range, 2-8.6 months) for those whose implants fit. In patients with at least 2-year follow-up (n=9), no failures occurred. Significant improvements were observed in all patient-reported outcome measures in those nine patients (American Shoulder and Elbow Score, P<0.01; Simple Shoulder Test, P=0.02; Single Assessment Numeric Evaluation, P<0.01; Western Ontario Osteoarthritis of the Shoulder Index, P<0.01). Range of motion improved for forward flexion and abduction (P=0.03 for both) and internal rotation up the back (P=0.02). Pain and satisfaction also improved (P<0.01 for both). CONCLUSIONS: Prolonged time (>6 months) from CT scan to device implantation resulted in bone loss that rendered the implants unusable. Satisfactory short-term radiographic and clinical follow-up can be achieved with a well-fitting device. Level of evidence: III.