Knowledge of the minimal clinically important difference (MCID) for different shoulder outcome metrics and range of motion after total shoulder arthroplasty (TSA) can be useful to establish a minimum ...threshold of improvement that defines successful treatment. This study quantifies how MCID varies with different prosthesis types, patient age, gender, and length of follow-up after TSA.
A total of 466 anatomic TSA (aTSA) and reverse TSA (rTSA) with 2-year minimum follow-up were performed by 13 shoulder surgeons. The MCID for the American Shoulder and Elbow Surgeons, Constant, University of California Los Angeles Shoulder Rating Scale, Simple Shoulder Test, Shoulder Pain and Disability Index, global shoulder function, and visual analog scale for pain scores, as well as active abduction, forward flexion, and external rotation, were calculated for different prosthesis types and patient cohorts using an anchor-based method.
The anchor-based MCID results were American Shoulder and Elbow Surgeons = 13.6 ± 2.3, Constant score = 5.7 ± 1.9, University of California Los Angeles Shoulder Rating Scale = 8.7 ± 0.6, Simple Shoulder Test score = 1.5 ± 0.3, Shoulder Pain and Disability Index score = 20.6 ± 2.6, global shoulder function = 1.4 ± 0.3, pain visual analog scale = 1.6 ± 0.3, active abduction = 7° ± 4°, active forward flexion = 12° ± 4°, and active external rotation = 3° ± 2°. Female gender and rTSA were associated with lower MCID values compared with male gender and aTSA patients.
The minimum improvement necessary for patients to achieve a result they believe is clinically meaningful after aTSA and rTSA is nominal and was achieved by at least 80% of the patients. Future endeavors should investigate the influence of different anchor questions on the MCID calculation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
The reverse total shoulder arthroplasty (rTSA) prosthesis has been demonstrated to be a viable treatment option for a variety of end-stage degenerative conditions of the shoulder. The clinical ...success of this prosthesis is at least partially due to its unique biomechanical advantages. As taught by Paul Grammont, the medialized center of rotation fixed-fulcrum prosthesis increases the deltoid abductor moment arm lengths and improves deltoid efficiency relative to the native shoulder. All modern reverse shoulder prostheses utilize this medialized center of rotation (CoR) design concept; however, some differences in outcomes and complications have been observed between rTSA prostheses. Such differences in outcomes can at least partially be explained by the impact of glenoid and humeral prosthesis design parameters, surgical technique, implant positioning, patient-specific bone morphology, and usage in humeral and glenoid bone loss situations on reverse shoulder biomechanics. Ultimately, a better understanding of the reverse shoulder biomechanical principles will guide future innovations and further improve clinical outcomes.
Background Repair of the subscapularis with reverse total shoulder arthroplasty (rTSA) is controversial. The purpose of this study is to quantify rTSA outcomes in patients with and without ...subscapularis repair to determine if there is any impact on clinical outcomes. Methods Three hundred forty patients received rTSA and had the subscapularis repaired, whereas 251 patients received rTSA and did not have the subscapularis repaired. The patients were scored preoperatively and at latest follow-up using the Simple Shoulder Test; University of California, Los Angeles; American Shoulder and Elbow Surgeons; Constant; and Shoulder Pain and Disability Index metrics. Motion was also measured. Mean follow-up was 37 months. Results All patients showed significant improvements in pain and function after treatment with rTSA. For both cohorts, American Shoulder and Elbow Surgeons and Constant scores significantly improved, as did range of motion. The repaired cohort had significantly higher postoperative scores as measured by 4 of the 5 metrics and significantly more internal rotation, whereas the non-repaired cohort had significantly more active abduction and passive external rotation. The complication rate was 7.4% (0% dislocations) for the subscapularis-repaired cohort and 6.8% (1.2% dislocations) for the non–subscapularis-repaired cohort. Conclusions Significant clinical improvements were observed for both the subscapularis-repaired and non-repaired cohorts, with some statistical differences observed using a variety of outcome measures. Repair of the subscapularis did not lead to inferior clinical outcomes as predicted by biomechanical models. No difference was noted in the complication or scapular notching rates between cohorts. These clinical results show that rTSA using a lateralized humeral prosthesis delivers reliable clinical improvements with a low risk of instability, regardless of subscapularis repair.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background Scapular notching is a complication unique to reverse total shoulder arthroplasty (rTSA), although its clinical implications are unclear and remains controversial. Methods We ...retrospectively reviewed rTSA patients of a single implant design in 476 shoulders with a minimum 2-year clinical and radiographic follow-up. Clinical measures included active range of motion and American Shoulder and Elbow Surgeons scores, in addition to one or more of the Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test (SST), and University of California, Los Angeles Shoulder Rating Scale. Complications and rates of humeral radiolucencies were also recorded. Results Scapular notching was observed in 10.1% (48 of 476) of rTSAs and was associated with a longer clinical follow-up, lower body weight, lower body mass index, and when the operative side was the nondominant extremity. Patients with scapular notching had significantly lower postoperative scores on the Shoulder Pain and Disability Index, Constant, Simple Shoulder Test, and University of California, Los Angeles, Shoulder Rating Scale compared with patients without scapular notching. Patients with scapular notching also had significantly lower active abduction, significantly less strength, and trended toward significantly less active forward flexion ( P = .0527). Finally, patients with scapular notching had a significantly higher complication rate and trended toward a significantly higher rate of humeral radiolucent lines ( P = .0896) than patients without scapular notching. Conclusions This large-scale outcome study demonstrates that patients with scapular notching have significantly poorer clinical outcomes, significantly less strength and active range of motion, and a significantly higher complication rate than patients without scapular notching. Longer-term follow-up is necessary to confirm that these statistical observations in the short-term will result in greater clinically meaningful differences over time.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
An understanding of the substantial clinical benefit (SCB) after total shoulder arthroplasty (TSA) may help to gauge a minimum threshold beyond which a patient perceives his or her outcome as being ...substantially better. This study quantifies SCB for 7 outcome metrics and active motion measurements after shoulder arthroplasty and determines how these values vary based on prosthesis type, patient age at surgery, sex, and length of follow-up.
A total of 1,568 shoulder arthroplasties with 2-year minimum follow-up were performed by 13 shoulder surgeons and enrolled in a multicenter registry. The SCB for the American Shoulder and Elbow Surgeons Shoulder Assessment, Constant Score, University of California Los Angeles Shoulder Rating Scale, Simple Shoulder Test, Shoulder Pain and Disability Index, global shoulder function, and visual analog scale pain scores, as well as active abduction, flexion, and external rotation were calculated for different patient cohorts using an anchor-based method.
The anchor-based SCB results were American Shoulder and Elbow Surgeons score, 31.5 ± 2.0; Constant Score, 19.1 ± 1.7; University of California Los Angeles Shoulder Rating Scale score, 12.6 ± 0.5; Simple Shoulder Test score, 3.4 ± 0.3; Shoulder Pain and Disability Index score, 45.4 ± 2.2; global shoulder function, 3.1 ± 0.2; visual analog scale, 3.2 ± 0.3; active abduction, 28.5° ± 3.1°; active forward flexion, 35.4° ± 3.5°; and active external rotation, 11.7° ± 1.9°. Anatomic TSA patients, male patients, and patients of longer follow-up duration were associated with higher SCB values than female patients, reverse TSA patients, and patients of shorter follow-up duration.
Our analysis demonstrated two-thirds of patients achieved the SCB threshold after TSA. Generally, a change of 30% of the total possible score for each outcome metric approximates or exceeds this SCB threshold.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Complications after anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty can be devastating to a patient's quality of life and require revisions that are costly to both the patient and the ...health care system. The purpose of this study is to determine the types, incidence, and timing of complications following aTSA and rTSA using an international database of patients who received a single-platform total shoulder arthroplasty system, in order to quantify the types of failure modes and the differences that occur between aTSA and rTSA.
A total of 2224 aTSA (male-female, 1090:1134) and 4158 rTSA (male-female, 1478:2680) patients were enrolled in an international database of primary shoulder arthroplasty performed by 40 different surgeons in the United States and Europe. Adverse events and revisions reported for these 6382 patients were analyzed to identify the most common failure modes associated for both aTSA and rTSA.
For the 2224 aTSA patients, 239 adverse events were reported for a complication rate of 10.7% and 124 revisions for a revision rate of 5.6%. The top 3 complications for aTSA were rotator cuff tear/subscapularis failure (n = 69; complication rate = 3.1%, revision rate = 1.9%), aseptic glenoid loosening (n = 55; complication rate = 2.5%, revision rate = 1.9%), and infection (n = 28; complication rate = 1.3%, revision rate = 0.8%). For the 4158 rTSA patients, 372 adverse events were reported for a complication rate of 8.9% and 104 revisions for a revision rate of 2.5%. The top 3 complications for rTSA were acromial/scapular fracture/pain (n = 102; complication rate = 2.5%, revision rate = 0.0%), instability (n = 60; complication rate = 1.4%, revision rate = 1.0%), and pain (n = 49; complication rate = 1.2%, revision rate = 0.2%).
This large database analysis quantified complication and revision rates for aTSA and rTSA. We found aTSA and rTSA complication rates of 10.7% and 8.9%, respectively; with revision surgery rates of 5.6% and 2.5%, respectively. The 2 most common complications for each prosthesis type (aTSA: subscapularis/rotator cuff tears, aseptic glenoid loosening; rTSA: acromial/scapular fractures, instability) were unique to each device. The rate of infection was similar for both. Future prosthesis and technique development should work to mitigate these common complication types in order to reduce their rate of occurrence.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Internal rotation (IR) with reverse total shoulder arthroplasty (rTSA) can be unpredictable. Identifying the factors associated with loss of or improved IR could aid preoperative patient counseling. ...This study quantifies the change in IR experienced by rTSA patients with nonfracture indications and identifies the patient, implant, and operative factors associated with IR loss or gain at 2-year minimum follow-up.
A total of 1978 primary rTSA patients were analyzed from an international database of a single rTSA prosthesis to quantify IR at 2 years’ minimum follow-up. rTSA patients were divided into 2 cohorts based on their preoperative IR score, with group 1 patients having less active IR as defined by a preoperative IR score ≤3 and group 2 patients having greater active IR as defined by a preoperative IR score ≥4 (ie, L5 or higher). For both group 1 and 2 patients, univariate and multivariate analyses were performed to quantify the risk factors associated with IR loss after rTSA.
Overall, 58.9% of rTSA patients experienced IR improvement and 17.0% lost IR after rTSA. The occurrence of IR loss or gain was dependent on preoperative IR score, as 73.2% of group 1 patients improved IR and only 40.1% of group 2 patients improved IR, whereas 31.0% of group 2 patients lost IR and only 6.3% of group 1 patients lost IR after rTSA. Numerous risk factors for IR loss were identified. For group 1 patients, male sex (P = .004, odds ratio OR = 2.056), tobacco usage (P = .004, OR = 0.348), larger humeral stem diameter (P = .008, OR = 0.852), and not having subscapularis repaired (P = .002, OR = 2.654) were significant risk factors for IR loss. For group 2 patients, male sex (P = .005, OR = 1.656), higher body mass index (P = .002, OR = 0.946), a diagnosis other than osteoarthritis (P < .001, OR = 2.189), nonaugmented baseplate usage (P < .001, OR = 2.116), and not having subscapularis repaired (P < .001, OR = 3.052) were significant risk factors for IR loss.
The majority of patients improve IR after rTSA in the nonfracture setting. rTSA patients with substantial IR prior to surgery had a greater probability for losing IR compared to patients with poor preoperative IR. Numerous risk factors for IR loss were identified; these risk factors are useful for counseling patients considering rTSA, as some patients are more likely to lose IR than others.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
An improved understanding of how gender differences and the natural aging process are associated with differences in clinical improvement in outcome metric scores and ROM measurements after reverse ...total shoulder arthroplasty (rTSA) may help physicians establish more accurate patient expectations for reducing postoperative pain and improving function.
(1) Is gender associated with differences in rTSA outcome scores like the Simple Shoulder Test (SST), the UCLA Shoulder score, the American Shoulder and Elbow Surgeons (ASES) Shoulder score, the Constant Shoulder score, and the Shoulder Pain and Disability Index (SPADI) and ROM? (2) Is age associated with differences in rTSA outcome scores and ROM? (3) What factors are associated with the combined interaction effect between age and gender? (4) At what time point during recovery does most clinical improvement occur, and when is full improvement reached?
We quantified and analyzed the outcomes of 660 patients (424 women and 236 men; average age, 72 ± 8 years; range, 43-95 years) with cuff tear arthropathy or osteoarthritis and rotator cuff tear who were treated with rTSA by 13 shoulder surgeons from a longitudinally maintained international database using a linear mixed effects statistical model to evaluate the relationship between clinical improvements and gender and patient age. We used five outcome scoring metrics and four ROM assessments to evaluate clinical outcome differences.
When controlling for age, men had better SST scores (mean difference MD = 1.41 points 95% confidence interval {CI}, 1.07-1.75, p < 0.001), UCLA scores (MD = 1.76 95% CI, 1.05-2.47, p < 0.001), Constant scores (MD = 6.70 95% CI, 4.80-8.59, p < 0.001), ASES scores (MD = 7.58 95% CI, 5.27-9.89, p < 0.001), SPADI scores (MD = -12.78 95% CI, -16.28 to -9.28, p < 0.001), abduction (MD = 5.79° 95% CI, 2.74-8.84, p < 0.001), forward flexion (MD = 7.68° 95% CI, 4.15-11.20, p < 0.001), and passive external rotation (MD = 2.81° 95% CI, 0.81-4.8, p = 0.006). When controlling for gender, each 1-year increase in age was associated with an improved ASES score by 0.19 points (95% CI, 0.04-0.34, p = 0.011) and an improved SPADI score by -0.29 points (95% CI, -0.46 to 0.07, p = 0.020). However, each 1-year increase in age was associated with a mean decrease in active abduction by 0.26° (95% CI, -0.46 to 0.07, p = 0.007) and a mean decrease of forward flexion by 0.39° (95% CI, -0.61 to 0.16, p = 0.001). A combined interaction effect between age and gender was found only with active external rotation: in men, younger age was associated with less active external rotation and older age was associated with more active external rotation (β0 intercept = 11.029, β1 slope for age variable = 0.281, p = 0.009). Conversely, women achieved no difference in active external rotation after rTSA, regardless of age at the time of surgery (β0 intercept = 34.135, β1 slope for age variable = -0.069, p = 0.009). Finally, 80% of patients achieved full clinical improvement as defined by a plateau in their outcome metric score and 70% of patients achieved full clinical improvement as defined by a plateau in their ROM measurements by 12 months followup regardless of gender or patient age at the time of surgery with most improvement occurring in the first 6 months after rTSA.
Gender and patient age at the time of surgery were associated with some differences in rTSA outcomes. Men had better outcome scores than did women, and older patients had better outcome scores but smaller improvements in function than did younger patients. These results demonstrate rTSA outcomes differ for men and women and for different patient ages at the time of surgery, knowledge of these differences, and also the timing of improvement plateaus in outcome metric scores and ROM measurements can both improve the effectiveness of patient counseling and better establish accurate patient expectations after rTSA.
Level III, therapeutic study.
Identifying risk factors for acromial and scapular fractures improves our understanding about which variables are relevant to these fracture complications; however, these data are difficult to ...integrate into clinical practice because the majority of reverse total shoulder arthroplasty (rTSA) patients have ≥1 risk factor. The goal of this study was to better facilitate preoperative identification of patients at risk of acromial and scapular fractures and quantify the impact of accumulating risk factors on the incidence of fracture.
We retrospectively analyzed 9079 rTSA patients from a multicenter database of rTSA procedures performed with a single medialized glenoid–lateralized humerus onlay rTSA prosthesis to quantify the rate of acromial and scapular fractures. Univariate and multivariate analyses were performed to identify risk factors for fracture. Next, we quantified the number of patients with 1 or multiple significant risk factors for fracture. Finally, to facilitate preoperative identification of patients most at risk of fracture, we stratified our data set using multiple combinations of age, sex, and diagnosis risk factors and calculated the odds ratio for each cohort to quantify the impact of accumulating risk factors on the incidence of fracture.
A fracture of the acromion or scapula was radiographically identified in 138 of 9079 patients, for a rate of 1.52%. Patients with fractures were more likely to be older, of female sex, to have a diagnosis of rheumatoid arthritis and/or cuff tear arthropathy, and were less likely to have a diagnosis of diabetes. Eighty-five percent of rTSA patients had ≥1 fracture risk factor. Individually, age, sex, or diagnosis failed to identify any patient cohort with an odds ratio >2.5. Use of multiple combinations of patient risk factors refined the identification of at-risk patients better than any individual risk factor or 2–risk factor combination and demonstrated that the patients with the greatest fracture risk were female patients with a rheumatoid arthritis diagnosis who were aged >70, >75, and >80 years.
This 9079-rTSA multicenter study demonstrated that 1.52% of patients experienced acromial and/or scapular fractures with a single medialized glenoid–lateralized humerus onlay rTSA prosthesis. Our analysis identified numerous risk factors and quantified the impact of accumulating risk factors on fracture incidence. Patients who are considering rTSA and who have these age, sex, and diagnosis risk factors should be made aware of their elevated complication risk.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Glenoid baseplate augments have recently been introduced as a way of managing glenoid monoplanar or biplanar abnormalities in reverse shoulder arthroplasty (RSA). The purpose of this study is to ...evaluate the difference in clinical outcomes, complications, and revision rates between augmented and standard baseplates in RSA for rotator cuff arthropathy patients with glenoid deformity.
A multicenter retrospective analysis of 171 patients with glenoid bone loss who underwent RSA with and without augmented baseplates was performed. Preoperative inclusion criteria included minimum follow-up of 2 years and preoperative retroversion of 15°-30° and/or a beta angle 70°-80°. Version and beta angle were measured on computed tomographic scans, when available, and plain radiographs. Shoulder range of motion (ROM) and patient-reported outcomes were obtained from preoperative and multiple postoperative time points.
The study consisted of 84 standard baseplate patients and 87 augmented baseplate patients. The augment cohort had greater mean preoperative glenoid retroversion (17° vs. 9°, P < .001). At >5-year follow-up, the increase in postoperative active abduction (52° vs. 31°, P = .023), forward flexion (58° vs. 35°, P = .020), and internal rotation score (2.8° vs. 1.1°, P = .001) was significantly greater in the augment cohort. Additionally, >5-year follow-up American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score (87.0 ± 16.6 vs. 75.9 ± 22.4, P = .022), Constant score (78.0 ± 9.7 vs. 64.6 ± 15.1, P < .001), and Shoulder Arthroplasty Smart score (81.2 ± 6.5 vs. 71.2 ± 13.6, P = .003) were significantly higher in the augment cohort. Revision rate was low overall, with no difference between the augment and no augment groups (0.7% vs. 3.0%, P = .151).
In comparing augments to standard nonaugment baseplates in the setting of RSA with glenoid deformity, our results demonstrate greater postoperative improvements in multiple planes of active ROM in the augment cohort. Additionally, the augment cohort demonstrated greater postoperative level and improvement in scores for multiple clinical outcome metrics up to >5 years of follow-up with no difference in complication or revision rates, supporting the use of augmented glenoid baseplates in RSA with glenoid deformity.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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