This reprint focused on the advancements in the field of shoulder arthroplasty in recent years. These concern surgical indications that have dramatically evolved and planification and navigation. The ...rapid development of surgical techniques and new prosthetic designs, as well as glenoid and humeral reconstruction for various conditions, is also overviewed. Despite the important progress highlighted in this reprint, there is currently a myriad of prosthetic designs, highlighting the evolving nature of this field.
An analysis of costs associated with shoulder arthroplasty Chalmers, Peter N.; Kahn, Timothy; Broschinsky, Kortnie ...
Journal of shoulder and elbow surgery,
July 2019, 2019-Jul, 2019-07-00, 20190701, Letnik:
28, Številka:
7
Journal Article
Recenzirano
The purpose of this study was to identify factors associated with variation in direct costs with shoulder arthroplasty.
This was a retrospective study of all shoulder arthroplasties performed at a ...single facility between July 1, 2011, and November 30, 2016. We collected patient factors, indications, procedure (including implant details), implant brand (A, B, and other), and complications. We collected direct costs over a 90-day period using a validated internal tool. We identified patient and procedure characteristics associated with costs using multivariable generalized linear models.
A total of 361 patients were included, 19% with revision arthroplasty procedures, 32% with anatomic total shoulder arthroplasties, and 66% with reverse total shoulder arthroplasties (RTSAs). Of total costs, 13% were operative facility utilization costs and 58% were operative supply costs. Factors associated with increased total cost included younger age (P = .002) and an indication for surgery of other, that is, not osteoarthritis, a failed arthroplasty, or the sequelae of a rotator cuff tear (P = .030). Factors associated with increased operative costs included younger age (P = .002), use of an RTSA (P < .001), use of a bone graft (P < .001), implant brand B (P = .098), implant brands other than A and B (P = .04), the sequelae of a rotator cuff tear as an indication for surgery (P = .041), or an indication for surgery of other (P = .007).
Most short-term (90-day) costs with shoulder arthroplasty are operative costs. Nonmodified factors associated with increased cost included younger age and less common indications for surgery, whereas potentially modifiable factors included the intraoperative use of a bone graft, implant brand, and RTSA use.
Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. ...Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up.
A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, range of motion (ROM), strength, complications, re-admissions, and re-operations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up.
A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < 0.0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different.
This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with mid-term follow-up.
Technological advancements in implant design and surgical technique have focused on diminishing complications and optimizing performance of reverse shoulder arthroplasty (RSA). Despite this, there ...remains a paucity of literature correlating prosthetic features and clinical outcomes. This investigation utilized a machine learning approach to evaluate the effect of select implant design features and patient-related factors on surgical complications after RSA.
Over a 16-year period (2004 – 2020), all primary RSA performed at a single institution for elective and traumatic indications with a minimum follow-up of 2 years were identified. Parameters related to implant design evaluated in this study included inlay vs onlay humeral bearing design, glenoid lateralization (medialized or lateralized), humeral lateralization (medialized, minimally lateralized, or lateralized), global lateralization (medialized, minimally lateralized, lateralized, highly lateralized, or very highly lateralized), stem to metallic bearing neck shaft angle (NSA), and polyethylene NSA. Machine learning models predicting surgical complications were constructed for each patient and Shapley additive explanation (SHAP) values were calculated to quantify feature importance.
A total of 3,837 RSAs were identified, of which 472 (12.3%) experienced a surgical complication. Those experiencing a surgical complication were more likely to be current smokers (Odds ratio OR = 1.71; P = .003), have prior surgery (OR = 1.60; P < .001), have an underlying diagnosis of sequalae of instability (OR = 4.59; P < .001) or non-union (OR = 3.09; P < .001), and required longer OR times (98 vs. 86 minutes; P < .001). Notable implant design features at an increased odds for complications included an inlay humeral component (OR = 1.67; P < .001), medialized glenoid (OR = 1.43; P = .001), medialized humerus (OR = 1.48; P = .004), a minimally lateralized global construct (OR = 1.51; P < .001), and glenohumeral constructs consisting of a medialized glenoid and minimally lateralized humerus (OR = 1.59; P < .001), and a lateralized glenoid and medialized humerus (OR = 2.68; P < .001). Based on patient- and implant-specific features, the machine learning model predicted complications after RSA with an area under the receiver operating characteristic curve (AUC ROC) of 0.61.
This study demonstrated that patient-specific risk factors had a more substantial effect than implant design configurations on the predictive ability of a machine learning model on surgical complications after RSA. However, certain implant features appeared to be associated with a higher odd of surgical complications.
Preoperative and postoperative patient self-reported measures are the key to understanding the benefit of shoulder arthroplasty for patients with different diagnoses and having different surgical ...approaches. The minimal clinically important difference (MCID) for patient-reported outcomes such as the Simple Shoulder Test (SST) is often used to document the amount of improvement that is of importance to the patient; however, the MCID may differ for different types of shoulder arthroplasty. The objective of this study was to report the MCID of the SST and the MCID of the percentage of maximal possible improvement (%MPI) for 5 different arthroplasty types.
Eight hundred eighty-seven patients undergoing shoulder arthroplasty with preoperative SST scores, 2-year postoperative SST scores, and patient satisfaction were included. The sample comprised 368 patients undergoing anatomic total shoulder arthroplasty (aTSA), 330 patients undergoing ream-and-run arthroplasty (R&R), 80 patients undergoing reverse total shoulder arthroplasty (rTSA), 53 patients undergoing cuff tear arthropathy arthroplasty, and 56 patients undergoing hemiarthroplasty. For each type of arthroplasty, the anchor-based method was used for calculating the MCID for both absolute SST scores and %MPI.
Significant improvements in SST values were seen for all arthroplasty types. The MCID for SST change was 2.3 overall but ranged from 1.6 for aTSA, to 2.6 for R&R, to 3.7 for rTSA. The MCID for %MPI was 32% overall but ranged from 22% for aTSA to 42% for hemiarthroplasty. The percentage of patients exceeding the MCID threshold was highest for aTSA at 96% and lowest for hemiarthroplasty at 61%.
The same MCID value may not be appropriate for different types of shoulder arthroplasty. This study reports MCID thresholds that can be used when assessing the effectiveness for each of the common types of shoulder arthroplasty.
Background
Two classes of primary reverse total shoulder arthroplasty (rTSA), inlay (in-rTSA), and onlay (on-rTSA) were compared to determine differences in rates of revision.
Methods
Between 1 ...January 2012 and 31 December 2020, all primary in-rTSA or on-rTSA procedures were compared from a large national arthroplasty registry by cumulative percentage revision (CPR). Kaplan–Meier estimates of survivorship and hazard ratios from Cox proportional hazard models adjusted for age, gender, glenosphere size, and humeral fixation determined any associations to the risk of revision.
Results
Of the 14,807 in-rTSA and 6590 on-rTSA procedures, the CPR at seven years was 4.9%. There was an increased risk of revision for in-rTSA vs on-rTSA (p = 0.039) when adjusted for age, gender, glenosphere size, and humeral fixation. Glenosphere size <38 mm adjusted for age and gender (p = 0.016) increased the revision risk. Revision for instability/dislocation occurred more often for in-rTSA vs on-rTSA (p < 0.001) in the first three months. Males had a higher rate of revision than females for in-rTSA (3months+, p = 0.001) and for on-rTSA (p < 0.001).
Discussion
Care should be taken when considering in-rTSA particularly in males, and if preoperative planning suggests a small (<38 mm) glenosphere.
Level of evidence
Level III, therapeutic study. Original article.
Cutibacterium acnes is the bacterium most commonly responsible for shoulder periprosthetic joint infection (PJI) and is often cultured from samples obtained at the time of revision for failed ...shoulder arthroplasty. We sought to determine whether these bacteria originate from the patient or from exogenous sources. We also sought to identify which C. acnes genetic traits were associated with the development of shoulder PJI.
We performed bacterial whole-genome sequencing of C. acnes from a single-institution repository of cultures obtained before or during primary and revision shoulder arthroplasty and correlated the molecular epidemiology and genetic content of strains with clinical features of infection.
A total of 341 isolates collected over a 4-year period from 88 patients were sequenced. C. acnes cultured from surgical specimens demonstrated significant similarity to the strains colonizing the skin of the same patient (P < .001). Infrequently, there was evidence of strains shared across unrelated patients, suggesting that exogenous sources of C. acnes culture-positivity were uncommon. Phylotypes IB and II were modestly associated with clinical features of PJI, but all phylotypes appeared inherently capable of causing disease. Chronic shoulder PJI was associated with the absence of common C. acnes genes involved in bacterial quorum-sensing (luxS, tqsA).
C. acnes strains cultured from deep intraoperative sources during revision shoulder arthroplasty demonstrate strong genetic similarity to the strains colonizing a patient's skin. Some phylotypes of C. acnes commonly colonizing human skin are modestly more virulent than others, but all phylotypes have a capacity for PJI. C. acnes cultured from cases of PJI commonly demonstrated genetic hallmarks associated with adaptation from acute to chronic phases of infection. This is the strongest evidence to date supporting the role of the patient's own, cutaneous C. acnes strains in the pathogenesis of shoulder arthroplasty infection. Our findings support the importance of further research focused on perioperative decolonization and management of endogenous bacteria that are likely to be introduced into the arthroplasty wound at the time of skin incision.
Revision of prior hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) to reverse shoulder arthroplasty (RSA) is a technically challenging procedure with high complication rates. The purpose of ...this study was to compare intraoperative complications between convertible humeral stems and nonconvertible humeral stems stratified by stem length for conversion of TSA or HA to RSA.
A multicenter retrospective analysis of patients undergoing revision of a primary TSA or HA to RSA was conducted. Patients were divided into 2 groups based on convertible or nonconvertible humeral stem design from the index surgery. The primary outcome measures were the following intraoperative variables and complications: total operative time, blood loss, intraoperative fracture, overall complication rate, and blood transfusions. Rates were compared between groups and analyzed according to primary stem length for the nonconvertible group.
A total of 279 patients were included in the study, 70 with convertible stems and 209 with nonconvertible stems. About 70% of convertible stems were successfully retained. Operative time was similar between the 2 groups overall. Patients with nonconvertible stems had higher intraoperative blood loss (P = .0001), higher overall complication rate (P = .009), and greater risk of intraoperative fracture (P= .002). Revising stemless and short stems to RSA had significantly reduced operative time compared to standard length stems (97 and 116 minutes vs. 141 minutes, P < .0001 and P = .035, respectively). When revising stemless implants, there was a significantly lower rate of intraoperative fracture (3.6%) compared to short stems (24%, P = .004) and standard stems (23.4%, P = .001). When revising stemless implants to RSA, there was shorter operative time (P= .0001) and similarly low rate of intraoperative fracture (P= .820) compared to convertible stems.
In revision of anatomic TSA to RSA, convertible stems lead to lower blood loss and intraoperative fracture rate compared to nonconvertible stems when broadly including all stem types. However, differences appear to be based on stem type. Among nonconvertible stems, revision of short stem and stemless implants are associated with reduced operative time compared to standard length stems. Revision of stemless implants to RSA is associated with the shortest operative time of all implant types as well as a similar rate of intraoperative fracture compared to convertible stems.
Level III; Retrospective Cohort Comparative Study
Superior augment use may help avoid superior tilt while minimizing removal of inferior glenoid bone. Therefore, our goal is to compare superior augments versus no augment baseplates in RSA for ...patients with rotator cuff dysfunction and no significant superior glenoid erosion.
A multicenter retrospective analysis of 145 patients who underwent RSA with intraoperative navigation (Exactech, Equinoxe GPS) and three-year follow-up (mean 32-month follow-up, range 20 to 61 months) who had preoperative superior inclination less than 10 degrees and retroversion less than 15 degrees. Patient demographics, radiographic measurements, surgical characteristics, patient-reported outcomes at preoperative and postoperative visit closest to three years, and adverse events at final follow-up were obtained. Operative time, planned inclination, and planned version of the baseplate were obtained. Chi-square test used to compare categorical variables and student t-test used to compare augment and no augment cohorts.
The study population consisted of 54 superior augment patients and 91 no augment patients. The augment cohort had lower BMI (27.2 vs. 29.4, p-0.023), higher native superior inclination (5.9 vs. 1.4 degrees, p<0.001). No difference between the augment and no augment cohorts was found regarding age (p=0.643), gender (p=0.314), medical comorbidities (p>0.05), surgical indication (p=0.082), and native glenoid version (p=0.564). The augment cohort had higher internal rotation score (4.6 vs. 3.9, p=0.023), all remaining ROM and PROs preoperatively were not significantly different. At final follow-up, active ROM in all planes was not different between the cohorts. Regarding PROs, the postoperative SAS score was significantly higher (78.0 vs. 73.6, p=0.042), and ASES score trended towards higher (83.6 vs. 77.5, p=0.063) in the augment cohort. The augment cohort had significantly lower proportion of patients planned to have superior baseplate tilt (1.9% vs. 14.3%, p=0.012), and had greater mean inclination correction (6.3 vs. 1.3 degrees, p<0.001), compared to no augment cohort. Adverse events were rare, and there was no significant difference found between the augment and no augment cohorts (5.6% vs. 3.3%, p=0.509).
Superior augmented baseplate in RSA with minimal superior glenoid erosion is associated with similar ROM and adverse events with somewhat improved postoperative PROs compared to non-augmented baseplates at 3-year follow-up. Additionally, superior augments resulted in a greater proportion of baseplates planned to avoid superior tilt, and trended toward shorter operative times. Further investigation of long-term glenoid baseplate loosening is imperative to fully understand the cost-effectiveness of superior augments in the setting of minimal glenoid deformity.
Clinical significance, as opposed to statistical significance, has increasingly been utilized to evaluate outcomes after total shoulder arthroplasty (TSA). The purpose of this study was to identify ...thresholds of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for TSA outcome metrics and determine if these thresholds are influenced by prosthesis type (anatomic or reverse TSA), sex, or preoperative diagnosis.
A prospectively collected international multicenter database inclusive of 38 surgeons was queried for patients receiving a primary aTSA or rTSA between 2003 and 2021. Prospectively, outcome metrics including ASES, shoulder function score (SFS), SST, UCLA, Constant, VAS Pain, shoulder arthroplasty smart (SAS) score, forward flexion, abduction, external rotation, and internal rotation was recorded preoperatively and at each follow-up. A patient satisfaction question was administered at each follow-up. Anchor-based MCID, SCB, and PASS were calculated as defined previously overall and according to implant type, preoperative diagnosis, and sex. The percentage of patients achieving thresholds was also quantified.
A total of 5851 total shoulder arthroplasties (TSAs) including aTSA (n = 2236) and rTSA (n = 3615) were included in the study cohort. The following were identified as MCID thresholds for the overall (aTSA + rTSA irrespective of diagnosis or sex) cohort: VAS Pain (−1.5), SFS (1.2), SST (2.1), Constant (7.2), ASES (13.9), UCLA (8.2), SPADI (−21.5), and SAS (7.3), Abduction (13°), Forward elevation (16°), External rotation (4°), Internal rotation score (0.2). SCB thresholds for the overall cohort were: VAS Pain (−3.3), SFS (2.9), SST 3.8), Constant (18.9), ASES (33.1), UCLA (12.3), SPADI (−44.7), and SAS (18.2), Abduction (30°), Forward elevation (31°), External rotation (12°), Internal rotation score (0.9). PASS thresholds for the overall cohort were: VAS Pain (0.8), SFS (7.3), SST (9.2), Constant (64.2), ASES (79.5), UCLA (29.5), SPADI (24.7), and SAS (72.5), Abduction (104°), Forward elevation (130°), External rotation (30°), Internal rotation score (3.2). MCID, SCB, and PASS thresholds varied depending on preoperative diagnosis and sex.
MCID, SCB, and PASS thresholds vary depending on implant type, preoperative diagnosis, and sex. A comprehensive understanding of these differences as well as identification of clinically relevant thresholds for legacy and novel metrics is essential to assist surgeons in evaluating their patient's outcomes, interpreting the literature, and counseling their patients preoperatively regarding expectations for improvement. Given that PASS thresholds are fragile and vary greatly depending on cohort variability, caution should be exercised in conflating them across different studies.
