BACKGROUND:This study quantifies the rate of improvement after anatomic and reverse total shoulder arthroplasty; a better understanding of the rate of improvement associated with each prosthesis type ...may better establish patient expectations for recovery.
METHODS:Prospectively collected data on 1,183 patients who underwent either anatomic total shoulder arthroplasty (n = 505) or reverse total shoulder arthroplasty (n = 678) were collected. The Simple Shoulder Test (SST), University of California at Los Angeles (UCLA) Shoulder, American Shoulder and Elbow Surgeons (ASES), Constant, and Shoulder Pain and Disability Index (SPADI) scores, along with range of motion, were recorded preoperatively and at routine postoperative time points. All included patients had a minimum follow-up of 2 years. The rate of improvement of these outcome measures was quantified for patients who underwent anatomic total shoulder arthroplasty and those who underwent reverse total shoulder arthroplasty to compare recovery over time.
RESULTS:In this study, 3,587 visits by 1,183 patients were analyzed and several differences between prosthesis types were noted. Patients who underwent reverse total shoulder arthroplasty experienced larger improvements in the Constant score and active forward flexion, and patients who underwent anatomic total shoulder arthroplasty demonstrated better improvement in external rotation compared with patients who underwent reverse total shoulder arthroplasty at nearly all time points. By 72 months, improvement in flexion and abduction decreased for each prosthesis type, but in particular for reverse total shoulder arthroplasty. Full improvement was achieved by 24 months, although the majority of improvement was achieved in the first 6 months, with all 5 scoring metrics following a similar rate of improvement. The ASES, SPADI, and UCLA Shoulder scores closely mirrored each other in the magnitude of improvement, and the SST score demonstrated the largest improvement and the Constant score demonstrated the smallest improvement for both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty.
CONCLUSIONS:Both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty reliably result in improved patient outcomes. However, anatomic total shoulder arthroplasty more reliably improves range of motion, particularly external rotation. Most improvement occurs by 6 months, with some additional improvement up to 2 years for both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty. Although the indications for anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty are substantially different, in addition to the biomechanical differences, the improvement in outcome scores over time can be expected to be very similar. This study is helpful to patients and health-care providers to establish expectations regarding the rate of recovery after total shoulder arthroplasty.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Metallosis is an unusual but consequential complication arising from orthopedic hardware implantation, characterized by the deposition of metallic particles in the periprosthetic soft tissues. The ...incidence of metallosis associated with shoulder arthroplasties is exceptionally rare since the shoulder is not a weight-bearing joint, making it less susceptible to mechanical wear and, consequently, to conditions like particle disease and metallosis. Nevertheless, anomalous metal-on-metal interactions can develop in total shoulder arthroplasties if the polyethylene component fails due to wear, fracture, or dissociation. If left unaddressed, metallosis can incite an adverse immune-mediated local tissue response, culminating in joint destruction and adjacent soft tissues and muscle necrosis. In this case report, the diagnosis of metallosis was made in a patient with an anatomic total shoulder arthroplasty using a state-of-the-art photon counting detector CT supplemented by post-processing metal artifact reduction algorithms. This advanced imaging approach was effective in discerning the source of implant failure and in identifying manifestations of severe metallosis including osteolysis and pseudotumor formation. Advanced imaging methods can accurately characterize the severity and extent of metallosis, thereby helping guide surgical planning to mitigate serious complications associated with this condition.
BackgroundThe reverse Delta III shoulder prosthesis can relieve pain and restore function in patients with cuff tear arthropathy. The most frequently reported radiographic complication is inferior ...scapular notching. The purpose of the present study was to evaluate the clinical relevance of notching and to determine the anatomic and radiographic parameters that predispose to its occurrence.MethodsSeventy-seven consecutive shoulders in seventy-six patients with an irreparable rotator cuff deficiency were managed with a reverse Delta III shoulder arthroplasty and were followed clinically and radiographically for a minimum of twenty-four months. The effects of cranial-caudal glenoid component positioning and the prosthesis-scapular neck angle on the development of inferior scapular notching and clinical outcome were assessed.ResultsAll shoulders that had development of notching did so in the first fourteen months. Of the seventy-seven shoulders that were studied, thirty-four (44%) had inferior scapular notching, twenty-three (30%) had posterior notching, and six (8%) had anterior notching. Osteophytes along the inferior part of the scapula occurred in twenty-one (27%) of the seventy-seven shoulders. The angle between the glenosphere and the scapular neck (r = 0.667) as well as the craniocaudal position of the glenosphere (r = 0.654) were highly correlated with inferior notching (p < 0.001). A notching index was calculated with use of the height of implantation of the glenosphere and the postoperative prosthesis-scapular neck angle. This allowed prediction of the occurrence of notching with a sensitivity of 91% and specificity of 88%. The height of implantation of the glenosphere had approximately an eight times greater influence on inferior notching than the prosthesis-scapular neck angle did. Inferior scapular notching was associated with a significantly poorer clinical outcome.ConclusionsInferior scapular notching after reverse total shoulder arthroplasty adversely affects the intermediate-term clinical outcome. It can be prevented by optimal positioning of the glenoid component.Level of EvidencePrognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
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.
BackgroundReports have demonstrated that reverse shoulder arthroplasty restores overhead elevation but fails to restore active external rotation. The teres minor muscle-tendon unit contributes to ...active external rotation, and its deficiency may impair the clinical outcome. It was therefore the purpose of this study to evaluate the influence of fatty infiltration of the teres minor muscle on the clinical outcome after reverse total shoulder replacement.MethodsForty-two shoulders in forty-two patients (average age, seventy-one years) with painful cuff tear arthropathy or an irreparable rotator cuff deficiency with pseudoparesis were treated with a reverse Delta-III shoulder arthroplasty and followed clinically for a minimum of twenty-four months. Preoperatively, fatty infiltration of the teres minor was assessed, according to the grading system of Goutallier et al., with use of magnetic resonance imaging. The effect of teres minor fatty infiltration on the subjective and objective outcomes of the reverse shoulder arthroplasty was evaluated.ResultsThe thirty shoulders with stage-0, 1, or 2 fatty infiltration of the teres minor muscle (group 1) had a significantly better ultimate Constant score, a significantly better subjective shoulder value, and significantly greater preoperative-to-postoperative improvement than the twelve shoulders with stage-3 or 4 fatty infiltration (group 2). In group 1 the relative Constant score increased by an average of 41% and the subjective shoulder value increased by an average of 44%, whereas in group 2 the respective increases were 32% (p = 0.033) and 25% (p = 0.018). Group 1 had an average increase of 6.2 points in the score for extremity positioning, whereas group 2 gained only 5.3 points (p = 0.033). Group 1 had a net gain of 9° of external rotation with the arm at the side compared with an average net loss of 7° in group 2 (p < 0.001).ConclusionsStage-3 or 4 fatty infiltration of the teres minor compromises the clinical outcome of reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tears.Level of EvidencePrognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
Magnetic resonance imaging (MRI) is frequently obtained to assess for pathology in the setting of shoulder pain and dysfunction. MRI of the shoulder provides diagnostic information that helps ...optimize patient management and surgical planning. Both general and subspecialized orthopaedic surgeons routinely order and review shoulder MRIs in practice. Therefore, familiarity with the MRI appearance of common shoulder pathologies is important. This document reviews the most common shoulder pathologies using a standardized MRI interpretative approach. Instructional videos demonstrating a musculoskeletal radiologist interpreting normal and abnormal shoulder MRIs are also provided.
Satisfaction following shoulder arthroplasty (TSA), which is commonly reported using patient-reported outcome measures (PROMs), is partially dependent upon restoring shoulder range of motion (ROM). ...We hypothesized there exists a minimum amount of ROM necessary to perform functional tasks queried in PROM questionnaires, beyond which further ROM may provide no further improvement in PROMs.
A retrospective review of a multicenter international shoulder arthroplasty database was performed between 2004-2020 for patients undergoing anatomic or reverse TSA (aTSA, rTSA) with minimum 2-year follow-up. Our primary outcome was to determine the threshold in postoperative active ROM (abduction, forward elevation FE, external rotation ER, and internal rotation IR score) whereby additional improvement was not associated with additional improvement in PROMs (Simple Shoulder Test SST, American Shoulder and Elbow Surgeons ASES score, and the Shoulder Pain and Disability Index SPADI). For comparison, we also evaluated the Shoulder Arthroplasty Smart (SAS) score, which is not subject to the ceiling effect.
We included 4,459 TSAs (1,802 aTSAs, 2,657 rTSAs) with minimum 2-year follow-up (mean, 56±32 months). The threshold in postoperative ROM that were associated with no further improvement were: active abduction, 107-113° for PROMs versus 163° for the SAS score; active FE, 149-162° for PROMs versus 176° for the SAS score; active ER, 50-52° for PROMs versus 72° for the SAS score; IR score, 4-5 points for all PROMs versus 6 points for the SAS score. Out of 3,508 TSAs with complete postoperative ROM data, 8.5% achieved or exceeded all ROM thresholds (14.5% aTSAs, 4.8% rTSAs).
Our findings demonstrate that postoperative ROM exceeding 113° of abduction, 162° of FE, 52° of ER, and IR to L1 is associated with minimal additional improvement in PROMs. While individual patient needs vary, the thresholds may provide helpful targets for patients undergoing postoperative rehabilitation.
Background This study evaluated the clinical and radiographic outcomes of reverse total shoulder arthroplasty (RTSA) in a senior athletic population playing both low- and high-impact sports. ...Materials and methods We evaluated 41 RTSAs performed in 40 patients who continued to play both low- and high-impact sports after surgery. The mean age was 73 years, and the mean follow-up period was 43 months, with a minimum of 35 months. Clinical and radiographic outcomes were examined. Results Ninety-five percent of patients indicated that they were able to return to sports at the same level as before surgery or at a higher level, and only 13% reported increased pain after playing their sport after undergoing an RTSA. The median American Shoulder and Elbow Surgeons score improved from 31 preoperatively to 72 postoperatively ( P < .001). The median Constant score improved from 25 preoperatively to 83 postoperatively ( P < .001). The median Subjective Shoulder Value improved from 27% preoperatively to 90% postoperatively ( P < .001), and the median visual analog scale score improved from 7.2 preoperatively to 1.1 postoperatively ( P < .001). The overall complication rate was 7%. One zone of lucency was noted in 17% of humeral stems, with 1 case of early subsidence but no cases with loosening at final follow-up. The glenoid notching rate was 7%, with no cases of glenoid subsidence, lucency, or loosening. Conclusion RTSA in senior athletes can be safely performed with good clinical results. No prominent mode of mechanical or clinical failure has been identified with short-term follow-up.
Anxiety and depression are the 2 most commonly diagnosed psychiatric disorders in the United States. The effect of these disorders on total shoulder arthroplasty (TSA) outcomes must be appreciated. ...The purpose of this study was to examine the correlation between a preoperative diagnosis of anxiety and depression and postoperative outcomes after TSA. The secondary goals were to determine whether patients contemporaneously treated with medication for their mental health diagnosis fared better than a cohort treated without medication and to examine the degree to which Patient-Reported Outcomes Measurement Information System Mental Health (PROMIS-MH) scores correlate with patient outcomes. Our hypothesis was that a history of anxiety and/or depression would negatively impact patient outcomes after TSA.
We performed a retrospective analysis of a prospectively collected cohort at a single institution. Patients undergoing anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) with anxiety and/or depression were identified and compared with a cohort of patients without a mental health diagnosis enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant types, range of motion, adverse events, and clinical outcome metric scores—PROMIS-MH score, American Shoulder and Elbow Surgeons score, Constant score, Shoulder Arthroplasty Smart Score—were recorded. Outcomes between cohorts were analyzed using conventional statistics, as well as stratification by the minimal clinically important difference and substantial clinical benefit thresholds where applicable.
The study comprised 218 patients (114 rTSA and 95 aTSA patients) with a diagnosis of either anxiety and/or depression and 378 patients (153 rTSA and 217 aTSA patients) with no history. Although both cohorts achieved the minimal clinically important difference and substantial clinical benefit thresholds for the postoperative American Shoulder and Elbow Surgeons score, the cohort with anxiety and/or depression showed lower postoperative outcome scores (P < .05), higher AE rates, and significantly lower preoperative-to-postoperative differences in all variables when compared with the cohort without anxiety and/or depression. There were no differences in outcome scores after rTSA or aTSA between patients being treated for anxiety and/or depression and those not receiving treatment. The PROMIS-MH score was positively correlated with postoperative outcomes and patient satisfaction.
This study shows that patients with anxiety and/or depression who underwent TSA had inferior postoperative outcomes and higher rates of AEs compared with a cohort without a mental health diagnosis. In addition, patients taking medication for treatment of depression and/or anxiety did not gain any significant benefit in terms of their postoperative shoulder outcomes or satisfaction rate compared with those with this diagnosis but not taking medication. Additionally, we found that, independent of a patient's underlying shoulder pathology or psychiatric diagnosis, lower PROMIS-MH scores were correlated with worse postoperative outcomes.
In high functioning patients, the ceiling effect associated with many patient-reported outcome measures (PROMs) limits the ability to appropriately stratify success. The percentage maximal possible ...improvement (%MPI) was introduced as another evaluation tool, with a proposed threshold of success at 30%. It remains unclear if this threshold correlates with perceived patient success following shoulder arthroplasty. The purpose of this study was to compare the proportion of patients that achieved the minimal clinically important difference (MCID) and %MPI for different outcome scores and to define the %MPI thresholds associated with patient satisfaction following primary reverse total shoulder arthroplasty (rTSA).
A retrospective review was performed of an international shoulder arthroplasty database between 2003 and 2020. All primary rTSAs performed using a single implant system with minimum 2-year follow-up were reviewed. Pre- and postoperative outcome scores were evaluated for all patients to determine the raw improvement and %MPI. The proportion of patients achieving the MCID and 30% MPI were determined for each outcome score. Thresholds for the minimal clinically important %MPI (MCI-%MPI) were calculated using an anchor-based method for each outcome score and stratified by age and sex.
A total of 2573 shoulders with a mean follow-up of 47 months were included. Outcome scores with known ceiling effects (Simple Shoulder Test SST, Shoulder Pain and Disability Index SPADI, University of California–Los Angeles shoulder score UCLA) had higher rates of patients achieving the 30% MPI but not the previously reported MCID. Inversely, outcome scores without significant ceiling effects (Constant and Shoulder Arthroplasty Smart SAS scores) had higher rates of patients achieving the MCID, but not the 30% MPI. The MCI-%MPI differed among outcome scores and mean values were as follows: 33% for the SST, 27% for the Constant score, 35% for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, 43% for the UCLA score, 34% for the SPADI score, and 30% for the SAS score. The MCI-%MPI increased with greater age for SPADI (P < .04) and SAS (P < .01) scores, meaning that patients with higher thresholds required a greater fraction of the possible improvement for a given score to be satisfied but did not reach statistical significance for other scores. Females had a greater MCI-%MPI for the SAS and ASES scores and a lower MCI-MPI% for the SPADI score.
The %MPI offers a simple method to quickly assess improvements across patient outcome scores. However, the %MPI that represents patient improvement after surgery is not uniformly the previously established 30% threshold. Surgeons should use score-specific estimates of the MCI-%MPI to gauge success when evaluating patients undergoing primary rTSA.
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