Background Reverse total shoulder arthroplasty (RTSA) has classically been reserved for patients older than 65 years with rotator cuff arthropathy, pseudoparalysis, and severe pain. This ...investigation assessed outcomes in a consecutive series of patients aged 65 and younger undergoing primary RTSA. Methods There were 63 patients (67 shoulders; 40 women, 27 men) with a mean age of 60 years (range, 50-65 years). Indications were cuff tear arthropathy (CTA) in 51, severe glenohumeral arthritis in 15, and osteonecrosis in 1. The primary end point was revision-free implant survival. Pain scale, motion, strength, and radiographic outcomes were also studied. Results At a mean follow-up of 3 years (range, 2-8 years), the 2-year and 5-year revision-free survival was 99% and 91%, and reoperation-free survival was 97% and 90%, respectively. Complications occurred in 9%. Smoking increased the risk for revision, reoperation, and complications ( P < .03). Patients experienced improvements in pain ( P < .0001), active abduction (57.5° vs. 132.4°, P < .0001), and active external rotation (20.1° vs. 39.4°, P < .001). At the most recent follow-up, 90% patients were satisfied with their result, and 85% felt they were better or much better than before surgery. There was an 18% incidence notching, 3% incidence of dislocation, and no loosening. Conclusions At both 2 and 5 years, RTSA is a reliable operation in patients aged younger than 65 years. Patients gain significant improvements in pain level, range of motion, and strength, without a large number of early failures. Long-term follow-up is needed to understand late component mechanical problems and loosening.
Hypothesis and background The purpose of this study was to compare the accuracy of patient-specific guides for total shoulder arthroplasty (TSA) with traditional instrumentation in arthritic cadaver ...shoulders. We hypothesized that the patient-specific guides would place components more accurately than standard instrumentation. Materials and methods Seventy cadaver shoulders with radiographically confirmed arthritis were randomized in equal groups to 5 surgeons of varying experience levels who were not involved in development of the patient-specific guidance system. Specimens were then randomized to patient-specific guides based off of computed tomography scanning, standard instrumentation, and anatomic TSA or reverse TSA. Variances in version or inclination of more than 10° and more than 4 mm in starting point were considered indications of significant component malposition. Results TSA glenoid components placed with patient-specific guides averaged 5° of deviation from the intended position in version and 3° in inclination; those with standard instrumentation averaged 8° of deviation in version and 7° in inclination. These differences were significant for version ( P = .04) and inclination ( P = .01). Multivariate analysis of variance to compare the overall accuracy for the entire cohort (TSA and reverse TSA) revealed patient-specific guides to be significantly more accurate ( P = .01) for the combined vectors of version and inclination. Patient-specific guides also had fewer instances of significant component malposition than standard instrumentation did. Conclusion Patient-specific targeting guides were more accurate than traditional instrumentation and had fewer instances of component malposition for glenoid component placement in this multi-surgeon cadaver study of arthritic shoulders. Long-term clinical studies are needed to determine if these improvements produce improved functional outcomes.
Background To examine the rates and predictors of deep periprosthetic infections after primary total shoulder arthroplasty (TSA). Methods We used prospectively collected data on all primary TSA ...patients from 1976-2008 at Mayo Clinic Medical Center. We estimated survival free of deep periprosthetic infections after primary TSA using Kaplan-Meier survival. Univariate and multivariable Cox regression was used to assess the association of patient-related factors (age, gender, body mass index), comorbidity (Deyo-Charlson index), American Society of Anesthesiologists class, implant fixation, and underlying diagnosis with risk of infection. Results A total of 2,207 patients, with a mean age of 65 years (SD, 12 years), 53% of whom were women, underwent 2,588 primary TSAs. Mean follow-up was 7 years (SD, 6 years), and the mean body mass index was 30 kg/m2 (SD, 6 kg/m2 ). The American Society of Anesthesiologists class was 1 or 2 in 61% of cases. Thirty-two confirmed deep periprosthetic infections occurred during follow-up. In earlier years, Staphylococcus predominated; in recent years, Propionibacterium acnes was almost as common. The 5-, 10-, and 20-year prosthetic infection–free rates were 99.3% (95% confidence interval CI, 98.9-99.6), 98.5% (95% CI, 97.8-99.1), and 97.2% (95% CI, 96.0-98.4), respectively. On multivariable analysis, a male patient had a significantly higher risk of deep periprosthetic infection (hazard ratio, 2.67 95% CI, 1.22-5.87; P = .01) and older age was associated with lower risk (hazard ratio, 0.97 95% CI, 0.95-1.00 per year; P = .05). Conclusions The periprosthetic infection rate was low at 20-year follow-up. Male gender and younger age were significant risk factors for deep periprosthetic infections after TSA. Future studies should investigate whether differences in bone morphology, medical comorbidity, or other factors are underlying these associations.
Background Loosening of the glenoid component is a primary reason for failure of an anatomic shoulder arthroplasty. Pegged glenoids were designed in an effort to outperform keeled components. This ...study evaluated the midterm clinical and radiographic survival of a single implant design with implantation of an in-line pegged glenoid component and identified risk factors for radiographic loosening and clinical failure. Materials and methods There were 330 total shoulder arthroplasties that had been implanted with a cemented, all-polyethylene, in-line pegged glenoid component evaluated with an average clinical follow-up of 7.2 years. Of these shoulders, 287 had presurgical, initial postsurgical, and late postsurgical radiographs (mean radiographic follow-up, 7.0 years). Results At most recent follow-up, 30 glenoid components had been revised for aseptic loosening. This translated to a rate of glenoid component survival free from revision for all 330 shoulders of 99% at 5 years and 83% at 10 years. Of 287 glenoid components, 120 were considered loose on the basis of radiographic evaluation. Four humeral components were considered loose. Component survival (Kaplan-Meier) free from radiographic failure at 5 and 10 years was 92% and 43%. Severe presurgical glenoid erosion (Walch A2, B2, C) and patient age <65 years were risk factors for radiographic failure. Late humeral head subluxation was associated with radiographic failure. Conclusion Despite the predominant thinking that pegged glenoid components may be superior to keeled designs, midterm radiographic and clinical failure rates were high with this pegged component design, particularly after 5 years. Advanced presurgical glenoid erosion and younger patient age are risk factors for radiographic loosening. Revision rates underestimate radiographic glenoid loosening.
Revision of a shoulder arthroplasty to a reverse shoulder arthroplasty in the presence of glenoid bone loss is especially challenging. The purpose of the present study was to determine the ...complications and results of glenoid bone-grafting in revision to a reverse shoulder arthroplasty.
Between 2005 and 2010, 143 consecutive reverse shoulder arthroplasties performed as revision procedures were performed at our institution. Glenoid bone-grafting was performed in forty-one shoulders (29%), with 98% (forty) that had follow-up of more than two years (mean, 3.1 years). The 102 patients who did not undergo grafting served as a control group.
Seven patients (18%) required another revision surgery because of glenoid loosening (four patients), instability (two patients), or infection (one patient). The two and five-year implant survival rate free of revision for shoulders that had glenoid bone-grafting was 88% and 76%, respectively, which was lower than that for patients who had not required glenoid bone-grafting. The survival rate free of radiographic glenoid loosening at two and five years for the shoulders that had bone-grafting was 92% and 89%, respectively, which was worse than that for those that had not had glenoid bone-grafting. Patients had significant pain relief and improvement in their shoulder range of motion, and they had an increased level of satisfaction compared with the preoperative status. Increased rates of glenoid loosening were seen in patients who had an increased body mass index, an implant with a lateral center of rotation, a previous total shoulder replacement (versus hemiarthroplasty), and in those who were smokers.
Although there were relatively high rates of glenoid loosening and reoperation at mid-term follow-up, glenoid reconstruction with bone graft in the revision setting was able to relieve pain and restore shoulder function and stability.
Background The purpose of this study was to determine the risk of periprosthetic infection after primary shoulder arthroplasty (SA) in patients undergoing previous nonarthroplasty shoulder surgery ...compared with those without previous surgery. Materials and methods All patients undergoing primary SA at our institution between 1970 and 2012 were included in this study. The cohort consisted of 4577 patients treated with 2890 total SAs, 1233 hemiarthroplasties, and 454 reverse SAs; 813 (18%) patients had undergone prior nonarthroplasty shoulder surgery on the operative side. Patients with and without previous surgery were compared for postoperative periprosthetic infection. Univariate and multivariable analyses were used. Results Deep postoperative infection of the shoulder was diagnosed in 68 patients (1.49%). Of the 813 patients who had undergone previous surgery, 20 (2.46%) developed a deep postoperative infection. However, of the 3764 patients who did not have previous shoulder surgery, 48 patients (1.28%) sustained deep shoulder infection. This difference was significant in both the univariate ( P = .0094) and multivariate analyses ( P = .0390). In addition, older age and female gender were significantly associated with a lower risk of deep postoperative infection ( P = .0150 and P = .0074, respectively). A higher number of previous surgeries was also significantly associated with an increased risk of deep postoperative infection ( P = .0272). Conclusions The risk of infection after primary SA is significantly higher in patients with a history of prior non–arthroplasty-related surgery. This finding should be discussed with the patients before their surgery, and potential preoperative and intraoperative workup should be undertaken to identify at-risk patients.
Background Severe glenoid bone loss remains a challenge in patients requiring shoulder arthroplasty and may necessitate glenoid bone grafting. The purpose of this study was to determine results, ...complications, and rates of failure of glenoid bone grafting in primary reverse shoulder arthroplasty. Methods Forty-one shoulders that underwent primary reverse arthroplasty between 2006 and 2013 with a minimum follow-up of 2 years (mean, 2.8 years; range, 2-6 years) were reviewed. Thirty-four (83%) received corticocancellous grafts and 7 (17%) structural grafts. Results Active range of motion and pain levels were significantly improved ( P < .001), with mean American Shoulder and Elbow Surgeons score of 77, Simple Shoulder Test score of 9, and patient satisfaction of 93% at the most recent follow-up. Preoperative severe glenoid erosion and increasing body mass index were significantly associated with worse American Shoulder and Elbow Surgeons scores ( P = .04). On radiographic evaluation, 7 patients (18%) had grade 1 or grade 2 glenoid lucency. Glenoid bone graft incorporation was observed in 31 patients (78%). Twelve patients (30%) suffered from grade 1 or grade 2 scapular notching. All of the patients with structural grafts showed graft incorporation and no signs of glenoid lucency. Conclusion Although glenoid lucency, glenoid graft resorption, and scapular notching were present at short-term to midterm follow-up, none of the patients needed revision surgery. Primary reverse shoulder arthroplasty with glenoid reconstruction using bone graft relieved pain and restored shoulder function and stability.
Background Little information is available on the long-term outcome of shoulder arthroplasty in young patients. The purpose of this study was to report the results, complications, and revision rate ...of total shoulder arthroplasties (TSAs) in patients younger than 50 years at a minimum 20-year follow-up. Materials and methods Between 1976 and 1985, a single surgeon performed 78 Neer hemiarthroplasties (HAs) and 36 Neer TSAs in patients < 50 years. Fifty-six HAs and 19 TSAs with a minimum 20-year follow-up, or follow-up until reoperation, were analyzed for clinical, radiographic and survivorship outcomes. Results Both HA and TSA showed significant improvements in pain scores ( P < .001), abduction ( P < .01), and external rotation ( P = .02). Eighty-one percent of shoulders were rated much better or better than preoperatively. Modified Neer ratings were similar between groups ( P = .41). Unsatisfactory ratings in HA were due to reoperations in 25 (glenoid arthrosis in 16) and limited motion, pain, or dissatisfaction in 11. Unsatisfactory ratings in TSA were due to reoperations in 6 (component loosening in 4) and limited motion in 5. Estimated 20-year survival was 75.6% (confidence interval, 65.9-86.5) for HAs and 83.2% (confidence interval, 70.5-97.8) for TSAs. Discussion At long-term follow-up, both HA and TSA continue to provide lasting pain relief and improved range of motion. However, there are a large number of unsatisfactory Neer ratings. Whereas both groups have survivorship in excess of 75% at 20 years, surgeons should remain cautious in performing shoulder arthroplasty in the young patient.
Background The purpose of this study was to examine the effect of smoking on the incidence of complications after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty ...(RSA). Methods All patients who underwent primary TSA or RSA at our institution between 2002 and 2011 and had a minimum 2-year follow-up were included. Smoking status was assessed at the time of surgery. Current smokers, former smokers, and nonsmokers were compared for periprosthetic infection, fractures (intraoperative and postoperative), and loosening after surgery. Results The cohort included 1834 shoulders in 1614 patients (814 in smokers and 1020 in nonsmokers). Complications occurred in 73 patients (75 shoulders; 44 in smokers and 31 in nonsmokers). There were 20 periprosthetic infections (16 in smokers and 4 in nonsmokers), 27 periprosthetic fractures (14 in smokers and 13 in nonsmokers), and 28 loosenings (14 in smokers and 14 in nonsmokers). Smokers had lower periprosthetic infection-free survival rates (95.3%-99.4% at 10 years; P = .001) and overall complication-free survival rates (78.4%-90.2%; P = .012) than nonsmokers. Multivariable analyses showed that both current and former smokers had significantly higher risk of periprosthetic infection in comparison with nonsmokers (hazard ratio HR, 7.27 and 4.56, respectively). In addition, current smokers showed a higher risk of postoperative fractures than both former smokers (HR, 3.63) and nonsmokers (HR, 6.99). Conclusions This study demonstrates that smoking is a significant risk factor of complications after TSA and RSA. These findings emphasize the need for preoperative collaborative interventions, including smoking cessation programs.
Introduction This study was conducted to determine the survival of different glenoid component designs, assess the reasons for revision surgery, and identify patient and diagnostic factors that ...influence this need. Methods Between January 1, 1984, and December 31, 2004, 1337 patients underwent 1542 total shoulder arthroplasties with 6 types of glenoid components: Neer II all-polyethylene, Neer II metal-backed, Cofield 1 metal-backed bone-ingrowth, Cofield 1 all-poly keeled, Cofield 2 all-poly keeled, and Cofield 2 all-poly pegged. Results Revision was required in 125 shoulders for glenoid component failure. Survival rates free of revision by glenoid implant type at 5, 10, and 15 years were, respectively, 96%, 96%, and 95% for 99 Neer II all-poly; 96%, 94%, and 89% for 316 Neer II metal-backed; 86%, 79%, and 67% for 316 Cofield 1 metal-backed; 94%, 94%, and 87% for 18 Cofield 1 all-poly; 99%, 94%, and 89% for 497 Cofield 2 all-poly keeled; and 99% at 5 years for 358 Cofield 2 all-poly pegged. Glenoid component type was significantly associated with component revision ( P < .001). Male gender was associated with a higher risk of revision ( P < .001). Compared with degenerative arthritis, posttraumatic arthritis ( P = .02) and avascular necrosis ( P = .06) were associated with increased risk of revision. Conclusions Survival is improved with cemented all-polyethylene glenoid components. Revision of cemented all-polyethylene components may be lessened with the use of pegged components in early follow-up. Male gender and the operative diagnoses of posttraumatic arthritis or avascular necrosis are associated with an increased risk of failure. Level of Evidence Level IV, Case Series, Treatment Study.