Is reverse total shoulder arthroplasty (rTSA) more advantageous than anatomic TSA (aTSA) for osteoarthritis with intact cuff tendon? A systematic review and meta-analysis

Purpose We aimed to compare the outcomes and complications of anatomical shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) for primary glenohumeral osteoarthritis with intact cuff tissue. Materials and methods The MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 2, 2021 using the PRISMA guidelines. Studies were included if they directly compared aTSA and rTSA for treating primary glenohumeral arthritis. A meta-analysis was performed using six studies that compared radiologic outcomes, functional scores, and range of motion (ROM). All the data were pooled using a random-effects model. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as dichotomous data, while continuous data were analyzed using mean differences with 95% CIs. Results Two independent researchers reviewed 1,061 studies. Six studies met the inclusion criteria. The range of motion, especially external rotation, was better for aTSA than for rTSA (MD = − 10.28, 95% CI: − 16.69 to − 3.88, P = 0.002). Functional scores showed no difference between aTSA and rTSA. Glenoid loosening (OR = 0.17, 95% CI: 0.06–0.50, P = 0.001) was more common with aTSA, and scapula notching (OR = 10.63, 95% CI: 1.73–65.27, P = 0.01) with rTSA. In the mid-term follow-up, the overall revision rate showed no difference between aTSA and rTSA, with a pooled OR of 0.33 (95% CI: 0.07–1.57, P = 0.16). Conclusion A better ROM was achieved after aTSA than after rTSA. There was no difference in the revision rate at mid-term follow-up between aTSA and rTSA. Glenoid loosening was more common with aTSA, and scapula notching with rTSA. Level of evidence: Level IV, Meta-analysis.

Minimum five-year outcomes of reverse total shoulder arthroplasty using a trabecular metal glenoid base plate

Aims Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes. Methods All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up. Results The implant was revised in ten shoulders (5.2%) with a median time to revision of 21.2 months (interquartile range (IQR) 9.9 to 41.8). The Kaplan-Meier survivorship estimate at seven years was 95.9% (95% confidence interval (CI) 91.7 to 98; 35 RTSAs at risk) for aseptic mechanical failure of the glenoid and 94.8% (95% CI 77.5 to 96.3; 35 RTSAs at risk) for all-cause revision. Minimum five-year clinical and radiological outcomes were available for 103 and 98 RTSAs respectively with a median follow-up time of six years (IQR 5.2 to 7.0). Median postoperative Oxford Shoulder Score was 38 (IQR 31 to 45); median Constant and Murley score was 60 (IQR 47.5 to 70); median forward flexion 115° (IQR 100° to 125°); median abduction 95° (IQR 80° to 120°); and external rotation 25° (IQR 15° to 40°) Scapular notching was seen in 62 RTSAs (63.2%). Conclusion We present the largest and longest-term series of TM-backed glenoid implants demonstrating 94.8% all-cause survivorship at seven years. Specifically pertaining to glenoid loosening, survival of the implant increased to 95.9%. In addition, we report satisfactory minimum five-year clinical and radiological outcomes. Cite this article: Bone Joint J 2021;103-B(8):1333–1338.

Clinical and Radiological Results of Hemiarthroplasty and Total Shoulder Arthroplasty for Primary Avascular Necrosis of the Humeral Head in Patients Less Than 60 Years Old

Background: Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) have shown good clinical outcomes in primary avascular necrosis of the humeral head (PANHH) both in short and long terms. The purpose of this study was to assess the complications, the clinical and radiological outcomes of shoulder arthroplasty in young patients with PANHH. Methods: One hundred and twenty-seven patients aged under 60 years old and suffering from PANHH were operated with arthroplasty. Patients were assessed clinically and radiographically before surgery with a minimum of 2 years of follow up (FU). Results: HA was performed on 108 patients (85%). Two patients were revised for painful glenoid wear after 2 and 4 years. TSA was performed on 19 patients (15%). Five TSA had to be revised for glenoid loosening (n = 4) or instability (n = 1). Revision rate was 26% with TSA and 2% with HA. There were no significant differences between HA and TSA in terms of clinical outcomes. Conclusions: With a mean FU of 8 years, HA and TSA improved clinical outcomes of patients with PANHH. HA revisions for painful glenoid wear were rare (2%). The revision rate was excessively high with TSA (26%).

Is preoperative glenoid bone mineral density associated with aseptic glenoid implant loosening in anatomic total shoulder arthroplasty?

Background Aseptic loosening of glenoid implants is the primary revision cause in anatomic total shoulder arthroplasty (aTSA). While supported by biomechanical studies, the impact of glenoid bone quality, more specifically bone mineral density (BMD), on aseptic glenoid loosening remains unclear. We hypothesized that lower preoperative glenoid BMD was associated with aseptic glenoid implant loosening in aTSA. Methods We retrospectively included 93 patients (69 females and 24 males; mean age, 69.2 years) who underwent preoperative non-arthrographic shoulder computed tomography (CT) scans and aTSA between 2002 and 2014. Preoperative glenoid BMD (CT numbers in Hounsfield unit) was measured in 3D using a reliable semi-automated quantitative method, in the following six contiguous volumes of interest (VOI): cortical, subchondral cortical plate (SC), subchondral trabecular, and three successive adjacent layers of trabecular bone. Univariate Cox regression was used to estimate the impact of preoperative glenoid BMD on aseptic glenoid implant loosening. We further compared 26 aseptic glenoid loosening patients with 56 matched control patients. Results Glenoid implant survival rates were 89% (95% confidence interval CI, 81–96%) and 57% (41–74%) at 5 and 10 years, respectively. Hazard ratios for the different glenoid VOIs ranged between 0.998 and 1.004 (95% CI [0.996, 1.007], p≥0.121). Only the SC VOI showed significantly lower CTn in the loosening group (622±104 HU) compared with the control group (658±88 HU) (p=0.048), though with a medium effect size (d=0.42). There were no significant differences in preoperative glenoid BMD in any other VOI between patients from the loosening and control groups. Conclusions Although the preoperative glenoid BMD was statistically significantly lower in the SC region of patients with aseptic glenoid implant loosening compared with controls, this single-VOI difference was only moderate. We are thus unable to prove that lower preoperative glenoid BMD is clearly associated with aseptic glenoid implant loosening in aTSA. However, due to its proven biomechanical role in glenoid implant survival, we recommend extending this study to larger CT datasets to further assess and better understand the impact of preoperative glenoid BMD on glenoid implant loosening/survival and aTSA outcome.

Is preoperative glenoid bone mineral density associated with aseptic glenoid implant loosening in anatomic total shoulder arthroplasty?

Background: Aseptic loosening of glenoid implants is the primary revision cause in anatomic total shoulder arthroplasty (aTSA). While supported by biomechanical studies, the impact of glenoid bone quality, more specifically bone mineral density (BMD), on aseptic glenoid loosening remains unclear. We hypothesized that lower preoperative glenoid BMD was associated with aseptic glenoid implant loosening in aTSA.Methods: We retrospectively included 93 patients (69 females and 24 males; mean age, 69.2 years) who underwent preoperative non-arthrographic shoulder computed tomography (CT) scans and aTSA between 2002 and 2014. Preoperative glenoid BMD (CT numbers in Hounsfield unit) was measured in 3D using a reliable semi-automated quantitative method, in the following six contiguous volumes of interest (VOI): cortical, subchondral cortical plate (SC), subchondral trabecular, and three successive adjacent layers of trabecular bone. Univariate Cox regression was used to estimate the impact of preoperative glenoid BMD on aseptic glenoid implant loosening. We further compared 26 aseptic glenoid loosening patients with 56 matched control patients.Results: Glenoid implant survival rates were 89% (95% confidence interval CI, 81%-96%) and 57% (41%-74%) at 5 and 10 years, respectively. Hazard ratios for the different glenoid VOIs ranged between 0.998 and 1.004 (95% CI [0.996, 1.007], p≥0.121). Only the SC VOI showed significantly lower CTn in the loosening group (622±104 HU) compared with the control group (658±88 HU) (p=0.048), though with a medium effect size (d=0.42). There were no significant differences in preoperative glenoid BMD in any other VOI between patients from the loosening and control groups.Conclusions: Although the preoperative glenoid BMD was statistically significantly lower in the SC region of patients with aseptic glenoid implant loosening compared with controls, this single-VOI difference was only moderate. We are thus unable to prove that lower preoperative glenoid BMD is clearly associated with aseptic glenoid implant loosening in aTSA. However, due to its proven biomechanical role in glenoid implant survival, we recommend extending this study to larger CT datasets to further assess and better understand the impact of preoperative glenoid BMD on glenoid implant loosening/survival and aTSA outcome.Trial registration: Retrospectively registered

Is Peoperative Glenoid Bone Mineral Density A Risk Factor for Aseptic Glenoid Implant Loosening in Anatomic Total Shoulder Arthroplasty?

Background: Aseptic loosening of glenoid implants is the primary revision cause in anatomic total shoulder arthroplasty (aTSA). While supported by biomechanical studies, the impact of glenoid bone quality, more specifically bone mineral density (BMD), on aseptic glenoid loosening remains unclear. We hypothesized that lower preoperative glenoid BMD was associated with and a risk factor for aseptic glenoid implant loosening in aTSA.Methods: We retrospectively included 93 patients (69 females and 24 males; mean age, 69.2 years) who underwent preoperative non-arthrographic shoulder computed tomography (CT) scans and aTSA between 2002 and 2014. Preoperative glenoid BMD (CT numbers in Hounsfield unit) was measured in 3D using a reliable semi-automated quantitative method, in the following six contiguous volumes of interest (VOI): cortical, subchondral cortical plate (SC), subchondral trabecular, and three successive adjacent layers of trabecular bone. Univariate Cox regression was used to estimate the impact of preoperative glenoid BMD on aseptic glenoid implant loosening. We further compared 26 aseptic glenoid loosening patients with 56 matched control patients.Results: Glenoid implant survival rates were 89% (95% confidence interval CI, 81%-96%) and 57% (41%-74%) at 5 and 10 years, respectively. Hazard ratios for the different glenoid VOIs ranged between 0.998 and 1.004 (95% CI [0.996, 1.007], p≥0.121). Only the SC VOI showed significantly lower CTn in the loosening group (622±104 HU) compared with the control group (658±88 HU) (p=0.048), though with a medium effect size (d=0.42). There were no significant differences in preoperative glenoid BMD in any other VOI between patients from the loosening and control groups.Conclusions: Although the preoperative glenoid BMD was statistically significantly lower in the SC region of patients with aseptic glenoid implant loosening compared with controls, this single-VOI difference was only moderate. We are thus unable to prove that lower preoperative glenoid BMD is clearly associated with and a risk factor for aseptic glenoid implant loosening in aTSA. However, due to its proven biomechanical role in glenoid implant survival, we recommend extending this study to larger CT datasets to further assess and better understand the real impact of preoperative glenoid BMD on glenoid implant loosening/survival and aTSA outcome overall.Trial registration: Retrospectively registered

Shoulder arthroplasty in patients with upper extremity lymphedema may result in transient or permanent lymphedema worsening

Introduction Upper extremity lymphedema can complicate mastectomy, lymph node dissection, and radiation. The purpose of this study is to present the outcomes of shoulder arthroplasty in patients with lymphedema. Methods The 19 shoulders with a shoulder arthroplasty and lymphedema on the surgical side (6 anatomic, 12 reverse, 1 hemiarthroplasty) were followed for four years (1–10 years). There were 2 males and 17 females; average age was 67.8 (48–86) years. Breast carcinoma was the most common reason for lymphedema (75%). A dedicated lymphedema questionnaire could be completed for 14 shoulders. Results Pain improved from moderate or severe preoperatively to no or mild in 18 shoulders. Motion improved in elevation (55° preoperatively, 107° at last follow-up), external rotation (14°, 43°), and internal rotation (sacrum, L5). Complications included an acromion stress fracture with a deep infection (1), deep infection (1), superficial infection (1), and glenoid loosening (1). Lymphedema worsened in nine cases, but worsening was permanent in only four. Currently, lymphedema treatment is being performed by 93% of survey respondents. No patients reported lymphangitis or lymphangiosarcoma. Conclusion Shoulder arthroplasty for an upper extremity with lymphedema provides substantial improvements in pain and motion; however, infection is a concerning complication. Fifty percent of the patients will experience worsening of their lymphedema and in 20% worsening may be permanent.

Mid-term radiological results of a cementless short humeral component in anatomical and reverse shoulder arthroplasty

Aims Shoulder arthroplasty using short humeral components is becoming increasingly popular. Some such components have been associated with relatively high rates of adverse radiological findings. The aim of this retrospective review was to evaluate the radiological humeral bone changes and mechanical failure rates with implantation of a short cementless humeral component in anatomical (TSA) and reverse shoulder arthroplasty (RSA). Patients and Methods A total of 100 shoulder arthroplasties (35 TSA and 65 RSA) were evaluated at a mean of 3.8 years (3 to 8.3). The mean age at the time of surgery was 68 years (31 to 90). The mean body mass index was 32.7 kg/m2 (17.3 to 66.4). Results Greater tuberosity stress shielding was noted in 14 shoulders (two TSA and 12 RSA) and was graded as mild in nine, moderate in two, and severe in three. Medial calcar resorption was noted in 23 shoulders (seven TSA and 16 RSA), and was graded as mild in 21 and moderate in two. No humeral components were revised for loosening or considered to be loose radiologically. Nine shoulders underwent reoperation for infection (n = 3), fracture of the humeral tray (n = 2), aseptic glenoid loosening (n = 1), and instability (n = 3). No periprosthetic fractures occurred. Conclusion Implantation of this particular short cementless humeral component at the time of TSA or RSA was associated with a low rate of adverse radiological findings on the humeral side at mid-term follow-up. Our data do not raise any concerns regarding the use of a short stem in TSA or RSA. Cite this article: Bone Joint J 2019;101-B:610–614.