CORR InsightsÂ®: Substantial Inconsistency and Variability Exists Among Minimum Clinically Important Differences for Shoulder Arthroplasty Outcomes: A Systematic Review
Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients â‰¥65 Years Old: A Critical Analysis Review
»/UNASSIGNED:The majority of proximal humeral fractures (PHFs) in patients who are â‰¥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population. »/UNASSIGNED:Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are â‰¥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence. »/UNASSIGNED:RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve. »/UNASSIGNED:RTSA for an acute PHF is indicated in patients who are â‰¥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures. »/UNASSIGNED:RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.
Analysis of patient's willingness and concerns for discharge following shoulder arthroplasty
Background/UNASSIGNED:Patient's willingness and barriers for discharge after shoulder arthroplasty (SA) has not been studied. The aim of this study was to prospectively analyze patient's willingness for discharge and barriers to discharge beyond postoperative day #1 (POD#1) after SA. Methods/UNASSIGNED:In this prospective study, patients undergoing primary or revision SA (anatomic, reverse, or hemiarthroplasty) at our institution were enrolled to determine their willingness and concerns for discharge after SA. Patient's willingness for discharge was inquired daily until discharge. Demographic information, patient's medical history, intraoperative details (duration of surgery, estimated blood loss, intraoperative complication), discharge disposition, length of stay (LOS), and reasons for extension of LOS beyond POD#1 were analyzed. Results/UNASSIGNED:A total of 184 patients who underwent SA were included. Eight patients were discharged on POD#0, 114 patients on POD#1, 37 patients on POD#2, and 25 patients after POD#2. One hundred nineteen (119) patients were discharged to home, 40 were discharged to home with services, 15 were discharged to nursing facilities, and 10 were discharged to rehabilitation centers. Reasons for extension of LOS past POD#1 included patients failing to clear home safety evaluation (nÂ =Â 4), inadequate pain control (nÂ =Â 6), worsening of preexisting medical conditions (nÂ =Â 8), delay in patient disposition (awaiting placement in a rehabilitation facility [nÂ =Â 6] and awaiting culture results [nÂ =Â 9]). Social reasons (nÂ =Â 29) were the most common reasons for extension of LOS. These included patients requesting an extra day of stay (nÂ =Â 20), patients requesting rehabilitation facility placement (nÂ =Â 5), lack of a timely ride home (nÂ =Â 2), and family-related reasons (death in the family [nÂ =Â 1], lack of home help [nÂ =Â 1]). Conclusions/UNASSIGNED:This prospective study demonstrates modifiable factors associated with LOS beyond POD#1 (inadequate pain control, logistic delays in disposition, and patient-related social concerns) after SA. With increasing interest in same-day discharge and rising concerns to control cost and use bundled payment initiatives with SA, improving patient's willingness to discharge by addressing their concerns can improve early discharge after SA.
What's Important: On Becoming the "Historical Perspective" in the Room
Characteristics of Anatomic and Reverse Total Shoulder Arthroplasty Patients Who Achieve Ceiling Scores with 3 Common Patient Reported Outcome Measures
BACKGROUND:Legacy shoulder outcome scores have postoperative ceiling scores effects when quantifying clinical outcomes for anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty patients. This study utilizes data from an international database of a single shoulder prosthesis utilizing data from 30 different clinical sites to quantify and compare the percent of aTSA and rTSA patients achieving postoperative ceiling scores with multiple outcome measures and defines the patient demographics, comorbidities, implant, and operative parameters associated with ceiling scores for each outcome measure. METHODS:Clinical outcomes for 1817 aTSA and 2635 rTSA patients between 2007 and 2019 were quantified with the ASES, SST, UCLA, Constant, and SAS scores. The number of aTSA and rTSA patients with ceiling scores were calculated and sorted into those that achieved ceiling scores with the SST, ASES, and UCLA measures and compared to patients without ceiling scores. A univariate and multivariate analysis then identified the patient demographics, comorbidities and implant and operative parameters associated with ceiling scores for each outcome measure. RESULTS:aTSA patients achieved ceiling scores at a significantly greater rate than rTSA patients for all outcome measures, except SAS. The SST score was the most susceptible to ceiling scores (aTSA=43.4%, rTSA=34.1%, p<0.0001), followed by the ASES (aTSA=23.7%, rTSA=13.3%, p<0.0001), and UCLA (aTSA=22.2%, rTSA=10.6%, p<0.0001) scores. Ceiling scores were least likely with the Constant (aTSA=0.4%, rTSA=0%, p=0.0060) and SAS (aTSA=0.1%, rTSA=0%, p=0.0750) scores. Male patients had a significantly higher ceiling score rate than female patients using the SST and ASES scores and no differences in ceiling score rates were observed with the UCLA, Constant, or SAS scores. Finally, we identified numerous patient demographic, comorbidity, implant, and operative parameters associated with SST, ASES, and UCLA ceiling scores for aTSA and rTSA patients. DISCUSSION/CONCLUSIONS:Postoperative ceiling scores occur at a high rate for aTSA and rTSA patients with the SST, ASES, and UCLA scores. Patients most susceptible to ceiling scores are aTSA patients treated with cage glenoids, aTSA patients of lower BMI, rTSA patients of male gender, rTSA patients with OA diagnosis, and rTSA patients with subscapularis repair. Clinical researchers should consider utilizing alternative scores, such as the SAS score, to ensure a more normalized distribution of data and more accurately quantify aTSA and rTSA outcomes.
Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction
Background/UNASSIGNED:History of prior rotator cuff repair (RCR) may adversely affect the outcomes of reverse total shoulder arthroplasty (RTSA), but there is no information regarding the influence of prior superior capsular reconstruction (SCR) surgery on the outcomes of RTSA. The purpose of this study is to evaluate the outcomes of RTSA following failed arthroscopic SCR. Methods/UNASSIGNED:All patients who underwent RTSA for failed SCR (SCR cohort) at our institution were identified from our institutional database. A comparative cohort of patients who had RTSA with a history of failed RCR (Control cohort) was also reviewed. Demographic information, 90-day complication rate, 90-day emergency department visits, length of stay, and outcome scores (patient-reported outcomes measurement information system [PROMIS] physical function upper extremity, Visual Analog Scale score, and range of motion) were compared. Results/UNASSIGNED:From 2015 to 2020, 87 arthroscopic SCRs were performed at our institution and of these, 13 patients underwent RTSA at a mean time of 14.6 months (5.8-32.4) after SCR and were followed up for an average of 17.9 months (1.6-44.6). The average number of shoulder surgeries prior to RTSA was 2.8 (1-7), with the last surgery being SCR. During the same period, we identified 15 patients who underwent an RTSA after a failed RCR (control cohort). The RTSA in the control cohort was performed on average at 12.8 months (1.5-39.5) following the last RCR, and patients were followed up for an average of 27.7 months (2.8-53.9). The average number of shoulder surgeries before the RTSA in the control cohort was 1.4 (1-3). Although the SCR cohort had significant improvements in pain scores and forward flexion (FF), there was only a modest functional improvement with PROMIS scores and no meaningful improvement with external rotation. Complications (23%) in the SCR cohort included 1 periprosthetic joint infection requiring 2-stage revision, 1 acromion stress fracture, and 1 ulnar neuritis. Overall, compared to the SCR cohort, patients in the control cohort had better function (PROMIS physical function upper extremity), lower Visual Analog Scale score, and greater range of motion (FF and external rotation) preoperatively and at last follow-up, but there were no differences in the length of stay and 90-day emergency department visits, infection, and complication rate between the 2 cohorts. Conclusion/UNASSIGNED:RTSA after failed SCR improves pain and FF but is associated with modest functional improvements and high complication rates. However, these findings will require confirmation in a larger cohort with longer follow-up.
Glenohumeral Arthritis in the Young Adult Current Concepts in Treatment
Glenohumeral osteoarthritis (GHOA) in the young adult remains a challenging clinical problem to treat. These difficulties stem from the high physical demands and expectations of this patient population, limited longevity of existing treatment modalities, and need for a future revision surgery after primary surgical intervention. Given the heterogeneous etiology, clinical presentation, and radiographic findings, a thorough understanding of the pathology, patient expectations, and outcomes of existing treatment options available is necessary to deliver a treatment that is tailored to individual needs of the patient. None of the available treatment options have shown to alter the natural history of GHOA. Nonsurgical modalities continue to be the first line treatment but there is no consensus if one treatment is more effective than the other. Surgical options include shoulder preserving and shoulder replacing procedures and are usually considered after the nonsurgical options become ineffective in controlling a patient's symptoms. Total shoulder arthroplasty provides predictable pain relief and improvement of function but is limited by the longevity of the implant. Despite the growing research, there continues to be search for a long lasting, durable treatment option that would compete with a young adult's lifetime.
Reverse Total Shoulder Arthroplasty Biomechanical Considerations and the Concept of Lateralization
The biomechanical concepts underlying total shoulder arthroplasty including differences between the anatomic total and reverse total shoulder arthroplasty (RTSA) are reviewed. The concept of lateralization and its implications on outcomes after RTSA is explained through a historical perspective. Finally, how lateralization can be achieved via different components of an RTSA construct, as well as the potential disadvantages or trade-offs that must be considered when lateralizing in reverse shoulder arthroplasty, are discussed.
Performance and responsiveness to change of PROMIS UE in patients undergoing total shoulder arthroplasty
The Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test (PROMIS UE CAT) is a newer patient-reported outcome measure for upper extremity physical function. To date, no longitudinal study exists assessing PROMIS UE CAT responsiveness in patients undergoing shoulder arthroplasty. The purpose of this prospective longitudinal study is to report PROMIS UE CAT responsiveness to change and correlation to legacy instruments in patients undergoing total shoulder arthroplasty (TSA). Ninety-sixÂ patients (97 shoulders) undergoing TSA completed the PROMIS UE, Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST)Â preoperatively and postoperatively at 6 weeks, 12 weeks, and after 6 months. Spearman's correlation coefficients (r) were calculated between PROMIS UE and other scores at each time-point. Responsiveness to change was assessed using the effect size (Cohen'sÂ d) and standardized response meanÂ compared with the preoperative time-point. Floor and ceiling effects were also assessed. PROMIS UE CAT demonstrated positive responsiveness at all time-points after TSA. It demonstrated excellent correlation (range: 0.68-0.84) with ASES, SST, and OSS at all postoperative time-points, but the correlation was weaker (râ€‰<â€‰0.6, except OSS) preoperatively. Only OSS and SST showed ceiling effects at the 6-12-month time-point (16.8% and 18.2%, respectively). PROMIS UE CAT responsiveness to change and strength of correlation with legacy instruments improves with time elapsed after TSA. Further quantification of meaningful responsiveness to change will require estimation of the minimal clinically important difference and substantial clinical benefit for PROMIS UE CAT.
Anatomic versus reverse shoulder arthroplasty for post-traumatic sequelae of operatively and nonoperatively treated proximal humerus fractures
Background: This study aimed to determine whether there is a long-term difference in outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) performed for proximal humerus fracture (PHF) sequelae. Hypotheses were as follows: (1) patients undergoing aTSA would have improved functional outcomes but a greater incidence of adverse events (AEs) and reoperation than those undergoing rTSA and (2) patients undergoing shoulder arthroplasty after open reduction internal fixation (ORIF) would have worse outcomes with more AEs and reoperations than those undergoing shoulder arthroplasty for sequelae of nonoperatively managed PHF. Methods: A prospectively collected database was queried for patients with PHF sequelae undergoing aTSA or rTSA between 2007 and 2020 with minimum 2-year follow-up. Baseline demographics, perioperative data, postoperative AEs, functional outcomes, and range of motion (ROM) were compared between aTSA and rTSA groups. A secondary analysis was performed to compare patients treated with prior PHF ORIF vs. those treated nonoperatively. Results: There were 17 patients in the aTSA group and 83 patients in the rTSA group. Type I PHF sequelae predominated among patients who underwent aTSA (71% vs. 40%, P = .026). Incidence of total postoperative AEs was greater after aTSA than that after rTSA (12% vs. 5%, P = .277), with a significantly higher rate of glenoid aseptic loosening after aTSA (6% vs. 0%, P = .026). All AEs required reoperation except one in the rTSA group. The mean follow-up was 66 months for aTSA compared with 45 months for rTSA (P = .002). No differences in functional outcomes or ROM between aTSA and rTSA persisted beyond 3 months or at the final follow-up except external rotation, which favored aTSA for 3 years postoperatively. In the secondary analysis, there were 33 patients in the ORIF group and 67 in the non-ORIF group. One (3%) postoperative AE occurred in the ORIF group vs. five (7%) in the non-ORIF group (P = .385). At a mean follow-up of 4 years, there were no differences in functional outcome scores or ROM between ORIF and non-ORIF groups, except for patient-reported shoulder function (6.3 vs. 7.4, respectively, P = .037). Conclusion: For treatment of PHF sequelae, aTSA may result in a higher incidence of postoperative AEs and reoperation than rTSA, particularly due to glenoid aseptic loosening. No difference in functional outcome scores between aTSA and rTSA persists beyond 3 months or at the final follow-up. Although active external rotation is significantly improved after aTSA for the first 3 years postoperatively, no differences in ROM exist beyond 4 years at the final follow-up. Patients undergoing shoulder arthroplasty for PHF sequelae have comparable outcomes regardless of prior ORIF or nonoperative management. Level of evidence: Level III; Retrospective Cohort Design; Treatment Study