Failed prior rotator cuff repair is associated with worse clinical outcomes after reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to determine the comparative risk profile and clinical outcomes for patients undergoing reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy (CTA) without failed prior rotator cuff repair (RCR) compared with RTSA for CTA with prior RCR.MethodsFrom 2006 to 2014, all patients who underwent RTSA by two surgeons after failed RCR with minimum 2-year follow-up were identified. Patients who underwent RTSA with failed prior RCR were matched in a 1:1 ratio to patients undergoing primary RTSA, while controlling for demographic factors, prosthesis design, and surgeon. Postoperative active forward elevation and active external rotation were recorded. Outcome measures included American Shoulder and Elbow Surgeons score, Visual Analog Scale (VAS), and Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were noted, and comparative multivariate analysis was performed.ResultsOf 262 patients, 192 (73.3%) were available at minimum 2-year follow-up. The prior RCR group had a significantly higher complication rate (17.4%, n = 15) than the primary RTSA group (3.8%, n = 4) (P = .001), although no significant difference in periprosthetic infection (P = .469) or secondary revision rate (P = .136) was observed. At mean 36.3 ± 26.1-month follow-up, the prior RCR group had statistically worse American Shoulder and Elbow Surgeons score (P < .001), VAS (P = .001), Simple Shoulder Test (P < .001), and active forward elevation (P = .006). Patients with multiple failed RCR attempts (n = 38) before RTSA demonstrated no significant differences versus isolated failed RCR (n = 48; P > .05).ConclusionThis study demonstrated that patients with RTSA after prior failed RCR have significantly worse patient-reported outcomes and greater rate of perioperative complications than patients undergoing primary RTSA for CTA.     

Long-term relation between deltoid muscle volume and clinical outcomes in a reverse shoulder arthroplasty

BackgroundDeltoid muscle function is important in reverse shoulder arthroplasty (RSA). Concerns are raised on the resistance of the deltoid muscle against the postoperative distalization. We hypothesize that a decreased volume of the deltoid muscle is related to worse clinical outcomes after a long-term follow-up. An observational study was conducted to evaluate the relation between volume of the deltoid muscle and clinical outcomes after a long-term follow-up on RSA.MethodsEligible for inclusion was patients who underwent RSA for cuff arthropathy after minimum 3 years follow-up. Fifty-nine patients were enrolled in this study. Preoperative volume was measured on magnetic resonance imaging or computed tomography. Postoperative deltoid volume was evaluated on ultrasonography. Distalization of the humerus was measured on radiographs. Clinical outcomes were measured by the Constant-Murley Score (CMS), Oxford Shoulder Score, and range of motion. Multivariable linear regression models were used to examine the association between the deltoid volume and clinical outcomes, and between distalization and deltoid volume or clinical outcomes.ResultsThe mean follow-up period was 88.7 ± 29.1 months. Postoperative deltoid volume positively correlated with both CMS (P = .045) and abduction strength, in both operated (P = .01) and contralateral side (P < .001). No association between deltoid volume and Oxford Shoulder Score or range of motion, and no association between preoperative volume and postoperative CMS was found. The mean distalization of the humerus was 21.2 mm [95% CI: 19.4-22.9 mm]. Distalization negatively correlated with deltoid volume (P = .012) and CMS (P = .009).ConclusionsPostoperative deltoid volume correlated with clinical outcomes as measured by CMS and abduction strength after a long-term follow-up on RSA.     

Glenoid and scapulohumeral characteristics and their influence on preoperative range of motion and patient-determined outcomes

BackgroundIt is not clear if glenoid and scapulohumeral characteristics influence preoperative range of motion (ROM) and patient-determined outcomes. It is important to understand these interactions when planning and performing total shoulder arthroplasty in efforts of improving patient satisfaction and implant longevity.MethodsA retrospective review of patients that had three-dimensional computed tomography imaging for total shoulder arthroplasty was performed. Patients were separated into 2 groups determined by the presence (rotator cuff tear arthropathy [RCTA]) or absence (osteoarthritis [OA]) of an irreparable rotator cuff tear. Using the computed tomography measurements, shoulders were stratified by glenoid version (anteverted, normal, and retroverted), glenoid inclination (inferior, normal, and superior), and scapulohumeral subluxation (anterior, centered, and posterior) based on criteria determined from a review of the orthopedic literature. The Western Ontario Osteoarthritis Scale and the American Shoulder and Elbow Surgeons scores and ROM were determined preoperatively.ResultsIn OA patients (n = 154), version was associated with scapulohumeral subluxation (P < .0001). Retroverted glenoids had less flexion (96° vs. 108°; P = .049) and external rotation (15° vs. 21°; P = .04) compared with normal version. Inferiorly inclined glenoids had greater posterior subluxation (77%) than those with normal (67%; P = .001) and superior inclination (68%; P = .01). There were no relationships between excessive inclination or subluxation on ROM. In RCTA patients (n = 115), retroverted glenoids had greater superior inclination compared with normal glenoids (12.1° vs. 8.4°; P = .049). Version was associated with scapulohumeral subluxation (anteverted = mean 34% subluxation; normal version = 56.4% subluxation; retroverted = 71.2% subluxation; P < .0001). Retroverted glenoids had less flexion compared with normal version (70° vs. 90°; P = .048), less abduction (62°) than normal glenoids (88°; P = .03) and anteverted glenoids (115°; P = .03), and less abduction/internal rotation (7°) than normal (22°; P = .03) and anteverted glenoids (36°; P = .04). Superiorly inclined glenoids have more posterior subluxation than normally inclined glenoids (64% vs. 56.6%; P = .02). There was no relationship between inclination and ROM. Patients with posterior subluxation had less external rotation compared with those with a centered humeral head (10° vs. 22°; P = .009) and less abduction/internal rotation compared with anterior subluxation (12° vs. 35°; P = .02). There was no relationship between version, inclination, or subluxation with preoperative Western Ontario Osteoarthritis Scale or American Shoulder and Elbow Surgeons in patients with OA (P > .17) or RCTA (P > .31).ConclusionsAn interaction between version, inclination, and scapulohumeral subluxation in patients with OA and RCTA was found. Retroverted glenoids had decreased ROM measurements. RCTA shoulders with posterior scapulohumeral subluxation had decreased ROM. There was no relationship between glenoid and scapulohumeral morphology and patient-determined outcome scores.Level of evidenceLevel III; Retrospective Case-Control Prognosis Study     

Arthroscopic glenoid removal for symptomatic component loosening in anatomic total shoulder arthroplasty: can it work?

BackgroundGlenoid loosening is a common cause of failure in anatomic total shoulder arthroplasty (aTSA). Arthroscopic evaluation and removal of the loose glenoid component is a treatment option, but data on this technique is limited. The purpose of this study was to evaluate the outcomes following arthroscopic glenoid removal for aTSA patients with symptomatic glenoid loosening.MethodsA retrospective case series was performed to identify aTSA patients with symptomatic glenoid component loosening, who underwent arthroscopic evaluation and glenoid removal from 2005-2019. Date of index shoulder arthroplasty, culture results, and any subsequent revision shoulder procedures were documented. All patients were contacted via telephone to obtain American Shoulder and Elbow Surgeons, Simple Assessment Numeric Evaluation, satisfaction scores (0-100), reoperation performed at an outside facility, and whether they would undergo the operation again.ResultsTwenty-three patients were identified who underwent arthroscopic glenoid removal, of which 20 (87%) were available for a follow-up. Patients had a mean age of 65.6 ± 11.9 years, body mass index of 29.4 ± 6.2 kg/m², and 12/20 were females (60%). The average time from index aTSA to arthroscopic glenoid removal was 7.0 ± 3.6 years (range, 1.9-11.9 years). All patients had loose glenoids at the time of arthroscopic evaluation and 5 patients (25%) had concurrent rotator cuff tears. All patients had cultures obtained at the time of arthroscopy and none were positive. Five patients (25%) underwent revision to reverse total shoulder arthroplasty at a mean 7.4 ± 4.2 months, for a survival of 75% at final follow-up. Comparing patients who underwent revision to those who did not, there was no difference in age (61.0 ± 9.2 vs. 67.1 ± 12.6 years, P = .34), body mass index (29.8 ± 9.5 vs. 29.2 ± 5.1 kg/m², P = .86), sex (100% vs. 47% female, P = .06), time from index aTSA to glenoid removal (63.0 ± 38.4 vs. 91.4 ± 43.9 months, P = .34), or presence of rotator cuff tear (20% vs. 27%, P = 1.0). Of the 15 patients (75%) who did not undergo reoperation, the average American Shoulder and Elbow Surgeons, Simple Assessment Numeric Evaluation, and Satisfaction scores were 54.3 ± 29.2, 53.5 ± 27.6, and 65.9 ± 37.9 respectively, at an average follow-up of 36.0 ± 19.5 months (range, 12-67 months). No patient (0%) who underwent reoperation would undergo the arthroscopic glenoid removal again, whereas 12 patients (60%) who did not undergo reoperation would choose to have an arthroscopic glenoid removal again.ConclusionsGlenoid loosening is an unfortunate complication of aTSA. Survival was 75% for patients who underwent arthroscopic glenoid removal with modest patient reported outcomes. In appropriately selected patients, arthroscopic glenoid removal is a reasonable treatment option to consider for symptomatic glenoid component loosening.     

Stemless and stemmed total shoulder arthroplasty: a comparison of short-term clinical and radiographic outcomes

BackgroundStemless total shoulder arthroplasty could provide benefits over stemmed arthroplasty which has represented the gold standard for decades. Proposed benefits of stemless arthroplasty include better reproduction of anatomy and reduction in stress shielding; however, this does not appear to be confirmed by any study. The hypothesis was there would be no clinical differences between the stemless and the short-stem prosthesis, but the stemless prosthesis would better reproduce coronal radiographic anatomy and have less radiographic evidence of stress shielding.Materials and MethodsA prospectively collected data of patients undergoing primary, anatomic total shoulder arthroplasty for osteoarthritis were retrospectively reviewed. Patient-determined outcomes including the Western Ontario Osteoarthritis Index, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Shoulder Activity Level were recorded preoperatively, at 1 year, and at 2 years. Preoperative and 1-year postoperative range of motion was recorded. Radiographic parameters to assess restoration of proximal humeral anatomy included humeral head height, humeral neck angle, humeral centering on the glenoid, and postoperative restoration of the anatomic center of rotation. Final postoperative radiographs were assessed for evidence of stress shielding.ResultsForty-eight patients had a stemmed humeral prosthesis, and 109 patients had a stemless prosthesis. Patient-determined outcomes were available from 2 years postoperatively in 99.4%. Both groups had significant improvements in all patient-reported outcomes and range-of-motion metrics, but there were no differences between the stemless and stemmed groups in these outcomes. The prosthetic humeral head of the stemmed components was more likely to extend further superior to the humeral osseous margin than that of the stemless group (2.0 ± 2.4 vs. 0.8 ± 1.4 mm; P = .0004). The stemless group had a smaller postoperative deviation from the anatomic center of rotation than the stemmed group (2.5 ± 1.9 vs. 3.2 ± 2.1 mm; P = .04). The humeral neck angle was comparable between the stemmed group and the stemless group (133 ± 7° vs. 131 ± 8°; P = .06). There was similar mean deviation of humeral head centering on the glenoid prosthesis between the stemmed and stemless groups (1.9 ± 1.8 vs. 1.6 ± 1.7 mm; P = .20). There was evidence of stress shielding in 10 patients (21%) with a stemmed prosthesis and in no patients with a stemless prosthesis at 1-year follow-up (P < .0001).ConclusionsThere were no differences in patient-determined outcomes between the groups at 2-year follow-up. Restoration of proximal humeral anatomy was either better or equivalent with the stemless prosthesis compared to the stemmed one. Radiographic evidence of stress shielding was found in the stemmed prosthesis but not in the stemless prosthesis at 1-year follow-up.     

Staged BiCompartmental Knee Arthroplasty has Greater Functional Improvement,but Equivalent Midterm Survivorship,as Revision TKA for Progressive Osteoarthritis After Partial Knee Arthroplasty

BackgroundProgressive arthritis in the unresurfaced compartments of the knee is one failure mode after partial knee arthroplasty (PKA). While progressive arthritis after PKA is typically treated with revision to TKA (rTKA), staged bicompartmental knee arthroplasty (sBiKA) –the addition of another PKA - is an alternative. This study compared outcomes of sBiKA and rTKA for progressive arthritis after PKA.MethodsA retrospective comparative study of non-consecutive cases at four institutions were performed in patients with an intact PKA, without loosening or wear, who underwent sBiKA (n = 27) or rTKA (n = 30), for progressive osteoarthritis. Outcomes studied were new Knee Society Function and Objective Scores (KSSF, KSSO), KOOS, Jr., ROM, operative times, length of stay, complication rates and the need for reoperations.ResultsMean time to conversion was 7.4 ± 6 years for sBiKA and 9.7 ± 8 for rTKA, P = .178. Patient demographics and pre-operative outcomes were similar among cohorts. At an average of 5.7 ± 3 (sBiKA) and 3.2 ± 2 years (rTKA), KOOS, Jr. significantly improved, P < .001, by an equivalent amount. Post-operative KSSO and KSSF were significantly higher in the sBiKA cohort, respectively, (90.4 ± 10 vs 72.1 ± 20, P < .001) and (80.3 ± 18 vs 67.1 ± 19, P = .011). sBiKA patients had significantly greater improvement in KSSO (30.7 ± 33 vs 5.2 ± 18, P = .003). One sBiKA patient underwent reoperation for continued pain.ConclusionSBiKA has equivalent survivorship, but greater improvement in functional outcomes as rTKA at short to midterm follow-up. Given the shorter operative times and length of stay, sBiKA is a safe and cost-effective alternative to rTKA for progressive osteoarthritis following PKA. Nevertheless, further follow-up is necessary to determine whether sBiKA is a durable option.     

Mixed-reality holographic-assisted placement of glenoid guidewire in shoulder arthroplasty: preliminary comparison to patient-specific instrumentation in B2 glenoid model

BackgroundThree-dimensionally (3D) printed patient-specific instrumentation (PSI) guides and computer navigation are 2 forms of commercially available options for improved accuracy of glenoid guide pin placement during shoulder arthroplasty. Mixed reality (MR) and virtual reality devices have been used in medical education thus far, but there has been limited assessment of their intraoperative viability in specific settings such as shoulder arthroplasty. The purpose of this study was to compare the accuracy of MR holographic model–assisted glenoid guidewire placement to freehand (FH) and PSI options.MethodsSixty 3D printed glenoid polyurethane sawbones models with a B2 glenoid defect were created. The 3D model of the B2 glenoid with a guide pin in place was programmed into a Unity-based application installed on the Microsoft HoloLens2 MR device. In randomized fashion, 5 surgeons placed a guide pin into the “sawbones” models using FH, PSI, or MR with the attempt to replicate the desired preoperative plan. Using fine-cut computed tomography, average version, average inclination, and starting point were analyzed among all models and surgeons.ResultsThe average starting point from the plan for the FH group was 2.21 ± 0.95 mm, 2.27 ± 0.80 mm for the PSI group, and 1.745 ± 0.84 mm for the MR group, P = .12. The average inclination was 10.56 ± 7.37 degrees, 3.02 ± 3.36 degrees, and 8.16 ± 5.69 degrees for the FH, PSI, and MRI groups, respectively, P = .0004. The average version was 13.52 ± 9.21 degrees, 7.26 ± 4.64 degrees, and 12.36 ± 9.19 degrees for the FH, PSI, and MRI groups, respectively, P = .04. Subgroup analysis of FH to PSI and PSI to MR demonstrated significantly less inclination from plan in the PSI group, P = .0003 and P = .02, respectively. There were no differences in version in the subgroup analysis between the FH and MR and PSI and MR groups. Degrees of deviation of inclination from plan were significantly less when comparing all models among more experienced surgeons, P = .026, whereas no statistical differences in deviation of start point or version were noted across all models in the more experienced group. When further analyzing the inclination among the FH, PSI, and MR groups among higher level surgeons, the PSI model demonstrated less deviation from plan compared to the FH model, P = .02, but there were no differences in inclination when comparing the PSI to MR and MR to FH models.ConclusionMR permits accurate glenoid guide pin placement comparable to FH placement in a polyurethane B2 glenoid bone substitute model.     

Operative choice for displaced proximal humeral fractures in adolescents with open visible physis: A comparative study of external fixator vs. Kirschner wire

BackgroundFor adolescents with severely displaced proximal humeral fracture (PHF), surgery is a good choice yielding excellent outcomes, and Kirchner wire (KW) is a cost-effective choice for fixation. Purpose of this study is to compare the clinical outcomes of external fixator (EF) and KW for the treatment of PHF in adolescents.MethodsPatients of PHF operated at our institute, from January 2008 to January 2016, were reviewed retrospectively. Demographic data, including sex, age at the time of surgery, operated side, and hardware choice, were collected from the hospital database. Preoperative radiographs were reviewed and classified according to Neer-Horwitz classification. Shoulder function was evaluated at the last follow-up using the American Shoulder and Elbow Surgeons (ASES) score. Complications, including infection, malunion, nonunion, stiffness of the shoulder joint, and failure of fixation were also recorded.ResultsThirty-five patients, including 23 males and 12 females, were included in the EF group, whereas 40 patients, including 25 males and 15 females, were included in the KW group (P = 0.867). The average age of patients in the EF group was 13.3 ± 1.7 years, and that of KW was 13.6 ± 1.8 years (P = 0.409). Patients in both groups were followed-up for at least 12 months. The operative time in the EF group (42.4 ± 11.2 min) was significantly shorter than those in the KW group (54 ± 13.6 min) (P < 0.001). The frequency of fluoroscopy in the EF group (12 ± 2.4 times) was significantly less than those in the KW group (17 ± 2.8 times (P < 0.001). The rate of open reduction was significantly higher in KW (35%) group than those in the EF group (0%) (P < 0.001). There was no case of nonunion and malunion in both groups.ConclusionExternal fixator is superior to Kirschner wire in the treatment of proximal humeral fractures in adolescents with shorter operative time and lower rate of open reduction with comparable clinical outcomes.     

Prevalence and predictors of persistent pain 2 years after total shoulder arthroplasty

BackgroundElective total shoulder arthroplasty is highly successful, but there is a subset of patients who continue to experience pain after this procedure. The purposes of this study were to elucidate the prevalence and patient characteristics predictive of persistent pain after shoulder arthroplasty.MethodsWe identified patients who had received an elective primary shoulder arthroplasty (anatomic or reverse) between 2016 and 2017 from our prospectively maintained, single-surgeon registry. Patients were stratified by the presence or absence of persistent pain at 2 years postoperatively, as defined by a Visual Analog Pain score of ≥2. This value was chosen in accordance with previously reported values for minimal clinically important differences. Multivariable logistic regression was used to identify factors associated with persistent pain.ResultsOf the 244 patients included for analysis, 46(18.9%) had persistent pain at 2 years postoperatively. The average pain score in this group was found to be significantly greater than the patients without pain (3.6 ± 1.6 vs 0.14 ± 0.35, P< .001). Patients with persistent pain had a higher incidence of preoperative opioid use (26.1% vs 13.6%, P= .038), diabetes (28.3% vs 11.6%, P= .004), number of self-reported allergies (3 ± 4.8 vs 1.9 ± 2.3,P= .03), peak postoperative inpatient pain (8.1 ± 1.9 vs 6.9 ± 2.1,P< .001), incidence of prior ipsilateral shoulder surgery (50% vs 30%, P= .011), and a higher percentage received a reverse shoulder arthroplasty (87% vs 70.7%, P= .024). The patient characteristics that were independently predictive of persistent pain were history of prior ipsilateral shoulder surgery (odds ratio 2.44; 95% confidence interval 1.21-4.91; P = .013) and greater postoperative inpatient pain intensity (odds ratio, 1.26 per 1 unit increase; 95% confidence interval 1.03-1.55; P = .024).ConclusionAbout 1 in 5 patients report persistent pain after elective primary shoulder arthroplasty. Prompt identification of at-risk patients (eg, those with severe postoperative inpatient pain and a history of prior shoulder surgery) may prove effective in optimizing the pain experience after shoulder arthroplasty.Level of evidenceLevel III; Cohort Study with Prospective Data and Retrospective Study Design.     

Portable Accelerometer-Based Navigation System for Cup Placement of Total Hip Arthroplasty: A Prospective,Randomized, Controlled Study

BackgroundMalposition of the acetabular component during total hip arthroplasty (THA) is associated with increased risk of dislocation, reduced range of motion, and accelerated wear. The purpose of this study is to compare cup positioning with a portable, accelerometer-based hip navigation system and conventional surgical technique.MethodsIn a prospective, randomized, clinical study, cups were implanted with a portable, accelerometer-based hip navigation system (navigation group; n = 55) or conventional technique (conventional group; n = 55). THA was conducted in the lateral position and through posterior approach. The cup position was determined postoperatively on pelvic radiograph and computed tomography scans.ResultsAn average cup abduction of 39.2° ± 4.6° (range, 27° to 50°) and an average cup anteversion of 14.6° ± 6.1° (range, 1° to 27.5°) were found in the navigation group, and an average cup abduction of 42.9° ± 8.0° (range, 23° to 73°) and an average cup anteversion of 11.6° ± 7.7° (range, −12.1° to 25°) in the conventional group. A smaller variation in the navigation group was indicated for cup abduction (P = .001). The deviations from the target cup position were significantly lower in the navigation group (P = .001, .016). While only 37 of 55 cups in the conventional group were inside the Lewinnek safe zone, 51 of 55 cups in the navigation group were placed inside this safe zone (P = .006). The navigation procedure took a mean of 10 minutes longer than the conventional technique.ConclusionUse of the portable, accelerometer-based hip navigation system can improve cup positioning in THA.     

Can the reverse total shoulder arthroplasty provide as good of an outcome as an anatomic shoulder arthroplasty

BackgroundReverse total shoulder arthroplasty (RTSA) is an excellent treatment option for a variety of shoulder pathologies. Anatomic total shoulder arthroplasty (TSA) remains an excellent treatment for patients with glenohumeral arthritis and a functioning rotator cuff. RTSA has become a much more common procedure than TSA in recent times. It is currently unclear if patients who have a good outcome following TSA outperform patients who have a good outcome following RTSA. The purpose of this study was to compare the 2-year outcomes of patients with good outcomes, defined as having forward flexion of >130° and American Shoulder and Elbow Surgeons score of >70, following TSA and RTSA.MethodsAll patients who underwent TSA or RTSA between 2015 and 2019 with minimum 2-year follow-up were eligible for inclusion. Patients were included if their postoperative forward flexion was >130° and American Shoulder and Elbow Surgeons score was >70. Patients were excluded if they were a revision surgery, were treated with an arthroplasty for fracture, or had a latissimus transfer. Demographic variables were analyzed between groups. Range of motion (ROM), strength, and patient-reported outcome (PRO) scores were compared between groups.ResultsOverall, 318 TSAs were included; 155 (49%) met the criteria for a “good” outcome. Among RTSAs, 428 were included; 154 (36%) met the criteria for a “good” outcome. When comparing PROs between groups, RTSA patients had worse preoperative and postoperative PRO scores (all P < .05). When comparing preoperative physical examination findings, RTSA patients had worse ROM and strength (all P < .05) and worse Constant Power scores and Constant scores (P < .001 in both cases). Postoperatively, RTSA patients had worse ROM and strength (all P < .05) and worse Constant scores (P = .028). The magnitude of change (delta) from preoperative to postoperative function was often greater following RTSA than TSA. There were no significant differences in whether expectations were met or exceeded between RTSA and TSA patients in regards to pain control (99% vs. 98%; P = .177), motion and strength (93% vs. 96%; P = .559), ability to return to activities of daily living (98% vs. 99%; P = .333), or return to sporting activities (95% vs. 91%; P = .268).ConclusionPatients do well following both TSA and RTSA. In patients who have a good outcome following either TSA or RTSA, those patients who underwent TSA have superior outcomes to patients following RTSA. However, the change in outcome scores from pre- to post-surgery is often more significant with RTSA, as they often start out with worse motion and clinical scores.     

Overcoming Mismatch Concerns for Adult Recipients of Small Pediatric Deceased Donor Kidneys

BackgroundKidneys from very young pediatric donors continue to be underutilized. To reduce discard, the Organ Procurement and Transplantation Network (OPTN) policy was recently updated to allow kidneys from donors weighing <18 kg to be recovered en bloc.MethodsWe reviewed our center's experience with kidney transplantation in adult recipients of <18 kg pediatric donor kidneys to assess renal function outcomes specific to solitary vs en bloc usage.ResultsThe majority of <18 kg donors were used en bloc (n = 39, 72.2% vs n = 15, 27.8%). Donor weight (kg) was similar between the 2 groups (12.3 ± 3.2 vs 14.1 ± 2.5, P = .05). Recipient weight was lower in the solitary kidney group (P = .01). Both groups had a similar donor-to-recipient body weight ratio (0.24 ± 0.3 vs 0.18 ± 0.3, P = .51). The solitary kidney group had a lower estimated glomerular filtration rate at 1 (56.9 ± 24.3 vs 81.8 ± 24.8, P = .01) and 2 years (72 ± 18.6 vs 93.7 ± 21.6, P = .03). By 2 years, both groups had an average estimated glomerular filtration rate >60 mL/min. Kidney allograft growth occurred in both groups, with the largest increase occurring the first month posttransplant (11.9%, 18.6%, P < .0001).ConclusionFor pediatric donors weighing <18 kg, improvements in renal function continue beyond the first posttransplant year. Risk for hyperfiltration injury appears low and renal mass-recipient mass matching is useful in guiding decision-making for solitary vs en bloc utilization.     

Long-term results of shoulder resurfacing hemiarthroplasty: Poor functional outcomes in rotator cuff deficient patients

Background: Shoulder resurfacing hemiarthroplasty is a bone-conserving procedure used in the treatment of multiple painful shoulder conditions. Previous studies have reported mixed results with some indicating that rotator cuff arthropathy leads to inferior clinical outcomes when compared to other preoperative diagnoses. We compared the medium- to long-term subjective and functional outcomes of resurfacing hemiarthroplasty performed for rotator cuff arthropathy versus other indications.Methods: Patients who underwent shoulder resurfacing hemiarthroplasty, with minimum two-year follow-up, were included for review. The primary outcome measure was the final postoperative American Shoulder and Elbow Surgeons score, while secondary measures included final postoperative active forward elevation, revision arthroplasty, as well as the change in pre- and postoperative outcome scores and forward elevation.Results: Eighty-four shoulders in 77 patients were reviewed, including 39 shoulders with preoperative rotator cuff arthropathy. Mean follow-up time was 76.82 months (range 24 to 147 months). Improvements in subjective outcome scores and visual analog pain scores were observed with all preoperative diagnoses following surgery. There was no significant difference in final postoperative subjective scores when comparing patients with rotator cuff arthropathy and those with an intact rotator cuff (66.0 ± 22.8 vs. 74.2 ± 20.3, p = 0.09). Final postoperative active forward elevation was significantly worse in the rotator cuff arthropathy group compared to other diagnoses (119.1˚± 41.8˚ vs 136.9˚ ± 34.6˚, p = 0.040). Patients with rotator cuff arthropathy lost an average of 26.9˚ of forward elevation while those with an intact rotator cuff gained an average of 8.7˚ postoperatively (p = 0.001). Six shoulders from the rotator cuff arthropathy group were revised to reverse total shoulder arthroplasty compared to two from all other groups (15.4% vs 4.4%, p = 0.183).Conclusion: Shoulder resurfacing hemiarthroplasty is effective in relieving pain and improving subjective outcome scores across all diagnoses but does not reliably restore or maintain function in rotator cuff deficient patients. In fact, patients with rotator cuff arthropathy lost a significant amount of range of motion after resurfacing hemiarthroplasty. While patients predictably improve in terms of pain scores and subjective outcome scores, caution should be exercised in performing this procedure in patients with rotator cuff arthropathy, even those with preserved preoperative overhead active range of motion, due to potential loss of active range of motion after surgery.Level of evidence: Level III; Retrospective Comparative Study     

Outcomes for reverse total shoulder arthroplasty after failed open reduction internal fixation versus primary reverse total shoulder arthroplasty for proximal humerus fractures

BackgroundThe purpose of this study is to determine the clinical and radiographic outcomes of reverse total shoulder arthroplasty (RTSA) after failed open reduction internal fixation (ORIF) for proximal humerus fracture (PHF) and compare them to outcomes of primary RTSA for PHF.MethodsWe performed a retrospective comparative study of patients who underwent RTSA between 2008 and 2015 at our institution by one of two fellowship-trained shoulder and elbow surgeons for an acute PHF or for continued pain or functional limitations following ORIF of a PHF. We compared the American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, range-of-motion, and radiographic measurements between cohorts.ResultsIn total, there were 20 patients treated with RTSA after failed ORIF and 30 patients treated acutely with RTSA for PHF. The average ASES score was significantly greater for primary RTSA (82.0 ± 13.5) than for delayed RTSA (64.0 ± 27.2, P = 0.016). The average SST score for primary RTSA (69.4%±19.1%) was significantly higher than the average for delayed RTSA (49.1%±8.9%, P = 0.020). Forward elevation achieved postoperatively was significantly greater for patients treated with primary RTSA versus those with delayed RTSA (130±31° vs 107±31°, P = 0.035). No difference was detected between groups in postoperative external rotation (P = 0.152) or internal rotation (P = 0.872). Radiographically, the tuberosities healed in an anatomic position in 70% of the primary cases versus the prior ORIF group in which the tuberosities were in an anatomic position in all cases (P = 0.007).ConclusionsIn an elderly population, primary RTSA for PHF resulted in better clinical outcomes compared to RTSA following failed ORIF in this retrospective cohort study.Level of EvidenceLevel III; Retrospective Comparative Study     

Recurrent anterior shoulder instability in patients 40–60 years old. Accompanying injuries and patient outcomes of arthroscopic repair

BackgroundAccompanying injuries are frequently seen in middle aged patients with recurrent instability. The aim of this study was to elucidate the associated injuries, report patient outcomes of the following arthroscopic instability surgery regarding 40–60 years old patients with recurrent shoulder instability.MethodsPatients that underwent arthroscopic instability surgery due to recurrent shoulder instability between February 2008 and November 2015, and which were 40–60 years old were included and evaluated retrospectively. Minimum follow-up duration was 24 months. Anterior-inferior labral injuries and accompanying pathologies such as rotator cuff tears and SLAP lesions were documented. Postoperative patient-reported outcome evaluation was made using Oxford Shoulder Instability Score.ResultsAmong 355 patients that underwent arthroscopic instability surgery, 88 patients which had pathology of recurrent instability were in the range of 40–60 years old. Patients who had previous shoulder surgery or fracture (n = 8) epileptic seizure history (n = 3), neurologic deficit (n = 2) were excluded from the study. 75 patients were included with a mean follow-up 69 ± 23 months (32–125). The percentage of middle-aged and elderly (40–60 years old) was 24.8% among recurrent shoulder instability patients. 44% had isolated Bankart lesion whereas 56% revealed multiple pathologies. Bankart + SLAP lesions were found in 32%, whereas Bankart + Rotator Cuff tears in 26.7% (13 isolated supraspinatus, 4 supraspinatus + subscapularis, 1 isolated subscapularis full-thickness and 2 partial-thickness supraspinatus tears). The mean Oxford Shoulder Instability Score was 38.4 ± 5.2 (26–48). The scores of patients which were treated with labrum and rotator cuff repair (median 42, range 30–48) were significantly better than the patients who were treated with isolated labrum repair (median 39, range 20–46) (p = 0.015). There was no difference regarding patients with or without SLAP repair (median 39 vs 39 and range 30–48 vs 20–48, respectively) (p = 0.702).ConclusionsArthroscopic repair of capsulolabral lesions is a safe and successful technique in 40–60 years old patients. Furthermore, the presence of repaired rotator cuff tears led to even superior results. Accompanying SLAP lesions did not affect the results.Study designRetrospective Case Series.Level of evidence4, Retrospective Case Series.     

Displaced proximal humerus fractures in older patients: reverse total shoulder arthroplasty or nonoperative treatment?

BackgroundReverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs) in older patients has been shown to be an effective treatment modality. Recent studies have questioned the superiority of RTSA over nonoperative treatment. The purpose of this study was to compare outcomes after RTSA and nonoperative treatment of PHF.MethodsA retrospective case-matched review of 72 displaced PHFs who underwent either RTSA or nonoperative treatment between August 2016 and August 2019 was conducted. Nine RTSA and 6 nonoperative patients were excluded. Thirty-seven RTSAs in 36 patients (1 bilateral) were compared to twenty patients who met operative criteria for RTSA but did not elect to undergo surgery.ResultsMean VAS pain scores decreased significantly in both groups at the final follow-up. Although there was no statistically significant difference in VAS scores at the time of most-recent follow-up between the two cohorts (1.5 RTSA vs. 1.9 nonop, P = .49), patients who underwent RTSA had a more rapid improvement in pain than nonoperative patients. RTSA patients had significantly lower VAS scores at 2 weeks (2.7 ± 3.1 vs. 5.6 ± 3.2, P = .03), 6 weeks (1.7 ± 2.8 vs. 4.1 ± 3.4, P = .02), and 3 months (1.6 ± 2.8 vs. 3.7 ± 3.2, P = .04) postoperatively. RTSA patients also had better forward flexion (125.4 ± 26.4° vs. 92.1 ± 35.1°, P = 0.001) and abduction (87.1 ± 11.6° vs. 75 ± 13.4°, P = .002) than nonoperative patients at the final follow-up (minimum 6 months). There was a statistically significant difference in mean American Shoulder and Elbow Surgeons scores after RTSA compared with nonoperative patients at the time of final follow-up for acute RTSA and for 3- and 4-part fracture subgroups. Eight patients (21.6%) experienced a complication after RTSA, of which 3 required revision surgery.Discussion/ConclusionOlder patients with displaced PHF have significant improvement in pain and function after both RTSA and nonoperative treatment although RTSA does come with a greater risk of complications. Patients who undergo RTSA have a greater increase in overhead motion and abduction and experience a more rapid improvement in pain, with significantly lower pain scores in the early postoperative period.     

Open preperitoneal ventral hernia repair: Prospective observational study of quality improvement outcomes over 18 years and 1,842 patients

BackgroundThis study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications.MethodsProspective, tertiary hernia center data (2004–2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. “Early” (2004–2012) and “Recent” (2013–2021) groups were based on surgery date.ResultsComparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m²; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm²; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9–4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1–3.7], P = .02 vs 1.8 [1.1–3.1], P = .02), anterior component separation technique (1.8 [1.1–2.9], P = .02 vs 3.2[1.9–5.3], P < .01), and operative time (per minute: 1.01 [1.008–1.015], P < .01 vs 1.004 [1.001–1.007], P < .01). Diabetes (2.6 [1.7–4.0], P < .01) and tobacco (1.8 [1.1–2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1–20.1], P < .01 vs 3.4 [1.3–8.2]. P < .01) and recurrent hernias (4.9 [2.3–11.5], P < .01 vs 2.1 [1.1–4.2], P = .036).ConclusionDespite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center’s outcomes has significantly improved patient care results.     

The incidence of humeral bone resorption in uncemented reverse shoulder arthroplasty and the impact on functional outcomes

BackgroundFull-thickness bone resorption around the humeral stem in shoulder arthroplasty is an increasingly recognized phenomenon, but the impact on outcomes remains unclear. This study aims to investigate prevalence of bone resorption in patients with the Zimmer-Biomet Comprehensive reverse shoulder arthroplasty and the impact on the functional outcomes.MethodsA retrospective analysis was carried out on 65 consecutive patients with primary reverse total shoulder arthroplasty using the Comprehensive Shoulder System from 2014 to 2020, with a minimum of 12-month follow-up. The prevalence of humeral bone resorption was graded from 0 to 4, and risk factors for these changes and their impact on functional outcomes were further investigated.ResultsThe majority of patients (75%) were female with an average age of 75 years (53-93), with an overall average follow-up of 26 months (12-60). Bone resorption occurred in 53 patients (82%), and full-thickness bone resorption occurred in only 8 patients (12%). Metaphyseal bone (zones 1 and 7) is mostly at the risk of high-grade resorption. There was no difference in the final Oxford Shoulder Score between patients who had differential resorption grades from 0 to 4 (P = .5742). None of the risk factors from the previous literature including age, sex, indication for surgery, rotator cuff tear and repair, and intramedullary occupation ratio of the implant showed any impact on the rate of resorption.ConclusionFull-thickness humeral bone resorption occurred in approximately 12% of patients when using the Comprehensive reverse shoulder arthroplasty, but it has no impact on the functional outcomes or revision rate in the short-to-medium term.     

Primary reverse shoulder arthroplasty did not result in increased blood metal ion levels regardless of glenosphere size: A randomized controlled trial

BackgroundThe utilization of reverse shoulder arthroplasty (RSA) has increased over time. Toxic increases of metal ion levels have been reported selectively after hip arthroplasty. However, studies evaluating the effect of RSA on in vivo metal ion levels have not been evaluated. Therefore, the purposes of this study were (1) to determine in vivo levels of cobalt, chromium, and nickel in a randomized controlled trial of patients undergoing reverse total shoulder arthroplasty (RSA) with one of four glenosphere sizes, and (2) to identify possible factors affecting changes in metal ion levels.MethodsBetween May 2016 and September 2018, 72 shoulders with cuff tear arthropathy, massive irreparable cuff tears, or glenohumeral osteoarthritis with posterior subluxation were randomized to undergo RSA using a single implant system and four possible glenosphere options based on size (36 or 40 mm) and offset (+2 mm, +6 mm). In vivo metal ion levels (cobalt, chromium, nickel) and complete blood count (CBC) were assessed preoperatively, 3-months, and 1-year after surgery. Clinical evaluation included pain, motion, Subjective Shoulder Value, ASES scores, and Oxford Shoulder Scores.ResultsReverse shoulder arthroplasty led to statistically significant improvements in all outcome measures considered (p < 0.001). Changes in nickel, cobalt or chromium blood levels did not reach statistical significance at 3 months (p = 0.87, 0.86, 0.85, respectively) or 1 year (p = 0.88, 0.38, 0.98, respectively). There was no difference in any of these metal ion levels when assessed by (1) glenosphere size, or (2) offset at 3 months or 1 year. This was also true when each of the four groups were assessed individually at 3 months and 1 year.ConclusionIn this randomized controlled trial of patients undergoing reverse total shoulder arthroplasty with a single design, in vivo levels of cobalt, chromium, and nickel remained reassuringly low. In addition, increase in glenosphere size, offset, or both, did not appear to affect in vivo metal ion levels over the short-term. Longer term studies are needed to further assess the effects of implant modularity on metal ion levels and their potential adverse effects in patients undergoing reverse shoulder arthroplasty.Level of evidenceLevel I; Randomized Controlled Trial