Reverse Total Shoulder Arthroplasty

Reverse total shoulder arthroplasty was initially approved for use in rotator cuff arthropathy and well as chronic pseudoparalysis without arthritis in patients who were not appropriate for tendon transfer reconstructions. Traditional surgical options for these patients were limited and functional results were sub-optimal and at times catastrophic. The use of reverse shoulder arthroplasty has been found to effectively restore these patients function and relieve symptoms associated with their disease. The procedure can be done through two approaches, the deltopectoral or the superolateral. Complication rates associated with the use of the prosthesis have ranged from 8-60% with more recent reports trending lower as experienced is gained. Salvage options for a failed reverse shoulder prosthesis are limited and often have significant associated disability. Indications for the use of this prosthesis continue to be evaluated including its use for revision arthroplasty, proximal humeral fracture and tumor. Careful patient selection is essential because of the significant risks associated with the procedure.Download video file.^{(61M, mov)}     

Patient Reported Outcomes After Conversion vs. Primary Total Hip Arthroplasty: A Propensity Matched Analysis

BackgroundConversion total hip arthroplasty (cTHA) is increasingly utilized as a salvage procedure for complications associated with fracture fixation around the hip and acetabulum and for failed hip preservation surgery. While primary THA (pTHA) has a high success rate, little is known about outcomes following conversion THA. The purpose of this study is to evaluate patient reported outcomes (PROs) and complication rates following conversion THA compared to primary THA.MethodsPatients that underwent cTHA or pTHA from 2015-2020 at a large tertiary referral academic center were retrospectively identified. THA patients were propensity matched in a 1:1 fashion by age, body mass index (BMI), and sex. Pain scores and PROMIS physical function (PF), pain interference (PI), and depression (DA) scores were compared at preoperative and final postoperative follow up timepoints using independent t-tests. Differences in complication and reoperation rates between cohorts were assessed using chi square analysis.ResultsA total of 118 THAs (59 cTHA, 59 pTHA) were included in this analysis with an average follow up of 21.3 months. cTHAs were most commonly performed following hip fracture fixation (50.8%). The conversion cohort had significantly longer lengths of stay (3.6 days vs 1.9 days, p<0.01) and greater use of revision-type implants (39.0% vs 0.0%, p<0.01) compared to pTHA. There was no significant difference in complication rates (cTHA = 15.3%, pTHA = 8.5%; p=0.26), with intraoperative fracture being the most common for both. Primary and conversion THA groups also experienced similar reoperation rates (cTHA = 5.1%, pTHA = 6.8%; p=0.70). No significant differences in PROs at final follow up were identified between groups.ConclusionPatients undergoing cTHA required increased utilization of revision hip implants and had longer lengths of stay, but had comparable complication and reoperation rates, and ultimately demonstrated similar improvements in PROMIS scores compared to a matched cohort of pTHA patients. Level of Evidence: III     

Risk Factors for Blood Transfusions in Primary Anatomic and Reverse Total Shoulder Arthroplasty for Osteoarthritis

BackgroundThe purpose of this study was to determine risk factors for blood transfusion in primary anatomic and reverse total shoulder arthroplasty (TSA) performed for osteoarthritis.MethodsPatients who underwent anatomic or reverse TSA for a diagnosis of primary osteoarthritis were identified in a national surgical database from 2005 to 2018 by utilizing both CPT and ICD-9/ICD-10 codes. Univariate analysis was performed on the two transfused versus non-transfused cohorts to compare for differences in comorbidities and demographics. Independent risk factors for perioperative blood transfusions were identified via multivariate regression models.Results305 transfused and 18,124 nontransfused patients were identified. Female sex (p<0.001), age >85 years (p=0.001), insulin-dependent diabetes mellitus (p=0.001), dialysis dependence (p=0.001), acute renal failure (p=0.012), hematologic disorders (p=0.010), disseminated cancer (p<0.001), ASA ≥ 3 (p<0.001), and functional dependence (p=0.001) were shown to be independent risk factors for blood transfusions on multivariate logistic regression analysis.ConclusionSeveral independent risk factors for blood transfusion following anatomic/reverse TSA for osteoarthritis were identified. Awareness of these risk factors can help surgeons and perioperative care teams to both identify and optimize high-risk patients to decrease both transfusion requirements and its associated complications in this patient population. Level of Evidence: III     

Total Knee Arthroplasty: A Quantitative Assessment of Online Patient Education Resources

BackgroundPatients often turn to the online resources to learn about orthopedic procedures. As the rate of joint arthroplasty is projected to increase, the corresponding interest in relevant online education material will increase as well. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that publicly available online health information be written at the 6th grade or lower reading level to be fully understood by the average adult in the United States. Additionally, educational resources should be written such that readers can process key information (understandability) or identify available actions to take (actionability). The purpose of this study was to quantify the readability, understandability, and actionability of online patient educational materials regarding total knee arthroplasty (TKA).MethodsThe most common Google™ search term utilized by the American public was determined to be “knee replacement”. Subsequently two independent online searches (Google.com) were performed. From the top 50 search results, websites were included if directed at educating patients regarding TKA. Non-text websites (audiovisual), articles (news/research/industry), and unrelated resources were excluded. Readability was quantified using the following valid objective algorithms: Flesch-Kincaid Grade-Level (FKGL), Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index (CLI), and Gunning-Fog Index (GFI). PEMAT was utilized to assess understandability and actionability (0-100%; score ≥70% indicates acceptable scoring). The relationship between search rank with FKGL and PEMAT scores was quantified.ResultsA total of 34 (68%) unique websites met inclusion criteria. The mean FKGL, SMOG, CLI, and GFI was 11.8±1.6, 11.1±1.2, 11.9±1.4, and 14.7±1.6, respectively. None of the websites scored within the acceptable NIH/AMA recommended reading levels. Mean understandability and actionability scores were 54.9±12.1 and 30.3±22.0. Only 5.9% (n=2) and 9.2% (n=1) of websites met the ≥70% threshold for understandability and actionability. Only 29.4% (n=10) sources used common language and only 26.9% (n=9) properly defined complicated medical terms. Based on website type, the mean understandability scores for academic institution, private practice, and health information publisher websites were 57.2±8.8%, 52.6±11.1%, and 54.3±15.3% (p=0.67). Readability (rho: -0.07; p=0.69), understandability (rho: -0.02; p=0.93), and actionability (rho: -0.22; p=0.23) scores were not associated with Google™ search rank.ConclusionTKA materials scored poorly with respect to readability, understandability, and actionability. None of the resources scored within the recommended AMA/NIH reading levels. Only 5.9% scored adequately on understandability measures. Substantial efforts are needed to improve online resources to optimize patient comprehension and facilitate informed decision-making. Level of Evidence: III     

Return of Scapulohumeral Rhythm in Patients After Reverse Shoulder Arthroplasty: A Midterm Stereoradiographic Imaging Analysis

BackgroundReverse shoulder arthroplasty (RSA) is associated with high rates of midterm complications including scapular notching, implant wear, and mechanical impingement. Scapulo-humeral rhythm (SHR), described by Codman in the 1920’s, is defined as the ratio of glenohumeral motion to scapulothoracic motion. SHR is used as an indicator of shoulder dysfunction, as alterations in SHR can have profound implications on shoulder biomechanics. The determination of SHR can be hindered by soft-tissue motion artifacts and high radiation burdens associated with traditional surface marker or fluoroscopic analysis. EOS low dose stereoradiographic imaging analysis utilizing 3D model construction from a 2D X-ray series may offer an alternative modality for characterizing SHR following RSA.MethodsPatients (n=10) underwent an EOS imaging analysis to determine SHR at six and twelve months post-RSA. Leveraging 3D models of the implants, 2D/3D image registration methods were used to calculate relative glenohumeral and scapulothoracic positioning at 60, 90 and 120° of shoulder elevation. Subject-specific SHR curves were assessed and midterm changes in post-RSA SHR associated with follow-up time and motion phase were evaluated. Pearson correlations assessed associations between patient-specific factors and post-RSA SHR.ResultsMean post-RSA SHR was 0.81:1 across subjects during the entire midterm postoperative period. As a cohort, post-RSA SHR was more variable for 60-90° of shoulder motion. SHR for 90-120° of motion decreased (0.43:1) at twelve months post-RSA. Post-RSA SHR could be categorized using three relative motion curve patterns, and was not strongly associated with demographic factors such as BMI. 50% of subjects demonstrated a different SHR relative motion curve shape at twelve months post-RSA, and SHR during the 90120° of motion was found to generally decrease at twelve months.ConclusionMidterm post-RSA SHR was successfully evaluated using EOS technology, revealing lower SHR values (i.e., greater scapulothoracic motion) compared to normal values reported in the literature. SHR continued to change for some subjects during the midterm post-RSA period, with the greatest change during 90-120° of shoulder motion. Study findings suggest that future post RSA rehabilitation efforts to address elevated scapulothoracic motion may benefit from being patient-specific in nature and targeting scapular stabilization during 90-120° of shoulder motion. Level of Evidence: IV     

Differences in Infection Rates by Surgical Approach in Total Hip Arthroplasty and Patient Sex: A Systematic Review

BackgroundThere exists conflicting data that patient sex may influence complication and revision rates when undergoing total hip arthroplasty (THA), specifically when comparing different surgical approaches. Differences in body fat or muscular distribution are proposed mechanisms, but these are poorly understood and not well described in current literature.MethodsA systematic review of the literature was conducted from PubMed, Embase, and Web of Science from inception of the database through September 15, 2020. Studies were included if they included patients undergoing primary elective unilateral THA, delineated infections by surgical approach, and delineated infections by patient sex. Basic science, cadaveric, and animal studies were excluded as were case reports. Two authors screened abstracts and then extracted data from the full text article.ResultsThree studies, including 1,694 patients undergoing 1,811 THA were included. 80 infections were included. No study reported a statistically significant difference in infection risk by patient sex or surgical approach, though there was substantial heterogeneity in study design, approach, and analysis.ConclusionLimited data suggests no relationship between sexes across surgical approaches for infection rates. However, poor reporting and small sample sizes preclude definitive conclusions from being drawn. Future studies should emphasize reporting differences in outcomes by patient sex to better elucidate differences, if any, in adverse outcomes between sexes following THA across surgical approaches. Level of Evidence: IV     

The Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Open Reduction Internal Fixation for Proximal Humerus Fractures in the Elderly

BackgroundOpen reduction and internal fixation (ORIF) of proximal humerus fractures in elderly individuals (age >70) carries a relatively high short-term complication and reoperation rate but is generally durable once healed. Reverse total shoulder arthroplasty (RTSA) for fractures may be associated with superior short-term quality of life but carries the lifelong liabilities of joint replacement. The tradeoff between short and long-term risks, coupled with disparities in quality of life and cost, makes this clinical decision amenable to cost-effectiveness analysis.Methods A Markov state-transition model was constructed with a base case of a 75 year-old patient. Reoperation rates, quality of life values, mortality rates, and costs were based upon published literature. The model was run until all patients had died to simulate the accumulated costs and benefits.ResultsRTSA was associated with greater quality of life (7.11 QALYs) than ORIF (6.22 QALYs). RTSA was cost-effective with an incremental cost-effectiveness ratio of $3,945/QALY and $27,299/ QALY from payor and hospital perspectives, respectively. RTSA was favored and cost-effective at any age above 65 and any Charlson Score. The model was sensitive to the utility of both proceduresConclusionRTSA resulted in a higher quality of life and was cost-effective in comparison to ORIF for elderly patients.Level of Evidence: III     

Mini-Incision versus Standard Incision Total Hip Arthroplasty Regarding Surgical Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose

It remains controversial whether mini-incision (MI) benefits patients in total hip arthroplasty (THA). We performed a meta-analysis of randomized controlled trials (RCTs) to assess the effects of MI on surgical and functional outcomes in THA patients.

Methods

A systematic electronic literature search (up to May 2013) was conducted to identify RCTs comparing MI with standard incision (SI) THA. The primary outcome measures were surgical and functional outcomes. According to the surgical approach taken, MI THA patients were divided into four subgroups for sub-group meta-analysis. Standardized mean differences (SMDs) or risk differences (RDs) with accompanying 95% confidence intervals (CIs) were calculated and pooled using a fixed-effect or random-effect model according to the heterogeneity.

Results

A total of 14 RCTs involving THA 1,174 patients met the inclusion criteria. The trials were medium risk of bias. The overall meta-analysis showed MI THA reduced total blood loss (95% CI, -201.83 to -21.18; p=.02) and length of hospital stay ( 95% CI, -0.67 to -0.08; p=.01) with significant heterogeneity. However, subgroup meta-analysis revealed posterior MI THA had perioperative advantages of reduced surgical duration ( 95% CI, -8.45 to -2.67; P<.001), less blood loss ( 95% CI, -107.20 to -1.73; P=.04) and shorter hospital stay ( 95% CI, -0.74 to -0.06; p=.002) with low heterogeneity. There were no significant differences between MI and SI THA groups in term of pain medication dose, functional outcome (HHS), radiological outcome or complications (P>.05, respectively).

Conclusions

Although no definite overall conclusion can be arrived at on whether MI THA is superior to SI THA, posterior MI THA clearly result in a significant decrease in surgical duration, blood loss and hospital stay. It seems to be a safe minimally invasive surgical procedure without increasing the risk of component malposition or complications.     

Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background

Periprosthetic joint infections (PJIs) are dreaded complications of total joint arthroplasties. The risk of developing PJIs is likely to be influenced by several patient factors such as sociodemographic characteristics, body mass index (BMI), and medical and surgical histories. However, the nature and magnitude of the long-term longitudinal associations between these patient-related factors and risk of developing PJIs are uncertain.

Objective

To conduct a systematic review and meta-analysis to assess the associations between several patient-related factors and PJI.

Data Sources

MEDLINE, EMBASE, Web of Science, Cochrane Library, and reference lists of relevant studies from inception to September 2015.

Study Selection

Longitudinal studies with at least one-year of follow-up for PJIs after total joint arthroplasty.

Data Extraction and Synthesis

Two investigators extracted data on study characteristics, methods, and outcomes. A consensus was reached with involvement of a third. The relative risk (RR) with 95% confidence intervals was used as the summary measure of association across studies. Study-specific RRs with 95% confidence intervals were meta-analysed using random effect models and were grouped by study-level characteristics.

Results

Sixty-six observational (23 prospective cohort and 43 retrospective cohort or case-control) studies with data on 512,508 participants were included. Comparing males to females and smokers to non-smokers, the pooled RRs for PJI were 1.36 (1.18–1.57) and 1.83 (1.24–2.70) respectively. There was no evidence of any significant associations of PJI with age and high alcohol intake. Comparing BMI ≥ 30 versus < 30 kg/m²; ≥ 35 versus < 35 kg/m²; and ≥ 40 versus < 40 kg/m²; the pooled RRs were 1.60 (1.29–1.99); 1.53 (1.22–1.92); and 3.68 (2.25–6.01) respectively. Histories of diabetes, rheumatoid arthritis, depression, steroid use, and previous joint surgery were also associated with increased risk of PJI. The results remained similar when grouped by relevant study level characteristics.

Conclusions

Several potentially modifiable patient-related factors are associated with the risk of developing PJIs. Identifying patients with these risk factors who are due to have arthroplasty surgery and modulating these risk factors might be essential in reducing the incidence of PJI. Further research is however warranted to assess the potential clinical utility of these risk factors as risk assessment tools for PJI.

Systematic Review Registration

PROSPERO 2015: CRD42015023485