Highlights of Papers on Shoulder Topics
Failure of Rotator Cuff Repair after Corticosteroid Injections
Patients scheduled for rotator cuff repair should not receive corticosteroid injections in the operative shoulder in the 3 months before surgery due to the increased risk for failure of the repair, according to a study from Hospital for Special Surgery and The Steadman Clinic.
Past research has implicated corticosteroid injections in degeneration of tendons; they may even affect healing. To determine if corticosteroid injections could have a role in failure of rotator cuff repairs, researchers used a 5% sample of Medicare patients to identify:
- Patients who had undergone rotator cuff repair
- Patients from that group who had received a corticosteroid injection in the year before surgery
The overall failure rate for the more than 17,000 patients in the study was 5.9% at 2 years. Patients who had received a corticosteroid infection within 3 months of surgery had a failure rate of 9.5%, compared with 5.5% for patients who had not had a corticosteroid injection. Failure rates were higher in patients who had received corticosteroid injections more than 3 months before surgery, but multivariable regression found only injection within 3 months of surgery to be an independent risk factor for failure.
Schairer WW, Richardson SS, Warren RF, Provencher MT. Corticosteroid Injections within Three Months of Rotator Cuff Repair are Associated with Increased Revision Surgery at Two Years (Paper 283). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Lowering the Reoperation Rate for Reverse Total Shoulder Arthroplasty
In a 5-surgeon study at Mayo Clinic, the use of contemporary implants and improved surgical technique resulted in a reoperation rate of only 2.37% among 1,649 primary reverse total shoulder arthroplasty patients.
The researchers retrospectively reviewed outcomes of primary reverse procedures performed consecutively between 2009 and 2015. Only 39 patients required reoperation. Issues with the humeral component – humeral tray fracture, humeral stem aseptic loosening, periprosthetic humerus fracture – was the most common reason for reoperation (1.03%), primarily due to a design flaw in 1 implant system. Other reasons for reoperation were:
- Instability, 055%
- Infection, 0.55%
- Glenoid component issues, 0.36%
- Deltoid failure, 0.06%
Of note, reoperation for instability or an issue with the humeral component was more common in patients who underwent reverse total shoulder arthroplasty for a proximal humeral fracture.
Kang J, Dubiel MJ, Steinmann SP, Elhassan BT, Morrey ME, Cofield RH, Sperling JW, Sanchez-Sotelo J. Primary Reverse Shoulder Arthroplasty Using Contemporary Implants is Associated with Very Low Reoperation Rates (Paper 377). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Who Benefits from Reverse Total Shoulder Arthroplasty?
In a review of 770 consecutive cases from a single surgeon at the Florida Orthopaedic Institute, primary reverse total shoulder arthroplasty was found to be an effective treatment option for a variety of pathologies, with a low revision rate.Surgery was performed between January 2004 and December 2015 for 9 pathologies:
- Cuff tear arthropathy
- Osteoarthritis (OA)
- Massive cuff tear with osteoarthritis
- Massive cuff tear without osteoarthritis
- Inflammatory arthropathies
The surgeon used a reverse shoulder prosthesis with a lateralized center of rotation at the glenosphere and a 135° neck shaft angle of the humerus.
Patients who underwent reverse total shoulder arthroplasty for cuff tear arthropathy or osteoarthritis had the highest Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) scores. The lowest scores were seen in patients who underwent the procedure for malunion, acute fracture, and miscellaneous.
However, ASES and SST scores and range of motion (forward flexion, abduction, external rotation, and internal rotation) improved for all pathologies, with no statistically significant differences between categories.
Only 2.5% of shoulders (19/770) were revised, mostly among patients who underwent reverse total shoulder arthroplasty for inflammatory arthropathy or osteoarthritis.
Lindbloom BJ, Simon P, Christmas KN, Song E, Hess AV II, Mighell MA, Frankle MA. Is there a Relationship Between Preoperative Diagnosis and Clinical Outcomes in Reverse Shoulder Arthroplasty: An Experience of 770 Shoulders (Paper 379). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Subscapularis Repair in a Reverse Total Shoulder Arthroplasty
To improve the clinical outcome, should the surgeon repair the subscapularis when performing a reverse total shoulder arthroplasty?
To find out, a group of surgeons conducted a multicenter study involving 240 patients who underwent primary reverse total shoulder arthroplasty for treatment of cuff tear arthropathy or osteoarthritis with a rotator cuff tear. Surgeons used a medial glenoid/lateral humeral design implant and either repaired the subscapularis (n=115) or did not repair it (n=125).
At an average follow-up of 74.7 months, patients in both groups had significant improvement in pain and function, with no difference in the complication rate. The SST, UCLA, ASES, Constant Score, and SPADI metrics were virtually identical at the latest follow-up. Patients in the non-repair group had better abduction (113.4° vs 104.9°; P=0.02) and external rotation (33.2° vs 27.7°; P=0.03), while the repair group had better active internal rotation scores (4.7 vs 4.2 points; P=0.04).
The study authors said that the significantly better active abduction and external rotation in the non-repair group supports the contention that the subscapularis acts as an antagonist to the deltoid and posterior rotator cuff in reverse total shoulder arthroplasty.
Routman HD, Friedman RJ, Flurin P-H, Wright TW, Roche C, Zuckerman JD. Outcomes of Reverse Total Shoulder Arthroplasty: With and Without Subscapularis Repair (Paper 383). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Evaluating Variables Leading to Acromial and Scapular Problems in Reverse TSA
Which patients will develop acromial and scapular problems (ASP) after reverse total shoulder arthroplasty? The answer is unclear: Their occurrence appears to be unpredictable, according to a multicenter study involving 23 surgeons.
The study included more than 3500 patients who underwent reverse total shoulder arthroplasty between March 2007 and December 2017. The same implant design was used for all patients. Postoperative APS, defined as tenderness of the acromion, an acromial fracture, or a scapula fracture, was rare, occurring in 1.3% of patients at an average of 12 months after surgery (range, 1 week to 78 months).
The researchers then analyzed demographic and implant data to determine why some patients developed ASP and others did not. The only difference they found was height: Patients who developed ASP were significantly shorter (63.9 inches vs 65.1 inches; P= 0.0442), but that could be due to the higher percentage of women in the study.
The surgeons said additional follow up and analysis are warranted to find out if other factors are associated with ASP.
Routman HD, Friedman RJ, Flurin P-H, Wright TW, Zuckerman JD, Roche C. Acromial and Scapular Problems after Reverse Shoulder Arthroplasty: Analysis of 3,561 Patients with a Single Implant (Paper 384). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Outcomes with a Posterior Augmented Glenoid in Total Shoulder Arthroplasty
Use of a posterior augmented glenoid results in outcomes similar to those achieved with use of a non-augmented pegged glenoid in patients undergoing anatomic total shoulder arthroplasty (TSA), according to a multicenter study.
Patients in the augmented glenoid group (n=94) had significant posterior glenoid wear, while those in the non-augmented group (n=99) did not have glenoid wear. The researchers compared preoperative and postoperative SST, UCLA, ASES, Constant, and SPADI scoring metrics between groups, as well as active abduction, forward flexion, and internal/external rotation. They also assessed radiographs from the most recent follow-up for radiolucent glenoid lines.
Patients who need an augmented glenoid are at a disadvantage from the start due to glenoid wear. But in this study, they had significantly better scores on all outcome metrics and significantly more strength, abduction, forward flexion, and external rotation. The authors speculated that the augmented glenoid patients did so well due to correction of retroversion and posterior subluxation, with improved tensioning of the rotator cuff.
All patients – those with glenoid wear and those without – experienced mprovement in pain and function after surgery at a mean follow-up of 3 years, with similar complication rates and radiographic outcomes between groups.
Friedman RJ, Grey SG, Wright TW, Flurin P-H, Zuckerman JD, Roche C. Posterior Augmented Glenoids Compared to Non-Augmented Glenoids in Anatomic Total Shoulder Arthroplasty (Paper 827). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Cost Savings in a Bundled Payment Program for Outpatient Shoulder Replacement
Participation in a private insurance bundled payment program resulted in significant cost savings for outpatient anatomic total shoulder arthroplasty procedures performed at a freestanding ambulatory surgery center in Memphis, Tennessee.
A cost minimization analysis for a single surgeon at the ambulatory surgery center included 76 outpatient anatomic TSA patients, 39 in the bundled program and 37 outside the bundled program. Patients in the bundled group were older (58 years vs 54 years; P=0.021), but other demographics were similar between groups.
A direct cost line-by-line comparison for the 90-day episode of care found:
- Significantly lower average total implant charges for the bundled group: $24,822.43 vs $28,405.51 (P=0.014)
- Similar average total surgery supply charges and anesthesia supply charges for the 2 groups (P>0.05)
- Significantly lower mean total outpatient surgical day charges (surgical equipment, implants, and anesthesia equipment) for the bundled group: $29,782.43 vs $33,238.68 (P=0.022)
- Significantly lower average operating room staff costs on the day of surgery for the bundled group: $135.37 vs $162.55 (P=0.015)
- Similar charges during the 90-day postoperative period for the 2 groups
A bundled program provided cost savings in this analysis, but the study authors said that, “Each surgeon must carefully navigate his or her unique practice in the changing economic healthcare environment when creating an outpatient TSA and/or bundling program.”
Walters JD, Walsh R, Smith RA, Brolin TJ, Azar FM, Throckmorton TW. Bundled Payment Plans Produce Significant Cost Savings for Total Shoulder Arthroplasty in the Outpatient Setting (Paper 834). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
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