Preoperative COVID-19 Infection Increases Risk for 60-Day Complications Following Total Shoulder Arthroplasty: A Propensity-Matched Analysis.

BACKGROUND: Total shoulder arthroplasty (TSA) is an effective treatment for a wide range of shoulder pathologies. Literature investigating the impact of COVID-19 diagnosis on outcomes following TSA is limited. The objective of this study was to perform a retrospective multi-institutional database analysis to investigate the association between preoperative COVID-19 diagnosis and 60-day complications following TSA. METHODS: We queried the TriNetX database using Current Procedural Terminology (CPT) and the International Classification of Diseases, Tenth Revision (ICD-10) codes for patients who underwent a TSA from January 1, 2018 to July 1, 2023. Patients were categorized by those who had and those who did not have a diagnosis of COVID-19 within 30 days prior to surgery. The cohorts were matched based on age, gender, ethnicity, race, and past medical history. Chi-square analysis was performed to determine the relationship between COVID-19 diagnosis and 60-day postoperative complications including pneumonia, sepsis, emergency department (ED) visit, hospital admission, mortality, periprosthetic fracture, superficial wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), acute myocardial infarction (MI), and revision surgery. The search results identified a total 63,768 patients who met study criteria. Of these patients, 7,118 (11.08%) were diagnosed with COVID-19 within 30 days prior to their TSA procedure. Propensity score matching resulted in 6,982 patients in each of the two cohorts. RESULTS: Patients with a recent COVID-19 diagnosis prior to surgery had 1.96 (P = 0.0005) times the odds of sepsis, 1.42 (P = 0.0032) times the odds of superficial wound infections, 1.42 (P < 0.0001) times the odds of DVT, 1.52 (P = 0.0001) times the odds of PE, 1.10 (P = 0.0249) and 1.79 (P < 0.0001) times the odds of ED visits and hospital admissions, respectively, and 3.10 (P < 0.0001) and 2.87 (P < 0.0001) times the odds of periprosthetic fracture and revision surgery within 60 days of TSA. CONCLUSIONS: Our study suggests an increased risk of sepsis, ED visits, hospital admissions, periprosthetic fracture, superficial wound infection, DVT, PE, and revision surgery in TSA patients with a recent COVID-19 diagnosis. There may be significant benefit to closer monitoring and greater preventive measures to reduce the occurrence of postoperative complications in this setting. In addition, patients may benefit from postponing elective TSA procedures in the setting of a recent COVID-19 infection.

Patient-reported outcomes following total shoulder arthroplasty and hemiarthroplasty: an analysis of data from the National Joint Registry.

BACKGROUND: Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are used in the management of end-stage glenohumeral arthritis. Improvement in shoulder function and resolution of symptoms are high priorities for patients. The aim of this study was to compare patient-reported outcome measures (PROMs) following TSA and HA. METHODS: Records from the National Joint Registry of England, Wales, Northern Ireland, and the Isle of Man were linked to the PROMs data set. The study included anatomic shoulder arthroplasties performed for osteoarthritis in patients with an intact rotator cuff. Patients with preoperative and postoperative Oxford Shoulder Scores (OSSs) were included. The improvement in OSS at 6 months and 5 years and the trend in scores over time were analyzed for each prosthesis. A cohort of 2002 patients were matched on 10 variables using propensity scores. OSSs at 6 months following TSA vs. HA were compared in the matched sample. RESULTS: There was a significant improvement in the OSS in both groups (P < .001). At 6 months, the OSSs were superior following TSA compared with HA (median 42 vs. 36, P < .001). The median score at 5 years was 44 following TSA and 35 following HA. Score distributions were skewed toward the maximum score. The highest possible score (48) was achieved in 28% (134 of 478) of TSAs and 9% (20 of 235) of HAs at 5 years. The improvement in the preoperative to 6-month OSS reached the minimal clinically important difference of 5.5 in 92% (1653 of 1792) of TSAs and in 80% (416 of 523) of HAs. At 5 years, this improvement was maintained in 91% (339 of 374) of TSAs and 78% (136 of 174) of HAs. CONCLUSION: TSA resulted in superior OSSs at 6 months in patients with osteoarthritis. The median OSS improved from 6 months to 5 years following TSA; however, there was a small decline in scores following HA. A ceiling effect was shown in the OSS following TSA at 5 years.

Mid-term Results Following Reverse Shoulder Arthroplasty and the Role of Navigation in the Management of Glenoid Bone Loss.

Background Inaccurate positioning of the glenoid component has been well described as the most common cause of early failure following a reverse shoulder arthroplasty (RSA). Among the latest developments in operative technique, three-dimensional preoperative planning and navigation intraoperative systems have been developed to improve the accuracy of the baseplate positioning during RSA. The primary purpose of this retrospective analysis was to investigate the mid-term results of patients who underwent an elective RSA or for acute highly comminuted proximal humerus fractures. The secondary goal was to investigate the role of navigation in the execution of preoperative planning, especially in the management of glenoid bone loss. Methodology In total, 101 cases were included in this study. Patients were divided into the following two groups: 88 cases of RSA performed without the use of navigation (conventional RSA) and 13 cases performed using intraoperative navigation (navigated RSA). For all patients included in the study, preoperative planning software was employed. Patient demographics, gender, past medical history, indication of procedure, operated site, type of glenoid component used, length of baseplate screws, and clinical assessment scores (Oxford Shoulder Score, OSS) were reported for all patients. Cases of revision shoulder arthroplasty were excluded from this study. Results The postoperative clinical assessment of patients revealed that following RSA, all patients improved significantly with a consistently upward trend of the OSS noted for both groups (conventional and navigated RSA) throughout the postoperative assessment. Despite no statistically significant difference detected, the clinical scores of the navigated RSA group outperformed those of the conventional RSA group in the postoperative period. A higher incidence of augmented baseplate use was noted in the navigated RSA group than in the conventional group (23.07% vs. 5.68%, p < 0.001). Conclusions Our results indicate that the use of intraoperative navigation appears to be a valuable tool in preoperative planning, providing accurate positioning of the baseplate, a better understanding of the glenoid anatomy, and real-time monitoring of the length and direction of the baseplate screws. It is difficult to conclude if the use of navigation leads to superior clinical outcomes, and the cost-effectiveness of its use needs to be further analyzed. Prospective randomized trials are required to assess the cost-effectiveness of routine use of navigation in RSA.

Optimal analgesic regimen for total shoulder arthroplasty: a randomized controlled trial and network meta-analysis.

OBJECTIVE: Clinical approaches to analgesia following total shoulder arthroplasty include liposomal bupivacaine, local infiltration analgesia, single-shot interscalene block, and continuous interscalene block. However, the best method remains contentious. This study conducts a network meta-analysis comparing these four methods, aiming to identify the most effective analgesic approach. METHODS: Randomized controlled trials on analgesic regimens for total shoulder arthroplasty were identified through searches of PUBMED, Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Scopus databases, covering their inception through November 2023. Network meta-analysis was performed using STATA 15.1, and the Cochrane Handbook version 5.1.0 risk of bias tool was employed for quality assessment of the literature. RESULTS: Twelve randomized controlled trials were included, comprising 1537 patients undergoing total shoulder arthroplasty. The interventions compared were ssISB, cISB, LIA, and LB. Regarding the quality of the literature, four studies were deemed low risk, one high risk, and seven moderate risk. The network meta-analysis revealed that in terms of VAS scores in the PACU, the ssISB group was the most effective, followed by cISB and LB, with LIA being the least effective. This pattern continued in VAS scores on the first and second postoperative days. Regarding morphine consumption, the cISB group showed the most significant reduction in the PACU and on the first postoperative day, while the LIA group performed best in total postoperative morphine consumption. The shortest average hospital stay was noted in the cISB group. CONCLUSION: The ssISB method excels in controlling early postoperative pain, particularly during the PACU stage and early postoperative period. Additionally, the cISB method is notable for reducing postoperative morphine consumption and shortening average hospital stays. While the LIA method ranks first in reducing total morphine consumption, it is weaker in pain control. The LB method is underwhelming across most assessment parameters. These findings underscore the importance of selecting appropriate analgesic strategies for different postoperative recovery phases and provide valuable insights for clinicians to optimize postoperative pain management. Furthermore, they suggest a need for future research to explore the specific application and effectiveness of these methods in varying clinical contexts.

Complication rates following reverse and anatomic shoulder replacement in treatment of glenohumeral arthritis: a 10-year Medicare review study.

BACKGROUND: We sought to compare the complication rates after anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) for primary glenohumeral arthritis in a Medicare population. METHODS: Patients who underwent a shoulder arthroplasty were identified from the 5% subset of Medicare parts A/B between 2009 and 2019. Patients with less than 1-year follow-up were excluded. A total of 8846 patients with a diagnosis of glenohumeral arthritis were then subdivided into those who received aTSA (5935 patients) and RSA (2911 patients). A multivariate Cox regression analysis was then performed comparing complication rates at 3 months, 6 months, 1 year, 2 years, and 5 years. RESULTS: Statistically significant increased rates of instability (hazard ratio [HR] = 1.46), fracture of the scapula (HR = 7.76), infections (HR = 1.45), early revision (HR = 1.79), and all complications (HR = 1.32) were seen in the RSA group. There was no significant difference in revision rate at 5 years between the 2 groups. There was no difference in patient characteristics or comorbid conditions (smoking status, diabetes, Charlson score, etc.) or hospital characteristics (location, teaching status, public vs. private, etc.) between the 2 groups. CONCLUSION: An increased rate of early complications was observed with the use of RSA compared with aTSA for the treatment of primary glenohumeral arthritis, including instability, scapula fracture, infection, and all cause complication. No difference in revision rate between RSA and aTSA at 5 years was observed.

Functional outcomes of reverse total shoulder arthroplasty in Boileau class 1 and class 2 proximal humeral fracture sequelae: A meta-analysis and systematic review.

Background: Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae. Methods: A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed. Findings: Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%. Conclusion: Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.

The incidence and treatment of symptomatic acromioclavicular joint osteoarthritis following total shoulder arthroplasty.

Background: Acromioclavicular joint (ACJ) Osteoarthritis (OA) is very common in the general population. Despite this, there is little mention of concomitant glenohumeral and ACJ arthropathy in the literature, and no documented incidence of symptomatic ACJ OA post total shoulder arthroplasty (TSA). We present the incidence and timescale of the problem, and the response to treatments. Methods: Patients who had developed ACJ-related symptoms following a TSA were retrieved from a prospectively collected database. It was determined that these symptoms were not related to the prosthesis or other non-ACJ pathology. Results: There were 230 primary anatomic total shoulder replacements carried out over a 9-year period, with 219 with adequate follow-up for analysis. Thirty-five (16%) developed a symptomatic ACJ. The majority developed symptoms within the first two years however there was one patient who developed symptoms eight years later. Twenty six percent of patients responded to a period of rest. Seventy one percent had a cortisone injection in the ACJ and in 44% of patients this was effective. Twelve (34%) patients had an arthroscopic excision of distal clavicle with good resolution of the symptoms. Discussion: ACJ symptoms following a total shoulder replacement appears more common than thought and can be treated successfully.

Does Reverse Shoulder Arthroplasty Improve Function and Quality of Life in Patients With Rotator Cuff Tear Arthropathy?

Background This study aims to determine the change in functional capacity and quality of life in patients who underwent reverse shoulder arthroplasty (RSA) due to rotator cuff tear arthropathy (RCTA). Methodology A total of 89 patients who underwent RSA due to RCTA between 2016 and 2022 were included in the study, as examined by the senior author. The Constant-Murley Score (CMS) was used for functional assessment, whereas the Short Form-36 (SF-36) was used for quality-of-life evaluation. The assessment scores before and after the surgery were compared to the reference values of CMS and SF-36 scores, as determined by reference studies, based on age groups. The change in functional capacity and quality of life with RSA was calculated. In addition, the impact of age and body mass index (BMI) on the results was examined. Results No differences were found in demographic data except for BMI (p = 0.026). CMS did not reach the reference values of a normal shoulder during the 12-month postoperative period. However, a significant increase of 156% in comparison to the preoperative values was detected (p < 0.001). In the postoperative period, there was a statistically significant improvement in SF-36 scores compared to preoperative scores, except for social functioning (p = 0.099) and vitality (p = 0.255) (for all other parameters, p < 0.001). In patients under the age of 65 years, all parameters except for physical functioning, physical role, and social functioning statistically reached the reference values. A decrease in CMS scores was noted with an increase in BMI, and the negative correlation further increased in the postoperative period (preoperative: r = -0.274, 12-month postoperative: r = -0.476). Conclusions RSA performed for RCTA leads to an improvement in functional outcomes and quality of life. Although there was a considerable improvement after surgery for CMS compared to preoperatively, it was observed that normal shoulder reference values ​​could not be reached. For SF-36, it was observed that it reached normal shoulder reference values, especially in patients over 65 years of age.

Rehabilitation following shoulder arthroplasty: a survey of current clinical practice patterns of Italian physiotherapists.

BACKGROUND: The incidence of Total Shoulder Arthroplasty (TSA) and Reverse Total Shoulder Arthroplasty (RTSA) is constantly increasing. As a result, the interest in post-surgical rehabilitation has grown, since it is crucial in order to achieve full recovery and successful outcomes. The first aim of this study is to investigate the Italian physiotherapists (PTs) clinical practice in the management of patients with TSA and RTSA and to compare it with the best evidence available in the literature. The second purpose of this study is to assess any existing difference between the survey answers and the different sample subgroups. MATERIALS AND METHODS: This cross-sectional observation study was designed following the CHERRIES checklist and the STROBE guidelines. A 4-sections survey with a total of 30 questions was developed for investigating post-surgery rehabilitation management in patient with TSA and RTSA. The survey was sent to Italian PTs from December 2020 until February 2021. RESULTS: Six-hundred and seven PTs completed the survey regarding both TSA and RTSA; 43.5% of participants (n = 264/607) stated that TSA is more likely to dislocate during abduction and external rotation. Regarding reverse prosthesis, 53.5% (n = 325/607) affirmed RTSA is more likely to dislocate during internal rotation, adduction and extension. In order to recover passive Range of Motion (pROM), 62.1% (n = 377/607) of participants reported that they gain anterior flexion, abduction, internal rotation, external rotation up to 30°, with full pROM in all directions granted at 6-12 weeks. Regarding the active ROM (aROM), 44.2% (n = 268/607) of participants stated that they use active-assisted procedures within a range under 90° of elevation and abduction at 3-4 weeks and higher than 90° at 6-12 weeks, with full recovery at a 3-month mark. Sixty-five point seven percent of the sample (n = 399/607) declared that, during the rehabilitation of patients with TSA, they tend to focus on strengthening the scapular and rotator cuff muscles, deltoid, biceps and triceps. Conversely, 68.0% (n = 413/607) of participants stated that, for the rehabilitation of patients with RTSA, they preferably focus on strengthening the periscapular and deltoid muscles. Finally, 33.1% (n = 201/607) of participants indicated the instability of the glenoid prosthetic component as the most frequent complication in patients with TSA, while 42.5% (n = 258/607) of PTs identified scapular neck erosion as the most frequent post-RTSA surgery complication. CONCLUSIONS: The clinical practice of Italian PTs effectively reflects the indications of the literature as far as the strengthening of the main muscle groups and the prevention of movements, which may result in a dislocation, are concerned. Some differences emerged in the clinical practice of Italian PTs, regarding the restoration of active and passive movement, the starting and progression of muscle strengthening and the return to sport (RTS). These differences are actually quite representative of the current knowledge in post-surgical rehabilitation for shoulder prosthesis in the rehabilitation field. LEVEL OF EVIDENCE: V.

Mid-Term to Long-Term Follow-Up of Stemless Anatomic Total Shoulder Arthroplasty.

Background: The purpose was to report mid-term to long-term clinical outcomes in a multicentre series of patients who received stemless total shoulder arthroplasty (TSA). The hypothesis was that stemless TSA would be a safe and effective treatment with satisfactory clinical outcomes. Methods: Authors retrospectively reviewed records of 62 stemless TSAs implanted between March 2013 and December 2014. Six were excluded because they had fractures or muscular impairment, which left 56: primary osteoarthritis (n = 49), rheumatoid arthritis (n = 4), avascular necrosis (n = 1), or glenoid dysplasia (n = 2). Outcomes were absolute Constant Score (CS), age-/sex-adjusted CS, and the American Shoulder and Elbow Surgeons (ASES) score. Proportions of patients that achieved substantial clinical benefits for absolute CS and ASES scores were determined. Results: Of the 56 patients, 8 (14%) died (unrelated to TSA), 5 (9%) were lost to follow-up, and 2 (4%) refused participation. One patient was reoperated for infection with implant removal (excluded from analysis), and one for periprosthetic fracture without implant removal. At 7.6 ± 0.5 years (range 6.8-9.3), the remaining 40 patients, aged 71.0 ± 8.5 years, achieved net improvements of 40.7 ± 15.8 (CS), 62%±23% (age-/sex-adjusted CS), and 59.7 ± 16.4 (ASES). Of patients with complete absolute CS (n = 37) and ASES score (n = 28), respectively, 33 (89%) and 27 (96%) achieved substantial clinical benefits. Conclusions: Stemless TSA yields improvements in functional outcomes at mid-term to long-term that exceed the substantial clinical benefits of the absolute CS and ASES score at a mean follow-up of 7.6 years. Although the findings of this study revealed low complications and revision rates, more studies are needed to confirm long-term benefits of stemless TSA. Level of evidence: IV, case series.

Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures Treated With Trabecular Metal Prosthesis: Medium-Term Results.

Introduction Reverse shoulder arthroplasty (RSA) is becoming increasingly popular as a primary procedure for complex proximal humeral fractures (PHF) in acute trauma due to more emerging evidence and better patient outcomes. Methods This study is a retrospective case series of 51 patients who underwent a trabecular metal RSA for non-reconstructable, acute three or four-part PHF performed by a single surgeon between 2013 and 2019 with a minimum follow-up of three years. This included 44 females and seven males. Mean age was 76 years (range: 61-91 years). Oxford shoulder score (OSS) along with relevant patient information relating to demographics and functional outcomes were collected at regular intervals in outpatient clinic follow-ups. Complications were addressed accordingly during treatment and follow-up. Results The mean follow-up duration was 5.08 years. Two patients were lost to follow-up and nine patients died due to other causes. Four of them had developed severe dementia and were excluded as an outcome score from them could not be acquired. Two patients who had surgery beyond four weeks post-injury were excluded. Thirty-four patients in total were followed up. Patients had good range of motion and mean OSS of 40.28 post-operatively. The overall complication rate was 11.7%, and none of the patients had deep infections, scapular notching, or acromial fractures. Revision rate was 5.8% at mean follow-up of five years and one month (range: three years to nine years two months). Greater tuberosity union following intra-operative repair was evident on radiographs in 61.7% of the patients. Conclusion RSA is certainly a rewarding surgery in patients with complex PHF and was associated with good post-operative OSS along with patient satisfaction, and positive radiological outcomes at minimum three-year follow-up.

Early rehabilitation after reverse total shoulder prosthesis on fracture of proximal humerus in elderly patients provides better functional outcome.

PURPOSE: Reverse total shoulder arthroplasty (RSA) has revolutionized the management of proximal humerus fractures (PHF) in the elderly patients. There is few or no consensus regarding to management of postoperative rehabilitation in elderly patients. An early rehabilitation from D1 allowed better functional results compared to rehabilitation started to D30 independently from tuberosities consolidation. METHODS: 94 patients operated on for PHF were evaluated retrospectively, with a minimum radio-clinical follow-up of 2 years. Clinical evaluation included mobilities and four functional scores: ASES, quick DASH, gross constant, weighted constant. Radiological evaluation was performed on a frontal shoulder X-ray with evaluation of tuberosities' consolidation. RESULTS: The mean follow-up was 45 ± 19 months (24-88 months). Early rehabilitation was significantly associated with a better Constant Score (71.1 ± 17.2 vs. 56.4 ± 15.8; p < 0.001), better adjusted Constant score (92.4 ± 14.2 vs. 80.3 ± 19.5; p < 0.001), better quick DASH (22.8 ± 19.8 vs. 36.7 ± 21.3; p < 0.01), better ASES (78.6 ± 20.2 vs. 63 ± 22; p < 0.001). CONCLUSION: In traumatology, functional result of RSA seems not related in tuberosities' union but in rehabilitation in order to limit postoperative stiffness of operated shoulder. An early rehabilitation is related with better clinical and functional results, independently of tuberosities' union. LEVEL OF EVIDENCE: 3, control-case study.

[Revision of anatomic shoulder arthroplasty]. / Revision der anatomischen Schulterprothese.

With the increasing number of primary arthroplasties, revisions of anatomical prostheses are becoming increasingly important. The most common reasons for revision are glenoid loosening, including protrusion, rotator cuff insufficiency, including instability, and early/late infection. The reconstruction of glenoid defects can be done with an autograft or allograft. Depending on the size and situation, it is carried out in one or two stages. The stemless humeral head replacement and the short-stem prostheses that have been used more frequently in recent years have significantly simplified humeral revision. Platform systems take a different approach with the option of conversion without major interventions on the glenoid or revision stem. Intraoperative complications mainly occur on the humeral side. Postoperative complications include dislocation, component loosening, and infection. Revision of anatomical to reverse arthroplasty shows better clinical outcomes and lower complication rates than anatomical revision.

[Revision surgery in reverse shoulder arthroplasty : Management of the most common complications]. / Revision der inversen Schulterprothese : Management der häufigsten Komplikationen.

BACKGROUND: In recent years, the number of reverse shoulder arthroplasty implantations has increased continuously and a higher number of revision surgeries due to complications can be expected in the future. Current data show a mean complication rate for RSA of around 4%. The most common complications are instability, infection, component loosening, and periprosthetic fracture. TREATMENT OPTIONS: Revision surgery for RSA is challenging, and an individual treatment plan is necessary. For prosthetic instability, different operative or non-operative treatment options are available. Revision surgery for periprosthetic infection with replacement of the prosthesis is usually necessary for infection management. The treatment of periprosthetic fractures is based on techniques of general fracture treatment and depends on the fracture type. Knowledge of complications and risk factors may decrease complication rates in primary reverse shoulder arthroplasty in the future.

Biomechanical evaluation of subscapularis peel repairs augmented with the long head of the biceps tendon for anatomic total shoulder arthroplasty.

BACKGROUND: Subscapularis failure is a troublesome complication following anatomic total shoulder arthroplasty (aTSA). Commonly discarded during aTSA, the long head of the biceps tendon (LHBT) may offer an efficient and cheap autograft for the augmentation of the subscapularis repair during aTSA. The purpose of this study was to biomechanically compare a standard subscapularis peel repair to 2 methods of subscapularis peel repair augmented with LHBT. METHODS: 18 human cadaveric shoulders (61 ± 9 years of age) were used in this study. Shoulders were randomly assigned to biomechanically compare subscapularis peel repair with (1) traditional single-row repair, (2) single row with horizontal LHBT augmentation, or (3) single row with V-shaped LHBT augmentation. Shoulders underwent biomechanical testing on a servohydraulic testing system to compare cyclic displacement, load to failure, and stiffness. RESULTS: There were no significant differences in the cyclic displacement between the 3 techniques in the superior, middle, or inferior portion of the subscapularis repair (P > .05). The horizontal (436.7 ± 113.3 N; P = .011) and V-shape (563.3 ± 101.0 N; P < .001) repair demonstrated significantly greater load to failure compared with traditional repair (344.4 ± 82.4 N). The V-shape repair had significantly greater load to failure compared to the horizontal repair (P < .001). The horizontal (61.6 ± 8.4 N/mm; P < .001) and the V-shape (62.8 ± 6.1; P < .001) repairs demonstrated significantly greater stiffness compared to the traditional repair (47.6 ± 6.2 N). There was no significant difference in the stiffness of the horizontal and V-shape repairs (P = .770). CONCLUSIONS: Subscapularis peel repair augmentation with LHBT autograft following aTSA confers greater time zero load to failure and stiffness when compared to a standard subscapularis peel repair.

Resultados funcionales tras hemiartroplastía de hombro por fractura de húmero proximal: experiencia en nuestro centro / Functional results after shoulder hemiarthroplasty for proximal humerus fracture: experience in our center

Resumen: Introducción: la hemiartroplastía de hombro está siendo relegada como tratamiento de fracturas de húmero proximal no osteosintetizables. Nuestro objetivo es analizar los resultados funcionales de los pacientes tratados con hemiartroplastía por este motivo en nuestro centro. Material y métodos: estudio descriptivo transversal que incluye a los pacientes intervenidos entre Febrero de 2016 y Noviembre de 2021; 24 pacientes, con un seguimiento medio de 44.6 meses. Fueron recogidos el balance articular activo, el test de Constant-Murley, el cuestionario DASH y el dolor actual (EVA). Como parámetros radiográficos se analizó el número de fragmentos de fractura y la consolidación de las tuberosidades. Resultados: se obtuvo una media de 71.65 ± 13.75 en el Constant-Murley y de 18.14% ± 13.92 en el DASH. Para flexión de hombro la media fue de 108.75o ± 41.26; 104.5o ± 43.68 para abducción y 33o ± 14.73 para rotación externa. En rotación interna 60% llegaba hasta plano interescapular. EVA medio de 1.25 ± 1.74. Tuberosidades consolidadas en 90.5%. No hubo diferencias significativas entre el Constant-Murley, DASH ni rotaciones de pacientes mayores y menores de 65 años. Los mayores de 65 años obtuvieron flexión media de 125.91o ± 26.82 y los menores de 87.78o ± 26.82 (p = 0.038). La abducción media en mayores de 65 fue de 125.45 ± 28.94 versus 78.89 ± 46.29 en el grupo joven (p = 0.012). Conclusión: la hemiartroplastía otorga calidad de vida con aceptable funcionalidad y buen control del dolor, por lo que debe continuar siendo una alternativa a tener en cuenta en pacientes seleccionados.

Abstract: Introduction: shoulder hemiarthroplasty is being relegated as a treatment for non-osteosynthetic proximal humerus fractures. Our objective is to analyze the functional results of patients treated with hemiarthroplasty for this reason in our hospital. Material and methods: cross-sectional descriptive study that includes patients operated between February 2016 and November 2021; 24 patients, with an average follow-up of 44.6 months. Active joint balance, the Constant-Murley test, the DASH questionnaire and current pain (VAS) were collected. The radiographic parameters analyzed were the number of fracture fragments and the consolidation of the tuberosities. Results: a mean of 71.65 ± 13.75 was obtained in the Constant-Murley and 18.14% ± 13.92 in the DASH. For shoulder flexion, the mean was 108.75o ± 41.26; 104.5o ± 43.68 for abduction and 33o ± 14.73 for external rotation. About internal rotation, 60% of the patients reached the scapular plane. Average VAS was 1.25 ± 1.74. Consolidated tuberosities in 90.5%. There were no significant differences comparing the Constant-Murley test, DASH or rotations between both, over and under 65 years old group of patients. Those over 65 years of age obtained a mean flexion of 125.91o ± 26.82 whereas those under 87.78o ± 26.82 (p = 0.038). The mean abduction in those over 65 was 125.45 ± 28.94 vs 78.89 ± 46.29 in the young group (p = 0.012). Conclusion: hemiarthroplasty provides quality of life with acceptable functionality and good pain control, therefore it should continue to be an alternative to consider in selected patients.

Shoulder replacement: an epidemiological nationwide study from 2009 to 2019.

BACKGROUND: Shoulder replacement (SR) constitutes the gold standard treatment for severe shoulder diseases, including osteoarthritis, rheumatoid arthritis, complex fractures, avascular necrosis and rotator cuff arthropathy. Although several countries have national registries, there is a lack of epidemiological data on SR. Sharing national statistics and correlating those to other countries could be helpful to compare outcomes and costs internationally. This paper aims to evaluate the trend of hospitalizations for SR (both first implants and revisions of anatomical and reverse prosthesis) in Italy from 2009 to 2019, based on the National Hospital Discharge Reports (S.D.O) provided by the Italian National Health Service (INHS). Moreover, the economic impact on the healthcare system of SR and SR revisions was assessed, providing a statistical prediction for the next ten years. METHODS: The data used in this paper were about patients who underwent Total Shoulder Replacement (TSR), Shoulder Hemiarthroplasty (SH) or Revision of shoulder joint replacement (RSR) from 2009 to 2019 in Italy. Information about patients was anonymous and included age, sex, days of hospitalization, procedures and diagnoses codes. RESULTS: From 2009 to 2019, 73,046 TSR and SH were performed in adult Italian residents, with a cumulative incidence of 13.6 cases per 100,000 adult Italian residents. While, 2,129 revisions of shoulder replacement were performed, with a cumulative incidence of 0.4 cases per 100,000 residents. Overall, females represented the majority of the cases (72.4% of patients who underwent TSR or SH and 59.1% of patients who underwent RSR). From 2009 to 2019, has been assessed an overall cost of 625,638,990€ for TSR or SH procedures in Italy. While, an overall cost of 9,855,141€ for RSR procedures in Italy was calculated. CONCLUSIONS: The incidence of SR and RSR is expected to increase in the following years, constituting a burden for the healthcare systems. Overall, in Italy, the females represented the majority of patients. Further prospective studies on this topic in different countries can be con-ducted to make comparisons.

Are progressive shoulder exercises feasible in patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy?

BACKGROUND: Little is known about the feasibility of progressive shoulder exercises (PSE) for patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA). The aim of this study was to investigate whether 12 weeks of PSE is feasible in patients with glenohumeral OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program. METHODS: Twenty patients were included. Eighteen patients (11 women, 15 with OA), mean age 70 years (range 57-80), performed 12 weeks of PSE with one weekly physiotherapist-supervised and two weekly home-based sessions. Feasibility was measured by dropout rate, adverse events, pain, and adherence to PSE. At baseline and end of intervention, patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Data to assess feasibility were analyzed using descriptive statistics. RESULTS: Two patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (≥ 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions with no numeric rating scale (NRS) score over five for any exercise. WOOS improved with a mean of 23 points (95% CI 13;33), and DASH improved with a mean of 13 points (95% CI 6;19). CONCLUSION: Adherence to PSE was high and dropout rates were low. PSE is feasible, safe and may relieve shoulder pain, improve function and ROM in patients with glenohumeral OA or CTA. The patient-experienced gains after PSE seem clinically relevant and should be compared to arthroplasty surgery in a RCT setting. TRIAL REGISTRATION: According to Danish law, this study did not need an approval by the Central Denmark Region Committee on Health Research Ethics. Approval from The Danish Data Protection Agency (journal number 1-16-02-15-20) was obtained.

Persistent and profound peripheral nerve injuries following reverse total shoulder arthroplasty.

BACKGROUND: Peripheral nerve injuries associated with reverse total shoulder arthroplasty (rTSA) are rarely reported and are often dismissed as neuropraxias, particularly in the setting of perioperative nerve blocks. The purpose of this study was to evaluate nerve injuries following rTSA to determine if there is a pattern of injury and to evaluate outcomes of patients who sustain an intraoperative nerve injury. METHODS: A retrospective review was performed identifying patients who underwent rTSA and had a concomitant major nerve injury who were referred to a multidisciplinary peripheral nerve injury clinic. Demographic data, preoperative nerve block use, physical examination, electrodiagnostic studies, injury pattern, and time from injury to referral was collected. Radiographs, Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score, and outcomes surveys were obtained at final follow-up. RESULTS: Twenty-two patients were identified with postoperative nerve injuries. Average time from injury to referral was 9.0 months, with 18.8 months' follow-up. Eight patients had undergone prior shoulder surgery, and 11 patients had prior shoulder trauma. Injury patterns were variable and involved diffuse pan-plexopathies with severity localized to the posterior and medial cords (11), the upper trunk (5), lateral cord (2), and axillary nerve (4). The average postoperative acromiohumeral distance (AHD) was 3.7 cm, with an average change of 2.9 cm. The average postoperative lateral humeral offset (LHO) was 1.1 cm, with an average change of 0.2 cm. Seventeen patients were confirmed to have undergone preoperative nerve blocks, which were initially attributed as the etiology of nerve injury. Eighteen patients were initially treated with observation: 11 experienced residual debilitating neuropathic pain and/or disability, and 7 had substantial improvement. One patient underwent nerve transfers, whereas the others underwent procedures for hand dysfunction improvement. The average QuickDASH score was 53.5 at average of 4 years post rTSA. CONCLUSIONS: Although uncommon, permanent peripheral nerve injuries following rTSA do occur with debilitating effects. Preoperative regional blocks were used in most cases, but none of the blocks could be directly attributed to the nerve injuries. Nerve injuries were likely secondary to traction at the time of arthroplasty and/or substantial distalization and lateralization of the implants. Patients with medial cord injuries had the most debilitating loss of hand function. Surgeons should be cognizant of these injuries and make a timely referral to a peripheral nerve specialist.