Outcomes of reverse shoulder arthroplasty in patients under 55 years old: Results from the New Zealand joint registry.

Background: The appropriate age at which to perform reverse shoulder arthroplasty is controversial. The aim of this study was to compare the outcomes of reverse shoulder arthroplasty between younger and older patients. Methods: Patients who underwent primary reverse shoulder arthroplasty between January 2000 and December 2019 were identified from New Zealand Joint Registry records. Patients were stratified into two cohorts according to age at the time of surgery: < 55 years and ≥ 55 years. These two groups were then compared with regard to baseline characteristics, indications for surgery, revision rates, and patient-reported outcomes using the Oxford Shoulder Score and American Shoulder and Elbow Score (ASES). Results: A total of 5518 primary reverse shoulder arthroplasty cases were identified, with 75 patients < 55 years at the time of surgery (range: 34-54 years). The mean duration of follow-up was 2.36 years (range: 0.11-13.37 years) in the younger cohort and 3.10 years (range: 0.01-16.22 years) in the older patient cohort. Indications for surgery differed significantly between the two groups, with younger patients having higher rates of inflammatory arthritis (p < 0.001), posttraumatic arthritis (p < 0.001), and avascular necrosis (p = 0.049). The younger cohort had an inferior 6-month postoperative Oxford Shoulder Score compared to the older cohort (mean: 28.5 [younger cohort] vs. 35.7 [older cohort]; p < 0.001). There was no significant difference in revision rate between the younger and older patient cohorts during the study period (1.56 [<55 years] vs. 0.74 [≥55 years] revisions per 100 component-years; p = 0.332). Conclusion: Our early results suggest that younger patients undergoing reverse shoulder arthroplasty demonstrate high implant retention rates, comparable to older patients. Longer-term patient-reported outcomes in younger patients are required to guide appropriate patient selection for reverse shoulder arthroplasty. Level of evidence: Level III, retrospective case-control study.

The Effect of the Type of Screw Fixation Used in the Treatment of Slipped Capital Femoral Epiphysis.

Background: Slipped capital femoral epiphysis (SCFE) remains among the most common hip disorders in the adolescent population. The management of SCFE remains controversial; however, the aim of fixation is to stabilize the physis and prevent further slippage. In situ fixation remains the gold standard; however, in the young population, it can lead to reduced femoral neck growth and complications such as leg length discrepancies. The ideal form of in situ fixation for mild to moderate SCFE would stabilize the slip and allow continued proximal femoral growth. This study aimed to determine if partially threaded screws allowed more neck growth than fully threaded screws. Methods: A retrospective review of the radiographs of all patients undergoing in situ fixation for SCFE using partially threaded and fully threaded screws. Measurements included neck length, neck-to-screw ratio, neck shaft angle, neck width, and articular-trochanteric distance. Parameters were compared over a two-year period to determine whether there was any difference in proximal femoral growth between the two types of screws. Results: Fully threaded screw neck length increased by 5 mm versus 5 mm for proximally threaded screws (P ≤ 0.001). No significant difference was observed between the two groups with respect to neck width, neck shaft angle, and articular-trochanteric distance. Conclusions: No difference was observed in proximal femoral growth. Regardless of which type of fixation is used, neck length continues to increase by approximately 3 mm per year.

Implant Sizing and Positioning in Anatomical Total Shoulder Arthroplasty Using a Rotator Cuff-Sparing Postero-Inferior Approach.

Background: The goal of this study was to compare the effectiveness of a rotator cuff-sparing postero-inferior (PI) approach with subdeltoidal access to the traditional subscapularis-takedown deltopectoral approach, in terms of implant sizing and positioning in anatomical total shoulder arthroplasty (aTSA). Methods: This study involved 18 human cadaveric shoulders with intact rotator cuffs and no evidence of head deforming osteoarthritis. An Eclipse stemless aTSA (Arthrex, Naples, FL, USA) was implanted in nine randomly selected specimens using a standard subscapularis-tenotomy deltopectoral approach, and in the other nine specimens using the cuff-sparing PI approach. Pre- and postoperative antero-posterior (AP) and axillary fluoroscopic radiographs were analyzed by two independent, blinded raters for the following parameters: (1) anatomic and prosthetic neck-shaft angle (NSA); (2) the shift between the anatomic and prosthetic center of rotation (COR); (3) anatomical size matching of the prosthetic humeral head; (4) the calculated Anatomic Reconstruction Score (ARS); (5) glenoid positioning; as well as (6) glenoid inclination and version. Results: While the COR was slightly but significantly positioned (p = 0.031) to be more medial in the PI approach group (3.7 ± 3.4%, range: -2.3% to 8.7%) than in the deltopectoral approach group (-0.2 ± 3.6%, range: -6.9% to 4.1%), on average, none of the remaining measured radiographic parameters significantly differed between both groups (PI approach group vs. deltopectoral group: NSA 130° vs. 127°, p = 0.57; COR supero-inferior, 2.6% vs. 1.0%, p = 0.35; COR antero-posterior, 0.9% vs. 1.7%, p = 0.57; head size supero-inferior, 97.3% vs. 98.5%, p = 0.15; head size antero-posterior, 101.1% vs. 100.6%, p = 0.54; ARS, 8.4 vs. 9.3, p = 0.13; glenoid positioning supero-inferior, 49.1% vs. 51.1%, p = 0.33; glenoid positioning antero-posterior, 49.3% vs. 50.4%, p = 0.23; glenoid inclination, 86° vs. 88°, p = 0.27; and glenoid retroversion, 91° vs. 89°, p = 0.27). Conclusions: A PI approach allows for sufficient exposure and orientation to perform rotator-cuff sparing aTSA with acceptable implant sizing and positioning in cadaveric specimens.

Intraoperative cell salvage use reduces the rate of perioperative allogenic blood transfusion in patients undergoing periacetabular osteotomy.

Blood loss during periacetabular osteotomy (PAO) is variable, with losses ranging from 100 to 3900 ml in published series. Perioperative allogenic blood transfusion is frequently utilized although is associated with significant risk of morbidity. Cell salvage (CS) is a common blood conservation tool; however, evidence supporting its use with PAO is lacking. Our aim was to assess whether CS affects perioperative allogenic blood transfusion rate in patients undergoing PAO. The clinical records of 58 consecutive PAOs in 54 patients (median age 24.7 years, interquartile range 17.8-29.4 years) performed by a single surgeon between 1 January 2016 and 30 April 2018 were reviewed. Autologous blood pre-donation and surgical drains were not used. Due to variable technician availability, CS was intermittently used during the study period. PAOs were allocated into a CS group or no cell salvage group (NCS group), according to whether an intraoperative CS system was used. There was no significant difference in patient age, gender, body mass index, dysplasia severity, regional anesthetic technique, tranexamic acid administration, surgical duration or estimated blood loss (all P > 0.05) between the two groups. The CS group had a lower preoperative hemoglobin compared to the NCS group (median, 13.4 g/dl versus 14.4 g/dl, P = 0.006). The incidence of allogenic blood transfusion was significantly lower in the CS group compared to the NCS group (2.5% versus 33.3% patients transfused, P = 0.003). Multivariate modeling showed CS use to be protective against allogenic blood transfusion (P = 0.003), with an associated 80-fold reduction in the odds of transfusion (odds ratio, 0.01; 95th% CI, 0-0.57). To our knowledge, this is the first study to assess the effect of CS use on allogenic transfusion rate in patients undergoing PAO. Our results demonstrate CS to be a mandatory component of blood conservation for all patients undergoing PAO.

Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures.

BACKGROUND: Complex proximal humeral fractures may require prosthetic replacement of the humeral head. Surgical options include reverse shoulder arthroplasty (RSA) and shoulder hemiarthroplasty; however, the optimal technique remains controversial. The goal of this study was to compare functional outcomes and revision rates of RSA with hemiarthroplasty in patients with acute proximal humeral fractures. MATERIALS AND METHODS: Between January 1, 1999, and December 31, 2014, there were 218 patients who underwent RSA and 427 who underwent hemiarthroplasty for acute proximal humeral fractures identified through New Zealand Joint Registry records. Study groups were compared with regard to baseline characteristics, operative characteristics, and postoperative outcomes (Oxford Shoulder Score [OSS], revision rate, mortality rate) at 6 months and 5 years after surgery. RESULTS: RSA patients were significantly older (mean age, 78.2 vs. 71.6 years; P < .001), with a higher proportion of female patients (90% vs. 77%; P < .001) than in the hemiarthroplasty group. No statistically significant difference existed in revision rate per 100 component-years (0.58 [RSA] vs. 1.16 [hemiarthroplasty]; P = .137) or 1-year mortality (3.8% vs. 3.4%; P = .805) between both groups. There was no significant difference in 6-month OSS (29.6 vs. 28.4; P = .305). The RSA group demonstrated a superior mean 5-year OSS (37.6 vs. 32.7; P = .078); however, the difference did not achieve statistical significance. CONCLUSIONS: Although our results suggest that RSA patients may experience superior 5-year functional scores, we have identified no significant difference in functional outcomes and revision rates between RSA and hemiarthroplasty in the treatment of acute proximal humeral fractures.