High rate of clinically relevant improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis

BACKGROUND The minimal clinically important difference(MCID)is defined as the smallest meaningful change in a health domain that a patient would identify as important.Thus,an improvement that exceeds the MCID can be used to define a successful treatment for the individual patient.AIM To quantify the rate of clinical improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis.METHODS Patients were treated with the Global Unite total shoulder platform arthroplasty between March 2017 and February 2019 at Herlev and Gentofte Hospital,Denmark.The patients were evaluated preoperatively and 3 months,6 months,12 months,and 24 months postoperatively using the Western Ontario Osteoarthritis of the Shoulder index(WOOS),Oxford Shoulder Score(OSS)and Constant-Murley Score(CMS).The rate of clinically relevant improvement was defined as the proportion of patients who had an improvement 24 months postoperatively that exceeded the MCID.Based on previous literature,MCID for WOOS,OSS,and CMS were defined as 12.3,4.3,and 12.8 respectively.RESULTS Forty-nine patients with a Global Unite total shoulder platform arthroplasty were included for the final analysis.Mean age at the time of surgery was 66 years(range 49.0-79.0,SD:8.3)and 65%were women.One patient was revised within the two years follow-up.The mean improvement from the preoperative assessment to the two-year follow-up was 46.1 points[95%confidence interval(95%CI):39.7-53.3,P<0.005]for WOOS,18.2 points(95%CI:15.5-21.0,P<0.005)for OSS and 37.8 points(95%CI:31.5-44.0,P<0.005)for CMS.Two years postoperatively,41 patients(87%)had an improvement in WOOS that exceeded the MCID,45 patients(94%)had an improvement in OSS that exceeded the MCID,and 42 patients(88%)had an improvement in CMS that exceeded the MCID.CONCLUSION Based on three shoulder-specific outcome measures we find that approximately 90%of patients has a clinically relevant improvement.This is a clear message when informing patients about their prognosis.

Stresses in the Scapular Fossa Do Not Exceed the Yield Stress When Elevated up to 135 Degrees of Abduction after Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty (RSA) is an effective treatment for rotator cuff tears. Despite its advantages, complications occur at a high rate. Complications requiring revision include a high rate of base plate failure, 38% of which are due to instability. The primary stability the base plate ensures is a crucial factor and, thus, is the subject of much debate in clinical studies and biomechanical research. This study is aimed to provide data that will contribute to the base plate’s pri-mary stability and glenoid longevity by clarifying the stresses at the scapular fossa and base plate interface associated with elevation after RSA. A 3D finite element model was created from the DICOM data for the scapulohumeral joint and SMR shoulder system. For loading conditions, 30 N was applied for each posi-tion with abduction angles of 0, 45, 90, and 135 degrees. A three-dimensional fi-nite element analysis was performed using the static implicit method with LS-DYNA. The von Mises stresses in the scapular fossa were found not to exceed the yield stress on the bone even after elevation to an abduction angle of 135 de-grees after RSA. It is rough to uniformly compare the yield stress and the von Mises stress, but it was inferred that the possibility of fracture is low unless a large external force is applied. A maximum von Mises stress showed 0 degrees of abduction, suggesting that the lowered position is in a more severe condition than the elevated position. If better improvement is desired, it may be necessary to devise ways to reduce the stress on the upper screw. .

Efficacy and safety of intravenous tranexamic acid in total shoulder arthroplasty:A meta-analysis

BACKGROUND Total shoulder arthroplasty(TSA)results in a large amount of perioperative blood loss due to severe trauma.AIM To investigate the safety and efficacy of intravenous tranexamic acid(TXA)in TSA.METHODS We searched the PubMed,Cochrane Library,Embase and Web of Science databases for randomized controlled trials(RCTs)on the use of TXA in TSA.And all the results were checked and assessed by Reference Citation Analysis(https://www.referencecitationanalysis.com/).A meta-analysis was performed with Review Manager 5.3 to calculate the odds ratio(OR)or weighted mean difference(WMD)of related outcome indicators.RESULTS A total of 5 RCTs with level 1 evidence were included.There were 369 cases,with 186 in the TXA group and 183 in the placebo group.The meta-analysis showed that TXA can significantly reduce total blood loss during the perioperative period[WMD=-249.56,95%confidence interval(CI):-347.6 to-151.52,P<0.0001],and the incidence of adverse reactions was low(OR=0.36,95%CI:0.16-0.83,P=0.02).Compared with the placebo group,the TXA group had significantly less total haemoglobin loss(WMD=-34.39,95%CI:-50.56 to-18.22),less haemoglobin fluctuation before and after the operation(WMD=-0.6,95%CI:-0.93 to-0.27)and less 24-h drain output(WMD=-136.87,95%CI:-165.87 to-106.49).There were no significant differences in the operation time(P=0.11)or hospital length of stay(P=0.30)between the two groups.CONCLUSION The application of intravenous TXA in the perioperative period of TSA can significantly reduce the total volume of perioperative blood loss and reduce the incidence of adverse reactions,so TXA is worthy of widespread clinical use.

Return to work following shoulder arthroplasty:A systematic review

BACKGROUND Many patients prioritize the ability to return to work(RTW)after shoulder replacement surgeries such as total shoulder arthroplasty(TSA),reverse TSA(rTSA),and shoulder hemiarthroplasty(HA).Due to satisfactory clinical and functional long-term outcomes,the number of shoulder replacements performed will continue to rise into this next decade.With younger individuals who compose a significant amount of the workforce receiving shoulder replacements,patients will begin to place a higher priority on their ability to RTW following shoulder arthroplasty.AIM To summarize RTW outcomes following TSA,rTSA,and HA,and analyze the effects of workers’compensation status on RTW rates and ability.METHODS This systematic review and analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.A literature search regarding RTW following shoulder arthroplasty was performed using four databases(PubMed,Scopus,Embase,and Cochrane Library),and the Reference Citation Analysis(https://www.referencecitationanalysis.com/).All studies in English relevant to shoulder arthroplasty and RTW through January 2021 that had a level of evidence I to IV were included.Nonclinical studies,literature reviews,case reports,and those not reporting on RTW after shoulder arthroplasty were excluded.RESULTS The majority of patients undergoing TSA,rTSA,or HA were able to RTW betweenone to four months,depending on work demand stratification.While sedentary or light demand jobs generally have higher rates of RTW,moderate or heavy demand jobs tend to have poorer rates of return.The rates of RTW following TSA(71%-93%)were consistently higher than those reported for HA(69%-82%)and rTSA(56%-65%).Furthermore,workers’compensation status negatively influenced clinical outcomes following shoulder arthroplasty.Through a pooled means analysis,we proposed guidelines for the average time to RTW after TSA,rTSA,and HA.For TSA,rTSA,and HA,the average time to RTW regardless of work demand stratification was 1.93±3.74 mo,2.3±2.4 mo,and 2.29±3.66 mo,respectively.CONCLUSION The majority of patients are able to RTW following shoulder arthroplasty.Understanding outcomes for rates of RTW following shoulder arthroplasty would assist in managing expectations in clinical practice.

A Retrospective Comparison of Interscalene Continuous Catheter Verse Single-Injection with Liposomal Bupivacaine in Total Shoulder Arthroplasty

Background: One common method of pain control for total shoulder arthroplasty is long-duration delivery of local anesthetic via interscalene brachial plexus block (ISB) with a continuous catheter. Alternatively, liposomal bupivacaine has also been administered as an ISB as a means to prolong the analgesic effect. This study was completed to measure the non-inferiority of single-injection ISB with liposomal bupivacaine compared with ISB continuous catheter for total shoulder arthroplasty. Methods: We performed a retrospective chart review of patients who underwent total shoulder arthroplasty using either an ISB continuous catheter or a single injection ISB with liposomal bupivacaine for post operative analgesia. The primary goal of this study was to determine if single-injection with liposomal bupivacaine conferred non-inferior pain scores compared to the continuous catheter. Secondary outcomes evaluated oxygen saturation as a measure of hemidiaphragmatic paresis, post operative opioid requirements, and difference in cost. Results: We identified 333 patients for the study: 126 received continuous catheter and 207 received single-injection with liposomal bupivacaine. The median length of stay was 1 day. Pain scores for those treated with single-injection with liposomal bupivacaine were non-inferior to pain scores of those treated with the continuous catheter on post-op days 0, 1 and 2. Pain scores were lower for single-injection with liposomal bupivacaine patients on days 3 and 4, however they did not reach statistical significance. There was no significant difference in oxygen saturation between the two groups. Both groups had similar daily morphine milligram equivalent requirements. Liposomal bupivacaine ISB was also found to be less expensive. Conclusion: Single-injection ISB with liposomal bupivacaine provides non-inferior analgesia at a reduced cost compared with continuous catheter ISB for total shoulder arthroplasty.

Simultaneous bilateral acromial base fractures after staged reverse total shoulder arthroplasty: A case report

BACKGROUND Acromial and scapular spine fractures after reverse total shoulder arthroplasty(RTSA)are a well-known complication that may negatively impact the effects of long-term outcomes.However,to the best of our knowledge,there has been no report of simultaneous bilateral fractures of the acromion or scapular spine that occurred following staged RTSA.CASE SUMMARY A 79-year-old right-handed male visited our outpatient clinic with a chief complaint of pain and limited motion of both shoulder joints for a one-year duration.Based on plain radiographs and magnetic resonance images,the preoperative diagnosis was bilateral cuff tear arthropathy with failed rotator cuff repair.This patient was treated with staged bilateral RTSA at a two-month interval.At 5 and 3 mo after right and left side surgery,the patient returned to the outpatient clinic with severe pain and limited motion of both shoulder joints for 2 wk without a traumatic event.A computed tomography scan revealed nondisplaced acromial base fractures of both shoulders.Considering bilateral involvement,fracture location,and patient’s demand,open reduction and internal fixation(ORIF)using plate for bilateral acromial base fractures were performed.At 2 years after ORIF,the fracture was completely healed,and the patient was satisfied with shoulder status.CONCLUSION This report describes an extremely rare case of simultaneous bilateral acromial base fractures after staged RTSA managed successfully by ORIF with a precontoured plate designed for distal clavicle fractures.Although acromial fracture after RTSA can be treated conservatively,simultaneous bilateral fractures may warrant surgical intervention as a means of addressing difficulties in activities of daily living.

Conversion to reverse shoulder arthroplasty fifty-one years after shoulder arthrodesis:A case report

BACKGROUND Patients with a shoulder arthrodesis generally experience restriction in range of motion and limitations in activities of daily living.In addition,up to one-third of the patients deals with serious peri scapular pain.The conversion of a shoulder arthrodesis in a reverse shoulder arthroplasty(RSA)has been described as an effective treatment to achieve better function and decreased pain,although literature is sparse.We present the case of a conversion from a painful shoulder arthrodesis to RSA,after a 51 years interval.CASE SUMMARY A 71-year-old male presented with severe peri scapular pain and limited function 51 years after shoulder arthrodesis.Preoperative workup showed a normal bone stock of the glenoid and an intact axillary nerve,but atrophic posterior part of the deltoid muscle.The shoulder arthrodesis was successfully converted to RSA.Twelve months postoperative the patient was very satisfied.He has no pain at rest,nor with exercise and experienced definite improvements in activities of daily living,despite his limited range of motion.CONCLUSION Conversion from shoulder arthrodesis to a RSA can be performed safely,with a high chance of peri scapular pain relief;even after a longstanding arthrodesis.

Plate vs reverse shoulder arthroplasty for proximal humeral fractures:The psychological health influence the choice of device?

BACKGROUND Proximal humeral fractures represent the third most common observed osteoporotic fracture;the treatment in three and four-part proximal humeral fractures in patients over 65 years is still controversial.Among the treatments described in literature,open reduction and internal fixation(O.R.I.F)and reverse shoulder arthroplasty(RSA)are gaining an increasing popularity.AIM To investigate the correct treatment for three and four-part proximal humeral fractures according to psychological aspects.METHODS It was conducted a prospective study with a series of 63 patients treated with O.R.I.F.(group A)and with RSA(group B)for three and four-part proximal humeral fractures according to Neer classification system.A conservative treatment group,as control,was finally introduced.One independent observer performed clinical and a psychological evaluation at one(T0),six(T1)and twelve months(T2)postoperatively.The Constant’s score and The Disabilities of the Arm,Shoulder and Hand(DASH score)were used for clinical evaluation,while General Anxiety Disorder-7(GAD-7)and Caregiver Strain Scale(CSS)were used for psychological evaluation.RESULTS At one month follow up in group A the mean values were DASH score 50.8,Constant score 36.1,GAD-7 score 5.4,CSS 5.0.For the group B,the average values at T0 were:DASH score 54.6,Constant score 32.0;GAD-7 score 6.4,CSS 6.2.At six months in group A the average values were DASH score 42.1,Constant score 47.3,GAD-7 score 4.3,CSS 3.9.For the group B,the average values at T1 were:DASH score 39.1,Constant score 43.2,GAD-7 score 5.7,CSS 5.5.At twelve months in the group A,the mean values were DASH score 32.8,Constant score 60.0,GAD-7 score 3.2,CSS 3.1.For the group B shown these mean values:DASH score 33.6,Constant score 52.9,GAD-7 score 4.3,CSS 4.5.We demonstrated a better clinical and psychological outcome at T2 in the group treated with osteosynthesis compared to the group treated with arthroplasty(Constant P=0.049,GAD-7 P=0.012 and CSS P=0.005).A better clinical and psychological outcome emerged in control group at T2 comparing with surgical group(DASH score P=0.014,Constant score P<0.001,GAD-7 P=0.002 and CSS P=0.001).CONCLUSION Both open osteosynthesis and reverse shoulder arthroplasty are valid treatments for proximal humeral fractures.According to the best osteosynthesis results the authors suggested to perform a psychological analysis for each patient in order to choose the appropriate treatment.

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures

Purpose:Unsatisfactory results of hemiarthroplasty in Neer’’s 3- and 4-part proximal humerus fractures in elderly,have led to the shift towards reverse shoulder arthroplasty (RSA).The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.Methods:We include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head.Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded.According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month,the patients were divided into 2 groups,as the group with successful tuberosity repair and the other with failed tuberosity repair.Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independentt-test for normally distributed parameters and Mann-Whitney test for the parameters,where data was not normally distributed.Results:Of 41 patients,tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases.Lysis of the tuberosity occurred in 5 patients,tuberosity displacement in 2,and nonunion in 2.Mean age was 70.4 years (range 65 – 79 years) and mean follow-up was 58.7 months (range 18 – 93 months).There were no major complications.Group with successful tuberosity repair showed improvement in mean active range of movements,like anterior elevation (165.1°± 4.9°vs.144.6°± 9.4°,p < 0.000),lateral elevation (158.9°± 7.2°vs.138.4°± 9.6°,p < 0.000),external rotation (30.5°± 6.9°vs.35.0°± 6.3°,p = 0.367),internal rotation (33.7°± 7.5°vs.32.6°± 6.9°,p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1vs.55.5 ± 5.7,p < 0.000),American shoulder and elbow surgeons score (90.3 ± 2.4vs.69.0 ± 5.7,p < 0.000),disability of arm shoulder and hand score (22.1 ± 2.3vs.37.6 ± 2.6,p < 0.000).Conclusion:Successful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion,strength and shoulder scores.Standardized repair technique and interposition of cancellous bone grafts,harvested from the humeral head can improve the rate of tuberosity healing.

Unexpected positive cultures including isolation of Propionibacterium acnes in revision shoulder arthroplasty

Objective Little information is available to guide treatment strategies regarding patients with unexpected positive cultures （UPC）,including Propionibacterium acnes （PA）,without overt signs of infection in revision shoulder arthroplasty （RSA）.The purpose of our study was to analyze the prevalence,clinical meaning,treatment and prognosis of UPC in RSA.Data sources and study selection We performed a systematic review of the literature between 1950 and 2013 for all studies reporting on UPC for PA.Studies with the prevalence and prognosis of patients with UPC in RSA were analyzed.Results Six studies meeting our inclusion criteria yielded data for 1 402 patients who underwent a total of 1405 RSA.Based on the available data,following RSA 235 shoulders had UPCs with a pooled percentage of 16.7％ （235/1405）.The most commonly isolated bacteria from shoulders following RSA with UPCs was PA with pooled percentages of 63.4％ （149/235）.Occurrence of true infection from UPCs after RSA was seen in 24 shoulders （24/235,10.2％）.Antibiotic use did not influence the rate of the occurrence of true infection from UPCs （P=0.498）.Conclusions Our study showed a low risk of having a true infection from UPCs after RSA without clinical signs of preoperative infection at the time of the surgery.Therefore,prolonged antibiotic therapy may not be necessary in these patients.

The evaluation of reverse shoulder lateralization on deltoid forces and scapular fracture risk:A computational study

Reverse shoulder arthroplasty(RSA)can treat severe rotator cuff deficiency,but its medialized design of the shoulder's center of rotation(CoR)has been associated with scapular notching.Although lateralization of CoR provides a larger impingement-free range of motion,the changes in component positioning alter the biomechanics and may cause unforeseen complications.This work quantified the muscle forces and predicted the scapula fracture risk by coupling dynamic simulation analysis with finite element modeling.To identify bone failure patterns,the results were analyzed using three common failure measures.A parametric study showed greater lateralization produced higher strain/stress concentrations in the scapular spine(Levy Region Type II),with approximately a 10%increase for the 12 mm lateralized scenario,compared to a neutral configuration.Significant differences in fracture risk patterns were found between the maximum principal stress/strain results and the von Mises stress results.The lateralized configurations could increase the muscle and joint reaction forces during abduction and induce scapular fracture.Studying the effects of RSA lateralization on scapular fracture risk can help guide the continued optimization of RSA performance and surgical techniques.The findings of relationships between the loading style and bone failure measures can provide valuable insight into the investigation of bone failure criteria.

Transfer Learning-Based Class Imbalance-Aware Shoulder Implant Classification from X-Ray Images

Total shoulder arthroplasty is a standard restorative procedure practiced by orthopedists to diagnose shoulder arthritis in which a prosthesis replaces the whole joint or a part of the joint.It is often challenging for doctors to identify the exact model and manufacturer of the prosthesis when it is unknown.This paper proposes a transfer learning-based class imbalance-aware prosthesis detection method to detect the implant’s manufacturer automatically from shoulder X-ray images.The framework of the method proposes a novel training approach and a new set of batch-normalization,dropout,and fully convolutional layers in the head network.It employs cyclical learning rates and weighting-based loss calculation mechanism.These modifications aid in faster convergence,avoid local-minima stagnation,and remove the training bias caused by imbalanced dataset.The proposed method is evaluated using seven well-known pre-trained models of VGGNet,ResNet,and DenseNet families.Experimentation is performed on a shoulder implant benchmark dataset consisting of 597 shoulder X-ray images.The proposed method improves the classification performance of all pre-trained models by 10–12%.The DenseNet-201-based variant has achieved the highest classification accuracy of 89.5%,which is 10%higher than existing methods.Further,to validate and generalize the proposed method,the existing baseline dataset is supplemented to six classes,including samples of two more implant manufacturers.Experimental results have shown average accuracy of 86.7%for the extended dataset and show the preeminence of the proposed method.