Assessing glenoid arthroplasty component positioning for surgeons utilizing surgical planning software

Influence of glenoid wear pattern on glenoid component placement accuracy in shoulder arthroplasty.

Commentary Iannotti et al. present a very interesting and useful investigation into the use of three-dimensional preoperative imaging and templating to assist in planning the positioning of the glenoid component during anatomic shoulder arthroplasty. Additionally, any possible benefit of patient-specific instrumentation was evaluated. To my knowledge, this is the first investigation into the clinical efficacy of this particular emerging technology. All too often, new technological innovations are rapidly adopted without any proven efficacy. This study provides evidence of the role of three-dimensional imaging and templating in the surgical treatment of patients with primary osteoarthritis. This article provides a glimpse into the near future of anatomic shoulder arthroplasty. The Materials and Methods portion of this article was appropriate to achieve the goals of the study. The study consisted of a prospective, randomized controlled trial involving a comparison of patients undergoing three-dimensional imaging and templating with patients undergoing the same imaging and templating technique with the addition of patient-specific instrumentation to assist in glenoid component positioning; a third cohort of patients who had undergone conventional two-dimensional templating was used to serve as a historical control. The retrospective latter part of this study slightly weakens its experimental design. However, given that all of the surgical procedures were performed by experienced surgeons well into their learning curve, I doubt that prospectively collecting the data on the two-dimensional group would have appreciably impacted the results. It is unclear why the authors included twenty-five patients in one group, twenty-one patients in another group, and seventeen patients in the third group. Because no patient was lost to follow-up or withdrew from the study, a better explanation of the choice of the number of the subjects to be included in each group seems warranted. This investigation was limited to a computed tomographic evaluation of glenoid component positioning at a short-term follow-up (less than three weeks). No clinical data are provided, nor would they have been useful that early in the postoperative period. The Results portion of this article yields two very important points. First, three-dimensional imaging and templating are superior to conventional two-dimensional planning in achieving the desired placement of the glenoid component in anatomic shoulder arthroplasty for primary osteoarthritis. Second, the addition of patient-specific instrumentation did not appreciably improve the surgeon’s ability to place the glenoid component in the desired location. Unfortunately, because the follow-up was too short for any meaningful clinical data to be provided, the ultimate clinical implications of this improvement in glenoid component positioning with use of three-dimensional imaging and templating compared with two-dimensional imaging and templating remains unknown. Glenoid component loosening remains a pervasive factor in the failure of anatomic shoulder arthroplasty1. Although many factors undoubtedly contribute to glenoid component failure, proper positioning of the glenoid component would seem to be critical in avoiding this complication. Iannotti et al. have shown a reproducible and accurate method to place the glenoid component in the desired position with use of three-dimensional imaging and templating and have further demonstrated the superiority of this technique over conventional two-dimensional preoperative planning. The methods of glenoid positioning used in this study would seemingly prove useful in nearly all cases of anatomic total shoulder arthroplasty. The value of this method would likely prove more beneficial in difficult cases involving substantial glenoid wear. Another potential area of applicability for the three-dimensional preoperative planning shown in this study that was not discussed by the authors is the use of this technique to preserve existing glenoid bone. Walch et al. recently demonstrated the importance of preservation of subchondral bone in preventing glenoid component failure2. Using information gained from three-dimensional imaging and templating described by Iannotti et al., the radius of curvature of the native glenoid could be established to allow the use of instrumentation and implants that do not require removal of subchondral bone to permit component placement. Importantly, this investigation did not show the benefit in using patient-specific instrumentation. In the increasingly cost-conscious environment of health care, higher cost must yield substantial benefit. The main limitation of this study was the lack of clinical correlation with the radiographic results. Although the three-dimensional preoperative planning proved to be better than two-dimensional preoperative planning at achieving the desired glenoid component positioning, the clinical relevance of this is unclear. I would encourage the authors to continue to follow these patients and to correlate clinical outcomes, complications, and revision rates with glenoid component positioning. If a relationship is subsequently demonstrated, more value will be added to this technique. Congratulations to Dr. Iannotti and his associates for their work on this study. This article shows that the future is now in using novel technology to improve our radiographic results. Time will tell if these radiographic improvements will translate into better clinical results, lower complication rates, and improved prosthetic longevity for our patients.

Background Recent literature has described an increase in overall rates of shoulder arthroplasty procedures being performed. To date few reports have characterized the yearly trended earliest incidence of introduction of the then innovative reverse total shoulder arthroplasty (RTSA) since FDA approval in 2003. This study aimed to describe the earliest surgical trends in RTSA use performed in the United States over time. We believe this knowledge will help show how early trends in new innovations provide experience to understand later iterative innovation in the same device. Methods Two complementary datasets that recorded RTSA use discretely at the advent of use in America were reviewed to compare the rates of RTSA being performed on national and regional levels over time. The American Board of Orthopaedic Surgery (ABOS) national database was reviewed, to identify all shoulder arthroplasty cases reported by Part II candidates from 2005-2010. RTSA, total shoulder arthroplasty (TSA), and shoulder hemiarthroplasty cases were each identified separately. Additionally, a regional integrated healthcare system implant registry was reviewed to identify all RTSA, TSA, and shoulder hemiarthroplasty cases performed from 2005-2010. Surgical trends in RTSA rates from both datasets were calculated and compared. Results From 2005-2010 the national ABOS database reported 2,674 shoulder arthroplasty cases, of which 425 were RTSA. In 2005, 19 RTSA cases were reported to the ABOS and constituted 5.2% of all shoulder arthroplasty cases reported. In 2010, 108 RTSA cases were reported and constituted 24.5% of all shoulder arthroplasty cases, an increase of 369%. Meanwhile the regional integrated healthcare system implant registry from 2005-2010 reported 1519 shoulder arthroplasty cases of which 174 were RTSA. In 2005, 8 RTSA cases were reported through this registry and constituted 4.1% of all shoulder arthroplasty cases. In 2010, 49 RTSA cases were performed and constituted 14.9% of all shoulder arthroplasty cases, an increase of 173%. Conclusion Rates of RTSA being performed have increased dramatically since FDA approval. Both regional and national rates showed this increase, suggesting a lack of regional bias. The rise of RTSA use has continued since these early documented rates with newer literature supporting increases in indications and volumes. This report serves as a retrospective comparison of the earliest documented RTSA use. The use rates early in the experience of the innovative idea of RTSA may be instructive and educational to surgeons in this time of expanding indications for RTSA and with utilization of newer RTSA designs. Level of Evidence Level III Retrospective Comparative Study

Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy.

Reverse shoulder arthroplasty has higher perioperative implant complications and transfusion rates than total shoulder arthroplasty

BACKGROUNDThe optimal surgical approach for patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff remains debated. While anatomic total shoulder arthroplasty (TSA) has traditionally been favoured, reverse TSA (RTSA) is increasingly utilized.AIMTo systematically compare the outcomes of RTSA and TSA in this specific patient population.METHODSA systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Retrospective comparative studies evaluating RTSA and TSA in patients with GHOA and intact rotator cuff were included. Key outcomes assessed included complication and reoperation rates, patient-reported outcome measures (PROMs), and range of motion. Risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions tool.RESULTSTwelve studies encompassing 1608 patients (580 RTSA, 1028 TSA) met inclusion criteria. RTSA was associated with a lower reoperation rate compared to TSA [odds ratio = 0.37; 95% confidence interval (CI): 0.14-0.94; P value = 0.04], while no significant difference in overall complication rates was observed (odds ratio = 0.47; 95%CI: 0.19-1.16; P value = 0.10). RTSA patients showed superior outcomes in University of California Los Angeles, Simple Shoulder Test, and Shoulder Pain and Disability Index scores; however, the differences did not exceed the minimal clinically important difference. TSA patients had significantly better external rotation (mean difference= -9.0°; 95%CI: -13.21 to -5.02; P value < 0.0001). No significant differences were found in other range of motion measures or satisfaction scores. The overall methodological quality of included studies was moderate to serious.CONCLUSIONIn patients with GHOA and an intact rotator cuff, RTSA may offer comparable or improved outcomes to TSA with lower reoperation rates and similar complication profiles. Functional outcomes favour RTSA in certain patient-reported outcome measures, while TSA retains an advantage in external rotation. Surgical decision-making should remain individualized based on patient characteristics and functional demands.

Osteoporosis is a widespread and growing medical condition, with significant orthopaedic implications. However, the effect of osteoporosis on outcomes after total shoulder arthroplasty (TSA) is not well understood. The goal of the present study was to characterize the incidence of osteoporosis in patients undergoing shoulder arthroplasty and to examine whether patients with osteoporosis undergoing anatomic and reverse TSA are at an increased risk of prosthetic-related complications. Complication rates were calculated for patients with osteoporosis who underwent anatomic and reverse TSA as separate cohorts within 2 years of surgery including loosening/osteolysis, periprosthetic fracture, periprosthetic dislocation, and revision shoulder arthroplasty and compared using a multivariable logistic regression analysis to control for patient demographics and comorbidities during comparisons, including the indication for reverse TSA. The prevalence of an osteoporosis diagnosis at the time of surgery was 14.3% for anatomic TSA patients and 26.2% of reverse TSA patients. Anatomic TSA patients with osteoporosis experienced significantly higher rates of periprosthetic fracture (odds ratio [OR], 1.49; P = 0.017) and revision shoulder arthroplasty (OR, 1.21; P = 0.009) within 2 years of surgery compared with matched controls without osteoporosis. Patients in the reverse TSA group with osteoporosis also had significantly higher rates of periprosthetic fracture (OR, 1.86; P = 0.001) and revision shoulder arthroplasty (OR, 1.42; P = 0.005) within 2 years of surgery compared with matched controls. A significant number of patients undergoing both anatomic and reverse TSA have a concurrent diagnosis of osteoporosis. Osteoporosis represents a significant independent risk factor for periprosthetic fracture and revision shoulder arthroplasty within 2 years of surgery, regardless of the type of implant. Patients with osteoporosis should be counseled on their increased risk of complications after shoulder arthroplasty.

Sequential 3-dimensional computed tomography analysis of implant position following total shoulder arthroplasty

BackgroundShoulder arthroplasty is effective for reducing pain and improving shoulder function in older patients, but there is limited information on outcomes in patients aged 45 years and younger. Younger patients may be more active and require prolonged use of their operative shoulder, potentially increasing the risk of arthroplasty failure or revision. This study aimed to evaluate complication rates of anatomic total shoulder arthroplasty (TSA), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) in younger patients. We hypothesized that the complication rates would be comparable with those of older patients in existing literature.MethodsThis multicenter, retrospective study included patients aged 45 years and younger undergoing primary TSA, HA, or rTSA with a minimum 2-year follow-up. Exclusion criteria were patients older than 45 years or those with revision surgeries. Primary outcomes were complications, reoperations, and radiographic analysis of component loosening or failure. Secondary outcomes included American Shoulder and Elbow Surgeons scores, visual analog scale pain scores, and range of motion (ROM). Statistical analysis was used to assess differences in outcomes.ResultsSeventy patients, with an average follow-up of 85 months, underwent 35 TSA, 30 HA, and 5 rTSA procedures. The most common operative diagnosis was osteoarthritis (44%). The overall complication rate was 19% and the reoperation rate was 13%, with no significant differences between arthroplasty types. Radiolucent lines were present in 14.3% (10 cases) of the humeral components and 10.0% (7 cases) of the glenoid components. Glenoid radiolucencies were present only in the TSA group, with one (3%) patient undergoing revision for loosening. Clinical outcomes showed significant improvements in American Shoulder and Elbow Surgeons scores, visual analog scale pain, and ROM, with no differences between arthroplasty types.ConclusionYounger patients undergoing shoulder arthroplasty have an acceptable complication profile, but a relatively high risk of reoperation. Glenoid component loosening occurred only in the TSA, with a 3% revision rate. All arthroplasty types showed significant improvements in ROM, pain levels, and function, indicating that patients benefit from the procedure. Nevertheless, the relatively high complication and reoperation rates for all three types of arthroplasty should be taken into account when considering shoulder replacement in those patients.

What's New in Shoulder and Elbow Surgery.

» Treatment of glenoid bone loss continues to be a challenge in total shoulder arthroplasty (TSA). Although correcting glenoid wear to patient's native anatomy is desirable in TSA, there is lack of consensus regarding how much glenoid wear correction is acceptable and necessary in both anatomic and reverse TSA.» Use of augmented glenoid components is a relatively new treatment strategy for addressing moderate-to-severe glenoid wear in TSA. Augmented glenoid components allow for predictable and easy correction of glenoid wear in the coronal and/or axial planes while at the same time maximizing implant seating, improving rotator cuff biomechanics, and preserving glenoid bone stock because of off-axis glenoid reaming.» Augmented glenoid components have distinct advantages over glenoid bone grafting. Glenoid bone grafting is technically demanding, adds to the surgical time, and carries a risk of nonunion and graft resorption with subsequent failure of the glenoid component.» The use of augmented glenoid components in TSA is steadily increasing with easy availability of computed tomography-based preoperative planning software and guidance technology (patient-specific instrumentation and computer navigation).» Although different augment designs (full wedge, half wedge, and step cut) are available and a particular design may provide advantages in specific glenoid wear patterns to minimize bone removal (i.e. a half wedge in B2 glenoids), there is no evidence to demonstrate the superiority of 1 design over others.

The proportion of patients undergoing total shoulder arthroplasty (TSA) with obesity continues to grow every year in the United States. Although comorbid obesity is common among TSA patients, the relationship of obesity on medical and surgical complications remains debated. The goal of this study was to evaluate a national database for postoperative medical and surgical complications in patients undergoing TSA with comorbid obesity. Patients undergoing anatomic and reverse TSA were studied in the PearlDiver database. Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes were used to compare patients with and without preoperative obesity who underwent TSA, and they were stratified based on body mass index (BMI) into nonobese, obese, morbidly obese, and superobese. A matched comparison was performed at a 1:1 ratio based on age, sex, diabetes, smoking, tobacco use, and Charlson Comorbidity Index. From 2010 to 2020, a total of 113,634 patients undergoing anatomic or reverse TSA were identified in a national database. During this time, the percentage of TSA patients with obesity increased every year. Matched cohort analysis demonstrated higher odds of readmission, deep vein thrombosis and pulmonary embolism, superficial infection, and prosthetic joint infection at 90 days postoperatively in the obesity group. There were no increased odds of mechanical complications or revision surgery at 2 years in the obesity group when matched to nonobese patients with similar comorbidities. The number of patients undergoing TSA with obesity is rising. Medical complications and infection after TSA are greater in obese patients even when matching for medical comorbidities, age, and sex, and rates of complication increase as BMI increases. Obesity is not an independent risk factor for mechanical surgical complications and revision surgery, and the relatively higher rates are likely due to an increased burden of other comorbidities. Surgeons should counsel obese patients appropriately regarding their perioperative risk of medical complication, but they should not expect higher rates of mechanical complication or revision surgery at 2-year follow-up when compared to a matched control group with similar comorbidities.

Intravenous tranexamic acid vs. topical thrombin in total shoulder arthroplasty: a comparative study

Preoperative risk factors for lower physical therapy compliance rates after shoulder arthroplasty

Chronic steroid use and readmission following total shoulder arthroplasty.