What's New in Shoulder and Elbow Surgery.

Recurrent anterior shoulder instability after arthroscopic Bankart repair presents a challenging clinical problem, with the primary stabilization procedure often portending the best chance for clinical success. To determine if capsuloligamentous laxity affects failure (recurrent dislocation, subluxation, and/or perceived instability symptoms) after arthroscopic Bankart repair in patients with near-track lesions (ie, those with smaller distance to dislocation [DTD]). Case-control study; Level of evidence, 3. The authors retrospectively reviewed consecutive patients who underwent primary arthroscopic Bankart repair for recurrent anterior glenohumeral instability at a single institution between 2007 and 2019 and who had at least 2 years of follow-up data. Patients with glenoid bone loss >20%, off-track lesions, concomitant remplissage, or rotator cuff tear were excluded. Capsuloligamentous laxity, or hyperlaxity, was defined as external rotation >85° with the arm at the side and/or grade ≥2 in at least 2 planes with the shoulder at 90° of abduction. Near-track lesions were defined as those with a DTD <10 mm. Included were 173 patients (mean age, 20.5 years; mean DTD, 16.2 mm), of whom 16.8% sustained a recurrent dislocation and 6.4% had recurrent subluxations (defined as any subjective complaint of recurrent instability without frank dislocation), for an overall recurrent instability rate of 23.1%. The rate of revision stabilization was 15.6%. The mean time to follow-up was 7.4 years. Independent predictors of recurrent instability were younger age (P = .001), smaller DTD (P = .021), >1 preoperative instability episode (P < .001), and the presence of hyperlaxity during examination under anesthesia (P = .013). Among patients with near-track lesions, those with hyperlaxity had a recurrent instability rate almost double that of patients without hyperlaxity (odds ratio, 34.1; P = .04). The increased rate of failure and recurrent dislocation in the near-track hyperlaxity cohort remained elevated, even in patients with no bone loss. Capsuloligamentous shoulder laxity was a significant independent risk factor for failure after primary arthroscopic Bankart repair without remplissage and was more predictive of failure in patients with versus without near-track lesions.

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.

Comparison of reverse shoulder arthroplasty and total shoulder arthroplasty for patients with inflammatory arthritis.

Reverse total shoulder arthroplasty changes the lines of action of the shoulder muscles, resulting in increases in the moment arms of the major abductors and flexors of the glenohumeral joint; however, at present little is known about the axial rotation capacity of the musculature after this procedure. The purpose of this study was to measure the instantaneous axial rotation moment arms of all of the major muscles spanning the glenohumeral joint during abduction and flexion after reverse total shoulder arthroplasty. Reverse total shoulder arthroplasty was performed on eight entire cadaveric upper extremities. Specimens were mounted onto a testing apparatus, and the internal/external rotation moment arms of eighteen major muscle subregions involving the subscapularis, supraspinatus, infraspinatus, teres minor, teres major, deltoid, pectoralis major, and latissimus dorsi were measured during abduction and flexion. These muscle moment arms were compared with those measured preoperatively in the anatomical shoulders (i.e., before the arthroplasty). Reverse total shoulder arthroplasty resulted in loss of external rotation function in the posterior deltoid subregion. Postoperatively, the inferior subscapularis subregion had the largest internal rotation moment arm overall, whereas the teres minor and the inferior infraspinatus subregion had the greatest external rotation moment arms. The teres minor, infraspinatus, and deltoid subregions were external rotators during abduction, whereas only the teres minor, infraspinatus, and to a small extent the posterior deltoid subregion were external rotators during flexion. Reverse total shoulder arthroplasty results in an overall decrease in the external rotation moment arm of the deltoid and increases in the moment arms of the major internal rotators, including the latissimus dorsi and pectoralis major. Reverse total shoulder arthroplasty may result in complete loss of external rotation function if the teres minor and infraspinatus muscles are damaged.

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

Shoulder arthroplasty effectively treats various degenerative and traumatic shoulder conditions, but outcomes can be compromised by complications, limited mobility, and persistent pain. The impact of previous nonarthroplasty surgery on functional outcomes remains unclear. Therefore, the purpose of this study is to determine if a history of prior nonarthroplasty shoulder surgery is associated with worse functional outcomes after primary shoulder arthroplasty. This registry study with data sourced from the Dutch Arthroplasty Register (LROI) includes adult patients who underwent primary arthroplasty between 2014 and 2022, with or without a history of prior nonarthroplasty shoulder surgery. Prior surgeries were divided into the following categories: osteosynthesis, stabilization, rotator cuff, subacromial decompression, and other shoulder surgeries. The outcomes of the study include revision rate, shoulder function, and shoulder pain. Twenty-five thousand one hundred eighty-eight shoulder arthroplasty procedures were recorded in the registry between 2014 and 2022. Of the procedures, 18,160 (72.1%) were reverse total shoulder arthroplasty, 4,772 (18.9%) anatomic total shoulder arthroplasty, and 2,256 (9.0%) hemishoulder arthroplasty. A total of 4,203 patients (16.7%) underwent prior shoulder surgery, while 20,985 (83.3%) did not. From 2017 onward, completion rates of patient-reported outcome measures ranged from 21.2% to 30.0%. Prior shoulder surgery was associated with higher chance of revision surgery (hazard ratio [HR] (95% confidence interval [CI]) = 1.48 (1.31 to 1.68), n = 25,188). Prior surgery was associated with less improvement in shoulder function (regression coefficient (95%CI) = -2.84 (-3.83 to -1.84), n = 3,206), less improvement in pain score at rest (regression coefficient (95%CI) = -0.57 (-0.77 to -0.37), n = 3,325) and less improvement in pain during activity (regression coefficient (95%CI) = -0.64 (-0.88 to -0.41), n = 3,318) after 12 months. Patients with a history of osteosynthesis (HR (95%CI) = 1.58 (1.31 to 1.91)) or rotator cuff repair (HR (95%CI) = 1.47 (1.18 to 1.83)) had lower prosthesis survival compared to those without such interventions. A history of nonarthroplasty shoulder surgery is associated with higher revision rates and poorer patient-reported outcomes after primary shoulder arthroplasty. These findings highlight the importance of surgical history in preoperative counseling and risk stratification.

What's New in Sports Medicine.

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.

Glenoid reconstruction with autologous humeral head for glenoid dysplasia in reverse shoulder arthroplasty

* The most common indication for reverse total shoulder arthroplasty is primary rotator cuff tear arthropathy.* Indications for reverse total shoulder arthroplasty have expanded beyond rotator cuff tear arthropathy to include other pathologies such as irreparable rotator cuff tears, glenohumeral arthritis with an intact rotator cuff, acute proximal humeral fractures, the sequelae of proximal humeral fractures, neoplasms of the proximal part of the humerus, inflammatory arthropathies, and failed total shoulder arthroplasty and hemiarthroplasty.* Reverse total shoulder arthroplasty continues to have high rates of complications, which include instability, infection, scapular notching, neurologic injury, and component loosening, among others.

There are few reports on the revision or reintervention of reverse total shoulder arthroplasty (RTSA) in South Korea. The purpose of this study was to evaluate the true incidence of complications and reintervention of RTSA and clinical and radiological outcomes based on our 14-year experience in RTSA in a Korean population. Between March 2008 and June 2022, 412 consecutive cases of RTSA were performed in 388 patients with an average age of 74.4 years at our institute. Excluding 23 patients lost to follow-up, 365 patients (373 shoulders including 8 bilateral cases) who underwent primary RTSA with more than 6 months of follow-up were enrolled in this study. We evaluated those who had complications or reintervention including revision RTSA for failed RTSA. Patient charts were reviewed, and clinical outcomes including clinical scores, complications, and reintervention and radiologic outcomes were evaluated at the last follow-up. Among the 373 shoulders that underwent primary RTSA, complications were found in 50 patients (13.94%, 10 men and 40 women with a mean age of 75.9 ± 6.7 years [range, 51-87 years]). The causes of complications were as follows: 13 acromion, coracoid, or scapular spine fractures, 10 loosening (glenoid: 5, humeral stem: 5), 5 infections, 4 periprosthetic fractures, 2 instability, 2 neurologic complications, and 14 miscellaneous complications. Twenty patients (5.63%, 4 men and 16 women with a mean age of 74.2 ± 8.2 years [range, 51-87 years]) underwent reintervention. The interval to the first reintervention was 27.8 ± 23.1 months (range, 0.1-78 months). The causes of reintervention (20 cases) were 8 loosening (glenoid: 4, humeral stem: 4), 5 infections, 5 fractures, and 2 instability. Among them, 15 component revisions (4.02%) were performed. At the last follow-up, American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Simple Shoulder Test scores were improved from 25.4, 12.4, and 1.6 preoperatively to 40.4, 16.2, and 3.2, respectively. Forward flexion (48° to 87°), abduction (52° to 79°), external rotation (18° to 22°), and internal rotation (buttock to L2) were improved. After primary RTSA in a Korean population, the complication, reintervention, and revision rates were 13.94%, 5.63%, and 4.02%, respectively. Careful evaluation of the complications and adequate treatments should be performed.

Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty

Glenoid lateralization influences active internal rotation after reverse shoulder arthroplasty.

Limited Predictive Value of the Instability Severity Index Score: Evaluation of 217 Consecutive Cases of Recurrent Anterior Shoulder Instability

Editorial Commentary: Is It Time to Take a Stand? When Arthroscopic Bankart Repair Is No Longer a Viable Option for Anterior Shoulder Instability