Ryan Simovitch, MD
Read complete study: Younger patients report similar activity levels to older patients after reverse total shoulder arthroplasty
The authors conducted a study to measure a subjective questionnaire that reported type of activities, range of motion, pain and strength. The authors looked at patients younger and older than 65 to determine if there was a difference in activity levels and what the functional differences were in these patient populations. They broke activity level down into low, medium and high demand.
The authors bring up a good point for surgeons to think about. Older patients are not necessarily inactive patients. The patient population at my practice in South Florida is older demographically, but those patients still enjoy golfing, swimming, lifting weights, cycling, hunting and other similar activities that place high stresses on shoulder implants.
In my practice, I tend to view physiological age as a more important indicator than chronological age because my experience confirms what the study has above has found. Continue reading
Howard Routman, DO
Read the complete study: Causes of poor postoperative improvement after reverse total shoulder arthroplasty
This study reviewed comorbidities and results for higher baseline American Shoulder and Elbow Surgeons (ASES) scores that are correlated with poor post-operative improvement. The study collected data from a total of 150 patients who underwent reverse total shoulder arthroplasty (rTSA) from 2007-2013. A minimum of two-year post-operative ASES scores were included, and poor post-op improvement was defined as a change of ASES score of less than 12 points. Out of the 150 patients, male gender, presence of an intact rotator cuff at the time of surgery, depression, a higher baseline ASES score and higher total number of medical comorbidities were associated with poor post-operative improvement after rTSA. Neither patient age, nor indication for surgery, was found to correlate with poor improvement after rTSA. In general, the study population was older, with an average age of 71.6 +/- 8.8, and the majority of patients were female.
It should be noted that as the number of rTSAs continues to grow rapidly—due to its success in improving pain and function in most patients—some patients fail to improve clinically. Interestingly, the article also mentioned that patient satisfaction is now frequently linked to hospital and physician reimbursements. This study emphasizes reasons for poor post-operative improvement throughout with baseline pulled from ASES scores and patient data. Physical examination findings were not a focused component of the analysis.
The temptation to view the rTSA as a panacea that can fix everything is high. We need to temper our enthusiasm and ensure that we select our patients wisely.
When managing expectations with higher pre-operative ASES scores, I don’t really look at an ASES score pre-operatively as a screening tool, but I appreciate the concept of the ‘delta’ of improvement before surgery. If a patient’s radiograph shows a classic cuff tear arthropathy, and the patient has maintained overhead elevation and mild pain, the change in function and pain that can be provided with a perfect reverse is minimal. Ideally, patient selection can help us identify who best benefits from rTSA. By limiting the indications to patients who cannot elevate beyond 90⁰, and who identify themselves has having quality-of-life-altering pain, we can skew our delta favorably. The article referenced a study by Wall et al that noted patients who underwent rTSA for primary osteoarthritis had much smaller improvements in range of motion compared with patients who underwent rTSA for rotator cuff tear arthropathy or massive tears. Current expectations for improving post-operative function versus outcomes in patients with high levels of pre-operative function are to be noted.
In a cohort of 31 of my rTSA patients, the average post op ASES score was 82.68 (+/- 18.4), compared to 76 +/- 16.7 as mentioned in the study. Continue reading
Thomas Wright, MD
Read complete study: Risk of insufficient internal rotation after bilateral reverse shoulder arthroplasty: clinical and patient reported outcome in 57 patients.
This study focused on the effects and risks of bilateral reverse shoulder arthroplasty (rTSA) on internal rotation (IR) in 57 patients. Data was recorded up to two years after the second surgery. The study found that only 15 percent of patients had insufficient IR in both shoulders after 12 months and 5 percent after 24 months. Patients who had insufficient baseline IR in their second shoulder and insufficient IR 12 month post op after their first shoulder had a 100 percent risk of having insufficient IR in both shoulders. The conclusion of this article is a recommendation to use staged bilateral rTSA over the use of a hemiathroplasty. The authors found that the majority of patients would undergo the surgery again, as it does provide benefits, like reduction in pain, regardless of the issues with IR.
The authors of this study focused on the risks of staged bilateral rTSA on internal rotation. I agree with their concern, as bilateral decreased IR could result in difficulties with toileting. In my practice, I stage my bilateral cases; however the timing is up to the patient. I will proceed with the second surgery no sooner than 12 weeks, but I do not recommend waiting as long as a year. In 2014, we published an article on bilateral rTSA1 in which we found all patients eventually had enough IR to allow toileting with at least one shoulder. I agree with the authors and do not recommend using a hemiarthroplasty in the second shoulder, based on the positive results that we had with rTSA.
Although the article showed a 100 percent failure rate in achieving sufficient IR in the second shoulder when it comes to patients who have both insufficient baseline IR and insufficient IR 12 months post op in their first shoulder, we have not noted that to be a problem.
One example is a 79 year old male with symptomatic cuff tear arthropathy on the right and a failed total shoulder arthroplasty (TSA) on the left due to rotator cuff insufficiency.Because of the predictable nature of performing an rTSA as a primary, the right side was addressed first. At three months post-op he had IR to L5.
79 year old male, cuff tear arthropathy on the right side, 3 months post op
Joseph Zuckerman, MD
These authors studied the ability to implant a custom glenoid component in 10 cadaver glenoids with glenoid defects using patient-specific guides and traditional non-guided techniques. The use of the patient-specific guide reduced angular deviations from the plan and significantly improved the position and length of the screw placements when used to implant the custom made glenoid components.
The authors have focused on a well-known challenge in shoulder arthroplasty – treatment of the deformed glenoid during anatomic or reverse shoulder arthroplasty. There is no doubt that two approaches canbe developed to address this issue. The first is the use of patient-specific guides (or intraoperative positioning devices) to improve the accuracy of component placement. We all recognize that a properly placed glenoid component will have longer-term survival than a malpositioned component. The second approach is to have non-standard glenoid components available to address the deformity. These can be either custom-made implants specific for the patient being treated or augmented “off the shelf” implants that address the common deformities encountered.
I have found that using non-custom or “off the shelf” augmented glenoid components have addressed many of the bone-loss issues I have encountered.
The authors actually combine both approaches – they use a custom implant with a specimen-specific guide. This could be perceived as the “best of both” but in actuality it is quite impractical from a cost perspective. The incremental cost of a custom implant combined with a CT-generated, patient-specific guide would add significant incremental cost. In 2016, regardless of where the surgery is being performed in the world, it is a surgeon’s responsibility to consider cost, especially in the context of cost vs. potential benefit. In addition, the FDA has been very strict on the use of custom implant components, which leaves us surgeons limited options for this approach. Continue reading