Anatomic versus reverse total shoulder arthroplasty outcomes after prior contralateral anatomic total shoulder arthroplasty in patients with bilateral primary osteoarthritis with an intact rotator cuff.

We aimed to compare outcomes in patients that underwent bilateral anatomic total shoulder arthroplasty (aTSA) vs. aTSA/ reverse total shoulder arthroplasty (rTSA) for rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA) to further elucidate the role of rTSA in this patient population. A single-institution prospectively collected shoulder arthroplasty database was reviewed for patients undergoing bilateral total shoulder arthroplasty (TSA) for RCI-GHOA with a primary aTSA and subsequent contralateral aTSA or rTSA. Outcome scores (SPADI, SST, ASES, UCLA, Constant) and active range of motion (abduction, forward elevation [FE], external and internal rotation [ER and IR]) were evaluated. Clinically relevant benchmarks (minimal clinically important difference [MCID], substantial clinical benefit [SCB], and patient acceptable symptomatic state [PASS]) were evaluated against values in prior literature. Incidence of surgical complications and revision rates were examined in qualifying patients as well as those without <two year follow-up. Of the 55 bilateral TSA patients with an intact rotator cuff, 46 underwent aTSA/aTSA and 9 underwent aTSA/rTSA. At the time of the second TSA, patients undergoing aTSA/rTSA were older (71 ± 4 vs. 67 ± 7, P = .032) and more commonly had inflammatory arthritis (44% vs. 11%, P = .031). Mean time to the second TSA was shorter for aTSA/aTSA (2.3 ± 2.8 vs. 4.4 ± 3.6 years, P < .001). Postoperative outcomes were similar after the first aTSAs between groups with similar proportions achieving the MCID, SCB, and PASS (all P > .05). The 2nd TSAs between groups were similar preoperatively, but aTSA/rTSA had superior outcome scores, overhead motion, and active abduction compared to patients that underwent aTSA/aTSA. There were no differences in active ER and IR scores or complication rates between groups. Patients with RCI-GHOA have excellent clinical outcomes after either aTSA/aTSA or aTSA/rTSA.

Turnbull LM ，Hao KA ，Bindi VE ，Wright JO ，Wright TW ，Farmer KW ，Vasilopoulos T ，Struk AM ，Schoch BS ，King JJ ... -  《-》

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative rotational stiffness and an intact rotator cuff: a case control study.

Reverse total shoulder arthroplasty (rTSA) has begun to challenge the place of anatomic total shoulder arthroplasty (aTSA) as a primary procedure for certain indications. One purported benefit of aTSA is improved postoperative range of motion (ROM) compared to rTSA especially in internal rotation; however, it is unclear whether aTSA can provide patients with significant preoperative stiffness superior ROM compared to rTSA. Our purpose was to compare clinical outcomes of aTSA and rTSA performed in stiff vs. non-stiff shoulders for rotator cuff intact (RCI) glenohumeral osteoarthritis (GHOA). A retrospective review of an international shoulder arthroplasty database identified 1608 aTSAs and 600 rTSAs performed for RCI GHOA with minimum 2-year follow-up. Defining preoperative stiffness as ≤ 0° of passive external rotation (ER), we matched: (1) stiff aTSAs (n = 257) 1:3 to non-stiff aTSAs, (2) stiff rTSAs (n = 87) 1:3 to non-stiff rTSAs, and (3) stiff rTSAs (n = 87) 1:1 to stiff aTSAs. We compared ROM, outcome scores, and the rate of complications and revision surgery at latest follow-up. Despite stiff aTSAs having poorer preoperative ROM and functional outcome scores for all measures assessed (P < .001 for all), only poorer postoperative active abduction (113 ± 27° vs. 128 ± 35°; P < .001), active ER (39 ± 18° vs. 50 ± 20°; P < .001), and passive ER (45 ± 17° vs. 56 ± 18°; P < .001) persisted postoperatively compared to the non-stiff cohort. Similarly, stiff rTSAs had poorer preoperative ROM and functional outcome scores for all measures assessed compared to non-stiff rTSAs (P ≤ .044), but only poorer active abduction (108 ± 24° vs. 128 ± 29°, P < .001), active ER (28 ± 17° vs. 42 ± 17°, P < .001), and passive ER (36 ± 15° vs. 48 ± 17°, P < .001) persisted. When comparing stiff rTSAs to matched stiff aTSAs, no significant differences in preoperative ROM or functional outcome scores were found. However, stiff aTSAs had greater postoperative active internal rotation score (4.8 ± 1.5 vs. 4.2 ± 1.7, P = .022), active ER (40 ± 19° vs. 28 ± 17°, P < .001), and passive ER (46 ± 18° vs. 36 ± 15°, P = .001). Postoperative outcome scores were similar across all matched cohort comparisons despite motion differences. The rate of complications and need for revision surgery did not differ between any group comparisons. Patients with RCI GHOA who have preoperative rotational stiffness have poorer postoperative ROM compared with non-stiff patients following both aTSA and rTSA, but similar functional outcome scores. Notably, preoperative limitations in passive ER do not appear to be a limitation to utilizing aTSA. Indeed, patients with limited preoperative ER treated with aTSA had greater postoperative internal rotation and ER compared to those treated with rTSA.

Hao KA ，Greene AT ，Werthel JD ，Wright JO ，King JJ ，Wright TW ，Vasilopoulos T ，Schoch BS ... -  《-》

Prognostic value of the Walch classification for patients before and after shoulder arthroplasty performed for osteoarthritis with an intact rotator cuff.

The Walch classification is commonly used by surgeons when determining the treatment of osteoarthritis (OA). However, its utility in prognosticating patient clinical state before and after TSA remains unproven. We assessed the prognostic value of the modified Walch glenoid classification on preoperative clinical state and postoperative clinical and radiographic outcomes in total shoulder arthroplasty (TSA). A prospectively collected, multicenter database for a single-platform TSA system was queried for patients with rotator cuff-intact OA and minimum 2 year follow-up after anatomic (aTSA) and reverse TSA (rTSA). Differences in patient-reported outcome scores (Simple Shoulder Test, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Shoulder Pain and Disability Index, visual analog scale for pain, Shoulder Function score), combined patient-reported and clinical-input scores (Constant, University of California-Los Angeles shoulder score, Shoulder Arthroplasty Smart Score), active range of motion values (forward elevation [FE], abduction, external rotation [ER], internal rotation [IR], and radiographic outcomes (humeral and glenoid radiolucency line rates, scapula notching rate) were stratified and compared by glenoid deformity type per the Walch classification for aTSA and rTSA cohorts. Comparisons were performed to assess the ability of the Walch classification to predict the preoperative, postoperative, and improved state after TSA. 1008 TSAs were analyzed including 576 aTSA and 432 rTSA. Comparison of outcomes between Walch glenoid types resulted in 15 pairwise comparisons of 12 clinical outcome metrics, yielding 180 total Walch glenoid pairwise comparisons for each clinical state (preoperative, postoperative, improvement). Of the 180 possible pairwise Walch glenoid type and metric comparisons studied for aTSA and rTSA cohorts, <6% and <2% significantly differed in aTSA and rTSA cohorts, respectively. Significant differences based on Walch type were seen after adjustment for multiple pairwise comparisons in the aTSA cohort for FE and ER preoperatively, the Constant score postoperatively, and for abduction, FE, ER, Constant score, and SAS score for pre- to postoperative improvement. In the rTSA cohort, significant differences were only seen in abduction and Constant score both postoperatively and for pre- to postoperative improvement. There were no statistically significant differences in humeral lucency rate, glenoid lucency rate (aTSA), scapular notching rate (rTSA), complication rates, or revision rates between Walch glenoid types after TSA. Although useful for describing degenerative changes to the glenohumeral joint, we demonstrate a weak association between preoperative glenoid morphology according to the Walch classification and clinical state when evaluating patients undergoing TSA for rotator cuff-intact OA. Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses for patients undergoing TSA for rotator cuff-intact OA.

Simovitch RW ，Hao KA ，Elwell J ，Antuna S ，Flurin PH ，Wright TW ，Schoch BS ，Roche CP ，Ehrlich ZA ，Colasanti C ，Zuckerman JD ... -  《-》

Exactech Equinoxe anatomic versus reverse total shoulder arthroplasty for primary osteoarthritis: case controlled comparisons using the machine learning-derived Shoulder Arthroplasty Smart score.

The role of reverse total shoulder arthroplasty (rTSA) for glenohumeral osteoarthritis (GHOA) with an intact rotator cuff remains unclear with prior investigations demonstrating similar patient-reported outcome measures (PROMs) to anatomic total shoulder arthroplasty (aTSA). However, legacy PROMs are subject to skewed distributions with many patients achieving the maximum possible score (ceiling scores). We evaluated a cohort of primary rTSAs performed for GHOA with an intact rotator cuff compared with a case-matched cohort of aTSAs using the Shoulder Arthroplasty Smart (SAS) score, a machine learning-derived outcome measure that eliminates the ceiling effect. A retrospective review of an international shoulder arthroplasty database was performed between 2001 and 2020. Patients undergoing rTSA for rotator cuff intact GHOA (n = 367) were matched 1:1 with aTSA controls (n = 367) with a minimum of 2-year follow-up. Assessed variables included patient demographics, range of motion, American Shoulder Elbow Surgeons score (ASES), Constant score, Simple Shoulder Test (SST), and the SAS score. Preoperatively, the SAS (49.0 vs. 45.2; P < .001), SST (4.7 vs. 4.1; P = .002), and Constant score (42.5 ± 15.3 vs. 38.1 ± 14.2; P < .001) were greater in aTSA vs. rTSA. Similarly, the SAS score (82.3 vs. 77.6; P < .001) and SST score (10.8 vs. 10.3; P = .003) remained greater in aTSA postoperatively. In contrast, no differences in the ASES (P = .103) or Constant scores (P = .108) were found between aTSA and rTSA patients postoperatively. Improvement preoperatively to postoperatively did not differ between aTSA and rTSA patients when assessed using the SAS (P = .257), ASES (P = .888), or SST scores (P = .510). However, a higher rate of improvement in the Constant score (35.0 vs. 31.8; P = .022) was observed in rTSA compared with aTSA. Higher rates of complications (5.4% vs. 1.6%; P = .008) and revision surgery (4.1% vs. 0.5%; P = .002) were observed in aTSA compared with rTSA. Patients undergoing shoulder arthroplasty for rotator cuff intact GHOA experienced higher rates of complications and revisions in aTSA compared with rTSA, but similar levels of clinical improvement between implants when evaluated using a validated outcome score without a ceiling effect. Unlike the ASES and SST scores that are limited by ceiling effects, a higher mean postoperative SAS score after aTSA was observed, but preoperative to postoperative SAS differences were similar after rTSA.

Marigi EM ，Hao KA ，Friedman RJ ，Greene AT ，Roche CP ，Wright TW ，King JJ ，Schoch BS ... -  《-》

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative external rotation weakness and an intact rotator cuff: a case-control study.

Anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) are well-established treatments for patients with primary osteoarthritis and an intact cuff. However, it is unclear whether aTSA or rTSA provides superior outcomes in patients with preoperative external rotation (ER) weakness. A retrospective review of a prospectively collected shoulder arthroplasty database was performed between 2007 and 2020. Patients were excluded for preoperative diagnoses of nerve injury, infection, tumor, or fracture. The analysis included 333 aTSAs and 155 rTSAs performed for primary cuff-intact osteoarthritis with 2-year minimum follow-up. Defining preoperative ER weakness as strength <3.3 kilograms (7.2 pounds), 3 cohorts were created and matched: (1) weak aTSAs (n = 74) vs. normal aTSAs (n = 74), (2) weak rTSAs (n = 38) vs. normal rTSAs (n = 38), and (3) weak rTSAs (n = 60) vs. weak aTSAs (n = 60). We compared range of motion, outcome scores, strength, complications, and revision rates at the latest follow-up. Despite weak aTSAs having poorer preoperative strength in forward elevation and ER (P < .001), neither of these deficits persisted postoperatively compared with the normal cohort. Likewise, weak rTSAs had poorer preoperative strength in forward elevation and ER, overhead motion, and Constant, Shoulder Pain and Disability Index, and University of California, Los Angeles scores (P < .029). However, no statistically significant differences were found between preoperatively weak and normal rTSAs. When comparing weak aTSA vs. weak rTSA, no differences were found in preoperative and postoperative outcomes, proportion of patients achieving the minimal clinically important difference and substantial clinical benefit, and complication and rate of revision surgery. In preoperatively weak patients with cuff-intact primary osteoarthritis, aTSA leads to similar postoperative strength, range of motion, and outcome scores compared with patients with normal preoperative strength, indicating that preoperative weakness does not preclude aTSA use. Furthermore, patients who were preoperatively weak in ER demonstrated improved postoperative rotational motion after undergoing aTSA and rTSA, with both groups achieving the minimal clinically important difference and substantial clinical benefit at similar rates.

Hones KM ，Hao KA ，Trammell AP ，Wright JO ，Wright TW ，Vasilopoulos T ，Schoch BS ，King JJ ... -  《-》