Early dislocation after reverse total shoulder arthroplasty

doi:10.1016/j.jse.2013.08.015

Journal of Shoulder and Elbow Surgery

Volume 23, Issue 5, May 2014, Pages 737-744

https://doi.org/10.1016/j.jse.2013.08.015 Get rights and content

Background

Although instability can occur after reverse total shoulder arthroplasty (RTSA), the risk factors, the treatment, and ultimate fate of the implant in these patients remains poorly understood.

Methods

Demographics, acute treatment, and the need for revision were evaluated in all patients with RTSAs who sustained a subsequent dislocation within the first 3 months. Standardized outcome scores were collected preoperatively and at the final follow-up.

Results

Atraumatic instability occurred in 11 patients (incidence, 2.9%) treated with RTSA early (before 3 months postsurgery). The mean time to dislocation was 3.4 weeks. These patients tended to be previously operated-on (64%), male (82%), overweight (mean body mass index (BMI) of 32.2 kg/m², with 82% having a BMI ≥30 kg/m²), and without a satisfactory subscapularis repair at initial RTSA (64%). Initial treatment included closed reduction in 9 patients, open reduction in 1, and open reduction with a thicker polyethylene insert in 1. Four experienced recurrent instability requiring a thicker polyethylene insert. Two additional patients were converted to hemiarthroplasty due to persistent instability. Visual analog pain scores (P = .014) and American Shoulder and Elbow Surgeons scores (P = .018) were significantly improved. Simple Shoulder Test scores trended towards improvement (P = .073).

Conclusions

Early dislocations of the RTSA prosthesis were uncommon. The most common associated factors were a BMI >30 kg/m², male gender, subscapularis deficiency, and previous surgery; in these patients, we now use an abduction orthosis. Closed reduction alone was successful in 4 of the 9 closed reductions (44%). Five of 11 RTSAs (45%) required polyethylene exchange. The RTSA was retained in 82%, 36% with the original implant.

Section snippets

Materials and methods

This study was a retrospective record review of prospectively collected data. The operative log of the senior author (G.P.N.) was reviewed from 2004 until the present, and those patients who underwent RTSA who experienced an atraumatic radiographically documented dislocation within 3 months postoperatively were included in this study. Exclusion criteria included patients with incomplete medical records, patients in whom instability was the result of a direct trauma, such as a fall, and patients

Demographics

Of the 385 RTSAs performed during the study period, 11 met our inclusion criteria, for an instability rate of 2.9% (Table I). These patients were followed up for a mean of 2.5 ± 2.4 years (range, 0.5-6.8 years). Our cohort included 2 women (18%) and 9 men (82%), with a mean age of 68.0 ± 9.8 years (range, 54.2-79.5 years). Eighty-eight percent of patients were right-hand dominant, and all but 2 underwent RTSA on their dominant extremity. Seven of the 11 (64%) had previous surgery, which

Discussion

Although instability after RTSA does occur,9, 15, 31 and several studies have addressed possible causes biomechanically22, 28 and clinically,8, 11 to the best of our knowledge, no previous authors have described the clinical outcomes of those patients with instability after an RTSA. Herein we reviewed our clinical experience in 11 patients with a mean follow-up of 2.5 years. Instability developed in most of these patients in the acute postoperative period, within 5 weeks. The only patient who

Conclusion

Early dislocations of the RTSA prosthesis were uncommon. The most common associated factors were a BMI exceeding 30 kg/m², male sex, subscapularis deficiency, and previous surgery; in these patients, we now use an abduction orthosis postoperatively. Closed reduction alone was successful in 4 of the 9 closed reductions (44%). Five of 11 RTSAs (45%) required polyethylene exchange. Eighty-two percent were able to retain a reverse TSA, 36% with the original implant.

Disclaimer

Dr Nicholson is a paid consultant for Tornier, receives research support from Tornier, Ossur, and Smith & Nephew, and receives royalties from Innomed Inc. Dr Romeo receives royalties from Arthrex Inc; is on the speakers bureau for Arthrex Inc.; is a paid consultant for Arthrex Inc; receives research support from Arthrex Inc., DJO Surgical, Smith & Nephew, and Ossur; received other financial support from Arthrex Inc and DJO Surgical; receives publishing royalties from Saunders/Mosby-Elsevier;

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Cited by (146)

Outcomes and complications of revision reverse shoulder arthroplasty following failed primary reverse shoulder arthroplasty: a systematic review
2024, Seminars in Arthroplasty JSES
The purpose of this study is to systematically review the evidence in the literature to assess the functional outcomes, satisfaction scores, range of motion (ROM), and complication and reoperation rates following revision reverse shoulder arthroplasty (RSA) for a failed primary RSA.
Two independent reviewers performed the literature search based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing the EMBASE, MEDLINE, and the Cochrane Library databases. Studies were included if they reported clinical outcomes for revision RSA for a failed primary RSA.
Our review found 9 studies including 211 shoulders meeting our inclusion criteria. Most patients were male (56.3%), with a mean age of 69.5 years and a mean follow-up of 44.3 months. The two most common functional outcome scores were American Shoulder and Elbow Surgeons and Simple Shoulder Test, which improved from 40.4 to 63.2 and 3.4 to 6.2, respectively. Revision RSA had a high satisfaction rate of 89.2%. ROM results include forward flexion, abduction, and external rotation that improved from 62° to 118°, 51° to 103°, and 12° to 26°, respectively. The overall complication rate and additional reoperation rate were 34.3% and 28.6%, respectively, with instability/dislocation the most common complication for both index and revision RSA.
Revision RSA for a failed primary RSA has been shown to result in satisfactory functional outcomes and improved ROM. Most studies report high patient satisfaction rates in patients that did not have significant complications and/or required reoperations, with instability/dislocation and glenoid loosening complications the areas of the highest concern.
Effect of osteophyte removal on simulated range of motion using 3-dimensional preoperative planning software for reverse total shoulder arthroplasty
2024, JSES International
Glenohumeral osteophytes (OPs) can adversely influence postoperative range of motion (ROM) following shoulder arthroplasty due to mechanical impingement. Though commercial three-dimensional preoperative planning software (3D PPS) is available to simulate ROM before and after OP resection, little is known about the magnitude of effect OPs and their subsequent removal have on simulated glenohumeral ROM.
Included patients were 1) indicated for reverse total shoulder arthroplasty (rTSA) using 3D PPS and 2) presented with glenoid and/or humeral head OPs on preoperative two-dimensional computed tomography (2D-CT) imaging. Thirty patients met the inclusion criteria (9 females, 21 males; mean age 70.45 ± 4.99 years, range 63-80 years). All subjects (n = 30) presented with humeral OPs (mean volume: 2905.16 mm³, range 109.1-11,246 mm³), while 11 subjects also presented with glenoid OPs (mean volume 108.06 mm³, range 37.59-791.4 mm³). Preoperative CTs were used to calculate OP volume (mm³) and OP circumferential extent (clockface). Mean clockface position for circumferential humeral OPs originated at 6:09 (range 4:30-7:15) and extended to 8:51 (range 8:15-10:15). Mean clockface position for glenoid OPs originated at 3:00 (range 2:00-5:00) and extended to 6:16 (range 3:00-7:30). 3D implants on PPS were standardized to achieve 0° of version, 0° of inclination and 4 mm of net lateralization. Thirty-nine and thirty-six mm glenospheres were used for males and females, respectively. 3D PPS was used to evaluate simulated ROM differences before and after OP removal in the planes of adduction (ADD), abduction, internal rotation (IR), external rotation (ER), extension, and flexion. Impact of OP volume and circumferential extent on pre and postop removal ROM were also analyzed.
Humeral OP removal significantly increased impingement-free ADD, IR, ER, extension, and flexion. Removal of larger (mm³) humeral OPs positively correlated with improvement in IR (R = 0.452, P = .011), ER (R = 0.394, P = .033), and flexion (R = 0.500, P < .01). Greater circumferential extent of humeral OPs correlated with worse preremoval ROM in the planes of ADD (R = 0.364, P = .02) and extension (R = 0.403, P = .04), and improvements in ER postop removal (R = 0.431, P = .03).
Humeral OP removal significantly increases impingement-free ADD, IR, ER, extension, and flexion in simulated 3D PPS models following rTSA. Magnitude of simulated ROM improvement is influenced by initial humeral OP volume and circumferential clockface extent. Surgeons should consider these effects when using 3D PPS for rTSA planning to optimize postoperative ROM prognostics.
Impact of constrained humeral liner on impingement-free range of motion and impingement type in reverse shoulder arthroplasty using a computer simulation
2024, Journal of Shoulder and Elbow Surgery
Dislocation is a major complication of reverse total shoulder arthroplasty (RSA). The humeral liner may be changed to a constrained type when stability does not improve by increasing glenosphere size or lateralization with implants, and patients, particularly women with obesity, have risks of periprosthetic instability that may be secondary to hinge adduction on the thorax, but there are few reports on its impact on the range of motion (ROM). This study aimed to determine the influence of humeral liner constraint on impingement-free ROM and impingement type using an RSA computer simulation model.
A virtual simulation model was created using 3D measurement software for conducting a simulation study. This study included 25 patients with rotator cuff tears and rotator cuff tear arthropathy. Impingement-free ROM and impingement patterns were measured during flexion, extension, abduction, adduction, external rotation, and internal rotation. Twenty-five cases with a total of 4 patterns of 2 multiplied by 2, making a total of 100 simulations: glenosphere (38 mm normal type vs. lateralized type) and humeral liner constraint (normal type vs. constrained type). There were 4 combinations: normal glenosphere and normal humeral liner, normal glenosphere and constrained humeral liner, lateralized glenosphere and normal humeral liner, and lateralized glenosphere and constrained humeral liner.
Significant differences were found in all impingement-free ROM in 1-way analysis of variance (abduction: P = .01, adduction: P < .01, flexion: P = .01, extension: P = .02, external rotation: P < .01, and internal rotation: P < .01). Tukey’s post hoc tests showed that the impingement-free ROM was reduced during abduction, external rotation, and internal rotation with the combination of the normal glenosphere and constrained humeral liner compared with the other combinations, and improved by glenoid lateralization compared with the combination of the lateralized glenosphere and constrained humeral liner. In the impingement pattern, the Pearson χ² test showed significantly greater proportion of impingement of the humeral liner into the superior part of the glenoid neck in abduction occurring in the combination of the normal glenosphere and constrained humeral liner group compared with the other groups (P < .01). Bonferroni post hoc tests revealed that the combination of the normal glenosphere and constrained humeral liner was significantly different from that of the lateralized glenosphere and constrained humeral liner (P < .01). Using constrained liners resulted in early impingement on the superior part of the glenoid neck in the normal glenosphere, whereas glenoid lateralization increased impingement-free ROM.
This RSA computer simulation model demonstrated that constrained humeral liners led to decreased impingement-free ROM. However, using the lateralized glenosphere improved abduction ROM.
Predictors of dislocations after reverse shoulder arthroplasty: a study by the ASES complications of RSA multicenter research group
2024, Journal of Shoulder and Elbow Surgery
Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants.
A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA.
We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001).
The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA.
Comparison of short-term clinical outcomes and radiographic changes in Grammont reverse shoulder arthroplasty between the French and Japanese populations: A propensity score-matched analysis
2024, Journal of Orthopaedic Science
Although Grammont-style reverse total shoulder arthroplasty (RSA) showed excellent clinical results in Europe, its utility for Asian populations remains unclear. This study aimed to compare the French and Japanese populations in terms of range of motion (ROM), functional outcomes, and scapular notching rates in patients who underwent standard Grammont-style RSA. We hypothesized that RSA for the Japanese population may not provide as good ROM and functional results at the final follow-up as that for the French population.
A total of 25 Japanese patients undergoing RSA were propensity score matched to 25 French patients undergoing RSA. The patients were matched for four different covariates using a propensity score analysis. The minimum follow-up period was 2 years. We investigated differences between the populations with respect to body size and shoulder joint ROM and Constant score (CS) measured preoperatively and at the final follow-up. Scapular notching was examined using radiographs at the final follow-up.
The average height and weight of the French and Japanese patients were 164 cm and 70 kg and 152 cm and 56 kg, respectively. Anterior elevation (AE), external rotation (ER) at the side, internal rotation (IR), and CS total changed from 101° to 145°, 17° to 15°, 4.5 points to 5.5 points, and 36 points to 72 points, respectively, in the French population and from 63° to 119°, 8.5° to 13°, 4.6 points to 4 points, and 28 points to 58 points, respectively, in the Japanese population. AE improved in both the groups; ER and IR remained unchanged before and after surgery. The frequency of scapular notching (>grade 1) was higher in the Japanese population (56%) than in the French population (20%) (p = 0.019).
Grammont-style RSA improved AE and CS in both the populations, but AE and CS were significantly higher in the French population than in the Japanese population at the final follow-up. Scapular notching frequently occurs in the Japanese population.
The clinical utility of immediate post-operative PACU plain film radiographs following uncomplicated open Latarjet procedure – An institutional series of consecutive patients
2023, Journal of Orthopaedics
Immediate post-operative plain film radiograph x-rays in PACU following open Latarjet procedure are often ordered as routine. However, such radiographs utilize institutional cost and time, whilst potentially exposing patients to often-unnecessary additional radiation. This study sought to evaluate whether routine immediate post-operative radiographs following uncomplicated open Latarjet procedures impacted clinical decision-making in our institution.
From 2017 to 2020, patients who underwent open Latarjet procedure by one of four fellowship-trained upper limb surgeons at a single institution were included in this study. Post-operative radiographs taken immediately in PACU were reviewed to determine if any reported radiographic findings impacted on clinical decision-making in the immediate post-operative setting. SPSS was used for descriptive statistics.
A total of 337 patients underwent an X-ray in PACU immediate after uncomplicated open Latarjet procedure. Overall, 98.5% were male (n = 332), the mean patient age of included patients was 22.9 ± 4.2 years. No patient had an abnormal finding on their post-operative x-ray. Two patients returned to the operating room in the immediate post-operative period, both requiring washout and debridement due to haemtoma or superficial wound infection.
The findings of this study suggest that the use of post-operative plain films in PACU following open Latarjet procedure remains a costly use of resources, with little ultimate impact on clinical decision making in the short-term post-operatively.
IV – Institutional Case Series of Consecutive Patients.

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: This study was approved under Rush University Medical Center Institutional Review Board protocol #11102602.

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International shoulder and elbow articleEarly dislocation after reverse total shoulder arthroplasty

Background

Methods

Results

Conclusions

Section snippets

Materials and methods

Demographics

Discussion

Conclusion

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Orthop Sci

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Complications of the reverse prosthesis: prevention and treatment

Instr Course Lect

Grammont reverse prosthesis: design, rationale, and biomechanics

J Shoulder Elbow Surg

Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up

J Bone Joint Surg Br

The reverse shoulder prosthesis in the treatment of fractures of the proximal humerus in the elderly

J Bone Joint Surg Br

Revision arthroplasty with use of a reverse shoulder prosthesis-allograft composite

J Bone Joint Surg Am

Complications in reverse total shoulder arthroplasty

J Am Acad Orthop Surg

Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency

J Bone Joint Surg Am

International shoulder and elbow article
Early dislocation after reverse total shoulder arthroplasty