Total shoulder arthroplasty on the second side - don't rush it!

 The relationship of bilateral shoulder arthroplasty timing and postoperative complications

These authors investigated the effect of time between bilateral shoulder arthroplasties on the complication rate using two insurance databases.

 From 2005-2016, a total of 1764 patients (6.3%) underwent bilateral shoulder arthroplasty out of 27,962 shoulder arthroplasties

Of the bilateral patients, 49.1% waited more than 1 year before their second shoulder arthroplasty.

Patients waiting less than 3 months between surgeries comprised 4.9% of the total number of staged bilateral surgeries. 

Overall, implant complications were higher in patients with surgeries less than 3 months apart compared to controls, including revision arthroplasty, loosening/lysis, and periprosthetic fracture. There were no significant increases in any implant-related complications when surgeries were staged by 3 months or more compared to controls. 

Venous thromboembolism and blood transfusion occurred at a significantly higher rate in patients with less than 3 months between surgeries compared with controls. There were no differences in any medical complications when surgeries were staged by 3 months or more compared with controls.

Comment: Shoulder arthritis is often a bilateral condition. For a variety of reasons, patients and physicians may wish to have the second side arthroplasty done soon after the first. One of these reasons is to have the surgeries in the same calendar year so that a second deductible payment is not needed.  

This study indicates that if the second arthroplasty is performed within 3 months, the complication rate essentially doubles: 

revision arthroplasty -11.6% vs. 5.4%, 

loosening/lysis - 8.1% vs. 3.5%

periprosthetic fracture -  4.7% vs. 1.2%

venous thromboembolism - 8.1% vs. 2.2%

blood transfusion - 9.3% vs. 1.7%

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

Doing an arthroplasty on the opposite (second) side - don't rush it!

The relationship of bilateral shoulder arthroplasty timing and postoperative complications

These authors investigated the effect of time between bilateral shoulder arthroplasties on the complication rate using two insurance databases.

 From 2005-2016, a total of 1764 patients (6.3%) underwent bilateral shoulder arthroplasty out of 27,962 shoulder arthroplasties

Of the bilateral patients, 49.1% waited more than 1 year before their second shoulder arthroplasty.

Patients waiting less than 3 months between surgeries comprised 4.9% of the total number of staged bilateral surgeries. 

Overall, implant complications were higher in patients with surgeries less than 3 months apart compared to controls, including revision arthroplasty, loosening/lysis, and periprosthetic fracture. There were no significant increases in any implant-related complications when surgeries were staged by 3 months or more compared to controls. 

Venous thromboembolism and blood transfusion occurred at a significantly higher rate in patients with less than 3 months between surgeries compared with controls. There were no differences in any medical complications when surgeries were staged by 3 months or more compared with controls.

Comment: Shoulder arthritis is often a bilateral condition. For a variety of reasons, patients and physicians may wish to have the second side arthroplasty done soon after the first. One of these reasons is to have the surgeries in the same calendar year so that a second deductible payment is not needed.  

This study indicates that if the second arthroplasty is performed within 3 months, the complication rate essentially doubles: 

revision arthroplasty -11.6% vs. 5.4%, 

loosening/lysis - 8.1% vs. 3.5%

periprosthetic fracture -  4.7% vs. 1.2%

venous thromboembolism - 8.1% vs. 2.2%

blood transfusion - 9.3% vs. 1.7%

To see our approach to total shoulder arthroplasty, see this link.

To support our research to improve outcomes for patients with shoulder problems, click here.

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Total shoulder arthroplasty - "how soon can I have my other shoulder done?"

The Relationship of Bilateral Shoulder Arthroplasty Timing and Postoperative Complications

These authors reviewed patients from two insurance databases who underwent staged bilateral shoulder arthroplasty (either anatomic or reverse) between 2005 and 2016. Patients with prior infection, those undergoing hemiarthroplasty, arthroplasty for a diagnosis of proximal humerus fracture and revision shoulder arthroplasty were all excluded. Patients were then stratified by elapsed time between surgeries into four study groups: (1) less than three months, (2) 3-6 months, (3) 6-9 months, and (4) 9-12 months.

Surgical and perioperative medical complications of these patient cohorts were compared to a control group that underwent bilateral shoulder arthroplasty with greater than a one-year interval between surgeries.

From 2005-2016, 1,764 patients (6.3%) underwent bilateral shoulder arthroplasty out of 27,962 shoulder arthroplasties performed in the two databases.

Of the bilateral patients, 49.1% waited more than one year before their second shoulder arthroplasty. 

Patients waiting less than three months between surgeries comprised 4.9% of the total number of staged bilateral surgeries.

Implant complications were higher in patients with surgeries less than 3 months apart compared to controls, including revision arthroplasty (11.6% vs 5.4%), loosening/lysis (8.1% vs 3.5%) and periprosthetic fracture (4.7% vs 1.2%). 

There were no significant increases in any implant-related complications when surgeries were staged by 3 months or more compared to controls. 

Venous thromboembolism (8.1% vs 2.2%) and blood transfusion (9.3% vs 1.7%) occurred at a significantly higher rate in patients with less than 3 months between surgeries compared to controls. 

There were no differences in any medical complications when surgeries were staged by 3 months or more compared to controls.

Comment: Patients may be eager to have the "second side done", often because of the desire to minimize insurance deductibles by having both procedures done in the same year.  This article provides useful information regarding the risks of the second surgery within 3 months.

While it is not specifically addressed in this study, the data suggest that any major surgical procedure during the preoperative 3 months may increase the risk or surgical and medical complications from shoulder arthroplasty.

It is worth noting that complications after shoulder arthroplasty are not rare, even in the control group: 5.4% revision, 3.5% loosening/lysis, 1.2% periprosthetic fracture, 2.2% venous thromboembolism and 1.7% blood transfusion.

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A respected colleague emailed:

"This type of study gives us information but does not interpret it.

Is it possible that surgeons who are willing to agree to do bilateral shoulder arthroplasties with short time interval are more likely to cause surgical or implant related complications. How about the potential psychosocial aspects of patients who are in a rush to have elective treatment?"

The point is that the decision to "rush" to have the second side done may reflect characteristics of the surgeon and of the patient.

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Ream and run, returning to have the second side done

After a successful ream and run on one shoulder, patients are returning to have the procedure on the opposite shoulder. Here is an overview of three such patients from last week.

#1 51 year old man with mild dysplasia and a preoperative SST score of 3 out of 12 and these x-rays

Three years after surgery his SST score had improved from 3/12 to 12/12. His three year x-rays are shown below.

                                     

#2 44 year old man with chondrolysis following the intraarticular infusion of local anesthetics after a labral repair; preoperative SST score of 2 out of 12 and these x-rays

Two years after surgery his SST score had improved from 2/12 to 9/12. His two year x-rays are shown below.

                                 

#3 61 year old man with osteoarthritis and a preoperative SST score of 6 out of 12 and these x-rays

One year after surgery his SST score had improved from 6/12 to 11/12. His one year x-rays are shown below.

                                      

Comment: It is indeed reassuring to see that motivated patients are sufficiently pleased with the result of their recovery after a ream and run procedure to pursue having it done on the opposite arthritic shoulder.

Note that none of the following are used in the care of our ream and run patients: a plastic glenoid component, preoperative CT scans, patient-specific instrumentation, preoperative MRIs, platform stems, short stems, stemless components, bone ingrowth components, cement, biceps tenotomy, biceps tenodesis, brachial plexus blocks, or lesser tuberosity osteotomy.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including: shoulder exercises,  shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials' See from which cities our patients come.

In patients having bilateral cuff repairs, are the outcomes different between the two shoulders?

Functional outcomes after bilateral arthroscopic rotator cuff repair

These authors point out that many patients having a cuff tear on one side have similar pathology in the opposite shoulder. 

Arthroscopic view of cuff tear. 

Stump of torn tendon (red arrow), gap in cuff showing exposed humeral head (green arrow).

In a study comparing outcomes between the two shoulders having cuff repair, they found no significant difference in clinical outcomes when the shoulders were grouped by (a) arm dominance, (b) first vs second shoulder, and (c) tear size. Small or medium tears were present in 67 shoulders (63%), and 38 shoulders (36%) had large or massive tears. Shoulder dominance was not significantly associated with tear size.

12% of the repairs failed. Shoulders with intact cuffs by ultrasound had postoperative ASES scores averaging 86.2 with a range from 41.7 to 100, in comparison to the shoulders with retears, which had an average ASES score of 72.5 with a range from 43.3 to 100. This difference was not statistically significant (P = .2).

In their discussion the authors point out that healing after rotator cuff repair is extremely variable, with healing rates reported at 6% to 92% and that some studies demonstrate long-term well-preserved function despite tear recurrence.

Comment: These results are presented in terms of the clinical scores (ASES, SANE, Rowe) at the time of followup. It would have been of interest to compare these postoperative scores to preoperative scores documented for each shoulder before the surgery so that the improvement (i.e. the benefit) of the procedures could be assessed. This is particularly important because, as the authors point out, the shoulder opposite the one having cuff surgery is likely to have cuff a cuff tear, but the contralateral tear is often asymptomatic.

It is once again of interest to see how closely the postoperative functional results for retorn repairs resembles that of intact repairs.

In bilateral arthritis, how long after the first TSA should the contralateral TSA be done?

Staged bilateral total shoulder arthroplasty: improved outcomes with less than 6 months between surgeries

These authors analyzed 82 total shoulders  (41 patients, 70 ± 9 years old) comparing 4 “interval groups” based on timing between surgeries: <6 months, 6 to 12 months, 12 to 24 months, and >24 months.

Mean postoperative UCLA, Constant, and SST scores were 29, 72, and 9 points, respectively; 83% of patients reported satisfaction with both shoulders.

Patients with <6 months between surgeries (Group 1) demonstrated significantly better UCLA scores than 6- to 12-month interval patients (P = .04), greater Constant scores compared with all other groups (P < .001), and greater SST scores compared with 6- to 12-month and 12- to 24-month interval patients (P = .002), with no differences in length of follow-up between groups.

Thirty-four patients (83%) reported that they were satisfied with both shoulders and 3 patients (7%) were satisfied with 1 shoulder. Twenty-six patients (63%) reported that 1 side endured a more difficult recovery. Of these 26 patients, 17 (65%) reported that their first side was the more difficult side to recover from, whereas 13 (50%) reported their dominant side as the most difficult side to recover from.

The authors concluded that patients may be advised that having the second arthroplasty within 6 months of the first might optimize their postoperative functional outcomes and satisfaction compared with waiting a longer interval between surgeries.

Comment: The reasons that the < 6 month group seemed to have better outcomes than the longer interval groups are not clear. In that patients were not randomly assigned to different intervals between surgeries, one wonders what factors explained the different the timing selected by the patient and the surgeons.  It could be that the patients electing to have shorter intervals between surgery were more healthy or more optimistic.

In our practice we often consider the second side at about 6 months after the first so that the patient has time to regain their strength and to get far along with the rehabilitation of the first shoulder. As often is the case (as pointed out by these authors) external factors often influence the timing of the second side, for example patients may want to have both surgeries in the same calendar year so that they can avoid paying the insurance deductible for the the second side.

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Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Bilateral rotator cuff repair - are the results comparable?

Functional outcomes after bilateral arthroscopic rotator cuff repair

These authors proposed to determine if there are clinical differences in shoulders of patients who underwent staged bilateral rotator cuff repairs during their lifetime.

They retrospectively reviewed patients who underwent staged bilateral arthroscopic rotator cuff surgery with at least 2 years of follow-up.

Of 81 patients eligible, they were able to obtain questionnaire data from 55 (68%) through either phone call or in person evaluation. Thirty-eight patients (69% of enrolled patients) participated by phone call only. Seventeen patients  (31% of enrolled patients) had followup ultrasound to evaluate cuff integrity. 12% of these shoulders did not show complete healing. 

Followup ASES scores varied quite widely averaging 86.5 (36.7-100) in the dominant shoulder compared with 89.6 (23.3-100) in the nondominant shoulder (P = .42).

Comment: A challenge in such a study is to control for the length of followup in comparing two shoulders in the same individuals, recognizing that longer followup is associated with increasing retear rates and decreasing shoulder function. This is best done with a multivariate analysis of the factors associated with postoperative shoulder function in which time after surgery is included as a variable along with tear size, side, preoperative shoulder function, dominance, and date of surgery. However, this type of analysis requires a substantially greater sample size than that presented here.

Patients having bilateral cuff repairs provide an interesting opportunity to compare (1) the first and second side, (2) right vs left, and  (3) dominant vs non-dominant with respect to clinical outcome and retear rate. 

An effective way to make this comparison is with a scatter plot that would enables the reader to see how the variation among patients compares to the variation between shoulders. Here's a hypothetical example showing that the results for the dominant and non dominant shoulders of each patient are more similar than the results among patients. If these were real data, they would suggest that we could inform patients that the result they achieved on one side is likely to be similar to that on the other.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.