Complications were experienced by one out of every 25 patients having a shoulder joint replacement

It is tempting to assume that relationships in orthopadics are linear, for example "more active elevation of the arm gives proportionally better function"; however, the function of shoulders with active elevation of 10 degrees is not much different than those with active elevation of 40 degrees, and the function of shoulders with active elevation of 140 degrees is not much different than those with active elevation of 170 degrees.

Similarly, it may seem that the risk of complications after shoulder arthroplasty (TSA) would increase proportionally with increase in the body mass index (BMI). 

However, the authors of The Obesity Paradox: A Nonlinear Relationship Between 30-Day Postoperative Complications and Body Mass Index After Total Shoulder Arthroplasty found that this was not the case. They reviewed data on 31,755 TSAs and found that 4.5% experienced medical complications. The relationship between complication risk and BMI was not linear: the lowest risk was in patients with a BMI between 30 and 35 kg/m2. 

Underweight individuals (BMI <18.5 kg/m2) had the highest postoperative complication rates overall. 

The probability of medical complications increased with age and was greater for female patients.

This reinforces the data from Total shoulder arthroplasty and obesity   

showing that underweight patients had the highest rates of transfusion and return to the operating room after shoulder arthroplasty.

More information on the relationship of body mass index to shoulder arthroplasty outcomes can be found at the links below:

Anatomic and reverse total shoulder arthroplasty: over one third of patients are obese - does this matter?

Underweight Patients Are the Greatest Risk Body Mass Index Group for 30-Day Perioperative Adverse Events After Total Shoulder Arthroplasty

The not infrequent complications after reverse total shoulders - influence of body mass index

Total shoulder arthroplasty - relationship of complications to obesity

Total shoulder - a low BMI more than doubles the rate of complications

Total shoulder outcomes: are they related to obesity?

Complications of shoulder arthroplasty - body mass index matters

And importantly, bariatric surgery does not reduce the risk of complications and may, in fact, increase the risk. 

Does bariatric surgery reduce the risk of shoulder arthroplasty?

Comment: It may be that nutritional status, rather than BMI, should be our focus. Individuals with low serum albumin, poor wound healing, or other manifestations of poor nutrition deserve a workup to determine the cause and consultation for optimizing management prior to elective surgery.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

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Follow on facebook: https://www.facebook.com/frederick.matsen
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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 ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

The rising rate of obesity and its adverse effects on the outcome of shoulder arthroplasty

 In the United States, over one third, 36.5 percent, of adults have obesity. 

Another 32.5 percent of American adults are overweight. 

As pointed out by the authors of  Effect of obesity on short and long-term complications of shoulder arthroplasty, the number and percent of obese patients having shoulder arthroplasty in the United States is steadily increasing each year.

They sought to evaluate postoperative medical and surgical complications in patients with obesity undergoing anatomic and reverse total shoulder arthroplasty using a national database.

A matched cohort analysis demonstrated higher odds of readmission, deep vein thrombosis/pulmonary embolism, superficial infection, and prosthetic joint infection at 90 days postoperatively in the obesity group. Medical complications and infection after total shoulder arthroplasty were greater in obese patients even when matching for medical comorbidities, age, and sex. The rates of complication increased with higher body mass index (BMI).

While there was an increased risk of mechanical complications and revision surgery at 2 years in the obesity group, this effect was not significant when matched to non-obese patients with similar comorbidities.

The odds of readmission, DVT/PE, superficial infection, acute kidney injury and periprosthetic infection were doubled in severely obese patients. 

Comment: This study shows yet another serious health problem associated with the obesity epidemic. It prompts us to ask several questions:

(1) Is obesity truly a "modifiable" risk factor?

(2) Is there evidence that weight loss (i.e. from diet, bariatric surgery, medications) reduces the risks of surgery. Might abrupt weight loss actually increase surgical risk?

(3) In that shoulder arthroplasty is usually an elective procedure, how should these data affect our indications for this surgery?

(4) How does obesity affect the clinical outcomes of shoulder arthroplasty?

The authors of Effects of Obesity on Clinical and Functional Outcomes Following Anatomic and Reverse Total Shoulder Arthroplasty addressed point #4.

They identified 1520 patients having primary anatomic (aTSA) arthroplasty and 2054 patients having primary reverse total shoulder arthroplasty with a minimum follow-up of 2 years (mean 5 years). All patients received the same platform shoulder prosthesis. 

Patients were stratified according implant type (anatomic or reverse), and further stratification was based on patient BMI, with obese patients having a BMI ≥ 30 kg/m2 and non-obese patients with a BMI <30 kg/m2. 

41% of aTSA and 35% of rTSA were obese. 

Obese patients in both groups reported higher preoperative and postoperative visual analog scale (VAS) pain scores (i.e. more pain) and less preoperative and postoperative ROM compared to non-obese patients. 

Compared to non-obese patients, obese patients receiving an aTSA reported significantly worse postoperative SST, Constant, ASES, UCLA, and SPADI scores compared to non-obese patients, and those receiving rTSA reported significantly worse ASES and SPADI scores. However, these differences did not exceed the minimal clinical important difference (MCID) or substantial  benefit (SCB) criteria. 

Statistically significant  differences between obese and non-obese groups were not found to be clinically relevant given  that the differences between the two groups with regards to VAS pain scores, ROM, and functional outcome scores did not exceed the MCID and SCB criteria in both the aTSA and rTSA groups.

Radiographic analysis 23 showed that in rTSA, obese patients had significantly less postoperative scapular notching and a lower scapular notching grade when compared to non-obese patients (P<0.05).

Obese patients had more comorbidities, greater intraoperative blood loss.

Overall complication rates were similar between obese and non-obese groups for both aTSA (7.6% vs. 8.4%; p = 0.57) and rTSA (3.4% vs. 3.9%), including rotator cuff tears, instability, infection, component loosening or failure, dislocation, liner dissociation, stress fracture, neurological complaints, and pain. Revision rates secondary to these complications were also similar between obese and non-obese groups for both aTSA (5.1% vs  5.9%) and rTSA (2.1% vs. 1.7%).

One of the more interesting findings in this study was that obesity seemed to protect patients against scapular notching and a higher notching grade. It seems possible that obesity limited adduction of the arm, reducing the contact between the medial edge of the humeral cup and the lateral scapular neck.

It is of interest to review some of the previous posts on the topic:

Is it safe to operate on patients with obesity?

Obesity is a risk factor for dislocation, fracture, and revision after shoulder arthroplasty

Reverse total shoulder in patients with morbid obesity

Total shoulder arthroplasty and obesity

Total shoulder arthroplasty - relationship of complications to obesity

Does obesity affect the outcome of shoulder arthroplasty?

Infection risk increased by revision surgery, obesity, diabetes, smoking

Reverse total shoulder in obese patients - the 4 Ps

Malnutrition and arthroplasty outcomes

Shoulder arthroplasty - malnutrition increases risk

Adverse outcomes from total shoulder arthroplasty - the role of malnutrition

To add this blog to your reading list in Google Chrome, click on the reading list icon

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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 ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Anatomic and reverse total shoulder arthroplasty: over one third of patients are obese - does this matter?

 Effects of Obesity on Clinical and Functional Outcomes Following Anatomic and Reverse Total Shoulder Arthroplasty

These authors identified 1520 patients having primary anatomic (aTSA) arthroplasty and 2054 patients having primary reverse total shoulder arthroplasty with a minimum follow-up of 2 years (mean 5 years). All patients received the same platform shoulder prosthesis. 

Patients were stratified according implant type (anatomic or reverse), and further stratification was based on patient BMI, with obese patients having a BMI ≥ 30 kg/m2 and non-obese patients with a BMI <30 kg/m2. 

Obsesity is common among patients having elective arthroplasty: 41% of aTSA and 35% of rTSA were obese. 

Obese patients in both groups reported higher preoperative and postoperative visual analog scale (VAS) pain scores (i.e. more pain) and less preoperative and postoperative ROM compared to non-obese patients. 

Compared to non-obese patients, obese patients receiving an aTSA reported significantly worse postoperative SST, Constant, ASES, UCLA, and SPADI scores compared to non-obese patients, and those receiving rTSA reported significantly worse ASES and SPADI scores. However, these

22 differences did not exceed the minimal clinical important difference (MCID) or substantial  benefit (SCB) criteria. 

Statistically significant  differences between obese and non-obese groups were not found to be clinically relevant given  that the differences between the two groups with regards to VAS pain scores, ROM, and functional outcome scores did not exceed the MCID and SCB criteria in both the aTSA and rTSA groups.

Radiographic analysis 23 showed that in rTSA, obese patients had significantly less postoperative scapular notching and a lower scapular notching grade when compared to non-obese patients (P<0.05).

Obese patients had more comorbidities, greater intraoperative blood loss.

Overall complication rates were similar between obese and non-obese groups for both aTSA (7.6% vs. 8.4%; p = 0.57) and rTSA (3.4% vs. 3.9%), including rotator cuff tears, instability, infection, component loosening or failure, dislocation, liner dissociation, stress fracture, neurological complaints, and pain. Revision rates secondary to these complications were also similar between obese and non-obese groups for both aTSA (5.1% vs  5.9%) and rTSA (2.1% vs. 1.7%).

One of the more interesting findings in this study was that obesity seemed to protect patients against scapular notching and a higher notching grade. It seems possible that obesity limited adduction of the arm, reducing the contact between the medial edge of the humeral cup and the lateral scapular neck.

While obesity is commonly listed as a "modifiable" risk factor for shoulder arthroplasty outcomes, to our knowledge no study has demonstrated improved outcomes in patients who have "modified" their BMI. 

It seems that obesity is less of a concern in shoulder arthroplasty than in hip and knee arthroplasty, yet we take extra time to discuss with these patients the need for extra attention to skin care (in the axilla and underneath the breast) and to care to protect the arm after surgery. 

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)

Total shoulder outcomes: are they related to obesity?

The association of elevated body mass index (BMI) with complications and outcomes

following anatomic total shoulder arthroplasty: a systematic review

These authors conducted a systematic review is to summarize the correlation between elevated body mass index (BMI) and the prevalence of perioperative complications and clinical outcomes following anatomic total shoulder arthroplasty (aTSA).

11 studies were included - 9 studies reported solely on perioperative complications, 1 study solely on functional outcomes, and 1 study on bothbcomplications and outcomes following aTSA.

Most studies were found to have low methodological quality. 

The authors found no significant  association between elevated BMI and overall perioperative medical and surgical complications, surgical site infection (SSI), re-operation without revision, aseptic revision, periprosthetic fracture, intraoperative blood loss, need for blood transfusion, 90-day readmission, absolute hospital LOS or short-term mortality. 

They did find an increased risk for overall revision following aTSA and need for extended hospital LOS in patients with elevated BMI.

Comment: This analysis was compromised by the low quality of the studies evaluated. One of the challenges in trying to relate BMI to surgical outcomes is that the relationship may well be bimodal: individuals with low BMI may be malnourished with its associated risks for fracture and infection while individuals with hi BMI may be at increased risk for falls and extended hospital stay.

Here's another article on the topic:

Effects of Obesity on Clinical and Functional Outcomes Following Anatomic and Reverse Total Shoulder Arthroplasty

These authors identified 1520 patients having primary anatomic (aTSA) arthroplasty and 2054 patients having primary reverse total shoulder arthroplasty with a minimum follow-up of 2 years (mean 5 years). All patients received the same platform shoulder prosthesis. 

Patients were stratified according implant type (anatomic or reverse), and further stratification was based on patient BMI, with obese patients having a BMI ≥ 30 kg/m2 and non-obese patients with a BMI <30 kg/m2. 

41% of aTSA and 35% of rTSA were obese. 

Obese patients in both groups reported higher preoperative and postoperative visual analog scale (VAS) pain scores (i.e. more pain) and less preoperative and postoperative ROM compared to non-obese patients. 

Compared to non-obese patients, obese patients receiving an aTSA reported significantly worse postoperative SST, Constant, ASES, UCLA, and SPADI scores compared to non-obese patients, and those receiving rTSA reported significantly worse ASES and SPADI scores. However, these

22 differences did not exceed the minimal clinical important difference (MCID) or substantial  benefit (SCB) criteria. 

Statistically significant  differences between obese and non-obese groups were not found to be clinically relevant given  that the differences between the two groups with regards to VAS pain scores, ROM, and functional outcome scores did not exceed the MCID and SCB criteria in both the aTSA and rTSA groups.

Radiographic analysis 23 showed that in rTSA, obese patients had significantly less postoperative scapular notching and a lower scapular notching grade when compared to non-obese patients (P<0.05).

Obese patients had more comorbidities, greater intraoperative blood loss.

Overall complication rates were similar between obese and non-obese groups for both aTSA (7.6% vs. 8.4%; p = 0.57) and rTSA (3.4% vs. 3.9%), including rotator cuff tears, instability, infection, component loosening or failure, dislocation, liner dissociation, stress fracture, neurological complaints, and pain. Revision rates secondary to these complications were also similar between obese and non-obese groups for both aTSA (5.1% vs  5.9%) and rTSA (2.1% vs. 1.7%).

One of the more interesting findings in this study was that obesity seemed to protect patients against scapular notching and a higher notching grade. It seems possible that obesity limited adduction of the arm, reducing the contact between the medial edge of the humeral cup and the lateral scapular neck.

It is of interest to review some of the previous posts on the topic:

Is it safe to operate on patients with obesity?

Obesity is a risk factor for dislocation, fracture, and revision after shoulder arthroplasty

Reverse total shoulder in patients with morbid obesity

Total shoulder arthroplasty and obesity

Total shoulder arthroplasty - relationship of complications to obesity

Does obesity affect the outcome of shoulder arthroplasty?

Infection risk increased by revision surgery, obesity, diabetes, smoking

Reverse total shoulder in obese patients - the 4 Ps

Malnutrition and arthroplasty outcomes

Shoulder arthroplasty - malnutrition increases risk

Adverse outcomes from total shoulder arthroplasty - the role of malnutrition

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)

Is it safe to operate on patients with obesity?

 Level of Obesity is Directly Associated with Complications Following Arthroscopic Rotator Cuff Repair

These authors investigated the association between increasing levels of obesity and postoperative complications within 30 days of arthroscopic rotator cuff repair.

18,521 patients who underwent arthroscopic rotator cuff repair (ARCR) from 2015-2017were identified in the American College of Surgeons National Surgical Quality Improvement and stratified into three cohorts according to their body mass index (BMI). Patients with BMI <30 kg/m2 were placed in the nonobese cohort, patients with BMI between 30-40 kg/m2 were placed in the obese cohort, and patients with BMI >40 kg/m2 were placed in the morbidly obese cohort. 9,548 (51.6%) of the patients were nonobese, 7,438 (40.2%) were obese, and 1,535 (8.3%) were morbidly obese. 

Multivariate logistic regression was employed to investigate the relationship between increasing levels of obesity and postoperative complications within 30 days of surgery.

Among nonobese, obese, and morbidly obese patients showed increasing rates of complications.

In comparison to nonobese patients, multivariate analysis identified both obesity and morbid obesity as significant predictors of medical complications (OR 1.72; OR 2.16), pulmonary complications (OR 2.66; OR 4.06), and overall complications (OR 1.52; OR 1.77).

Among obese patients undergoing ARCR, functional dependence, COPD, steroid use, and diabetes were identified as comorbidities which also increased the risk of short-term complications.

Comment: These results are important. It seems reasonable to expect that the same risk profile for medical complications would apply to other surgeries, such as arthroplasty. 

The authors refer to obesity as a "modifiable" risk factor. It is, however, unclear how modifiable obesity is and whether having the patient shed some pounds will increase the safety of shoulder surgery.

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.

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

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. Also see the essentials of the ream and run.

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 

Obesity is a risk factor for dislocation, fracture, and revision after shoulder arthroplasty

Risk of poor outcomes in patients who are obese following total shoulder arthroplasty and reverse total shoulder arthroplasty: a systematic review and meta-analysis

These authors conducted a systematic review to investigate the impact of obesity ( (body mass index > 30 kg/m2) on outcomes following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

They found that patients who were obese were at increased odds of a dislocation (OR, 2.49; 95% confidence interval [CI], 2.32-2.66), fracture (OR, 1.92; 95% CI, 1.77-2.08), and revision (OR, 1.49; 95% CI, 1.40-1.58) following TSA or RTSA. 

Comment: Shoulder arthroplasty is most often an elective procedure. Obesity appears to be a risk factor for surgical complications, but is also likely to be associated with risks of medical complications, such as obstructive sleep apnea, deep venous thrombosis, and pulmonary emboli. 

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

To see a YouTube of our technique for a reverse 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'

Reverse total shoulder in patients with morbid obesity

Outcomes of primary reverse shoulder arthroplasty in patients with morbid obesity.

These authors state that obesity is a risk factor for worse outcomes in anatomic shoulder arthroplasty. 

They sought to determine outcomes in patients with morbid obesity (BMI ≥40 kg/m2 ) having primary reverse shoulder arthroplasty (RSA) between January 1, 2005, and December 31, 2012. Of 60 of these patients, 41 had more than 2 years of clinical followup (57% female, mean BMI was 44 kg/m2,  mean age was 67.7 years). The outcome of 30% of the patients is not known. The average followup was 3.2 years.

Indications for RSA included glenohumeral arthritis with rotator cuff insufficiency in 30, proximal humerus fracture in 8, pseudoparalysis in 2, and chronic shoulder dislocation in 1. Implants used included the Encore Reverse Shoulder Prosthesis in 1 patient (DJO Surgical, Vista, CA, USA), the Delta III prosthesis in 5 and the Delta Xtend prosthesis in 12 (DePuy Orthopaedics, Warsaw, IN, USA), the Comprehensive prosthesis in 20 (Biomet, Warsaw, IN, USA), and the Aequalis Reversed Shoulder prosthesis in 3 (Tornier, Bloomington, MN, USA). 

Clinical outcomes were substantially improved. The only intraoperative complication was an inferior glenoid fracture that remained stable after glenosphere implantation. 

2 patients (5%) required revision surgery for infection (n = 1) and humeral loosening (n = 1). Survival was 98% at 2 years and 92% at 5 years. 

Additional postoperative complications included ulnar neuropathy (n = 1) and heterotopic ossification (n = 2).  1 (2%) had humeral lucency, and 2 (5%) had inferior scapular notching. 

Laborers had higher risk for revision surgery (P = .01), and females had worse functional outcomes and shoulder motion (P < .02).

Comment: This study shows that reverse shoulder arthroplasty can improve comfort and function at an average of 3.2 years for carefully selected obese patients with a variety of diagnoses when performed by expert surgeons. Knowing the high qualifications of the surgeons contributing cases to this study, we suggest that patient selection and surgical experience played major roles in arriving at the results presented. 

Obesity remains an important co-morbidity for all surgery and this fact needs to be included in the shared decision making discussions with patients considering anatomic and reverse total shoulder arthroplasty.

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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'

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