What can we do to lower the risks of our patients having shoulder arthroplasty?

A number of recent articles have sought to identify important risk factors for adverse outcomes after shoulder arthroplasty. The question is "how can we lower these risks for our patients"?

Each complication is one too many.

Insurance status

A recent article reported that Medicaid status is independently predictive of increased complications, readmission, and mortality following primary total shoulder arthroplasty. 

See a detailed assessment of this paper here.

Let's start by putting this assertion to the "sniff test" by considering a hypothetical 63 year old widow living alone with diabetes, osteoporosis and shoulder arthritis. 

In the absence of alternatives, her health care is covered by Medicaid. The is scheduled for shoulder arthroplasty in two months. According to the article referenced above, she is at increased risk for complications, readmission, and mortality if she undergoes the arthroplasty. She has fallen in love with and marries a childhood friend and, as a result, now has high quality private insurance. Does this insurance change affect her risk of complications, readmission and mortality?

The article provides some useful comparisons of patients on Medicaid with others: patients on Medicaid were propensity score matched in a 1:1 proportion based on age, sex, and discharge weight.

From the below, we can see that the matching did not include the Cormorbidity Idex (CCI), the patient location, or household income; each of these characteristics could be expected to have an effect on the outcome of shoulder arthroplasty.

Note also that the study fails to control for the rates of preoperative congestive heart failure, chronic lung disease, coagulopathy, anemia, dementia, electrolyte disorder, hypertension, liver disease, lymphoma, myocardial infarction, obesity, paralysis, peptic ulcer, renal failure and substance abuse

There are probably other important differences between the two groups, such as occupation, surgeon experience, social support, nutrition, and nicotine and alcohol habits. 

Thus, what we have here is a fundamental attribution error: i.e. attributing the difference between the two groups to Medicaid status instead of to the differences in the two groups' social determinants of health and comorbidities. (In Thinking Fast and Slow, Kahneman addresses how we construct coherent stories and causal narratives, often ignoring situational factors in favor of internal traits —a hallmark of the fundamental attribution error.) 

With the realization that the two groups were not matched for key variables, we can understand the likely reasons for the differences in outcome between the two groups.

The statement "Medicaid status was independently predictive of readmission, complications, and mortality within 180 days of primary TSA, as well as other specific medical and surgical complications." focuses attention on insurance status - which in an of itself can't be a risk factor - rather than on the true risk factors which may be managed. 

Avoiding Acromioplasty

While some surgeons routinely perform acromioplasty in conjunction with cuff repair, there is only minimal evidence to support a clinically significant benefit in terms of patient reported outcomes:

Acromioplasty combined with arthroscopic rotator cuff repair can reduce the risk of reoperation: a systematic review and meta-analysis. "Combining arthroscopic cuff repair with acromioplasty can reduce the rate of reoperation, especially in patients with type 3 acromion, but it provides no clinically important change in the retear rate and postoperative patient reported outcomes compared with arthroscopic cuff repair without acromioplasty"

Chochrane on rotator cuff repair "Not surprisingly, there were no observed benefits to acromioplasty in terms of pain, function, or health-related quality of life—a finding that has been known for some time and is based on several high-quality randomized controlled trials"

Efficacy of concomitant acromioplasty in the treatment of rotator cuff tears: A systematic review and meta-analysis "our present study demonstrated that acromioplasty treatment is significantly superior to nonacromioplasty in shoulder pain relief at 12 months postoperatively and in ASES score improvement at the final follow-up in conjunction with rotator cuff repair. However, these statistically significant differences were not clinically relevant. Thus, there were no differences in shoulder function or pain scores for patients undergoing rotator cuff repair with and without acromioplasty."

Reverse total shoulder arthroplasty is often performed for patients with failed rotator cuff repair. For example, It is known that acromioplasty can increase the risk of anterior/superior escape after a failed attempt at cuff repair.

One of the most debilitating complications of reverse total shoulder after failed cuff repair is acromial/scapular spine stress fracture. 

By definition, acromioplasty thins the acromion, making it more prone to fracture.

In addition, there is evidence that sacrifice of the coracoacromial arch can increase the risk of acromial stress fractures. 

The authors of Prior Subacromial Decompression is a Significant Risk Factor for Development of Acromial Stress Fracture After Reverse Total Shoulder Arthroplasty sought to determine if prior acromioplasty increases the risk of these fractures after reverse total shoulder arthroplasty (rTSA). 106,599 patients undergoing primary rTSA were identified. One out of 100 patients sustained an acromial stress fracture.  Prior acromioplasty was a significant independent risk factor, conferring a 26% higher risk. Additional independent risk factors for these fractures included increased Charlson Comorbidity Index, history of a rotator cuff tear, osteoporosis and inflammatory arthropathy.

In performing rotator cuff repair, surgeons need to balance the possible advantages of acromioplasty against the increased risk of acromial / spine fractures should subsequent reverse total shoulder arthroplasty become necessary.

Managing Body weight

Obesity and total joint arthroplasty: Does weight loss in the preoperative period improve perioperative outcomes? assessed whether a 10% weight loss prior to TJA had a impact on perioperative and 30-day outcomes in obese patients. The authors found no difference between groups with or without weight loss in terms of operative time, length of stay, discharge destination, or 30-day adverse events, including complications, re-admissions, re-operations, and mortality. 

An abrupt weight loss before surgery may create a state of malnutrition, increasing the risk of complications by making the patient catabolic with adverse effects on healing, strength and balance. Medical and social support of the patient and careful monitoring increase the chances of success.

GLP-1) receptor agonists

One in five patients having shoulder arthroplasty has diabetes and one in three are obese. Glucagon-like peptide-1 (GLP-1) receptor agonists, are increasingly used for diabetes management and weight loss. The authors of Glucagon-like Peptide-1 Receptor Agonist Use is Associated With Increased Risk of Perioperative Complication and Readmission Following Shoulder Arthroplasty conducted a propensity matched study of 1259 patients taking GLP-1 receptor agonists to 1259 patients not taking the medication with respect to adverse outcomes after anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty. They found that GLP-1 receptor agonist users experienced significantly higher 90-day rates of medical complications, such as deep vein thrombosis, myocardial infarction, pneumonia, transfusion and readmission. There may also be an increased risk of aspiration, nausea and vomiting because these agents delay gastric emptying. The increase in the rate of surgical revision of the arthroplasties was statistically insignificant. 

At present, guidelines for the perioperative management of patients taking GLP-1 receptor agonists are still being fine tuned. The American Society of Anesthesiologists (ASA) has recommended holding daily GLP-1 RAs (e.g., liraglutide) on the day of surgery and holding weekly GLP-1 RAs (e.g., semaglutide, dulaglutide) at least 1 week prior to surgery. The potential risks of holding GLP-1 RAs before surgery include hyperglycemia, overeating post-op, increased cardiovascular risk and gastrointestinal symptoms. Preoperative consultation with internal medicine and anesthesia is advisable.

Managing Nutrition

The authors of Preoperative Malnutrition is Associated with Increased Risk of 90-day Major Medical Complications and Increased 2-Year Revision Rates Following Total Shoulder Arthroplasty sought to determine the relationship between preoperative malnutrition and implant complications (90-day postoperative adverse events and 2-year revision rates) in patients having shoulder arthroplasty. The authors defined malnutrition using lab values: albumin <3.5g/dL, transferrin <204mg/dL, total leukocyte count <1,500 cells/mm3. [Body mass index <18.5 and recent weight loss can also be indicators of malnutrition]. They compared propensity matched malnourished and non-malnourished groups (1,936 patients per group).

Malnourished patients had significantly higher risks of 90-day major complications, including sepsis, myocardial infarction, readmission, pneumonia, renal failure, and blood transfusion. These patients were also at increased risk of periprosthetic infection and surgical revision within 2 years after arthroplasty.

Consultation with an experienced nutritionist and social support are indicated for malnourished patients. The patients need to be advised that the necessary dietary changes can be difficult and may take months or longer to create a meaningful reduction in surgical risk.

Stopping tobacco use

While it is commonly recognized that cigarette smoking increases the risk of surgical complications, patients may wish to continue their use of other forms of tobacco. The authors of Effects of Smokeless Tobacco Use on Primary Total Shoulder Arthroplasty Outcomes compared outcomes between smokeless tobacco users and nontobacco users. They found that patients using smokeless tobacco had higher average Charlson-Deyo Comorbidity Indices and concomitant alcohol use and lower socioeconomic status. Smokeless tobacco users had higher rates of acute respiratory disease syndrome, sepsis, and mortality at 180 days. These adverse outcomes are attributed to the vasoconstriction, impaired tissue oxygenation, and immunosuppression occurring with tobacco use. Tobacco use predicts a more difficult episode of care after anatomic total shoulder arthroplasty pointed out that current tobacco use is associated with increased postoperative pain. 

The current thinking is that use of all tobacco products should be discontinued at least three months prior to elective arthroplasty. Active use of tobacco may be associated other risk-taking patterns of behavior, such as alcohol abuse and failure to comply with postoperative restrictions. Impulsivity is associated with behavioral decision-making deficits

Managing Osteoporosis

As every orthopaedic surgeon knows, osteoporosis predisposes patients to fractures and failure of joint reconstructions. One in four women over the age of 65 has this condition. Because there is a high prevalence of undiagnosed or untreated osteoporosis, surgeons need to screen patients with risk factors for this common condition: female, advanced age, low BMI, malnourishment, inflammatory arthropathy, steroid medication, inactivity, and poor diet. The authors of Anti-osteoporotic treatment reduces risk of revision following total shoulder arthroplasty in patients with osteoporosis investigated whether anti-osteoporotic therapy correlates with improved revision outcomes following total shoulder arthroplasty.

Patients with a preoperative diagnosis of osteoporosis were stratified into 2 groups: (1) patients with osteoporosis who underwent anti-osteoporotic therapy within 6 months prior to surgery (anti-OP cohort) and (2) patients with osteoporosis who never received anti-osteoporotic treatment (no anti-OP cohort).

In total 40,532 osteoporotic patients were included, with 11,577 (28.5%) having undergone anti-osteoporotic treatment.

Patients who did not receive anti-osteoporotic treatment had significantly higher odds of 2-year all-cause revision and mechanical loosening following TSA when compared to those treated for osteoporosis.

Simple steps can reduce the risk of osteoporosis: a diet with substantial protein (e.g. at least 1/2 gram of protein/pound of body weight), fat and calories, Vitamin C and D supplementation, calcium supplementation, and general bone-loading exercise (e.g. walking, rowing machine). Be aware of the "tea and toast" diet and inactivity. Patients at risk should be monitored with DEXA scans. Formal anti-osteoporotic treatment should be administered by a physician knowledgeable about metabolic bone disease. 

For those of us in the Pacific Northwest and other less sunny climates, it is notable that the authors of  Vitamin D Deficiency is Associated with Adverse Medical Outcomes Following Total Shoulder Arthroplasty found that Vitamin D deficiency was associated with higher rates of kidney failure (AKF), deep vein thrombosis (DVT), pulmonary embolism, pneumonia, and periprosthetic fractures at 90 days and at one year. Additionally, readmission rates were significantly higher in the vitamin D-deficient cohort at 1 year. At 2 years, AKF, DVT, pneumonia, and readmission continued to be significantly associated with vitamin D deficiency.

Managing steroid use

Approximately one in twenty patients having shoulder arthroplasty are taking chronic steroid medication. Chronic preoperative steroid use and total shoulder arthroplasty: a propensity score matched analysis of early-onset infectious outcomes aimed to evaluate the impact of chronic preoperative steroid use on early-onset postoperative infectious outcomes and readmission within 30 days following TSA compared to patients without chronic steroid use.  A total of 3,445 identified cases were included in this analysis after propensity score matching, with 1,157 exhibiting chronic steroid use. The steroid group demonstrated significantly greater rates of readmission; this study did not document the reasons for readmission. In this short term followup study, no significant differences were observed between groups in all other adverse outcomes, including reoperation and infectious outcomes. 

Managing Anemia

Anemia (e.g  preoperative hemoglobin < 13.5 g/L) is present in up to one of three patients having shoulder arthplasty. 

 Complications Associated with Preoperative Anemia and Risk Factors for Blood Transfusion after Shoulder Arthroplasty: A Systematic Review found the patients with preoperative anemia (PA) demonstrated a 24.4% complication rate in comparison to 8.8% in those without such a diagnosis. Stratification by PA severity revealed a 34.9% complication rate in patients with moderate to severe PA. In patients with PA, pulmonary complications were the most prevalent followed by thromboembolic, renal, and postoperative transfusion-related complications. 

Lower preoperative hemoglobin and revision shoulder arthroplasty were correlated with a higher risk of postoperative transfusion.

Because anemia is associated with chronic illness and malnutrition, it is difficult to know how much of the adverse effect is due to the anemia itself or to the underlying condition that may be contributing to it. Thus the management of PA is complicated. 

Erythropoiesis-stimulating agents can increase hemoglobin levels but carry potential risks (e.g., thromboembolic events), particularly in older populations.There is no strong evidence that administration of erythropoietin (EPO) significantly reduces complication rates in anemic patients undergoing shoulder arthroplasty. 

There is currently no strong evidence that preoperative blood transfusion lowers complication rates in mild or moderately anemic patients undergoing shoulder arthroplasty. In fact, preoperative transfusion may increase the risk of complications in some cases. Allogeneic blood transfusion, including preoperative transfusion, is associated with increased risk of surgical site infection, increased thromboembolic events and immunomodulatory effects.

In patients with ferritin <30 ng/mL or transferrin saturation <20%, oral or especially intravenous iron may be the most cost effective approach for raising serum hemoglobin before surgery

Notably, tranexamic acid (TXA) is effective in reducing blood loss and transfusion need; this medication is now in common use in patients having shoulder arthroplasty and has been found to have a very low rate of adverse reactions

Inspiring the patient

Finally, as surgeons we have an opportunity to inspire the patient to take responsibility for their own health as detailed here.

Conclusion

In order to do our very best for each of our patients, we need to be on the watch for and to manage the factors that may threaten the outcome of their shoulder arthroplasty.

At a young age, barred owls learn to be watchful for threats

Barred Owl Fledgeling

Washington Park Arboretum

June 5, 2025

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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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).

Proximal humeral fracture is associated with a six times increased risk of hip fracture, a call to action

Over 300,000 proximal humeral fractures occur each year in the United States, second in frequency only to hip and wrist fractures. Of these, hip fractures are associated with the greatest morbidity and mortality, The authors of Proximal Humeral Fracture as a Risk Factor for Subsequent Hip Fractures asked whether a proximal humeral fracture was associated subsequent hip fracture. They assessed a cohort of 8049 community dwelling white women 65 years or older with no history of a hip or humeral fracture who were enrolled in the Study of Osteoporotic Fractures and were followed for a mean of 9.8 years. The subjects came from four separate geographic areas of the United States (Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and Monongahela Valley, Pennsylvania), followed prospectively at regular intervals for up to ten years with a followup rate of 99%. Black women were excluded from the study because of the low risk of osteoporotic fractures in these women and the considerably shorter follow-up time available.

The risk of hip fracture after an incident humeral fracture was estimated with use of age-adjusted Cox proportional hazards regression analysis with time-varying variables; women without a humeral fracture were the reference group. Cox regression analysis was used to evaluate the timing between the proximal humeral and subsequent hip fracture.

321 women sustained a proximal humeral fracture, and 44 of them sustained a subsequent hip fracture.

The table below shows other risk factors for hip fracture in this population.





After adjustment for age and bone mineral density, the hazard ratio for hip fracture for subjects with a proximal humeral fracture relative to those without a proximal humeral fracture was 1.83 (95% confidence interval = 1.32 to 2.53). After multivariate adjustment, the risk was still significant (hazard ratio = 1.57; 95% confidence interval = 1.12 to 2.19).

The risk of a subsequent hip fracture after a proximal humeral fracture was highest within one year after the proximal humeral fracture, with a hazard ratio of 5.68 (95% confidence interval = 3.70 to 8.73). This association between humeral and hip fracture was not significant after the first year, with hazard ratios of 0.87 (95% confidence interval = 0.48 to 1.59) between one and five years after the humeral fracture and 0.58 (95% confidence interval = 0.22 to 1.56) after five years.

The bottom line is that in this cohort of older white women, a proximal humeral fracture independently increased the risk of a subsequent hip fracture more than five times in the first year after the humeral fracture.

Comment: This study indicates that there is a small window of time after a proximal humeral fracture during which we can implement medical and environmental interventions that may decrease the risk of subsequent hip fractures. Preventative measures should be implemented without delay.

(1) Informing the patient and family of the increased risk.

(2) Addressing fall risk: the mechanism of proximal humeral fractures tends to be more similar to that of hip fractures than to that of any other osteoporotic fracture; i.e., they occur when the individual is unable to break his or her forward or oblique fall and therefore lands directly onto the shoulder or hip. The humeral fracture itself may compromise the woman's balance and ability to protect herself from falling. Fall risk may be mitigated by addressing balance, vision, home safety, the influence of medications, and the use of assistive devices.

(3) Addressing bone density: oral bisphosphonates begin to reduce the risk of fractures within three to six months after they are started.

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/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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).

Osteoporosis and the risk of complications after shoulder arthroplasty

Osteoporosis is a common condition characterized by low bone mineral density. It has been estimated that 50% of women and 20% of men aged 50 years and older will sustain an osteoporotic fracture in their lifetime. Many patients having shoulder arthroplasty have concurrent osteoporosis.

The authors of Osteoporosis and Implant-Related Complications After Anatomic and Reverse Total Shoulder Arthroplasty sought to determine the effects of osteoporosis on shoulder arthroplasty outcomes and the risk of prosthetic-related complications.

Using a national database, they determined the complication rates for patients with osteoporosis who underwent anatomic and reverse total shoulder arthroplasty. 

They found that the prevalence of osteoporosis at the time of surgery was 14.3% for anatomic total shoulder patients and 26.2% of reverse total shoulder patients. 

Anatomic total shoulder patients with osteoporosis experienced significantly higher rates of periprosthetic fracture and revision shoulder arthroplasty within 2 years of surgery compared with matched controls without osteoporosis. 

Reverse total shoulder patients with osteoporosis also had significantly higher rates of periprosthetic fracture and revision shoulder arthroplasty within 2 years of surgery compared with matched controls.

They concluded that osteoporosis represents a significant independent risk factor for periprosthetic fracture and revision shoulder arthroplasty within 2 years of surgery, regardless of the type of implant.

This study does not clarify whether treatment for osteoporosis is effective in reducing the risk of shoulder arthroplasty complications.

Plain x-rays can reveal the diagnosis of osteoporosis (see this link).

Osteoporosis is a common risk factor for patients having shoulder arthroplasty (see this link)

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

Follow on twitter: https://twitter.com/RickMatsen or 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).

Rheumatoid arthritis, osteoporosis, and cuff tear arthropathy in a 60 year old lady - 12 year followup after CTAA

A 60 year old lady presented with pain and loss of motion of the left shoulder along with this radiographic appearance. 

After discussion of the alternatives of total and reverse shoulder arthroplasty, the patient elected a cuff tear arthropathy arthroplasty (CTAA - see this link).

At the time of surgery the complete absence of rotator cuff and subscapularis was noted along with very soft fragile bone.

She returned to the office 12 years after surgery with a painless functional shoulder

And these radiographs

Comment: It is noteworthy that the shoulder has remained stable in spite of the absence of the subscapularis and that there has been no medial erosion of the prosthetic humeral head in over a decade.

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).

Osteoporosis is a common risk factor for patients having shoulder arthroplasty

Osteoporosis and Implant-Related Complications After Anatomic and Reverse Total Shoulder Arthroplasty

In a study of the 68,730 patients, these authors found that the prevalence of an osteoporosis diagnosis at the time of surgery was 14.3% for anatomic TSA patients and 26.2% of reverse TSA patients.

Anatomic TSA patients with osteoporosis experienced significantly higher rates of periprosthetic fracture (odds ratio [OR], 1.49; P = 0.017) and revision shoulder arthroplasty (OR, 1.21; P = 0.009) within 2 years of surgery compared with matched controls without osteoporosis. 

Patients in the reverse TSA group with osteoporosis also had significantly higher rates of periprosthetic fracture (OR, 1.86; P = 0.001) and revision shoulder arthroplasty (OR, 1.42; P = 0.005) within 2 years of surgery compared with matched controls.

Comment: The risk of periprosthetic fracture cannot be eliminated in patients with osteoporosis. However, the risk may be lowered by attention to fall prevention, as discussed in this link. Certain surgical techniques may be effective in making the shoulder more resistant to fracture, such as impaction grafting of the humeral stem (see this link and this link).

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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'

Tuberosity bone atrophy in rotator cuff tears

Measurement of volumetric bone mineral density in proximal humerus using quantitative computed tomography in patients with unilateral rotator cuff tear.

These authors investigated the region-specific volumetric bone mineral density (vBMD) of the proximal humerus in 65 patients with unilateral rotator cuff tear (RCT).

The vBMD values of the symptomatic shoulder with cuff tears were significantly lower than those of the asymptomatic contralateral shoulder (P < .05). The vBMD value was the highest in the posterolateral portion and the lowest in the medial portions. The vBMD was lower for female patients.

Comment: These findings demonstrate that, like muscle and tendon, the quality of the bone deteriorates with detachment of the rotator cuff from its insertion. Higher degrees of local osteopenia may present difficulties with suture fixation.

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To learn more about shoulder arthritis and what can be done about it, see the Shoulder Arthritis Book.

To learn more about the rotator cuff, see the Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

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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, androtator cuff surgery as well as the 'ream and run essentials'

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Reverse total shoulder in a person with osteoporosis - impaction grafting hybrid

Patients with rotator cuff tear arthropathy needing a reverse total shoulder often have osteoporosis and often have a tendency to fall because of balance problems and poor vision and lower extremity dysfunction.
This is a bad combination in that conventional approaches to reverse total shoulder arthroplasty involve cementing a metal stem in a manner that stiffens the bone down to the end of the cement and then provides a sudden transition to the thin bone below (see the way the white cement on this x-ray ends suddenly).

A fall on such an arm risks fracture at the tip of the cemented prosthesis because of this stress riser and because the reverse total shoulder does not have the 'give' of a normal shoulder. 

For these reasons, we've been exploring a hybrid method for fixing the humeral stem in which a smaller stem is selected, the canal around the stem is filled by impaction grafting and cement is used only at the upper end of the prosthesis as shown for the osteoporotic shoulder below.

Note the absence of cement in the canal except for the upper end and the canal filled with impaction grafted bone.

Here's another similar case from this week in a lady with paralysis of the opposite arm.

Note again the small stem and impacted bone graft.

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Plain x-ray of proximal humerus can reveal osteoporosis

Proximal humerus cortical bone thickness correlates with bone mineral density and can clinically rule out osteoporosis.

You have to see this site on osteoporosis put up by our friend Susan Ott

It is important that patients be evaluated for the possibility of osteoporosis. First of all, this condition needs to be managed to lower the risk of fractures of the spine, hip, and wrist. Second, with specific reference to shoulder (and elbow) arthroplasty, osteoporosis increases the risk of periprosthetic fractures of the humerus. This is especially the case for tightly fitted humeral components, cemented humeral components and reverse total shoulders. 

These authors studied 108 patients that had both shoulder radiographs and DXA scans. They describe two methods for evaluating cortical bone thickness and they evaluated the relationship between cortical bone thickness and femoral and lumbar DXA. 

They found that cortical bone thickness measurements at the proximal humerus strongly correlated with DXA femur measurements and moderately correlated with DXA lumbar measurements.

They propose that an average proximal humeral cortical thickness of 6 mm was a potential threshold value for predicting osteoporosis, with a sensitivity of 93%, specificity of 52%, and negative predictive value of 95%.

Virtually all of our patients get an AP x-ray of the shoulder. These authors are telling us to pay attention to the cortical thickness of the proximal humerus and to consider the diagnosis of osteoporosis when the bone is thin.

We've previously published on the relationship of shoulder fractures to osteoporosis

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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.

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Scapular fractures after reverse total shoulder

Scapular fractures after reverse shoulder arthroplasty: evaluation of risk factors and the reliability of a proposed classification.

Four of the six authors of this paper received payments from the company making a reverse total shoulder (RSA) and the study was funded by this company.

The authors identified 53 patients with scapular fractures after RSA and compared them to 212 control patients. The location of these fractures can be classified as (1) lateral acromion, (2) posterior to the AC joint and (3) scapular spine. They did not consider the first type. These fractures could be difficult to identify on plain films if they are not displaced.  Of note is that the average time from surgery to diagnosis of the fracture was 15 months. The risk of fracture was significantly increased in patients with osteoporosis. Fractures of the scapular spine tended to occur around the fixation screws.

Comment: Recognizing that patients needing reverse shoulder arthroplasty have reduced use of their shoulders prior to surgery with resulting disuse atrophy of the bone. This may be superimposed on osteoporosis, in that many patients are elderly females (over 80% in this report). The reverse total shoulder enables a sudden and dramatic increase in the loads applied to the scapular and also has the potential to weaken it with screw placement. These loads are increased if the deltoid is put under a lot of tension by distal translation of the shoulder. Additional loading may result from the patient's beginning to use the shoulder for assistance in rising from a chair or from use of walker, cane or crutch. 

Our practice is to advise patients of the risk of these fractures and to recommend a very gradual increase in arm use after RSA, especially in the presence of osteoporosis. If the patient presents with scapular pain at any time after this procedure, we find that clinical examination for scapular spine or acromial tenderness is very sensitive, perhaps more sensitive that imaging. These patients are advised to reduce activities while we monitor their progress.

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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.


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