Information that patients want and need to know about shoulder joint replacement arthroplasty for arthritis

In addition to the answers to frequently asked questions below, please also see

Arthritis of the shoulder- what patients need to know about the symptoms, diagnosis and treatment of shoulder arthritis

Patients frequently use internet search engines (such as Google (www.google.com) and Bing (www.bing.com) to seek information on shoulder arthritis and shoulder joint replacement. However, internet searches do not yield information; instead they yield links to sites with content that may related to the search terms. It is up to the patient to select which sites to visit and to synthesize the information found. This is a daunting task: a search "how long does it take to recover from shoulder joint replacement" yielded 13,700,000 results with an admixture of commercial, lawyer, journals, academic, private practice, orthopaedic societies and government websites - each with its own biases. Synthesizing a meaningful consensus is overwhelming.

A better option for patients is ChatGPT, a interactive language model developed by OpenAI, that uses a deep learning framework to understand queries and to generate coherent, contextually relevant responses based on a set of books, websites, and texts selected by unbiased researchers at OpenAI.  ChatGPT is currently available free of charge, generating friendly responses to queries posed by patients anytime day or night. It is, of course, critical to remember that while ChatGPT responses present syntheses of information from its comprehensive sources, they cannot be used as specific medical advice and may not be applicable to an individual patient. Patients should consult medical professionals for the most current and accurate information on their specific conditions.

A recent article, Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum found that Chatbot responses were rated of significantly higher quality than physician responses, with 3.6 times higher prevalence of good or very good quality responses for the chatbot. Chatbot responses were also rated significantly more empathetic than physician responses with 9.8 times higher prevalence of empathetic or very empathetic responses for the chatbot.

We used ChatGPT, to generate responses to the most commonly asked questions regarding shoulder arthroplasty as identified in What patients want to know about shoulder arthroplasty: a Google search analysis and Internet search analytics for shoulder arthroplasty: what questions are patients asking? It is of interest that patients are asking similar questions about rotator cuff repair: What Are Patients Asking and Reading Online? An Analysis of Online Patient Searches for Rotator Cuff Repair

Click on each of the frequently asked questions (FAQ) below to see the ChatGPT response

Are there alternatives to shoulder surgery for arthritis?

How can I avoid shoulder surgery?

Can you wait too long for shoulder replacement surgery?

What is the average age for a shoulder replacement?

How long does a shoulder replacement last?

What is the success rate of shoulder replacement surgery?

Where is the incision for shoulder replacement?

How painful is total shoulder replacement?

Why is shoulder surgery so painful?

Which is worse knee or shoulder replacement?

Can you ice too much after shoulder surgery?

Can you lay flat after shoulder replacement surgery?

Why do you have to sleep in a recliner after shoulder surgery?

How long should you sleep in a recliner after shoulder surgery?

What happens if you don't wear your sling after shoulder replacement surgery?

Can you wear a bra after shoulder joint replacement surgery?

How do you go to the bathroom after shoulder replacement surgery?

What is the fastest way to recover from shoulder replacement surgery?

How long is physical therapy after shoulder joint replacement?

How long does it take to recover from a shoulder joint replacement?

How long should you take off work after shoulder replacement surgery?

What are the possible limitations after total shoulder joint replacement surgery?

What can you not do after total shoulder joint replacement surgery?

Can you play sports after shoulder replacement?

Can I have an MRI after shoulder replacement?

These responses by ChatGPT are reasonable and include the caveat that patients cannot use them as advice about their personal situation, but rather they should consult with their orthopaedic surgeon for guidance on the evaluation and management of their shoulder.

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)

Age, smoking and failure of total shoulder arthroplasty

Smoking has been portrayed as being glamorous or macho, leading young people to take it up. Its habit-forming tendency prompts older individuals to continue.

There are many adverse physiological changes that can result from smoking, changes that can contribute to complications after joint replacement.

The authors of The impact of tobacco use on clinical outcomes and long-term survivorship after anatomic total shoulder arthroplasty explored the effect of smoking status on the outcomes of anatomic shoulder arthroplasty. 

Patients were stratified into three cohorts based on their smoking status on the date of their operation: 1) non-smokers (n=78) 2) former smokers (n=49) 3) current smokers (n=16). Nonsmokers were defined as individuals who had never smoked tobacco. Former smokers were defined as individuals who quit smoking tobacco at least one year prior to their index procedure; these individuals had previously smoked at least 0.25 packs per day. Current smokers were defined as individuals who started smoking at least one year prior to surgery and continued to smoke within one year of their surgery (consumption of at least 0.25 packs per day for one year).

Interestingly and importantly at the time of surgery, smokers were younger (51.5 years) than both non-smokers (64.9 years) and former smokers (65.1 years; . 

Visual Analog Scale, American Shoulder and Elbow, and Simple Shoulder Test scores were lower for smokers comparatively; these differences did not reach significance with the numbers of patients in this study.

Revision rates were lower in the non-smoking cohort (7.7%) compared to both former (20.4%) and current smokers (37.5%). 

Survival curves showed that non-smoker implants lasted longer than those of current smokers.

Comment: While this study focuses on the relationship between smoking and surgical outcomes, it is also recognized that smoking increases the risk of medical problems, such as urinary tract infections, pulmonary complications, myocardial infarctions, and readmission. According to the World Health Organization, Smoking greatly increases risk of complications after surgery: Tobacco smokers are at significantly higher risk than non-smokers for post-surgical complications including impaired heart and lung functions, infections and delayed or impaired wound healing. Nicotine and carbon monoxide, both present in cigarettes, can decrease oxygen levels and greatly increase risk of heart-related complications after surgery. Smoking tobacco also damages the lungs making it difficult for the proper amount of air to flow through, increasing the risk of post-surgical complications to the lungs. Smoking distorts a patient’s immune system and can delay healing, increasing the risk of infection at the wound site. Smoking just one cigarette decreases the body’s ability to deliver necessary nutrients for healing after surgery. However, new evidence reveals that smokers who quit approximately 4 weeks or more before surgery have a lower risk of complication and better results 6 months afterwards. Patients who quit smoking tobacco are less likely to experience complications with anesthesia when compared to regular smokers. Every tobacco-free week after 4 weeks improves health outcomes by 19%, due to improved blood flow throughout the body to essential organs. This report provides evidence that there are advantages to postponing minor or non-emergency surgery to give patients the opportunity to quit smoking, resulting in a better health outcome.

Some important questions present themselves:
(1) In that current smokers were over a decade younger than former or non-smokers, to what degree is the poorer survivorship for smokers due to patient age or to smoking status (recalling that patients <60 years of age do less well after shoulder arthroplasty)?
(2) To what degree does smoking contribute to the earlier development of arthritis?
(3) Aside from its adverse effect on health, does smoking reveal a tendency to take risks that may jeopardize the longevity of the arthroplasty? See Smokers’ Decision Making: More than Mere Risk Taking: "The fact that smoking is bad for people’s health has become common knowledge, yet a substantial amount of people still smoke. Previous studies that sought to better understand this phenomenon have found that smoking is associated with the tendency to take risk in other areas of life as well. The current paper explores factors that may underlie this tendency. An experimental analysis shows that smokers are more easily tempted by immediate high rewards compared to nonsmokers. Thus the salience of risky alternatives that produce large rewards most of the time can direct smokers to make bad choices even in an abstract situation such as the Iowa Gambling Task (see this link). These findings suggest that the risk taking behavior associated with smoking is not related to the mere pursuit of rewards but rather reflects a tendency to yield to immediate temptation."

(4) To what degree does smoking cessation reduce the risk? See Smoking Cessation Initiatives in Total Joint Arthroplasty, An Evidence-Based Review. Points from this article follow:

Hospital costs for total joint arthroplasty (TJA) are about $5,000 higher for smokers compared with nonsmokers. Currently, smoking cessation programs are the only intervention demonstrated to reproducibly improve outcomes for smokers undergoing TJA. Several randomized controlled trials have shown that perioperative smoking cessation programs confer short-term quit rates between 40% and 89%.

Initiating a smoking cessation program 4 weeks preoperatively is likely adequate to provide clinically meaningful reductions in postoperative complications for smokers following TJA. The evidence is that 2 to 6 weeks of abstinence would be necessary to reduce the incidence of infection, 3 to 4 weeks to reduce wound-related complications, and 6 to 8 weeks to reduce pulmonary complications. Longer periods of smoking cessation decreased the rate of postoperative complications further, with each week of cessation increasing the magnitude of the effect.

How can a surgeon know if the patient has ceased smoking? Smoking status is typically measured by patient self-reporting, Cotinine testing, or CO breath testing. One study found that self-reporting was accurate 97% of the time while others found that 20% falsely reported abstinence. Cotinine is the major metabolite of nicotine and may be measured in the urine or saliva using immunoassay-based test strips. It has a half-life of 7 to 14 hours. CO breath tests measure the concentration of CO in expired air. Breath CO is a good indicator of recent smoking, but it has a half-life of only 2 to 3 hours and usually becomes undetectable around 24 hours after smoking cessation.

What are the other benefits of smoking cessation? Smoking adds approximately $100 billion in annual direct health-care costs annually. Thus smoking cessation programs can provide even further potential value if abstinence from smoking is maintained. Additionally, it has been observed that smoking cessation programs encourage other positive lifestyle changes such as improved exercise, eating, and drinking habits, which can further contribute to improved patient health and decreased costs.

A recent systematic review, Smoking cessation prior to total shoulder arthroplasty: A systematic review of outcomes and complications found 24 studies on this topic. The authors concluded that patients who quit smoking at least 1 month preoperatively had improved outcomes compared to current smokers. Current smokers had statistically significant higher pain scores or opioid use. Five studies found increased rates of revision surgery in smokers. Smokers were significantly more likely to have increased rates of surgical, wound, superficial, and deep surgical site complications.  The authors recommend a period of four weeks or more of preoperative smoking cessation.

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).

Augmented glenoid components for B2 and B3 glenoids

An augmented glenoid component is used by some surgeons in cases of posterior bone loss and retroversion.

Its insertion requires concentric reaming of the anterior glenoid

followed by the removal of additional posterior bone to fit the back of the selected component using either an oscillating rasp

or a superior/inferior scraper

The size of posterior augment ranges from 3 to 7 mm. The amount of bone removed in a case using a 7 mm augment is shown below.

The authors of Factors Associated with Functional Improvement After Posteriorly Augmented Total Shoulder Arthroplasty sought to identify pre- and postoperative factors that impact range of motion and function after augmented TSA in patients with B2 or B3 glenoid morphology.

An individual highly experienced shoulder surgeon performed 1,044 consecutive anatomic TSAs. Of these 88% were performed using a standard (non-augmented) glenoid component. 121 (12%) were performed with posteriorly augmented, stepped glenoid components; the indications for the use of an augmented component were not specified.

50 patients (57%)(41 B2 and 9 B3 glenoids) with minimum 2 year followup were included in the analysis. Two patients having posterior dislocation were excluded.

There was strong agreement among the observers for preoperative and postoperative glenoid version as measured on plain x-rays.

There was strong agreement for plain X-ray measurements of humeral decentering preoperatively and moderate agreement for this measurement postoperatively.

Range of motion was improved over preoperative values.  

Preoperative glenoid retroversion did not significantly affect the postoperative range of motion. 

Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with range of motion in any plane.

Preoperative shoulder SANE and VAS scores were missing from this study. The mean postoperative VAS score was 0.5 and mean SANE score was 94.5  

Posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores.

While the amount of posterior decentering of the humeral head was reduced from a mean of 21 percent before surgery to 3 percent after surgery, the amount of glenoid version was only changed by 7 degrees (24 degrees to 17 degrees).  

Comment: The questions needing answers are 

(1) how important is version correction to a value of 15 degrees or less as proposed by some authors?

(2) while it is evident that postoperative posterior decentering can lead to eccentric loading and rocking horse loosening of the glenoid component

is "correction" of glenoid version necessary for re-centering the humeral head on the glenoid?
(3) are the results of anatomic shoulder arthroplasty with a standard glenoid component for B2 and B3 glenoids inferior to those for glenoid types A1 or A2?
(4) are the clinical results of anatomic shoulder arthroplasty for B2 and B3 glenoids using an augmented component superior to those obtained with a standard glenoid component?

Some of the answers may be found in Anatomic Total Shoulder Arthroplasty with All-Polyethylene Glenoid Component for Primary Osteoarthritis with Glenoid Deficiencies.These authors sought to evaluate the ability of shoulder arthroplasty using a standard glenoid component to improve patient self-assessed comfort and function and to correct preoperative humeral-head decentering on the face of the glenoid in patients with primary glenohumeral arthritis and type-B2 or B3 glenoids. They identified 66 shoulders with type-B2 glenoids (n = 40) or type-B3 glenoids (n = 26) undergoing total shoulder arthroplasties with a non-augmented glenoid component inserted without attempting to normalize glenoid version and with clinical and radiographic follow-up at a minimum of 2 years.

Shoulder pathoanatomy was characterized on the axillary "truth" view in terms of glenoid version (angle between lines G and S) and humeral head decentering on the face of the glenoid (distance between line P - the perpendicular bisector of line segment G - and the center of the humeral head, C). Preoperative CT scans and computer planning software were not used in this case series.

This method allowed direct comparison of glenoid version and humeral decentering before and after the arthroplasty

The Simple Shoulder Test (SST) score improved from 3.2  points preoperatively to 9.9  points postoperatively at a mean time of 2.8 years for type-B2 glenoids and from 3.0 points preoperatively to 9.4 points postoperatively at a mean time of 2.9 years for type-B3 glenoids. These patient reported outcomes were as good as those achieved with other glenoid types.

These outcomes were achieved without changing glenoid version: postoperative glenoid version was not significantly different from preoperative glenoid version.

The humeral head centering on the glenoid was restored without the use of an augmented component: the mean humeral-head decentering on the glenoid face was reduced for type-B2 glenoids from 14% preoperatively to 1% postoperatively and for type-B3 glenoids from 4% preoperatively to 1% postoperatively.

The rates of bone integration into the central peg for type-B2 glenoids (83%) and type-B3 glenoids (81%) were not inferior to those for other glenoid types (A1 67%, A2 85%, B1 74%, D 75%).

Anterior penetration of the glenoid neck by the central peg of the glenoid component was observed in 2 (11%) of 19 of the type-B1 glenoids, in 6 (15%) of 40 of the type-B2 glenoids, and in 6 (23%) of 26 of the type-B3 glenoids. Perforation of the glenoid by the central peg was not associated with inferior clinical or radiographic outcomes. Twelve of the 14 shoulders with glenoid neck penetration had ingrowth of bone between the flanges of the central peg with no radiographic evidence of component loosening. The final mean SST score for the 14 shoulders with central peg penetration was 9.4 points, a value not significantly different from that for all of the type-B2 and B3 glenoids (9.7 points).

These minimum 2-year outcomes for 40 shoulders with type-B2 glenoids and 26 shoulders with type-B3 glenoids do not appear to be inferior to the minimum 2-year results reported recently for a combined group of 71 shoulders with type-B2 or B3 glenoid anatomy treated with posteriorly augmented glenoids inserted using preoperative CT scans and 3-dimensional planning software (see this link).

This study demonstrates that good two year clinical outcomes can be achieved for B2 and B3 glenoid components using a standard (non-augmented) glenoid component inserted without changing glenoid version.

Further clinical research will be required to establish clinical practice guidelines and appropriate use criteria for augmented glenoid components. 

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).

Is it important to "correct" glenoid retroversion in total shoulder arthroplasty?

A large industry has formed around the assessment of, planing for, special components to address, and surgical "correction" of glenoid retroversion to 15 degrees or less in performing an anatomic total shoulder arthroplasty.

       

In Do glenoid retroversion and humeral subluxation affect outcomes following total shoulder arthroplasty? the authors studied 113 patients at an average of 4 years after arthroplasty.  Retroversion and humeral head subluxation before and after surgery were measured on axillary radiographs. 

          

Left figure above. Assessment of preoperative glenoid retroversion. Line A-C represents the glenoid plane, which is drawn connecting the anterior (A) and posterior (C) rims of the glenoid. Line B-Y represents the scapular plane. Line B-X is the perpendicular bisector of line A-C. The retroversion of glenoid is defined as the angle between lines B-X and B-Y. 

Right figure above. Assessment of preoperative subluxation. The same lines A-C and B-X are drawn. The humeral head circle is drawn with point Z at the center. Line segment D-F marks the humeral diameter, parallel to line A-C. Point E is the intersection between lines D-F and B-X. Subluxation is defined as the percentage of the humeral head posterior to line B-X, and is calculated as (E-F)/(D-F) X 100%.

At surgery, reaming of the anterior glenoid was carried out until satisfactory implant support (>80% of bony contact with the component) was achieved. There was no specific targeted amount of retroversion that was deemed acceptable.

In contrast to many other studies in which CT scans were used to measure the preoperative anatomical relationships and axillary views to make the postoperative measurements, these authors measured postoperative retroversion and subluxation in a manner identical to the preoperative measurements. As shown below.

 

At a mean followup of 4.2 years, the authors found no significant correlation between preoperative glenoid version or humeral head subluxation and the postoperative ASES scores. 

The authors found no significant correlation between postoperative glenoid version or humeral head subluxation and the postoperative ASES scores. 

For patients with preoperative retroversion of >15 degrees, there was no difference in outcome scores based on postoperative retroversion. 

There were no significant differences in preoperative or postoperative version for patients with or without glenoid lucencies.

The overall complication rate was 11.3%, including 5 periprosthetic joint infections, 3 with glenoid loosening, 2 rotator cuff failures, 2 periprosthetic fractures, 1 patient with stiffness treated with lysis of adhesions, and 1 patient with recurrent posterior instability after treatment with shoulder replacement after a locked posterior dislocation. Eleven of these patients underwent component revision. There was no observed difference between patients with or without revision surgery for either preoperative retroversion (15.2 ± 5.5 deg for failures vs. 15.3 ± 7.7 deg for non failures); or postoperative retroversion (7.1± 5.2 deg  vs. 10.0 ± 6.8). 

For the patients with eventual glenoid loosening, the preoperative retroversion was 15 and 17 deg in 2 of the 3 patients (third patient did not have available preoperative imaging) and the postoperative retroversion was 6, 8, and 19 deg. The preoperative subluxation was 64% and 60%, whereas postoperative subluxation was 58%, 49%, and 48%. 

Comment: This study does not support the need to "correct" glenoid version to < 15 degrees in performing an anatomic total shoulder. This is consistent with the findings in Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?

In a population of patients undergoing TSA in whom no specific efforts were made to change the version of the glenoid, these authors asked whether at 2 years after surgery patients having glenoid components implanted in 15° or greater retroversion had (1) less improvement in the Simple Shoulder Test (SST) score and lower SST scores; (2) higher percentages of central peg lucency, higher Lazarus radiolucency grades, higher mean percentages of posterior decentering, and more frequent central peg perforation; or (3) a greater percentage having revision for glenoid component failure compared with patients with glenoid components implanted in less than 15° retroversion. They examined the records of  TSAs performed using a standard all-polyethylene pegged glenoid component

inserted after conservative glenoid reaming without specific attempt to modify preoperative glenoid version.

They analyzed the two year outcomes in  71 TSAs, comparing the 21 in the retroverted group (the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°)) with the 50 in the non-retroverted group ( the glenoid component was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°)). 

The mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%).  The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, - 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. 

The radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4-6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). The percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids having revision (three of 50; [6%]; p = 0.251).

The authors concluded that in this series of TSAs, postoperative glenoid retroversion was not associated with inferior clinical results at 2 years after surgery. 

Also of relevance is Anatomic Total Shoulder Arthroplasty with All-Polyethylene Glenoid Component for Primary Osteoarthritis with Glenoid Deficiencies

This study evaluated the ability of shoulder arthroplasty using a standard glenoid component to improve patient self-assessed comfort and function and to correct preoperative humeral-head decentering on the face of the glenoid in patients with primary glenohumeral arthritis and type-B2 or B3 glenoids. 

The authors identified 66 shoulders with type-B2 glenoids (n = 40) or type-B3 glenoids (n = 26) undergoing total shoulder arthroplasties with a non-augmented glenoid component inserted without attempting to normalize glenoid version and with clinical and radiographic follow-up that was a minimum of 2 years. The Simple Shoulder Test (SST) score (and standard deviation) improved from 3.2 ± 2.1 points preoperatively to 9.9 ± 2.4 points postoperatively (p < 0.001) at a mean time of 2.8 ± 1.2 years for type-B2 glenoids and from 3.0 ± 2.5 points preoperatively to 9.4 ± 2.1 points postoperatively (p < 0.001) at a mean time of 2.9 ± 1.5 years for type-B3 glenoids; these results were not inferior to those for shoulders with other glenoid types. 

Postoperative glenoid version was not significantly different (p > 0.05) from preoperative glenoid version. The mean humeral-head decentering on the glenoid face was reduced for type-B2 glenoids from -14% ± 7% preoperatively to -1% ± 2% postoperatively (p < 0.001) and for type-B3 glenoids from -4% ± 6% preoperatively to -1% ± 3% postoperatively (p = 0.027). The rates of bone integration into the central peg for type-B2 glenoids (83%) and type-B3 glenoids (81%) were not inferior to those for other glenoid types.

The authors concluded that shoulder arthroplasty with a standard glenoid inserted without changing version can significantly improve patient comfort and function and consistently center the humeral head on the glenoid face in shoulders with type-B2 and B3 glenoids, achieving >80% osseous integration into the central peg. These clinical and radiographic outcomes for type- B2 and B3 glenoids were not inferior to those outcomes for other glenoid types

Long term followup of well-characterized patients treated with the different methods for managing glenoid retroversion will be required to define the relative risks, benefits, effectiveness and durability of each of them.

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).

Comparison of anatomic and reverse total shoulder arthroplasties

There is interest in comparing outcomes of anatomic and reverse total shoulders.

 Two such papers have been published recently.

In Can The Reverse Total Shoulder Arthroplasty Provide As Good Of An Outcome As An Anatomic Shoulder Arthroplasty the authors conducted a retrospective review of patients who underwent TSA or RTSA between 2015 and 2019 who were enrolled in prospective multicenter registry among more than 10 sites. Inclusion criteria were: (1) primary RTSA or TSA, (2) minimum of 2 year follow-up, (3) a minimum of 130° of postoperative forward flexion and (4) minimum postoperative ASES score of 70. Exclusion criteria were: (1) fracture diagnosis, (2) revision arthroplasty, (3) patients who had a concomitant latissimus transfer at the time of surgery and (4) incomplete follow-up.

During the study period, 401 TSAs were performed, of which 318 (79%) had two-year follow-up data. Of these, 155 (49%) met criteria for a “good” outcome. Among RTSAs, 545 were available during the study period, of which 428 (79%) had two-year follow-up data. Of these, 154 (36%) met criteria for a “good” outcome. Overall 20% of these patients were lost to followup by two years.

The authors concluded that patients do well following both TSA and RTSA. In patients who have a good outcome following either TSA and RTSA, those patients who underwent TSA have superior outcomes compared to patients following RTSA. However, the change in outcome scores from pre to post surgery is often more significant with RTSA as they often start out with worse motion and clinical scores.

It is important to note that the preoperative characteristics of the two groups were different, so this is not a comparison of the two types of arthroplasty in similar patients.

In Anatomic Versus Reverse Shoulder Arthroplasty for Glenohumeral Osteoarthritis with

Intact Rotator Cuff: A Retrospective Comparison of Patient-Reported Outcomes Using

the Systems Outcomes Database with up to 5-Year Follow-Up the authors conducted a retrospective study on data prospectively collected in a shoulder arthroplasty database between 2012 and 2021.  Inclusion criteria consisted of adult patients who underwent either RSA or TSA for the treatment of primary GHOA with an intact rotator cuff. Follow-up data was available for 70.6% of patients at 1 year, 65.3% at 2 years, and 50.7% at 5 years postoperatively. In other words, one third of these patients were lost to followup by two years.

The authors concluded that RSA as a treatment for GHOA with an intact rotator cuff seems to yield patient reported outcomes that are largely clinically equivalent to TSA extending to 5 years postoperatively. "The observed statistical significance favoring TSA appears to be of marginal clinical benefit based on established minimal clinically important differences and may be a result of the large sample size."

It is important to note that the preoperative characteristics of the two groups were different, so this is not a comparison of the two types of arthroplasty in similar patients. Furthermore, comparison data on the glenoid types and the degree of glenoid retroversion are not provided for the ATSA and RTSA groups.

Comment: In these two studies it is evident that the characteristics of patients and shoulders differed substantially between those indicated for anatomic and reverse total shoulder arthroplasties. 

To understand the differences in clinical outcomes for these two procedures - including the rates and types of complications - we need robust clinical research that controls for patient demographics, preoperative pathoanatomy, preoperative comfort and function, and patients lost to followup.

It is important to recall that the value of these procedures is calculated as the benefit to the patient divided by the cost.

Orthopaedic Network News provides some data on the recent average selling prices (ASP) of different implants. Note the substantial variation.

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).