Sperling, John W.

Abstract » A thorough understanding of glenoid deformity is essential to anticipate intraoperative needs and manage bony deficiencies. Management strategies include eccentric reaming, alternate scapular line baseplate orientation, bone grafting, or metallic augmentation as either “off-the-shelf” or custom baseplates. Accurate implantation of the glenoid component in the presence of glenoid bone loss (GBL) may also benefit from shoulderspecific guides, navigation, or robotic assistance. » GBL can negatively affect outcomes due to compromised bony fixation, altered soft tissue tensioning, and component malposition, which can contribute to impingement, dislocation, aseptic loosening, polyethylene wear, and component failure. » In this article, we provide a comprehensive review of published literature regarding the management of GBL in primary RSA and provide additional insight on the effectiveness of current approaches to manage bony deficiency.

Background: Periprosthetic joint infection (PJI) can be a devastating complication following shoulder arthroplasty. PJI following hip and knee arthroplasties has been found to increase mortality. However, anatomical and bacteriologic differences could potentially result in a different trend after shoulder arthroplasties. Thus, the purpose of the present study was to determine whether there is an association between shoulder PJI and all-cause mortality. Methods: Our institutional Total Joint Registry Database was queried to identify patients who underwent revision shoulder arthroplasty procedures between 2000 and 2018. A total of 1,160 procedures were then classified as either septic (21.8%) or aseptic (78.2%). Septic revisions were further subdivided into (1) debridement, antibiotics, irrigation, and implant retention (9.1%); (2) 2-stage reimplantation for deep infection (61.3%); (3) implant resection without reimplantation (3.6%); and (4) unexpected positive cultures at revision surgery (26.1%). The most common bacterium isolated was Cutibacterium acnes (64.4%). All-cause patient mortality was determined with use of our registry and confirmed with use of a nationwide mortality database. All-cause crude and adjusted mortality rates were then compared between groups. Results: The 1-year crude mortality rate was 1.8% (95% confidence interval [CI], 0.9% to 2.6%) for the aseptic group and 2.8% (95% CI, 0.7% to 4.8%) for the septic group (p = 0.31). Multivariate Cox regression analysis demonstrated an elevated but statistically similar adjusted hazard ratio for 1-year all-cause mortality of 1.9 (95% CI, 0.8 to 4.6) when comparing the septic to the aseptic group (p = 0.17). The risk of 2-year all-cause mortality was significantly higher in the septic group, with a hazard ratio of 2.2 (95% CI, 1.1 to 4.5; p = 0.029). In univariate analyses, increased 5-year mortality in the septic revision group was associated with age, Charlson Comorbidity Index, and methicillin-resistant Staphylococcus aureus infection, whereas C. acnes infection was associated with lower mortality. Conclusions: Shoulder PJI is associated with an adjusted 2-year all-cause mortality rate that is double that of aseptic patients. The results of the present study should be utilized to appropriately counsel patients who are considered to be at risk for infection following shoulder arthroplasty. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Although prophylactic antibiotics are considered the standard of care, data with regard to the comparative efficacy of specific antibiotics in the prevention of periprosthetic joint infection (PJI) have remained limited. This study evaluated whether perioperative antibiotic choice affects rates of PJI development in shoulder arthroplasty. Methods: From 2000 to 2019, all primary shoulder arthroplasty types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed for elective and trauma indications with perioperative antibiotic data and a minimum follow-up of 2 years were identified from a single institution. Demographic characteristics, PJI risk factors, and PJI-free survivorship data were retrieved. Multivariable analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Results: Of 7,713 shoulder arthroplasties, cefazolin was administered in 6,879 procedures (89.2%) and non-cefazolin antibiotics consisting of vancomycin (465 procedures [6.0%]), clindamycin (345 procedures [4.5%]), and alternative regimens (24 procedures [0.31%]) were administered in 834 procedures (10.8%). PJIs occurred in 101 shoulder arthroplasties (1.3%), with Cutibacterium acnes as the most common pathogen (44 procedures [43.6%]). PJI-free survivorship was greater in shoulder arthroplasties in which cefazolin was administered compared with those in which non-cefazolin antibiotics were administered, with 0.91% greater survival free of PJI at 1 month, 1.4% at 1 year, and 2.7% at 15 years (p < 0.001). Cefazolin administration, compared with non-cefazolin administration, was associated with a 69% reduction in all-cause PJI risk and a 78% reduction in C. acnes PJI risk (p < 0.001). A higher risk of PJI for both groups was observed with vancomycin; the hazard ratio [HR] was 2.32 (95% confidence interval [CI], 1.22 to 4.40; p = 0.010) for all-cause PJI and 2.94 (95% CI, 1.12 to 7.49; p = 0.028) for C. acnes PJI. A higher risk of PJI was also observed for both groups for clindamycin; the HR was 5.07 (95% CI, 2.83 to 9.05; p < 0.001) for all-cause PJI and 8.01 (95% CI, 3.63 to 17.42; p < 0.001) for C. acnes PJI. Conclusions: In primary shoulder arthroplasty, cefazolin administration was associated with a significantly lower rate of PJI compared with non-cefazolin alternatives, including both vancomycin and clindamycin. These risk discrepancies were observed across all infectious pathogens and may be considered even greater when C. acnes was the infecting bacterium. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Glenoid component loosening is a primary cause of failure of anatomical total shoulder arthroplasty (TSA) and is commonly associated with glenoid bone loss. The purpose of the present study was to evaluate the outcome and survival following revision to a reverse total shoulder arthroplasty (RSA) for the treatment of loosening of a polyethylene cemented glenoid component in the setting of failed TSA. Methods: Between 2010 and 2017, 151 shoulders underwent revision to RSA for the treatment of loosening of an anatomical polyethylene glenoid component. Shoulders with staged reconstruction for the treatment of infection were excluded. One hundred and twenty-seven patients (67 women and 60 men) had a single-stage reconstruction and were available for follow-up. The mean age at the time of surgery was 70 years (range, 41 to 93 years). In all cases, the humeral component was revised and a standard glenoid baseplate was utilized. Bone graft was used at the discretion of the treating surgeon. Medical records and radiographs were reviewed to collect demographic, intraoperative, and postoperative data; to quantify glenoid bone loss; and to determine the radiographic outcome. The mean duration of follow-up was 35 months (range, 24 to 84 months). Results: Revision to RSA resulted in significant improvements in terms of pain and motion. Sixteen shoulders (13%) underwent revision surgery for the treatment of baseplate loosening. Radiographic baseplate loosening was present in 6 additional shoulders (overall rate of baseplate loosening, 17%). Intraoperative fracture or fragmentation of the greater tuberosity occurred in 30 shoulders (24%). Other reoperations included resection for deep infection (3 shoulders), arthroscopic biopsies for unexplained persistent pain (2 shoulders), humeral tray exchange for dislocation (2 shoulders), revision for humeral loosening (1 shoulder), irrigation and debridement for hematoma (1 shoulder), and internal fixation of periprosthetic fracture (1 shoulder) (overall reoperation rate, 20%). Among shoulders with surviving implants at the time of the most recent follow-up, pain was rated as none or mild in 83 shoulders (65.4%) and the average active elevation and external rotation were 132° and 38°, respectively. With the numbers available, no risk factors for failure could be identified. Conclusions: Revision RSA for the treatment of loosening of an anatomical polyethylene component was associated with a 17% glenoid mechanical failure rate. Although this procedure resulted in improvements in terms of pain and function, it was not universally successful and thus needs further refinement in order to improve outcomes. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Aims Reverse shoulder arthroplasty (RSA) reliably improves shoulder pain and function for a variety of indications. However, the safety and efficacy of RSA in elderly patients is largely unknown. The purpose of this study was to report the mortality, morbidity, complications, reoperations, and outcomes of primary RSA in patients aged > 80 years. Patients and Methods Between 2004 and 2013, 242 consecutive primary RSAs were performed in patients aged > 80 years (mean 83.3 years (sd 3.1)). Of these, 53 were lost to follow-up before two years and ten had died within two years of surgery, leaving 179 for analysis of survivorship, pain, motion, and strength at a minimum of two years or until revision surgery. All 242 patients were considered for the analysis of 90-day, one-year, and overall mortality, medical complications (90-day and overall), surgical complications, and reoperations. The indications for surgery included rotator cuff arthropathy, osteoarthritis, fracture, the sequela of trauma, avascular necrosis, and rheumatoid arthritis. A retrospective review of the medical records was performed to collect all variables. Survivorship free of revision surgery was calculated at two and five years. Results One patient (0.4%) died within the first 90 days. A total of 45 patients (19%) were known to have died at the time of the final follow-up, with a median time to death of 67.7 months (interquartile range 40.4 to 94.7) postoperatively. Medical complications occurred in six patients (3%) and surgical complications occurred in 21/179 patients (12%). Survivorship free from revision was 98.9% at two years and 98.3% at five years; survivorship free from loosening was 99.5% at final follow-up. The presence of peripheral vascular disease correlated with a higher complication rate. Conclusion Primary RSA was safe and effective in patients aged > 80 years, with a relatively low rate of medical and surgical complications. Thus, age alone should not be a contraindication to primary RSA in patients aged > 80 years. However, a careful evaluation of comorbidities is required in this age group when considering primary RSA. Cite this article: Bone Joint J 2019;101-B:1520–1525

Background: Venous thromboembolism (VTE) complications, including deep vein thrombosis and pulmonary embolism, are dreaded complications of orthopaedic surgical procedures that can result in substantial morbidity and mortality. There is a paucity of data examining risk factors for VTE in shoulder arthroplasty. The purpose of the present study was to review the rate of symptomatic VTE, determine patient and operative risk factors for VTE, and report on complications associated with VTE following shoulder arthroplasty. Methods: Over a 16-year period, 5,906 patients underwent primary anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. Symptomatic VTE events were identified in 24 shoulders within 90 days of surgery. Patient records were reviewed for surgical indication, patient and operative risk factors, and management of VTE. Results: The rate of symptomatic VTE following shoulder arthroplasty was 0.41%. There were no deaths resulting from VTE events. Compared with patients who did not have VTE, those with symptomatic VTE events were found to be older (74.75 versus 68.51 years; p = 0.0028) and more likely to have had arthroplasty for a traumatic indication (3.31% versus 0.33%; p < 0.001). Age of >70 years and arthroplasty for a traumatic indication were found to be independent risk factors on multivariate nominal logistic regression analysis, whereas body mass index, sex, operative time, and type of arthroplasty performed were not found to be independent risk factors. There were 11 readmissions resulting directly from the VTE events, and patients diagnosed with VTE as inpatients had longer hospital stays than outpatients (13.71 versus 1.94 days; p = 0.0002). Conclusions: The risk of VTE following shoulder arthroplasty is low, and routine use of pharmacologic VTE prophylaxis may not be necessary. However, VTE complications can lead to substantial morbidity, longer hospital stays, readmission to the hospital, and further complications. Therefore, patients with multiple risk factors for VTE such as prior history of VTE, active malignancy, age of >70 years, or arthroplasty for traumatic indications should be considered for pharmacologic VTE prophylaxis. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Aims A number of methods have been described to remove a well-fixed humeral implant as part of revision shoulder arthroplasty. These include the use of cortical windows and humeral osteotomies. The router bit extraction technique uses a high-speed router bit to disrupt the bone-implant interface. The implant is then struck in a retrograde fashion with a square-tip impactor and mallet. The purpose of this study was to determine the characteristics and frequency of the different techniques needed for the removal of a well-fixed humeral stem in revision shoulder arthroplasty. Patients and Methods Between 2010 and 2018, 288 revision shoulder arthroplasty procedures requiring removal of a well-fixed humeral component were carried out at a tertiary referral centre by a single surgeon. The patient demographics, indications for surgery, and method of extraction were collected. Results Of the 288 revisions, 284 humeral stems (98.6%) were removed using the router bit extraction technique alone. Four humeral stems (1.39%) required an additional cortical window. Humeral osteotomy was not necessary in any procedure. Most of the humeral stems removed (78.8%) were cementless. Of the four humeral stems that required a cortical window, three involved removal of a hemiarthroplasty. Two were cemented and two were cementless. Conclusion The router bit extraction technique removed a well-fixed humeral component in a very high proportion of patients (98.6%). This method allows surgeons to avoid more invasive approaches involving a cortical window or humeral osteotomy, and their associated complications. Cite this article: Bone Joint J 2019;101-B:1280–1284

Introduction Cutibacterium acnes is a recognized culprit for implant-associated infections, but positive cultures do not always indicate clinically relevant infection. Studies have shown a correlation between the β-hemolytic phenotype of C. acnes and its infectious capacity, but correlation with genetic phylotype has not been performed in literature. The purpose of this study is to evaluate β-hemolysis phenotype, genetic phylotype, and mid-term clinical outcomes of C. acnes isolated from orthopedic surgical sites. Methods Fifty-four C. acnes isolates previously obtained from surgical wounds of patients undergoing hip, knee, shoulder, or spine implant removal were re-cultured. There were 21 females and 33 males with an average age of 59 years (range, 18–84). Twenty-four were from clinically infected sites whereas 30 were considered contaminants. De novo β-hemolysis was analyzed and a retrospective chart review was performed to evaluate clinical outcomes at 7.1 years (range, 0.1–12.8). Results On Brucella agar with 5% rabbit blood, 46% of contaminant and 43% of infectious isolates were hemolytic. Type II phylotype was significantly more nonhemolytic regardless of infectious or contaminant status (p < 0.05). Type 1B correlated with a hemolytic-infectious phenotype and Type 1A with a hemolytic-contaminant phenotype but was not statistically significant. Conclusion The β-hemolytic profile of C. acnes did not correlate with phylotype or clinically relevant orthopedic infection.

Introduction Upper extremity lymphedema can complicate mastectomy, lymph node dissection, and radiation. The purpose of this study is to present the outcomes of shoulder arthroplasty in patients with lymphedema. Methods The 19 shoulders with a shoulder arthroplasty and lymphedema on the surgical side (6 anatomic, 12 reverse, 1 hemiarthroplasty) were followed for four years (1–10 years). There were 2 males and 17 females; average age was 67.8 (48–86) years. Breast carcinoma was the most common reason for lymphedema (75%). A dedicated lymphedema questionnaire could be completed for 14 shoulders. Results Pain improved from moderate or severe preoperatively to no or mild in 18 shoulders. Motion improved in elevation (55° preoperatively, 107° at last follow-up), external rotation (14°, 43°), and internal rotation (sacrum, L5). Complications included an acromion stress fracture with a deep infection (1), deep infection (1), superficial infection (1), and glenoid loosening (1). Lymphedema worsened in nine cases, but worsening was permanent in only four. Currently, lymphedema treatment is being performed by 93% of survey respondents. No patients reported lymphangitis or lymphangiosarcoma. Conclusion Shoulder arthroplasty for an upper extremity with lymphedema provides substantial improvements in pain and motion; however, infection is a concerning complication. Fifty percent of the patients will experience worsening of their lymphedema and in 20% worsening may be permanent.