Cueto, Robert J.

» Instability and dislocation after reverse shoulder arthroplasty may occur in up to 31% of patients. » Clinical risk factors for instability include younger age, male sex, increased body mass index, preoperative diagnosis of proximal humerus fracture or rotator cuff pathology, history of instability of the native shoulder or after surgery, and a medical history of Parkinson’s disease. » Patients with rheumatoid arthritis and decreased proximity to the coracoid may also be at greater risk. » In patients at a high risk of instability, surgeons should consider a more lateralized prosthesis (particularly in patients with an incompetent rotator cuff), repairing the subscapularis (particularly when using a medialized prosthesis), and upsizing the glenosphere (>40 mm in male and 38–40 mm in female patients). » While potentially useful, less evidence exists for the use of a constrained liner (particularly with a lateralized glenosphere and/or in low-demand patients) and rotating the polyethylene liner posteriorly to avoid impingement. Level of Evidence: Level V . Narrative Review. See Instructions for Authors for a complete description of levels of evidence.

Background As no consensus exists on the optimal postoperative rehabilitation protocol in terrible triad injuries, we sought to characterize the reported protocols and relate them to postoperative range of motion (ROM) measures and Mayo Elbow Performance Score (MEPS). Methods A systematic review was performed by searching PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles on the operative treatment of terrible triad injuries reporting postoperative rehabilitation protocols were included. Included studies were descriptively summarized. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies criteria. Meta-analysis compared postoperative ROM measures and the MEPS between patients initiating passive ROM exercises at ≤7 days vs. >7 days. Results Our review included 36 articles with 1123 elbows (66% male, mean age: 43 years, follow-up: 27 months). Of the studies reporting physical therapy protocols, it was most commonly initiated at 7 days postoperatively (6/36, 17%), passive ROM exercises at 7 days (3/25, 12%), and active ROM at 21 days (4/26, 15%). On meta-analysis, early passive ROM initiation was not associated with improved elbow ROM or MEPS. Discussion While rehabilitation protocols commonly advised passive ROM at one week post-operatively, meta-analysis did not support functional benefits of early passive ROM. Study design Systematic Review; Level of evidence, 4.

Background This study sought to characterize the tipping point values (the functional scores that patients deem dysfunctional enough to warrant surgery) for patients undergoing first revision reverse total shoulder arthroplasty (rTSA). Methods This study was a retrospective review of a prospectively collected single-institution database of patients undergoing first revision rTSA between August 2015 and December 2019. Tipping point evaluation utilized preoperative scores including the American Shoulder and Elbow Surgeons (ASES), raw and normalized Constant, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), and University of California-Los Angeles (UCLA) scores, and active range of motion including abduction, forward elevation (FE), external rotation (ER), and internal rotation score (IR) prior to elective revision rTSA. Results We included 125 revision rTSAs. Tipping points were 37.6 ASES score, 30.5 raw Constant score, 35.5 normalized Constant score, 68.1 SPADI, 3.7 SST, 13.2 UCLA score, 64° abduction, 69° FE, 23° ER, and 3.1 IR. Higher SST was found for older patients and patients with a lower body mass index. Lower abduction and FE tipping points were reported in patients undergoing revision rTSA for rotator cuff failure, unexplained pain, and implant wear. Discussion These tipping points can help surgeons counsel patients regarding when to undergo revision rTSA. Level of evidence Level III; retrospective cohort study; treatment study.

Background Optimal glenosphere positioning in reverse shoulder arthroplasty (RSA) remains highly debated. We aimed to characterize the association between the prosthesis scapular neck angle (PSNA) and postoperative range of motion (ROM) and clinical outcome scores. Methods A retrospective review of 284 RSAs using a single design with minimum 2-year follow-up was performed. Glenosphere tilt was measured postoperatively using PSNA. ROM and functional outcome scores were assessed preoperatively and at latest follow-up. The PSNA was dichotomized to inferior or superior groups (>90° vs ≤ 90°, respectively) and stratified into quartiles; ROM and outcome score measures were compared between groups controlling for inferior glenosphere overhang. Results No range of PSNA was consistently associated with superior ROM, clinical outcome scores, or rates of complications including scapular notching. However, greater preoperative to postoperative improvement in active FE was found for superiorly (PSNA ≤ 90°) versus inferiorly tilted glenospheres (37° ± 33° vs 53° ± 35°, P = 0.005) and the greater improvement in active FE (57° ± 35°, P = 0.004) was further isolated to the first quartile (mean 85.1° ± 3.5°). Discussion A lack of variation in clinical outcomes based on PSNA suggests negligible short-term (median follow-up 3.1 years) clinical significance when glenosphere tilt falls within the distribution of this cohort (mean 92.6° ± 6.2°).