Farmer, Kevin W.

AimsWe sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients.MethodsA retrospective review of a prospectively collected shoulder arthroplasty database was performed between August 1991 and September 2020 to identify patients who underwent primary aTSA. Patients were excluded for preoperative diagnoses of fracture, infection, or oncological disease. Three cohorts were created based on smoking status: non-smokers, former smokers, and current smokers. Outcome scores (American Shoulder and Elbow Surgeons (ASES), Constant-Murley score, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), University of California, Los Angeles activity scale (UCLA)), range of motion (external rotation (ER), forward elevation (FE), internal rotation, abduction), and shoulder strength (ER, FE) evaluated at two- to four-year follow-up were compared between cohorts. Evaluation of revision-free survival was performed using the Kaplan-Meier method to final follow-up.ResultsWe included 428 primary aTSAs with a mean follow-up of 2.4 years (SD 0.6). Our cohort consisted of 251 non-smokers, 138 former smokers who quit a mean 21 years (SD 14) prior to surgery (25 pack-years (SD 22)), and 39 current smokers (23 pack-years (SD 20)). At two- to four-year follow-up, former smokers had less favourable SPADI, SST, and FE strength compared to non-smokers, and current smokers had less favourable SPADI, SST, ASES score, UCLA score, Constant-Murley score, FE, abduction, and ER strength compared to non-smokers. Non-smokers exhibited higher revision-free survival rates at two, five, eight, and ten years postoperatively compared to former smokers and current smokers, who had similar rates.ConclusionOur study suggests that smoking has a negative effect on aTSA functional outcomes that may persist even after quitting.Cite this article: Bone Joint J 2024;106-B(11):1263–1272.

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 The increasing incidence of reverse total shoulder arthroplasties (RTSA) has led to an increase in revision surgery. We aimed to compare patients undergoing re-revision RTSA to a matched cohort undergoing first-revision RTSA. Methods A retrospective review of all revision RTSAs was performed at a single institution. Sixteen shoulders that underwent re-revision RTSA were matched 1:3 to shoulders that underwent revision RTSA with a minimum two-year follow-up. Outcome scores including the American Shoulder and Elbow Surgeons Shoulder Score (ASES), Short-Form 12 (SF-12), Shoulder Pain and Disability Index (SPADI), and Simple Shoulder Test (SST) scores, range of motion (ROM), and improvement from preoperative to postoperative outcomes after re-revision RTSA were assessed. Additionally, postoperative outcomes after re-revision RTSA were compared to patients that underwent first revision RTSA and subsequently compared to the minimal clinically important difference (MCID) values for the outcome scores and ROM measurements assessed. Results Sixteen shoulders that underwent re-revision RTSA and 78 revision RTSAs met the final inclusion criteria to be included in this study. Significant improvement from preoperative to postoperative re-revision RTSA was seen in the ASES score (p = 0.046), SPADI score (p = 0.044), SST (p = 0.008), abduction (p = 0.016), and elevation (p = 0.025), but not the SF-12 score (p = 0.396), external rotation (p = 0.449), or internal rotation (p = 0.451). Outcomes after revision RTSA were found to be superior to outcomes after re-revision RTSA for all outcome scores (ASES p = 0.029, SF-12 p = 0.018, SPADI p = 0.003) except the SST score (p = 0.080) and all ROM measures (p > 0.05 for all). Internal rotation was equivalent postoperatively between both groups. From preoperative to postoperative re-revision RTSA, the mean improvement exceeded the MCID for the SST score, abduction, forward elevation, and external rotation. When comparing postoperative revision RTSA to postoperative re-revision RTSA, the mean difference between revision and re-revision RTSA exceeded the MCID for the SPADI score and external rotation. The complication rate was 19% in shoulders undergoing first revision and 41% in shoulders undergoing re-revision RTSA. Conclusion Patients undergoing re-revision RTSA receive improvement in clinical outcomes, but do not achieve outcomes comparable to those achieved after first revision RTSA.

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°).