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The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II

Open AccessPublished:September 09, 2020DOI:https://doi.org/10.1016/j.jseint.2020.07.018

      Background

      Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous.

      Methods

      Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests.

      Results

      The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%.

      Conclusions

      Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.

      Level of evidence

      Keywords

      Although initially indicated for patients with rotator cuff arthropathy,
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      • Sirveaux F.
      • Boileau P.
      Grammont's idea: The story of Paul Grammont's functional surgery concept and the development of the reverse principle.
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      Delta shoulder prosthesis for rotator cuff rupture.
      reverse shoulder arthroplasty (RSA) indications have recently expanded to include osteoarthritis with an intact rotator cuff
      • Wright M.A.
      • Keener J.D.
      • Chamberlain A.M.
      Comparison of clinical outcomes after anatomic total shoulder arthroplasty and reverse shoulder arthroplasty in patients 70 years and older with glenohumeral osteoarthritis and an intact rotator cuff.
      as well as tumor resection, postinfectious sequelae,
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      • Virani N.A.
      • Levy J.
      • Frankle M.A.
      • Derasari A.
      • Hines B.
      • et al.
      The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics.
      chronic dislocations, and revisions of failed arthroplasties.
      • Black E.M.
      • Roberts S.M.
      • Siegel E.
      • Yannopoulos P.
      • Higgins L.D.
      • Warner J.J.
      Reverse shoulder arthroplasty as salvage for failed prior arthroplasty in patients 65 years of age or younger.
      RSA is frequently used to treat difficult clinical diagnoses; consequently, it is not surprising to see a relatively high complication rate. Reports have concluded that indications such as rheumatoid arthritis have a higher risk of intraoperative and postoperative fracture
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      • Smith M.M.
      • Bacle G.
      • Moraga C.
      • Walch G.
      Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis.
      and that prior nonarthroplasty shoulder surgery confers a higher complication rate post RSA compared with those with no prior surgery on the ipsilateral shoulder.
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      • Lee S.
      • Sumner S.
      • Griffin J.
      • Leroux T.
      • Verma N.N.
      • et al.
      Shoulder arthroplasty outcomes after prior non-arthroplasty shoulder surgery.
      The use of RSA has continued to rise, and it has become the majority shoulder arthroplasty since 2016. It has had an even more profound effect on revision shoulder arthroplasty than what previously has been documented in the primary setting.
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      • Chang M.J.
      • Welp K.M.
      • Solberg M.J.
      • Hunt T.J.
      • Woodmass J.M.
      • et al.
      The impact of the reverse prosthesis on revision shoulder arthroplasty: analysis of a high-volume shoulder practice.
      Thus, precise knowledge of the probability and implications of the various complications are imperative for judicious use of RSA.
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      • Gerber C.
      Reverse total shoulder arthroplasty-from the most to the least common complication.
      Complications have been well described; the studies in the literature, however, are heterogeneous (eg, different indications, different prostheses, and different populations) and definitions vary between authors.
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      • Willis M.
      • Walker M.
      • Clark R.
      • Frankle M.A.
      Complications in reverse total shoulder arthroplasty.
      ,
      • Zumstein M.A.
      • Pinedo M.
      • Old J.
      • Boileau P.
      Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review.
      The reported complication rate is variable among reports and seems to be influenced substantially by the mix of primary and revision procedures included in each study.
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      • Romeo A.A.
      • Nicholson G.P.
      Complication rates comparing primary with revision reverse total shoulder arthroplasty.
      Patient factors including smoking status,
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      • Wagner E.R.
      • Itoi E.
      • Steinmann S.P.
      • Cofield R.H.
      • et al.
      Effect of smoking on complications following primary shoulder arthroplasty.
      diabetes,
      • Mahure S.
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      • Quien M.
      • Karia R.
      • Zuckerman J.
      • Kwon Y.
      Impact of diabetes on perioperative complications in patients undergoing elective total shoulder arthroplasty.
      Parkinson disease,
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      • Brockmeier S.F.
      Shoulder arthroplasty in patients with Parkinson's disease is associated with increased complications.
      and preoperative American Society of Anesthesiologists score
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      • McFarland E.G.
      Does preoperative American Society of Anesthesiologists score relate to complications after total shoulder arthroplasty?.
      have all been linked to increased complications and/or unfavorable outcomes. Some advocate that primary shoulder arthroplasty is performed more efficiently by higher-volume surgeons,
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      The effect of surgeon and hospital volume on shoulder arthroplasty perioperative quality metrics.
      and complications have been reported to decrease with surgeon experience.
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      Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon's experience?.
      Recent data have defined a volume-outcome relationship where, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways, hospital surgical volumes of 54-70 RSAs/yr correlate with the highest outcomes.
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      • Wagner E.R.
      Defining the volume-outcome relationship in reverse shoulder arthroplasty: a nationwide analysis.
      The majority of the published studies on RSA have historically reported on a Grammont-style RSA (glenosphere with medialized center of rotation [MG] along with an inlay humeral component that medializes the humerus [MH]). Lessons learned using this style of prosthesis have led to the introduction of new designs with multiple options for glenosphere lateral offset and eccentricity, different neck-shaft angulations, and humeral-based lateralization (LH). These design modifications translate into different biomechanics compared with the first generation of RSA. As the concept, design, and surgical technique of RSA continue to improve, the rates and types of complications may change over time. One study noted that after implant modifications, there have been statistically significant declines in baseplate failure, humeral dissociation, and glenosphere dissociation.
      • Stephens B.C.
      • Simon P.
      • Clark R.E.
      • Christmas K.N.
      • Stone G.P.
      • Lorenzetti A.J.
      • et al.
      Revision for a failed reverse: a 12-year review of a lateralized implant.
      Further, a recent study noted that primary RSA performed with contemporary implants and surgical techniques seems to be associated with a very low rate of reoperation.
      • Kang J.R.
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      • Cofield R.H.
      • Steinmann S.P.
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      • et al.
      Primary reverse shoulder arthroplasty using contemporary implants is associated with very low reoperation rates.
      As the indications and use of RSA continue to expand, it is important to track the rate and types of complication as the procedure continues to develop over time. The purpose of this 2-part study was to provide a focused systematic review for the most common complications of RSA using contemporary prosthetic designs, therefore limiting studies to those published after 2010. In this part II, a systematic review was performed for (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures, and (4) problems/miscellaneous. We established a study design and specific objectives before commencing each literature research.

      Instability

      Methods

      A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Group P.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      The search was performed using the PubMed medical database in April 2020 (Fig. 1). The search terms used were [(Dislocation) OR (Instability) OR (Revision) OR (Reoperation) OR (Complication) AND (reverse shoulder arthroplasty) OR (reverse total shoulder) OR (reverse total shoulder arthroplasty)] with filters as follows: date range (1/1/2010 to 12/31/2019), species (human), and language (English). The search resulted in 761 total titles. Inclusion criteria were titles that specified primary or revision RSA. Exclusion criteria were duplicate titles, review articles, editorials, technique articles without reported patient outcomes, cadaveric studies, kinematic/finite element model/computer model analyses, case reports, survey studies, elastography/histologic studies, cost-benefit analyses, and instructional course lecture articles. After application of these criteria, 323 titles remained for abstract review. Articles that reported 2-year follow-up studies with clearly reported instability, reoperation, revision, or complication data were included. Articles with <15 patients, a minimum average follow-up of <24 months, and evaluated treatment of shoulder periprosthetic infection, blood transfusion rates, venous thromboembolism rates, RSA with concomitant tendon transfer, or RSA for tumor were excluded. This process eliminated 154 more articles, leaving 169 for full-text review. Articles with repeat data from publications prior to 2010 without further instability on long-term follow-up were also excluded in the full-text review. Definition of instability/dislocation was left to the discretion of each individual study. This final elimination stage resulted in 137 articles for inclusion in the analysis. Two authors (A.M.R. and S.S.S.) reviewed the articles and collected the data.
      Figure thumbnail gr1
      Figure 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram for instability.
      The rates of instability overall and according to (1) revision status (primary vs. revision arthroplasty vs. failed open reduction internal fixation [ORIF] proximal humerus fracture [PHF]), (2) publication date (2010-2016 vs. 2017-2020), (3) diagnosis, (4) center of rotation (CoR) (medialized vs. lateralized), and (5) prosthesis design were determined by pooled statistics. CoR and prosthesis design was defined according to Routman et al,
      • Routman H.D.
      • Flurin P.H.
      • Wright T.W.
      • Zuckerman J.D.
      • Hamilton M.A.
      • Roche C.P.
      Reverse shoulder arthroplasty prosthesis design classification system.
      who stated that a glenosphere with a CoR of ≤5 mm to the glenoid face is considered an MG, and a glenosphere with a CoR >5 mm lateral to the glenoid face is considered a lateralized glenoid (LG). Comparisons were also made to Zumstein et al.
      • Zumstein M.A.
      • Pinedo M.
      • Old J.
      • Boileau P.
      Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review.
      Statistical analysis was performed using SPSS (version 26; IBM Corp., Armonk, NY, USA). Univariate analysis was performed with the chi-square test, or with Fisher exact test when the expected count for at least 1 cell in the comparison was less than 5. The alpha level for statistical significance was set to 0.05.

      Results

      The majority of the studies were Level IV (96) and III (37), with only 3 Level II and 1 Level I evidence studies.
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      .
      A total of 9306 shoulders were included in the analysis with a mean age of 72.1 years and 69.0% of female sex. The overall instability rate was 3.3% (308/9306 shoulders) at a mean follow-up of 3.2 years. When stratified by reoperations required and time to instability, 73.5% of dislocations required revision of components and 59.5% of shoulders with instability occurred within the first 90 days postoperatively (Table I). In total, there were 20 different implant systems encountered. Primary RSA instability rates were significantly lower at 2.5% vs. revision RSA (5.7%) or RSA for failed ORIF PHF rates (5.3%) (P < .001, P = .01, respectively) (Table II). The Grammont design (MG/MH) had a significantly higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001). Instability rates, especially modern non-Grammont designs, have significantly decreased compared with Zumstein et al
      • Zumstein M.A.
      • Pinedo M.
      • Old J.
      • Boileau P.
      Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review.
      (Table III).
      Table IInstability rates overall, stratified by reoperations required and time to instability
      Studies includedShouldersInstability presentRate, % (n/n)
      Overall137930630833 (308/9306)
      Stratified by reoperations1276620226
      Revision of components16673.5 (166/226)
       Closed reduction4118.1 (41/226)
       Open reduction10.4 (1/226)
      Stratified by time to instability32171284
       <90 d5059.5 (50/84)
       >90 d3440.5 (34/84)
      The majority of shoulders with instability occurred within the first 90 days postoperatively and were treated with revision of components as final treatment.
      Table IIRates of instability according to (1) publication date (2010-2016 vs. 2017-2020), (2) revision status (primary vs. revision arthroplasty vs. failed ORIF PHF), and (3) center of rotation
      Studies includedShouldersInstability presentRate, %P value
      Year published
       2010-20166846381653.6.18
       2017-20206946681433.1
      Primary vs. revision
       Primary RSA8666071682.5<.001 vs. revision; .01 vs. ORIF
       Revision arthroplasty371404805.7.81 vs. ORIF
       Failed ORIF PHF9226125.3
      Center of rotation
       Medialized8849501412.8.15
       Lateralized221065222.1
      ORIF, open reduction internal fixation; PHF, proximal humerus fracture; RSA, reverse shoulder arthroplasty.
      Primary RSA had significantly lower instability rates compared to both revision and failed ORIF PHF.
      Table IIIRates of instability according to diagnosis and prosthesis design
      Studies includedShouldersInstability presentRate, %P value
      Diagnosis
       Cuff tear arthropathy15905212.3.02 vs. PHF; <.001 vs. failed arthroplasty
       PHF361654674.1.03 vs. failed arthroplasty
       Failed arthroplasty291243725.8.62
      Fisher exact test.
      vs. instability arthropathy
       Instability arthropathy48033.8>.99
      Fisher exact test.
      vs. PHF; .44
      Fisher exact test.
      vs. CTA
      Prothesis design
       LG/MH221021202.0.02 vs. MG/LH
       MG/LH161888170.9.02 vs. LG/MH
       LG/LH14524.4
       Subtotal392954391.3<.001 vs. MG/MH
       MG/MH7329321164.0
      AuthorP value vs. Zumstein et al
       Zumstein et al21782374.7
       Current study13793033083.3.04
       Current study: subtotal of non-Grammont designs392954391.3<.001
      PHF, proximal humerus fracture; LG, lateralized glenoid; MH, medialized humerus; MG, medialized glenoid; LH, lateralized humerus; CTA, cuff tear arthropathy; JSES, Journal of Shoulder and Elbow Surgery.
      The Grammont design (MG/MH) had a significantly higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), instability rates, especially modern non-Grammont designs, have significantly decreased compared to Zumstein et al (JSES, 2011).
      Bold indicates statistical significance (P < .05).
      Fisher exact test.

      Humerus/glenoid fracture

      Methods

      A systematic review was performed using PRISMA guidelines.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Group P.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      The search was performed using the PubMed medical database in July 2019 (Fig. 2). The search terms used were [(perioperative complication) OR (Complication) OR (Humerus fracture) OR (Glenoid Fracture) OR (Fracture) OR (Intraoperative fracture) OR (postoperative fracture) OR (revision) OR (reoperation)] AND [(reverse shoulder arthroplasty) OR (reverse total shoulder) OR (reverse total shoulder arthroplasty)] with filters as follows: date range (1/1/2010 to 5/1/2019), species (human), and language (English). The search resulted in 573 total titles. Inclusion criteria were titles that specified primary or revision RSA. Exclusion criteria were duplicate titles, review articles, editorials, technique articles without reported patient outcomes, cadaveric studies, kinematic/finite element model/computer model analyses, case reports, survey studies, elastography/histologic studies, cost-benefit analyses, and instructional course lecture articles. After application of these criteria, 304 titles remained for abstract review. Articles that reported 2-year follow-up studies with perioperative complication data, postoperative complication data, or clearly reported humerus fracture, glenoid fracture, intraoperative fracture, and postoperative fracture were lincluded. Articles with <25 patients, a minimum average follow-up of <24 months, and evaluated treatment of shoulder periprosthetic infection, blood transfusion rates, venous thromboembolism rates, RSA with concomitant tendon transfer, or RSA for tumor were excluded. This process eliminated 195 more articles, leaving 109 for full-text review. Definition of glenoid/humerus fracture was left to the discretion of each individual study. This final elimination stage resulted in 94 articles for inclusion in the analysis. Two authors (B.G. and S.S.S.) reviewed the articles and collected the data.
      Figure thumbnail gr2
      Figure 2Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram for humerus/glenoid fracture.
      The rates of intraoperative humerus fracture (IHF), intraoperative glenoid fracture (IGF), postoperative humerus fracture (PostHF), postoperative glenoid fracture (PGF), overall and according to (1) diagnosis and (2) prosthesis design were determined by pooled statistics. Prosthesis design was defined according to Routman et al.
      • Routman H.D.
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      Comparisons were also made to Zumstein et al.
      • Zumstein M.A.
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      • Old J.
      • Boileau P.
      Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review.
      Statistical analysis was performed using SPSS (version 26). Univariate analysis was performed with the chi-square test, or with Fisher exact test when the expected count for at least 1 cell in the comparison was less than 5. The alpha level for statistical significance was set to 0.05.

      Results

      The vast majority of the studies were Level IV and III evidence studies.
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      .
      A total of 5539 shoulders were included in the analysis with a mean age of 71.3 years and 67.4% of female sex at a mean follow-up of 3.5 years. The overall rate was as follows: IHF = 1.8% (91/5539 shoulders), IGF = 0.3% (15/5539), PostHF = 1.2% (69/5539), and PGF = 0.1% (6/5539). In total, there were 20 different implant systems encountered. IGF and IHF rates using modern non-Grammont designs have significantly decreased compared with Zumstein et al (Table IV). Additionally, 62.7% of the postoperative fractures were attributed to traumatic events. When stratified by management, the majority of IHF and IGF were treated conservatively (Table V).
      Table IVFracture rates overall and compared to Zumstein et al
      Studies includedShouldersFx presentRate, %P value
      Current studyVs. Zumstein et al
       Intraop. humerus Fx945539971.8.56
       Intraop. glenoid Fx945539150.3.01∗
       Postop. humerus Fx945539691.2.71
       Postop. glenoid Fx94553960.1
      Zumstein et alVs. current study
       Intraop. humerus Fx21782162.0.56
       Intraop. glenoid Fx2178270.9.01∗
       Postop. humerus Fx21782111.4.71
       Postop. glenoid Fx21782NRNR
      Current study: subtotal of non-Grammont designsVs. Zumstein et al
       Intraop. humerus Fx105700.0<.001
       Intraop. glenoid Fx105710.1.01∗
       Postop. humerus Fx1057232.2.23
       Postop. glenoid Fx105710.1
      Intraop, intraoperatively; Postop., postoperatively; Fx, fracture; NR, not reported; JSES, Journal of Shoulder and Elbow Surgery.
      Intraoperative glenoid fracture rates and intraoperative humerus fracture using modern non-Grammont designs have significantly decreased compared with Zumstein et al (JSES, 2011).
      Bold indicates statistical significance (P < .05).
      Table VNumber of fractures treated conservatively and fracture rates stratified by diagnosis and prosthesis design
      Number of Fx treated conservativelyRate, % (n/n)
      Intraop. humerus Fx5253.6 (52/97)
      Intraop. glenoid Fx1066.7 (10/15)
      Postop. humer