Reverse total shoulder arthroplasty in wheelchair-dependent patients

doi:10.1016/j.jse.2015.11.006

Journal of Shoulder and Elbow Surgery

Volume 25, Issue 7, July 2016, Pages 1138-1145

https://doi.org/10.1016/j.jse.2015.11.006 Get rights and content

Background

Wheelchair-dependent patients have a high incidence of shoulder pathology, often causing severe impairment. This study reports outcomes of wheelchair-dependent lower extremity–impaired patients with symptomatic shoulder arthritis or severe rotator cuff pathology treated with reverse total shoulder arthroplasty (RTSA).

Methods

Data for 19 wheelchair-dependent patients who had an RTSA for symptomatic arthritis or rotator cuff pathology, or both, were obtained from the University of Florida Shoulder Arthroplasty Database. Included were 16 of 19 shoulders with adequate follow-up averaging 40 months. Functional outcome scores included the Simple Shoulder Test, University of California Los Angeles Shoulder Rating Scale, Shoulder Pain and Disability Index, American Shoulder and Elbow Surgeons score, Constant score, and 12-item Short Form (SF-12) health survey. Objective measures were active elevation, external rotation, and internal rotation. Radiographs were evaluated for lucent lines, notching, and prosthetic loosening.

Results

All measured parameters, except the SF-12, significantly improved at the final follow-up. Functional outcome scores included Shoulder Pain and Disability Index, 45; Simple Shoulder Test, 7; American Shoulder and Elbow Surgeons, 73; University of California Los Angeles Shoulder Rating Scale, 30; Constant, 70; and SF-12, 33. Active elevation was 112°, and active external rotation was 29°. Most patients (83%) were satisfied. The complication rate was 25%; baseplate failure and dislocation occurred early, and periprosthetic humeral fracture secondary to infection occurred late. The notching rate was 42%.

Conclusions

Shoulder pain and dysfunction due to arthritis and rotator cuff pathology can result in the loss of independence in wheelchair-dependent patients. We investigated whether RTSA can sustain the increased loads placed by these patients during transfers. Wheelchair-dependent patients can benefit from an RTSA for shoulder pain and dysfunction but must accept worsened impairment during the immediate postoperative period and a higher complication rate than the general population treated with an RTSA.

Section snippets

Materials and methods

A retrospective study was performed of clinical data obtained in a prospective manner from all patients who consented to the University of Florida Shoulder Arthroplasty Database. All surgeries were done at a tertiary referral center (University of Florida). All but one of these procedures was completed by the senior surgeon (T.W.W.). The inclusion criteria were patients aged 18 years or older who relied on a wheelchair as their primary means of ambulation and who underwent RTSA between January

Results

Review of the database identified 19 shoulders represented by 16 patients as potentially eligible for inclusion based on the criteria of our Institutional Review Board. An initial review of these 19 shoulders revealed that the implants failed in 3 patients shortly after surgery for a failure rate of 15.8% of eligible cases performed (Table I). One failure occurred when a patient with severe Parkinson disease fell 6 weeks postoperatively and dislodged the baseplate. Two other failures, both

Discussion

The literature is sparse concerning discussion of surgical treatment of shoulder pathology in patients with LEI, especially those who are wheelchair-dependent. Possible reasons for this may be the relative rarity of these patients combined with surgeon concerns of excessive postoperative forces, difficulty adhering to restrictions, and potential early failure. Four studies examining shoulder surgery in patients with paraplegic LEI were identified. Two of these articles, those by Hattrup et al⁹

Conclusion

RTSA is a viable option for wheelchair-dependent patients with symptomatic shoulder arthritis or cuff failure. These patients must be willing to fully cooperate with the postoperative therapy protocol, including no weight-bearing transfers with the operative arm for a minimum of 12 weeks. To be compliant with this plan, most patients will require 6 to 12 weeks in a rehabilitation facility. In addition, a successful RTSA has the ability to restore independent transfer and reach without pain, but

Disclaimer

Thomas W. Wright and Kevin W. Farmer receive royalties from Exactech Inc. The University of Florida receives research support from Exactech Inc. The other authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Acknowledgements

The authors thank Aimee M. Struk, MEd, MBA, ATC, LAT, their research assistant and a certified athletic trainer, for contributing substantially in identifying prospective subjects, compiling data, and ensuring timely incorporation of new clinical data. The authors thank Sonya T. Brisbane, MPH, for facilitating patient enrollment and coordinating Institutional Review Board approval and compliance.

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Cited by (28)

Shoulder arthroplasty in patients with multiple sclerosis: complications stratified by arthroplasty type
2023, Seminars in Arthroplasty JSES
Despite the prevalence of osteoarthritis in patients with multiple sclerosis (MS) being equivalent to that of the general population, very little research exists on outcomes and complications following shoulder arthroplasty in patients with this condition.
Patients with MS who underwent anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) were identified in a national insurance database. The following cohorts were then created for analysis: (1) patients with MS who underwent TSA, (2) patients with MS who underwent RSA for a diagnosis other than fracture, and (3) patients with MS who underwent RSA for a diagnosis of fracture. Patients who underwent TSA, RSA, and RSA for fracture without a diagnosis of MS were then identified and matched to study cohorts in a 5:1 manner for demographics and comorbidities for comparison purposes. Each cohort was then assessed for surgical complications (revision surgery, periprosthetic joint infection, prosthetic dislocation) and numerous medical complications. Comparisons were made with logistic regression analyses to control for confounders.
One thousand seventy seven patients with MS who underwent shoulder arthroplasty were identified, including 386 who underwent anatomic TSA, 570 who underwent RSA for a nonfracture diagnosis, and 121 who underwent RSA for acute or chronic fracture. These were compared to 1930 TSA controls, 2850 RSA controls, and 605 RSA for fracture controls without MS. Overall, the rates of surgical complications were similar between MS patients and their respective matched controls as well as between prosthesis types for MS patients, without any statistically significant differences. Patients with MS had significantly higher rates of urinary tract infections compared to controls for both TSA (odds ratio [OR] 2.48, P = .001) and RSA (OR 2.42, P < .001). Patients with MS who had an RSA for fracture had right rates of venous thromboembolism compared to controls (OR 4.01, P = .011) and RSA for nonfracture (OR 3.83, P = .016).
Patients with MS undergoing shoulder arthroplasty have similar rates of surgical complications compared to matched controls without MS and between prosthesis types. Patients with MS have higher rates of some postoperative medical complications, including urinary tract infection and venous thromboembolism. The results of the present study suggest that surgeons should not alter their treatment strategies or implant selection for patients undergoing shoulder arthroplasty with a diagnosis of MS.
Reverse shoulder arthroplasty in upper extremity ambulators: a matched-cohort analysis
2023, Journal of Shoulder and Elbow Surgery
Upper extremity ambulators (UEAs) who require prolonged use of assistive devices for mobility have a high incidence of shoulder pathology secondary to increased stress across the shoulder joint with upper extremity weight-bearing. Reverse shoulder arthroplasty (RSA) for rotator cuff arthropathy has historically been associated with increased complications in UEA, but more recent studies have shown more promising outcomes. The objective of this study is to evaluate clinical outcomes and complication rates between these 2 groups to define the relative risk of RSA in the UEA population and identify opportunities to improve treatment outcomes.
An institutional review board–approved retrospective chart review was performed in patients who underwent RSA at our institution by the senior author from 2004 to 2019. UEAs were defined as patients who used regular upper extremity assistive devices for community ambulation before initial consultation for the surgical extremity. Pre- and postoperative range of motion, visual analog scale scores, American Shoulder and Elbow Surgeons scores, Constant-Murley scores, and Simple Shoulder Test scores were measured at defined intervals. Complications including infection, instability, and need for revision surgery were also compared. All patients were followed for a minimum of 2 years postoperatively.
A total of 159 RSA procedures (70 UEAs, 89 controls) were performed during the study period. On average, UEA patients had more preoperative pain and less shoulder function than controls, with statistically significant differences in visual analog scores (6.897 vs. 5.532, P = .0010) and American Shoulder and Elbow Surgeons scores (33.50 vs. 40.20, P = .0290), respectively. Despite the lower baseline values, UEA patients experienced excellent postoperative improvement, leading to similar postoperative pain and shoulder function except for a lower average forward flexion in the UEA group (127° vs. 135°, P = .0354). Notching and complication rates were also similar between the 2 groups, with notching rates of 59% and 50% and complication rates of 14.3% and 13.5% in the UEA and control groups, respectively.
RSA in the UEA population can achieve similar pain and functional outcomes as compared with age-matched controls without a significant increase in complication rates; however, further studies are required to assess long-term comparative outcomes in this challenging patient population.
Reverse total shoulder arthroplasty in wheelchair-dependent patients: a matched cohort study
2022, Seminars in Arthroplasty JSES
Shoulder function in wheelchair-dependent patients is critical for preserving independence and quality of life due to lower extremity impairment. The purpose of this study was to report the revision rate, as well as clinical and radiological outcome in wheelchair-dependent patients treated with reverse total shoulder arthroplasty (RTSA) and to compare them to an ambulating population.
Prospectively obtained data of 21 primary RTSAs in 17 wheelchair-dependent patients (5 male, 12 female) with a median age of 72.4 years (range: 49-80) and a minimum follow-up of 2 years were analyzed retrospectively. Revision rate, clinical (Subjective Shoulder Value = SSV, relative Constant-Murley Score = rCS, wheelchair user’s shoulder pain index = WUSPI) and radiological (glenoid loosening, scapular notching, glenoid inclination) outcome, as well as implant-related parameters (baseplate peg length, glenosphere size, bony augmentation), were compared with a 2:1 matching cohort of 42 ambulating patients (10 male, 32 female) with a median age of 72.5 years (range: 56-78).
The revision rate was 9.5% in both cohorts. In the wheelchair cohort, two shoulders had to be revised due to a complete baseplate dislocation. In the matching cohort, four shoulders had to be revised due to one prosthetic dislocation, one traumatic and one atraumatic scapular spine fracture with glenoid baseplate dislocation, and one fracture of the greater tuberosity. Median preoperative SSV and rCS did not differ significantly between cohorts. Postoperative SSV was also comparable (wheelchair: median 70 (range: 10-99) vs. matching: median 70 (30-100), p = n.s.). Relative CS was significantly lower in the wheelchair cohort (65% vs. 81.4%, P = .004). Median postoperative WUSPI was 35 points (range: 13-40) for difficulty and 0 points for pain (range: 0-29). The highest difficulty and pain were found for ‘hygiene behind the back’ and ‘propulsion of wheelchair up a ramp or on uneven surface’. Glenoid loosening, scapular notching, and postoperative baseplate inclination did not differ significantly between cohorts. In the wheelchair cohort, glenoid autograft augmentation (38.1% vs. 7.1%, P = .002) and implantation of baseplates with longer pegs were performed more often (≥ 25mm: 38.1% vs. 7.1%, P = .004).
RTSA is a valuable therapeutic option for the treatment of advanced OA or irreparable rotator cuff tears in wheelchair-bound patients with high patient satisfaction. Postoperatively, poorer function and a higher rate of baseplate dislocations might be anticipated compared to ambulating patients.
Development of a predictive model for a machine learning–derived shoulder arthroplasty clinical outcome score
2022, Seminars in Arthroplasty JSES
We use machine learning to create predictive models from preoperative data to predict the Shoulder Arthroplasty Smart (SAS) score, the American Shoulder and Elbow Surgeons (ASES) score, and the Constant score at multiple postoperative time points and compare the accuracy of each algorithm for anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA).
Clinical data from 2270 patients who underwent aTSA and 4198 patients who underwent rTSA were analyzed using 3 supervised machine learning techniques to create predictive models for the SAS, ASES, and Constant scores at 6 different postoperative time points using a full input feature set and the 2 different minimal feature sets. Mean absolute errors (MAEs) quantified the difference between actual and predicted outcome scores for each model at each postoperative time point. The performance of each model was also quantified by its ability to predict improvement greater than the minimal clinically important difference (MCID) and the substantial clinical benefit (SCB) patient satisfaction thresholds for each outcome measure at 2-3 years after surgery.
All 3 machine learning techniques were more accurate at predicting aTSA and rTSA outcomes using the SAS score (aTSA: ±7.41 MAE; rTSA: ±7.79 MAE), followed by the Constant score (aTSA: ±8.32 MAE; rTSA: ±8.30 MAE) and finally the ASES score (aTSA: ±10.86 MAE; rTSA: ±10.60 MAE). These prediction accuracy trends were maintained across the 3 different model input categories for each of the SAS, ASES, and Constant models at each postoperative time point. For patients who underwent aTSA, the XGBoost predictive models achieved 94%-97% accuracy in MCID with an area under the receiver operating curve (AUROC) between 0.90-0.97 and 89%-94% accuracy in SCB with an AUROC between 0.89-0.92 for the 3 clinical scores using the full feature set of inputs. For patients who underwent rTSA, the XGBoost predictive models achieved 95%-99% accuracy in MCID with an AUROC between 0.88-0.96 and 88%-92% accuracy in SCB with an AUROC between 0.81-0.89 for the 3 clinical scores using the full feature set of inputs.
Our study demonstrated that the SAS score predictions are more accurate than the ASES and Constant predictions for multiple supervised machine learning techniques, despite requiring fewer input data for the SAS model. In addition, we predicted which patients will and will not achieve clinical improvement that exceeds the MCID and SCB thresholds for each score; this highly accurate predictive capability effectively risk-stratifies patients for a variety of outcome measures using only preoperative data.
Level III; Retrospective Comparative Study
Arthroplasty for weight-bearing shoulders
2022, Revue de Chirurgie Orthopedique et Traumatologique
Les transferts répétés et la propulsion d’un fauteuil roulant chez les patients avec déficit neurologique des membres inférieurs conduisent à une surcharge mécanique majeure des membres supérieurs et particulièrement des épaules, devenant locomotrices. Dans ces conditions, une arthroplastie est soumise à des contraintes importantes, si bien, qu’une telle indication sur ce terrain est toujours discutée.
Notre hypothèse était que les prothèses sur épaules locomotrices pouvaient soulager les douleurs et améliorer les mobilités, avec un impact favorable sur la fonction et l’autonomie, sans augmenter le taux de complications par rapport à la population valide.
Cette étude rétrospective porte sur 13 implants chez 11 patients (4 prothèses totales anatomiques, 4 hémi-arthroplasties et 3 prothèses totales inversées) avec un recul moyen de 33,7 ± 27 mois (12–85 mois). L’évaluation clinique incluait les mobilités actives et passives, la douleur, le score de Constant et le Weelchair User's Shoulder Pain Index (WUSPI). L’évaluation radiologique recherchait de signes de descellement ou d’encoche scapulaire. L’autonomie des patients était évaluée par le nombre de transferts quotidiens, le mode de déplacement (fauteuil manuel ou électrique), la mesure d’indépendance fonctionnelle (MIF). Deux sous-groupes étaient définis selon leur pathologie initiale : épaule neurologique et épaule fonctionnelle.
Les 11 patients, d’âge moyen de 64 ± 19 ans (23–85 ans), étaient tous des utilisateurs d’un fauteuil roulant au long cours (électriques ou mécaniques). L’évaluation analytique retrouvait une diminution de l’EVA : de 8,17 ± 3 en préopératoire à 4,17 ± 2 en postopératoire (p = 0,003). Le score moyen de constant a augmenté de 90 %, passant de 22 (±11), en préopératoire à 41,8 ± 23 en postopératoire (p = 0,008). Le score WUSPI a diminué de 73 %, passant de 80,0 ± 30 à 21,3 ± 15 (p = 0,001). Les mobilités étaient améliorées dans le sous-groupe des épaules fonctionnelles mais pas dans le sous-groupe des épaules neurologiques. On retrouvait une modification du mode de déplacement chez 5 patients (63 %) avec acquisition d’un fauteuil électrique, sans modification significative du nombre de transferts quotidiens. L’analyse radiographique ne retrouvait pas de descellement au dernier recul. Deux prothèses ont été révisées, une conversion de prothèse totale anatomique en inversée pour rupture secondaire de coiffe, un cas de sepsis précoce a nécessité le changement des implants en deux temps.
L’arthroplastie prothétique sur épaule locomotrice représente une solution efficace à moyen terme dans les omarthroses centrées et excentrées, principalement sur la douleur, avec amélioration modérées des mobilités, selon la pathologie initiale. Cette intervention nécessite une adaptation du mode de vie par modification des modes de transferts quotidiens, et du mode de déplacement.
IV ; série rétrospective.
Arthroplasty for weight-bearing shoulders
2022, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
In the case of glenohumeral OA or rotator cuff tear arthropathy, the indication for shoulder replacement is controversial, with reluctance being due to the large stresses applied to the implants. Despite the high prevalence of such lesions in weightbearing shoulders, few studies have reported the outcomes of joint replacement; those that did had a low sample size [13–16]. The primary aim of our study was to show that arthroplasty on a weightbearing shoulder would lead to less pain, with positive impact on the patient's locomotion and autonomy, with no increase in the complication rate.
Repeated transfers and wheelchair propulsion in patients with a neurological deficit of the lower limbs overloads the upper limbs mechanically, particularly the shoulders, which become weight-bearing. Under these conditions, arthroplasty implants are subjected to large stresses, even though this indication is controversial in such a context. We hypothesized that joint replacement in weight-bearing shoulders will relieve pain and improve range of motion, with a positive impact on function and autonomy, without increasing the complication rate relative to the able-bodied population.
This retrospective study involved 13 implants in 11 patients (4 total shoulder arthroplasty, 4 hemi-arthroplasty and 3 reverse shoulder arthroplasty) who had a mean follow-up of 33.7 ± 27 months (12-85 months). The clinical assessment included active and passive range of motion, pain, Constant score, and the Wheelchair User's Shoulder Pain Index (WUSPI). Radiographs were evaluated to look for signs of loosening and scapular notching. The patients’ autonomy was evaluated through the number of transfers, means of locomotion (manual or electric wheelchair) and the functional independence measure (FIM). Two subgroups were defined based on the initial pathology: neurological shoulder or functional shoulder.
The 11 patients had a mean age of 64 ± 19 years (23-85 years) and were all long-term wheelchair users (electrical or mechanical). The pain level on VAS decreased from 8 ± 3 preoperatively to 4 ± 2 postoperatively (p = 0.003). The mean Constant score increased 90% from 22 ± 11 preoperatively to 42 ± 23 postoperatively (p = 0.008). The WUSPI score decreased by 73% from 80 ± 30 to 21 ± 15 (p = 0.001). The range of motion improved in the subgroup of patients with functional shoulders but not in the subgroup of patients with neurological shoulders. The means of locomotion was altered in five patients (63%) by the acquisition of an electric wheelchair, but with no significant change in the number of daily transfers. There were no radiographic signs of implant loosening at the final assessment. Two implants had to be revised: one anatomical prosthesis was converted to a reverse configuration because of a secondary rotator cuff rupture; one case of early infection required a two-stage implant change.
Joint replacement in weight-bearing shoulders is an effective medium-term solution for cuff tear arthropathy and glenohumeral OA, mainly for addressing pain, with slight improvements in range of motion, depending on the initial pathology. This intervention requires lifestyle adaptations such as changes in daily transfer practices and means of locomotion.
IV, retrospective study.

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: The University of Florida Gainesville Health Science Center Institutional Review Board approved this study (IRB#: IRB201300308).

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Reverse total shoulder arthroplasty in wheelchair-dependent patients

Background

Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Conclusion

Disclaimer

Acknowledgements

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