Robert H. Cofield

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.

Introduction: The effect of weight-bearing on a shoulder arthroplasty (SA) remains unclear, and recommendations regarding the use of a walker in SA patients have not been established. The purpose of this study was to determine outcomes and survivorship of SA in patients who routinely use a walker. Methods: Fifty-three primary SA (10 hemiarthroplasties (HAs), 33 anatomic total shoulder arthroplasties (TSAs), 10 reverse shoulder arthroplasties (RSAs)) in 41 walker-dependent patients were followed for a minimum of three years (mean 64 months, range, 36-156). The average age at SA was 76 years. Shoulders were assessed for pain, range of motion (ROM), satisfaction, Neer ratings, American Shoulder and Elbow Surgeons (ASES) score, complications, survivorship, and radiographic outcomes. Results: At most recent follow-up, 40 shoulders (75%) were pain free, elevation and external rotation improved significantly (P < .0001), and 87% of the patients were satisfied. Postoperative ASES scores averaged 74 (range, 38-92) points. There were 25 excellent, 16 satisfactory, and 12 unsatisfactory results based on modified Neer ratings. Four shoulders (7.5%) required reoperation at a mean of 40 months after the index arthroplasty. Radiographically, there were six cases of glenoid loosening in the anatomic SA group (25%), and two cases of severe glenoid erosion in the HA group (25%). Conclusion: Routine use of a walker does not appear to lead to a markedly increased rate of SA failure at mid-term follow-up. Concerning radiographic findings were more common after HA and anatomic TSA than after RSA. Longer follow-up is required to determine the long-term impact of walker use on SA.

Purpose Rheumatoid arthritis has been associated with poor clinical outcomes in hemiarthroplasty and unconstrained total shoulder arthroplasty. The reverse shoulder arthroplasty can be utilized to address the shortcomings of hemiarthroplasty and unconstrained total shoulder arthroplasty in the inflammatory arthritis patient population. The objective of the present study was to retrospectively review clinical and radiographic outcomes of patients who underwent reverse shoulder arthroplasty for rheumatoid arthritis and other inflammatory arthropathies and provide a comprehensive analysis to identify factors that may alter patient outcomes. Methods We identified 91 primary reverse shoulder arthroplasties performed between 2006 and 2013 in patients with inflammatory arthritis. Seventy-five had at least two years of follow up with an average follow-up of 4.0 years. The average age at the time of surgery was 70 years old. Peri-operative use of steroids, biologics, and methotrexate were reviewed. Outcomes evaluated included revision and reoperation rates, complications, American Shoulder and Elbow Surgeons (ASES) scores, simple shoulder test (SST) scores, component loosening, and scapular notching. Results The two and five year implant revision-free survival was 99%. The two and five year re-operation-free survival was 97%. Eighteen (24%) glenoid components required augmentation with corticocancellous autograft from the humeral head. There were two cases of glenoid loosening with gross changes in position. Patients experienced significant pain relief with a 92% satisfaction rate. Shoulder elevation and external rotation improved from 65 and 21 degrees pre-operatively to 138 and 45 degrees post-operatively, respectively (p < .01). Average ASES and SST scores were 72 and 7.0, respectively. The use of prednisone, DMARDs, or biologic medications had no significant impact on outcomes.

Background: Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. The purpose of this study was to examine the clinical outcomes of glenohumeral arthrodesis. Methods: Twenty-nine patients with 29 affected shoulders underwent primary glenohumeral arthrodesis between 1992 and 2009. Surgical indications included rotator cuff arthropathy and pseudoparalysis (n = 7), neurologic injuries (n = 12), chronic infection (n = 3), recurrent dislocations (n = 3), and proximal humeral or shoulder girdle tumors (n = 4). Surgical fixation techniques included plates and screws in 18 patients and screws only in 11 patients. Results: All patients were examined, with a mean follow-up of 12 years (range, 2 to 22 years). Twelve patients (41%) had postoperative complications, including 6 periprosthetic fractures, 7 nonunions, and 3 infections. Eleven patients (38%) required additional surgical procedures after arthrodesis, including revision internal fixation to achieve glenohumeral fusion after nonunions (n = 7), irrigation and debridement with antibiotic treatment for deep infections (n = 2), open reduction and internal fixation to treat fracture (n = 2), and implant removal to treat symptomatic patients (n = 3). Patients experienced reasonable overall pain relief. The mean postoperative scores were 35 points for the Subjective Shoulder Value, 58 points for the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 54 points for the Short Form-36. Eighty-seven percent of patients reported postoperative limitations. Patients with neurologic injuries had worse functional outcomes, and an arthrodesis position of ≥25° yielded better functional outcomes. Conclusions: Glenohumeral arthrodesis is associated with a high rate of patients with complications (41%). Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction Previous reports have shown an increased risk of complications after arthroplasty in the obese population. It remains unclear if gastric bypass surgery prior to shoulder arthroplasty modifies the complication and failure rate. The purpose of this study is to assess the complication and re-operation rates following shoulder arthroplasty in this population. Methods Between 2002 and 2012, 39 shoulders with prior gastric bypass underwent shoulder arthroplasty (3 HA, 16 TSA, 20 RSA). The mean time from the gastric bypass to arthroplasty was 13 years (range, 0.7-32). Shoulders were followed for a minimum of two years (mean, 3.8 years) or until re-operation. Outcome measures included pain, range of motion, satisfaction, modified Neer ratings, and ASES scores. Results Complications occurred in seven shoulders (18%), with five requiring re-operation. There was no common failure mechanism. Re-operations occurred for aseptic glenoid loosening, periprosthetic fracture, and unexplained pain. Those shoulders with complications were similar to those without in regard to age, sex, and BMI. Complications were more common following anatomic arthroplasty compared to reverse arthroplasty (5 vs 1, p = 0.06); however, complications were not improved compared to historical controls with morbid obesity. Overall, pain improved significantly from 4.8 preoperatively to 2.3 postoperatively (p < 0.001). All groups, regardless of arthroplasty type, demonstrated significant improvements in forward elevation and external rotation. Conclusion Gastric bypass surgery prior to shoulder arthroplasty leads to clinical improvement in both pain and range of motion. Prior gastric bypass surgery does not result in a lower surgical complication rate compared to previously published reports in the morbidly obese population. Level of Evidence: Level 4, case series.

Background: Although obesity is associated with increased complication rates after lower-extremity arthroplasty, there is a relative paucity of studies examining the effect of body mass index (BMI) on shoulder arthroplasty. The purpose of this investigation was to evaluate the effect of BMI on implant survival and the rate of complications after shoulder arthroplasty. Methods: Using an institutional total joint registry, 4,567 consecutive shoulder arthroplasty cases from 1970 to 2013 were studied. The mean BMI was 29.7 kg/m² (range, 14 to 66 kg/m²), with 1,622 patients (36%) with a BMI of 30 to 40 kg/m² and 297 patients (7%) with a BMI of >40 kg/m². There were 2,493 female patients (55%). BMI was dichotomized after examination of the smoothing spline curve. The associations of factors and complications were assessed using Cox proportional hazard regression analysis. Results: Increasing BMI was associated with an increased risk of a revision surgical procedure, reoperation, revision for mechanical failure, and superficial infection, and it was negatively associated with risk of a periprosthetic fracture. The risk of a revision surgical procedure increased in a linear fashion with increasing BMI (hazard ratio [HR], 1.05, or a 5% increased risk per 1 unit of BMI; p = 0.03). Increased BMI was also associated with an increased risk of revision for mechanical failure (HR, 1.05; p = 0.004). In a multivariate model, the association of BMI and risk of a revision for any reason, revision for mechanical failure, and reoperation maintained significance (p ≤ 0.02). The most marked association between increasing BMI and any complication in shoulder arthroplasty was its association with superficial wound infection (HR, 1.09; p = 0.03). Conclusions: Increasing BMI is strongly associated with increased rates of revision surgical procedures and postoperative complications after shoulder arthroplasty. It is important to consider these findings when counseling patients, estimating risks, and estimating complication risks in policy decisions. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.