Gregory T. Mahony

Patient Activity Levels After Reverse Total Shoulder Arthroplasty What Are Patients Doing

Objectives: Indications for reverse total shoulder arthroplasty (RTSA) are expanding, resulting in younger patients who wish to remain active following the procedure. Little information, however, is available to help manage expectations of both physicians and patients for return to sporting activities. The purpose of this study was to determine the rate of return of sports activities, assess average time to return to sports for patients having undergone RTSA. Methods: A prospectively collected registry was queried for consecutive patients who underwent RTSA at our institution between 2007 and 2013. Patients with a minimum of 1-year follow-up were included. Patients without preoperative sporting activity were excluded. All patients were asked to complete a questionnaire regarding their physical fitness, sporting activities. The questionnaire was designed in accordance with previously published activity assessments for total joint arthroplasty. Each patient also completed an ASES and VAS assessment. Results: 76 patients played a sport preoperatively and met inclusion/exclusion criteria. The average follow-up was 31.6 months (12-65 mons) and average age was 74.84 years (49.9 - 92.6 yrs). Preoperative diagnoses were cuff tear arthropathy (55.2%), osteoarthritis (30.9%), proximal humerus fracture (17.1%), and rheumatoid arthritis (5.2%). 73% of the cohort had undergone prior ipsilateral shoulder surgery. Average VAS pain scores improved from 6.57 to 0.63 (p<0.001). Average ASES scores improved from 34.30 to 81.45 (p<0.001). 85.5% of patients who participated in sports preoperatively returned to at least one sport following RTSA. Average time to full return to sport was 5.3 months. Walking had the highest direct rate of return (85.7%), followed by fitness sports (81.5%), swimming (66.7%), running (57.1%), cycling (50.0%) and golf (50%). Age less than 70 years had significant improvement in rate of return to sports (p<0.002). 41.1% reported improved physical fitness following RTSA. 88.2% felt their sports outcome was good to excellent and 93.4% felt their surgical outcome was good to excellent. The two most commonly reported reasons for not returning to a sport were pain (13.1%) and lack of interest (9.2%). For all types of sports and rates of return see fig 1. Conclusion: Patients undergoing RTSA had an 85% rate of return to one or more sporting activities at an average of 5.3 months following surgery. Non-contact high demand activities (swimming, skiing, golf, and tennis) had lower return rates than lower demand activities. Age greater than 70 years old was a significant predictor of decreased return to activities. This is the only study to document both preoperative and postoperative sports and activities of daily living following RTSA. The present study offers valuable information to help manage patient and surgeon expectations.

Sports after shoulder arthroplasty: a comparative analysis of hemiarthroplasty and reverse total shoulder replacement

BACKGROUND Traditionally, fewer postoperative sport restrictions are imposed on hemiarthroplasty (HHA) patients on than reverse total shoulder arthroplasty (RTSA) patients. However, functional outcomes have been shown to be superior in RTSA. No direct comparison of RTSA vs HHA has been done on rates of return to sports in patients with glenohumeral arthritis and rotator cuff dysfunction, proximal humeral fractures, or rheumatoid arthritis. METHODS This is a retrospective review of consecutive RTSA and HHA patients collected from our institutions shoulder arthroplasty registry. All patients playing sports preoperatively with minimum 1-year follow-up were included. Final follow-up included an additional patient-reported questionnaire with questions regarding physical fitness and sport activities. RESULTS The study included 102 RTSA and 71 HHA patients. Average age at surgery was 72.3 years for RTSA compared with 65.6 years for HHA (P < .001). Patients undergoing RTSA had improved visual analog scale scores compared with HHA (-5.6 vs -4.2, P = .007), returned to sports after RTSA at a significantly higher rate (85.9% vs 66.7%, P = .02), and were more likely to be satisfied with their ability to play sports (P = .013). HHA patients were also more likely to have postoperative complaints than RTSA patients (63% vs 29%, P < .0001). No sports-related complications occurred. Female sex, age <70 years, surgery on the dominant extremity, and a preoperative diagnosis of arthritis with rotator cuff dysfunction predicted a higher likelihood of return to sports for patients undergoing RTSA compared with HHA. CONCLUSIONS Despite traditional sport restrictions placed on RTSA, patients undergoing RTSA can return to sports at rates higher than those undergoing HHA, with fewer postoperative complaints.

Hemiarthroplasty Versus Total Shoulder Arthroplasty for Shoulder Osteoarthritis: A Matched Comparison of Return to Sports

Background: Return to activity is a commonly used indication for shoulder hemiarthroplasty (HA) compared with total shoulder arthroplasty (TSA). Despite clinical studies demonstrating better functional outcomes after TSA, the literature has failed to show a difference in return to sports. Purpose: To compare rates of return to sports in a matched cohort of TSA and HA patients with a preoperative diagnosis of glenohumeral osteoarthritis (OA). Study Design: Cohort study; Level of evidence, 3. Methods: A prospectively collected registry was queried retrospectively for consecutive patients who underwent HA. Inclusion criteria were preoperative diagnosis of OA and more than 2 years of follow-up. After meeting the inclusion criteria, all HA patients were statistically matched to a TSA patient. All patients had end-stage OA with significant glenohumeral joint space narrowing. Results: At final follow-up, 40 HA patients and 40 TSA patients were available. The average (±SD) age at surgery was 65.7 ± 10.5 years and 66.2 ± 9.6 years for the HA and TSA groups, respectively (P = .06). Average follow-up was 62.0 months and 61.1 months for the HA and TSA groups, respectively (P = .52). Average American Shoulder and Elbow Surgeons scores improved from 36.3 to 70.2 for HA patients and from 34.0 to 78.5 for TSA patients (P < .001 for both); final scores were not significantly different between groups (P = .21). Average visual analog scale pain scores improved from 6.3 to 2.2 for HA patients and from 6.1 to 0.6 for TSA patients (P < .001 for both). HA patients had significantly worse final visual analog scale scores compared with the TSA group (P = .002). Significantly more TSA patients were satisfied with their surgery compared with HA patients (100% vs 70%) (P = .01). Of both groups, 65.5% of HA patients (19 of 29) returned to at least 1 sport postoperatively compared with 97.3% of TSA patients (36 of 37) (P < .001). Average timing for return to full sports was 5.5 ± 4.2 months and 5.4 ± 3.1 months for the HA and TSA groups, respectively (P = .92). Significantly more TSA patients returned to higher upper extremity use sports (P = .01). Conclusion: In patients with OA, rate of return to sports was significantly better after TSA compared with HA. HA patients had significantly more pain, worse surgical satisfaction, and decreased ability to return to high upper extremity use sports. For patients with OA who wish to return to sporting activities, these results help manage expectations.

Sports- and Work-Related Outcomes After Shoulder Hemiarthroplasty

Background: With an active aging population, more patients expect to return to previous activities and work after surgery. Purpose: To determine the rate and timing to return of sports and employment after shoulder hemiarthroplasty. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of consecutive patients who underwent shoulder hemiarthroplasty from 2007 to 2013. Follow-up consisted of a patient-reported questionnaire regarding physical fitness, sporting activities, and work status. Results: From 105 patients screened, 79 were available for follow-up. The average follow-up time was 63.1 months, and the average age at follow-up was 69 years. Scores on the visual analog scale for pain improved from 6.2 to 2.1 (P < .001) postoperatively, and those on the American Shoulder and Elbow Surgeons (ASES) shoulder assessment improved from 34.6 to 71.3 (P < .001). Patients older than 65 years had significantly lower absolute postoperative ASES scores (P = .041) but experienced similar improvement from their preoperative baseline (P = .158) compared with patients younger than 65 years. There were 58 patients who played sports preoperatively, and 67.2% of these restarted at least 1 of their previous sports postoperatively. The average time to return to full sports was 6.5 months for those who returned. Direct rates of return were as follows: fitness sports (69%), swimming (65%), running (64%), cycling (63%), and doubles tennis (57%). Younger age was associated with highest demand level achieved (P = .023). Forty-nine patients worked preoperatively, with 69.4% returning to previous employment after surgery; the average time to return to work was 1.4 months. In comparative analysis, patients who did not return to work had a higher mean body mass index (32 ± 7 vs 27 ± 5 kg/m2; P < .008). Conclusion: In this hemiarthroplasty cohort, there was a 67.2% rate of return to 1 or more sports at an average of 6.5 months postoperatively. Patients older than 65 years experienced similar improvements in ASES scores compared with patients younger than 65 years, although absolute scores were lower on average. Those who returned to higher demand sports were younger on average. Of patients working preoperatively, 69.4% returned to their previous employment at an average of 1.4 months. Patients who did not return to employment had significantly higher body mass index on average. These findings will help surgeons manage expectations of shoulder hemiarthroplasty candidates preoperatively.

Pectoralis major tendon tears: functional outcomes and return to sport in a consecutive series of 40 athletes

BACKGROUND There are limited data on the outcomes of surgically repaired pectoralis major tendon (PMT) tears. The purpose of this study was to report the functional outcomes, return to sport, and second surgery rates in a consecutive series of PMT tears. METHODS Forty patients with acutely repaired PMT tears were retrospectively identified. Follow-up was conducted with functional outcome scores and adduction strength testing at final follow-up. Return to sport and incidence of subsequent surgery were also recorded. RESULTS The average age of the patients was 34.4 years (range, 23-59 years). Average follow-up was 2.5 years (range, 2-7.0 years). Twenty-three injuries (58%) occurred in the nondominant extremity. Bench press (n = 26) and contact sport participation (n = 14) were the most common mechanisms. Postoperative Single Assessment Numeric Evaluation scores averaged 93.6 (range, 62-100), with patient satisfaction of 9.6 of 10 (range, 6-10). All athletes returned to preinjury level of function approximately 5.5 months postoperatively (range, 4.5-6.5 months); 23.1% and 2.6% described mild or moderate difficulties with sport participation. Isokinetic strength evaluation revealed an average decrease of 9.9% (range, -18% to 41%). Application of the Bak criteria revealed 37% excellent, 26% good, and 37% fair outcomes, with most in the fair group reporting cosmetic concerns. Removing cosmesis, 46% scored excellent, 37% good, and only 17% fair. Three athletes required a second surgical procedure (7.5%). CONCLUSIONS Surgical repair of PMT tears resulted in high patient satisfaction, with excellent restoration of function and adduction strength, early return to sport, and few reoperations, albeit with the potential for mild cosmetic concerns.

Causes of poor postoperative improvement after reverse total shoulder arthroplasty

BACKGROUND Although reverse total shoulder arthroplasty (RTSA) has been successful in improving pain and function in most patients, some patients fail to improve clinically. The present study used a large registry of RTSA patients to evaluate associations between patient-related factors and poor postoperative improvement after RTSA. MATERIALS AND METHODS A prospectively collected shoulder arthroplasty registry was queried for consecutive patients who underwent RTSA from 2007 to 2013. Patients with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. Poor postoperative improvement was defined as a change in the ASES of less than 12 points. Multivariate logistic regression analysis was used to identify independent risk factors. RESULTS A total of 150 patients met inclusion and exclusion criteria. Logistic regression revealed that male sex (adjusted odds ratio [OR], 7.9; P = .004), presence of an intact rotator cuff at the time of surgery (adjusted OR, 4.8; P = .025), depression (adjusted OR, 11.2; P = .005), a higher baseline ASES score (P < .001), and higher total number of medical comorbidities (P = .035) were associated with poor postoperative improvement after RTSA. CONCLUSIONS Surrogates for better preoperative function after RTSA, such as a higher baseline ASES score and intact rotator cuff at the time of surgery, correlated with poor postoperative improvement. In addition, male sex, depression, and total number of medical comorbidities also correlated with poor postoperative improvement. Interestingly, factors such as patient age and indication for surgery were not found to correlate with poor improvement after RTSA.

A comparative analysis of work-related outcomes after humeral hemiarthroplasty and reverse total shoulder arthroplasty

BACKGROUND The return to work of young patients undergoing shoulder arthroplasty is increasingly important. Whereas studies have shown superior outcomes of reverse total shoulder arthroplasty (RTSA) compared with humeral hemiarthroplasty (HHA), no prior literature has compared RTSA with HHA in regard to return to work. METHODS A retrospective review of a prospectively collected shoulder arthroplasty registry was performed to analyze all patients who underwent RTSA or HHA at a single institution. A validated questionnaire evaluating return to work postoperatively was administered at baseline and at follow-up in addition to the American Shoulder and Elbow Surgeons and visual analog scale (VAS) pain surveys. RESULTS The study included 40 RTSA and 41 HHA patients. The average age at surgery was 68.6 years in the RTSA group and 60.8 years in the HHA group (P < .001). Postoperatively, 65% of RTSA patients returned to work compared with 70.7% of HHA patients (P = .64). There was no significant difference in the time to return to work between the RTSA (2.3 months) and HHA (3.1 months) groups (P = .46). Both groups had statistically significant improvements in both the American Shoulder and Elbow Surgeons and VAS scores. The improvement in pain on the VAS for patients undergoing RTSA (-5.6) trended toward significance compared with HHA (-4.2) (P = .056). CONCLUSION Roughly two-thirds of patients undergoing either HHA or RTSA were able to return to work postoperatively, with no significant difference found between the 2 groups in terms of time to return to work, despite that patients undergoing RTSA were significantly older.

Reverse Total Shoulder Arthroplasty and Work-Related Outcomes

The average retirement age is increasing, and the indications for reverse total shoulder arthroplasty (RTSA) are being broadened. The goal of the current study was to determine objective findings for rate of return to work and time to return to work after RTSA. The authors performed retrospective data collection for consecutive patients who underwent RTSA at their institution between 2007 and 2013. All patients were asked to complete a questionnaire about their work history and their ability to participate in work-related activities. A total of 40 patients reported working before surgery. Average patient age was 74.7 years (range, 56-82 years). Average follow-up was 2.6 years (range, 1-4.7 years). Average American Shoulder and Elbow Surgeons score improved from 34.0 to 81.7 (P<.001). Average visual analog scale pain score decreased from 6.5 to 0.7 (P<.001). Most patients (65.4%) classified their job as sedentary, 34.6% classified their job as light work, and no patients classified their job as heavy work. Of patients who worked preoperatively, 65% (n=26) returned to work after RTSA. Only a previous diagnosis of heart disease affected return to work (P=.04). Overall, average time to return to work was 2.3 months (range, 0.5-11 months). Patients with sedentary jobs returned to work more quickly (1.4 months) than those with light work (4.0 months). A total of 96.2% of patients reported good to excellent surgical outcomes. Of patients who worked before RTSA, 65% were still working at final follow-up. Only 5% of patients retired for reasons attributed to the operated shoulder. On average, patients returned to work less than 3 months after surgery.

Posterior Instability Caused by Batter's Shoulder

In summary, batter’s shoulder is a rare and only recently recognized entity. This condition is posterior shoulder instability caused by a missed attempt at hitting a pitch, especially with an outside pitch. The lack of counterforce from hitting a ball produces increased forces imparted on the posterior capsulolabral complex of the lead shoulder during batting. If the player fails conservative management, she or he can undergo an arthroscopic posterior labral repair instead of debridement. After treatment, the player can expect to return to play after approximately 6 to 7 months. Initial results from a small, retrospective series demonstrate greater than 90% excellent results. These findings are similar to current literature for arthroscopic treatment of posterior instability, which reports success rates that range from 75% to 91%. Longer-term follow-up will be needed to determine the natural history and prognosis or batter’s shoulder. Based on initial results, the authors predict good to excellent results for most players with batter’s shoulder who undergo proper treatment. Additionally, with the exception of switch hitters, the nonthrowing arm is affected. This can also improve the athlete’s return to play.

Outcomes following Structural Grafting of Distal Femoral Osteochondral Injuries in Patients Aged 40 Years and Older

Abstract Osteochondral lesions of the distal femur represent a challenging clinical entity, particularly in patients > 40 years of age. Microfracture has demonstrated inferior results in this population with clinical deterioration beyond 1 to 2 years postoperatively. Limited evidence exists to support alternative cartilage restoration procedures. The purpose of this study was to report functional outcomes and activity levels following cartilage restoration procedures in patients > 40 years with symptomatic distal femoral osteochondral lesions. From 2000 to 2012, 61 patients with distal femoral osteochondral injuries were retrospectively identified. Mean follow‐up was 3.6 ± 1.4 years; mean age was 51.6 years (range 40‐71); 59% were male. Of 61 patients, 35 patients (57%) were treated with synthetic scaffold (SS) plugs (off‐label), 14 (23%) with osteochondral allograft (OCA), and 12 (20%) with autologous osteochondral transfer (AOT). Validated outcome measures including activity of daily living (ADL) score, International Knee Documentation Committee (IKDC) subjective evaluation form, and Marx activity scale (MAS) were used. The average lesion size was 3.8 ± 2.1 cm2. Lesion size was significantly greater in the OCA group (5.8 ± 1.8 cm2), compared with the SS (3.2 ± 1.9 cm2) and AOT group (3.3 ± 1.8 cm2, p ≤ 0.0024). Collectively, outcome scores for the entire population demonstrated significant improvement in ADL (61.36 ± 17.76‐76.81 ± 17.2, p < 0.0001) and IKDC scores (40.28 ± 13.28‐61.84 ± 20.83, p < 0.001) from baseline to final follow‐up, with no significant change in MAS (4.19 ± 5.13‐2.59 ± 3.92, p = 0.07). Similarly, subgroup analysis identified that all treatment groups (SS, OCA, and AOT) demonstrated significant improvement in ADL and IKDC scores from preoperative to final postoperative visit (p ≤ 0.0361). MAS scores were maintained in the OCA and AOT groups (p ≥ 0.1704), but significantly decreased in the SS group (4.3 ± 5.2‐2.7 ± 4.11, p = 0.0163). Ten patients (16.3%) required revision surgery at a mean of 4.4 years (range 0.3‐13.4 years). Cartilage restoration procedures using structural grafts are successful in patients 40 years and older, with improved pain and functional outcome scores compared with preoperative baseline scores. OCA and AOT should primarily be used, given recent concerns with SS implants.