Risk factors for revision surgery after humeral head replacement: 1,431 shoulders over 3 decades

doi:10.1016/j.jse.2011.06.015

Journal of Shoulder and Elbow Surgery

Volume 21, Issue 8, August 2012, Pages 1039-1044

https://doi.org/10.1016/j.jse.2011.06.015 Get rights and content

Hypothesis

To assess the long-term risk of revision surgery and its predictors after humeral head replacement (HHR).

Methods

We used prospectively collected data from the Mayo Clinic Total Joint Registry and other institutional electronic databases. Revision-free survival for HHR at 5, 10, and 20 years was calculated by use of Kaplan-Meier survival analysis. We used univariate and multivariate-adjusted Cox regression analyses to examine the association of age, gender, body mass index (BMI), comorbidity assessed by Deyo-Charlson index, American Society of Anesthesiologists class, implant fixation (cemented vs uncemented), and underlying diagnosis with the risk of revision surgery. Hazard ratios with 95% confidence intervals (CIs) and P values are presented.

Results

During the study period (1976-2008), 1,359 patients underwent 1,431 shoulder HHRs. The mean age was 63 years, 63% of patients were female, the mean BMI was 28 kg/m², and 60% of implants were cemented. During the follow-up, 114 HHRs were revised. At 5, 10, and 20 years, the shoulder implant survival rate was 93.6% (95% CI, 92.1%-95%), 90% (95% CI, 88%-92%), and 85% (95% CI, 81.8%-88.4%), respectively. In multivariate-adjusted analyses, older age was associated with a lower hazard of revision, with a hazard ratio of 0.97 (95% CI, 0.96-0.99; P < .001), and higher BMI was associated with a higher hazard ratio of 1.04 (95% CI, 1.01-1.08; P = .02).

Conclusions

Long-term survival of HHR at 20 years was excellent. Obesity and younger age are risk factors for a higher revision rate after HHR. Further studies should investigate the biologic rationale for these important associations. Surgeons can discuss these differences in revision risk with patients, especially young obese patients.

Section snippets

Study population

The Mayo Clinic Joint Registry was used to conduct this study. This prospective registry has captured every arthroplasty performed at the Mayo Clinic, Rochester, Minnesota, USA, since 1969, including all shoulder arthroplasties performed since 1976. The Mayo Clinic medical center provides primary and specialty care to residents of Olmsted County and specialty care to referred patients. All patients who undergo shoulder arthroplasty are invited to return for a clinic visit at 1, 2, and 5 years

Clinical characteristics

The patient characteristics are summarized in Table I. During the study period (1976-2008), 1,359 patients underwent 1,431 shoulder HHRs. The mean age was 63 years, 63% of patients were female, and the mean BMI was 28 kg/m²; 60% of implants were cemented. The ASA class was 1 or 2 in 49% and 3 or 4 in 51%. The mean cohort follow-up was 7 years (SD, 7 years; range, 1 day to 32 years) with median follow-up of 5 years.

Revision rates

Of the 1,413 shoulders that underwent HHR, 114 were revised during the follow-up.

Discussion

In this study, which included 1,359 patients with 1,431 shoulder HHRs performed over a 33-year period, we found that 85% were revision free at 20-year follow-up. Although in univariate analyses several variables were associated with a higher risk of revision, including male gender, older age, higher BMI, higher ASA class, and underlying diagnosis, in multivariate analyses we found that only younger age and higher BMI were significantly associated with a higher risk of revision. To our

Conclusion

This study provides the revision-free survival rate for HHR up to 20-year follow-up. The revision-free survival rate at 20-year follow-up after HHR was good, at 85%. Higher BMI and younger age were significant risk factors for revision surgery, whereas other patient factors such as gender, comorbidity, ASA class, and underlying diagnoses were not associated with revision risk. Studies are needed to explore the reasons for higher revision rates in obese patients undergoing HHR and to examine the

Acknowledgments

We thank Scott Harmsen, MS, and Cathy D. Schleck, BS, for performing statistical analyses and Youlonda Lochler for providing the study cohort.

Disclaimer

This material is the result of work supported by National Institute of Health Clinical Translational Science Award 1 KL2 RR024151-01 (Mayo Clinic Center for Clinical and Translational Research) and the resources and use of the facilities at the Birmingham VA Medical Center. The study sponsors had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

The authors, their

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Epidemiology of revision shoulder arthroplasty in the United States: incidence, demographics, and projected volume from 2018 to 2030
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Thorough understanding of surgical indications and type of revision shoulder arthroplasty (SA) performed aids policy making decisions, resource allocation, and research into cost and utilization. The purpose of this study was to determine indications for and the type of revision SA performed in the United States.
Healthcare Cost and Utilization Project National Inpatient Sample database was used to analyze clinical, demographic, and economic data from 61,615 revision SA procedures performed from 2012 to 2018. The prevalence of revision procedures was calculated for population subgroups in the United States that were stratified according to age, sex, diagnosis, primary payer class, and type of hospital using the most recent year of data. The indication for revision and average length of stay after revision surgery were also determined for each type of revision arthroplasty procedure. Linear regression was used to estimate procedures through 2030, using incidence values from 2012 to 2018.
Annual volume of revision SA in the United States increased by 153% from 5650 procedures in 2012 to 14,300 procedures in 2018. Linear regression predicted a continued increase in this annual volume, increasing to 37,329 revision SA procedures by 2030. The most common SA procedure performed in the revision setting was reverse shoulder arthroplasty and the most common indications for revision were for instability (25%) and infection (21%). Revision SA procedures were most commonly performed in patients aged 60-70 years, with a mean age of 66.6 years and with Medicare insurance (66%). The mean length of hospital stay for revision SA was 3.1 days.
Annual volume of revision SA increased by 153% from 2012 to 2018 in the United States with a continued predicted increase through 2030. Instability and infection are the most common indications for surgery. Reverse shoulder arthroplasty was the most commonly performed surgery in the revision setting.
Complicated four-part proximal humerus fracture combined with shoulder dislocation undergoing the artificial humeral head replacement
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Although open reduction and internal fixation is a standard treatment for the management of severe proximal humeral fractures, it is associated with high risk for humeral head necrosis. Therefore, stemmed hemiarthroplasty (SHA) may be successfully used for older patients, but the expected long-term outcomes for young, active patients remain unclear. Therefore, in this study, we report the long-term clinical outcomes of SHA of the shoulder in young, active patients aged <40 years.
Between 1986 and 2003, we investigated 11 shoulders of 11 patients (all male) for primary SHA of the shoulder. Five patients received cemented hemiarthroplasty. The average age was 28.6 years (range, 17–40 years), and the average follow-up was 20.5 years (range, 18–26 years). Fractures were 2-part (dislocation of anatomical neck fracture) in 3 patients, 3-part in 2 patients, and 4-part in 6 patients. Clinical function was assessed using the Japanese Orthopaedic Association score and Constant score. Acromiohumeral interval, prosthetic loosening, superior migration, and glenoid erosion were compared between the immediate postoperative and 5-year, 10-year, and most recent (final) follow-up radiographs.
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There was good long-term survival of primary SHA (average, 20.2 years). No long-term concerns were identified in terms of implant loosening or severe osteoarthritis of the glenoid, despite the young age of the patients at implant (<40 years). However, poor clinical results were found in older patients with regard to absorption and malunion of the greater tuberosity. In addition, there remain substantial concerns regarding progressive glenoid erosion and the outcomes of revision to a more standard arthroplasty.
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Variations in humeral component designs in hemiarthroplasty and anatomic total shoulder arthroplasty cases can impact the degree of difficulty during a revision surgery that necessitates the removal of the humeral stem. However, no metric exists to define stem extraction effort nor to identify associated factors that contribute to extraction difficulty. The purpose of this study is to describe a method to quantify stem extraction difficulty and to define features that will impact the effort during stem removal.
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ABOS Part II examinees with at least 1 shoulder arthroplasty in the examination years 2008-2019 were collected. Hemiarthroplasty, TSA, and RSA performed from 2007-2018 for a diagnosis of primary GHOA were included. Arthroplasty for primary or secondary diagnoses of fracture, infection, tumor, rotator cuff arthropathy or tear, revision, and non-arthroplasty procedures were excluded. Proportion and volume of cases were evaluated, with sub-analyses of geographic region and fellowship training. Univariate logistic regression determined statistical significance (P< .05).
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: This study was approved by the Mayo Clinic Institutional Review Board, and all investigations were conducted in conformity with ethical principles of research.

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ShoulderRisk factors for revision surgery after humeral head replacement: 1,431 shoulders over 3 decades

Hypothesis

Methods

Results

Conclusions

Section snippets

Study population

Clinical characteristics

Revision rates

Discussion

Conclusion

Acknowledgments

Disclaimer

J Clin Epidemiol

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Arthroplasty

Rates of revision knee replacement in Ontario, Canada

J Bone Joint Surg Am

The role of anesthesia in surgical mortality

JAMA

Shoulder
Risk factors for revision surgery after humeral head replacement: 1,431 shoulders over 3 decades