背景:反向肩关节置换术(RSA)后的不稳定是最常见的并发症之一,仍然是临床挑战。目前的证据受到样本量小的限制,单中心,或单植入方法限制了普遍性。我们试图确定RSA术后脱位的发生率和患者相关的危险因素。使用一个大的,具有不同植入物的多中心队列。
方法:回顾性研究,多中心研究涉及美国15个机构和24个ASES成员。纳入标准包括在2013年1月至2019年6月期间接受原发性或修订RSA的患者,并进行至少3个月的随访。所有定义,纳入标准,并使用德尔菲法确定收集的变量,涉及所有主要研究者的迭代调查过程,要求至少75%的共识被认为是每个研究元素的方法的最终组成部分.脱位被定义为肱骨组件和关节球之间的关节完全丧失,并且需要影像学检查确认。进行二元逻辑回归以确定RSA术后脱位的患者预测因素。
结果:我们确定了6,621例符合纳入标准的患者,平均随访时间为19.4个月(范围3-84)。研究人群为40%的男性,平均年龄为71.0岁(范围23-101)。整个队列的脱位率为2.1%(n=138),1.6%(n=99)的主要注册会计师,修订RSAs为6.5%(n=39)(P<.001)。脱位发生在手术后的中位数为7.0周(IQR3.0-36.0),创伤后占23.0%(n=32)。与其他诊断的患者相比,主要诊断为肩袖完整的肱骨骨关节炎的患者的整体脱位率较低(0.8%vs.2.5%;P<.001)。患者相关因素独立预测脱位,按照效果的大小,在影像学证实的脱位之前有术后半脱位的病史(赔率比[OR]19.52,P<.001),骨折不愈合的主要诊断(OR6.53,P<.001),翻修关节成形术(OR5.61,P<.001),肩袖疾病的主要诊断(OR2.64,P<.001),男性(OR2.21,P<.001),手术时无肩胛骨下修复(OR1.95,P=.001)。
结论:与脱位相关的最重要的患者相关因素是术后半脱位病史,并且主要诊断为骨折不愈合。值得注意的是,骨关节炎的RSAs显示脱位率低于肩袖疾病的RSAs。这些数据可用于在RSA之前优化患者咨询,尤其是在接受翻修RSA的男性患者中。
BACKGROUND: Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants.
METHODS: A retrospective, multicenter
study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each
study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA.
RESULTS: We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The
study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001).
CONCLUSIONS: The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA.