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Abstract

Background

The coexistence of cervical disease and shoulder pathology is not uncommon. The purpose of this study is to evaluate the early complication rates and outcomes after shoulder arthroplasty in patients with prior cervical arthrodesis.

Methods

A retrospective analysis was performed on a prospectively collected cohort at a single institution. Shoulder arthroplasty (TSA or RTSA) patients with prior cervical fusion (cervical arthrodesis-shoulder arthroplasty [CASA]) were identified and age-matched to controls without cervical fusion from 2012 to 2015. Early (<90-day) complications, visual analog scale (VAS) pain scores, and hospital length of stays were analyzed. Active shoulder range of motion (ROM) and American Shoulder and Elbow Surgeon (ASES) scores preoperatively, 6-week, 6-month, and 1-year postoperatively were compared.

Results

Seventeen CASA patients were matched to 34 controls. Patients were similar in gender, American Society of Anesthesiologist score, body mass index, opioid use, and arthroplasty procedure (TSA vs RTSA). CASA patients had similar postoperative VAS pain scores (4.6 vs 4.0), hospital length of stay (2.3 vs 2.5), and 90-day complications (3/17 vs 3/34) when compared to controls. Active shoulder ROM and ASES preoperatively and postoperatively at 6-week, 6-month, and 1-year were similar between the 2 groups. CASA patients had similar improvements in ASES scores at 1-year from preoperative scores when compared to controls (25.8 ± 24.3 vs 35.8 ± 21.4, P = .25).

Conclusion

Prior cervical fusion does not appear to be a risk factor for increased perioperative complications or poorer patient reported outcomes in patients undergoing shoulder arthroplasty.

Keywords

shoulder arthroplasty cervical fusion outcomes

Introduction

The use of shoulder arthroplasty, particularly for the management of severe osteoarthritis, proximal humerus fractures, and rotator cuff arthropathy, has been on the rise over the past 3 decades with good outcomes in terms of improvements in pain and upper extremity function.^1–8 Recent literature on utilization trends between 2005 and 2013 in the United States reported an overall 8% yearly increase in the incidence of shoulder arthroplasty, a 12% yearly increase in total shoulder arthropathy (TSA) for osteoarthritis, and a 33% yearly increase in reverse total shoulder arthroplasty (RTSA) for rotator cuff arthropathy.¹ The approval of a reverse shoulder arthroplasty device by the U.S. Food and Drug Administration (FDA) in 2003 is likely partly responsible for this consistent increase in utilization. In 2011 alone, RTSA accounted for 42% of all primary shoulder arthroplasties.⁶ Unsurprisingly, the number of revisions due to mechanical complications or dislocations has also grown in tandem, with one study noting a 4-fold increase over a 10-year period from 2001 to 2010.⁴

As the population grows and ages, supply and demand for primary shoulder arthroplasty is only expected to increase. Padegimas et al.⁵ projected demand to increase by 755.4% among patients older than 55 years from 2011 to 2030. While outcomes after shoulder arthroplasty are generally favorable, certain patients still experience complications. Thus, it is imperative to determine patient characteristics and potentially modifiable factors that may put patients at increased risk for perioperative complications. This information is crucial to improving preoperative patient counseling, patient expectation, patient selection, and resource allocation for shoulder arthroplasties. Research analyzing risk factors is mostly limited to small single-center studies with often contradictory findings regarding the relationship between shoulder outcomes and patient-related factors such as age, gender, weight, substance use, and certain medical comorbidities.^9–20

Patients who present with shoulder pain may often have concomitant neck pathology.²¹ One study estimated that approximately 1 in 25 patients seen at an orthopedic surgeon’s clinic for a presumed shoulder or neck issue may actually exhibit a crossover or coexistence of neck and shoulder pathology.²² This phenomenon is seen elsewhere in the body and is known at “hip-spine syndrome” which refers to patients who have concomitant lumbar stenosis and hip arthritis. Recent literature has demonstrated the negative effects of prior lumbar spine fusion on perioperative complications after total hip arthroplasty (THA) including higher rates of dislocation, revision, narcotic use, and need for general anesthesia.^23–26 Whether an analogy to this “hip-spine syndrome” exists between the cervical spine and shoulder is largely unknown.

Although the cervical spine and glenoid do not share a direct anatomic connection, they do share a neuromuscular connection via the C5 nerve root, which contributes largely to the proper functioning of the deltoid and rotator cuff in shoulder abduction, flexion, and external rotation. Injury to the C5 nerve root is a well-known complication of cervical surgery, though most studies report its occurrence from posterior surgical approaches.^27,28 The purpose of this study was to evaluate the early complication rates and outcomes after shoulder arthroplasty in patients with and without prior cervical arthrodesis.

Methods and Materials

This was a retrospective case–control study analyzing a prospectively collected database of patients from a single tertiary care, academic institution between 2012 and 2015. All primary (TSA and RTSA) and revision shoulder arthroplasty patients at our institution who had undergone prior cervical fusion (cervical arthrodesis-shoulder arthroplasty [CASA]) were identified via chart review. Prior cervical arthrodesis was identified by patient-reported surgical history, operative notes, or radiographs identifying spinal fusion instrumentation which included both posterior cervical fusion as well as anterior cervical fusion. CASA patients were then matched (1:2) using propensity scoring based on age, sex, American Society of Anesthesiologist (ASA) score, and arthroplasty procedure to a control group of shoulder arthroplasty patients who had not undergone a prior cervical arthrodesis. Patients were excluded if total shoulder arthroplasty was performed for acute fractures or oncologic diagnoses.

The standard perioperative protocol at our institution was employed for all patients within the cohort including regional anesthesia and multimodal pain control postoperatively consisting of nonsteroidal anti-inflammatory drugs, acetaminophen, and oral narcotics. Deep venous thrombosis prophylaxis included mechanical prophylaxis immediately postoperatively. Antibiotic prophylaxis was continued for 24 h postoperatively.

Demographics and early postoperative outcome data were collected via chart review from the electronic medical record retrospectively. Demographic data collected included age, gender, and body mass index (BMI). Early outcomes data collected included pain scores using the visual analog scale (VAS), opiate usage (calculated as morphine equivalent/day), and postoperative mobility as measured by walking distance with physical therapy (recorded in maximum distance ambulated/therapy session). Disposition following hospital discharge was recorded as either home or facility (skilled nursing facility or acute rehabilitation facility). Complications (both operative and nonoperative) were recorded by direct chart review of all available records, as were any readmissions or reoperations that occurred within 90 days of surgery. Active shoulder range of motion (ROM) and American Shoulder and Elbow Surgeon (ASES) scores preoperatively and postoperatively at 6-week, 6-month, and 1-year time points were compared between CASA and control groups.

Comparisons between CASA and control cases were performed using Pearson’s chi-squared or Fisher exact tests for categorical variables and Student’s t test continuous variables. Statistical significance was defined as P < .05. All analyses were performed using R versions 3.0.2 (R Project).

Results

Seventeen CASA patients were identified from our institution’s shoulder arthroplasty database and matched to 34 controls. Patients were similar in age, gender, ASA score, BMI, smoking status, preoperative opioid use, and type of arthroplasty procedure (Table 1). Of the CASA patients, 13 had anterior cervical discectomy and fusion (ACDF) alone, 3 had combined anterior and posterior cervical fusion, and 1 patient had posterior cervical fusion alone. Of the patients with ACDF alone, 7 patients underwent 1-level fusion, 2 patients had 2-level fusion, and 4 had 3-level fusion.

Table 1.

Characteristics of Study Population.

	CASA	Control	P
Total	17	34
Age, mean (SD)	68.8 (7.6)	73.2 (8.9)	0.091
Sex, n (%)			0.92
Female	9 (52.9)	20 (58.8)
Male	8 (47.1)	14 (41.2)
ASA, mean (SD)	2.6 (0.6)	2.6 (0.6)	0.865
BMI, n (%)			0.65
Underweight (<18.5)	1 (6.2)	0 (0)
Normal (18.5–24)	5 (31.2)	6 (18.8)
Overweight (25–29)	6 (37.5)	12 (37.5)
Obese class I (30–34)	3 (18.8)	8 (25)
Obese class II (35–40)	1 (6.2)	4 (12.5)
Obese class III (>40)	0 (0)	2 (6.2)
Smoking status, n (%)			0.483
Former	4 (23.5)	10 (29.4)
Never	10 (58.8)	22 (64.7)
Smoker	3 (17.6)	2 (5.9)
Surgery, n (%)			0.444
Revision total shoulder	3 (17.6)	3 (8.8)
Reverse total shoulder	9 (52.9)	24 (70.6)
Anatomic total shoulder	5 (29.4)	7 (20.6)
Preoperative opioid use, n (%)	10 (58.8)	14 (41.2)	0.372

ASA, American Society of Anesthesiologists; BMI, Basal Metabolic Index.

CASA patients had similar postoperative VAS pain scores (4.6 vs 4.0) and hospital length of stay (2.3 vs 2.5) when compared to controls (Table 2). Complications of all types occurring within 90 days were rare in both groups. Three of the 17 CASA patients (17.6%) had postoperative complications. One patient experienced a right pneumothorax on postoperative day 1 which eventually resolved after chest tube placement. Another patient was diagnosed with a brachial plexopathy 2 months after TSA which moderately improved over time. A third patient experienced glenoid dissociation 1 month after RTSA and required revision surgery. From the control group, 3 of 34 patients (8.8%) had complications, including a chest wall hematoma on postoperative day 2 and a superficial wound infection requiring incision and drainage 6 weeks after RTSA. A third control patient died on postoperative day 1 after RTSA due to complications from her medical comorbidities.

Table 2.

Early Postoperative Outcomes.

	CASA	Control	P
Total	17	34
Average VAS, mean (SD)
Preoperative	3.8 (3.1)	3.2 (3.4)	0.533
POD0	2.8 (2.2)	2.4 (2)	0.536
POD1	4.6 (2.3)	3.9 (2.2)	0.305
POD2	4.1 (2)	2.9 (2.2)	0.124
POD3	6.1 (1)	3.5 (2.3)	0.057
Average morphine equivalents consumed, mean (SD)
Total	101.2 (82.3)	75 (70.8)	0.244
POD0	23.7 (19.5)	18.2 (16.2)	0.295
POD1	45.8 (33.6)	37.8 (32.6)	0.412
POD2	18.6 (24)	16 (27.7)	0.735
POD3	6.8 (15.9)	2.9 (7.9)	0.239
Distanced walked by POD 1, mean (SD)	170.9 (163.6)	163 (177)	0.898
Length of stay, mean (SD)	2.3 (1.7)	2.5 (1.1)	0.624
Disposition			1
Home	1 (5.9)	3 (8.8)
Not home	16 (94.1)	30 (88.2)
Complications (90 days)	3 (17.6)	3 (8.8)	1

CASA, cervical arthrodesis-shoulder arthroplasty; POD, postoperative day; VAS, visual analog scale.

Active ROM for the shoulder (forward flexion, abduction, and external rotation) and ASES scores, CASA, and control patients exhibited similar scores preoperatively and postoperatively at 6 weeks, 6 months, and 1 year (Table 3). When the mean difference in preoperative and 1-year outcomes was further analyzed, CASA patients had less mean improvement in ASES scores at 1-year from preoperative scores when compared to controls (25.8 ± 24.3 vs 35.8 ± 21.4); however, this was not statistically significant (Table 4).

Table 3.

Preoperative and Postoperative Shoulder Range of Motion and ASES Scores.

	CASA	Control	P
Shoulder range of motion, mean degrees (SD)
Forward flexion
Preoperative	86.66 (43.61)	89.81 (42.12)	0.823
Postoperative: 6 weeks	65.63 (24.46)	80.5 (37.48)	0.157
Postoperative: 6 months	106.50 (32.47)	128.83 (30.49)	0.056
Postoperative: 1 year	110.27 (29.77)	125.11 (30.66)	0.181
Abduction
Preoperative	74.63 (44.61)	74.25 (38.42)	0.976
Postoperative: 6 weeks	69.63 (18.44)	71.72 (27.16)	0.783
Postoperative: 6 months	94.60 (31.35)	114.30 (37.46)	0.143
Postoperative: 1 year	94.36 (27.9)	116.78 (36.35)	0.075
External rotation
Preoperative	39.63 (19.67)	31.97 (25.89)	0.304
Postoperative: 6 weeks	11.13 (33.28)	22.97 (27.87)	0.20
Postoperative: 6 months	23.0 (34.98)	38.27 (24.26)	0.13
Postoperative: 1 year	25.0 (27.2)	34.93 (22.47)	0.253
ASES, mean score (SD)
Preoperative	36.88 (22)	30.66 (18.12)	0.32
Postoperative: 6 weeks	41.79 (16.3)	46.5 (14.5)	0.33
Postoperative: 6 months	64.26 (31.69)	71.49 (20.79)	0.43
Postoperative: 1 year	65.28 (23.90)	71.86 (23.22)	0.43

ASES, American Shoulder and Elbow Surgeons; CASA, cervical arthrodesis-shoulder arthroplasty.

Table 4.

Mean Difference in Preoperative and 1-year Shoulder Range of Motion and ASES Scores.

	CASA	Control	P
Shoulder range of motion, mean degrees (SD)
Forward flexion	34.56 (36.88)	25.95 (35.93)	0.56
Abduction	27.56 (33.58)	35.95 (40.73)	0.59
External rotation	−10.3 (17.41)	3.76 (25.62)	0.14
ASES, mean score (SD)	25.84	35.76	0.25

ASES, American Shoulder and Elbow Surgeons; CASA, cervical arthrodesis-shoulder arthroplasty.

Discussion

This is the first study to analyze the clinical and functional outcomes after shoulder arthroplasty in patients with a history of cervical arthrodesis. Although we found no differences in early complications rates or outcomes after shoulder arthroplasty between those patients with and without a history of prior cervical arthrodesis, both groups had a mean improvement in their preoperative ASES scores at 1 year above previously reported MCID of 21 for shoulder arthroplasty.²⁷ Improvement in shoulder range of motion was also similar between the 2 groups. These findings suggest that patients with a history of cervical fusion may experience similar gains in shoulder function with shoulder arthroplasty when compared to those without prior cervical fusion.

With the growing popularity of TSA and RTSA in the treatment of degenerative glenohumeral disease and rotator cuff arthropathy, it is important to understand the modifiable and non-modifiable risk factors that contribute to poor patient outcomes.^1–8 Current primary literature addressing specific predictors of complications after shoulder arthroplasty have reported inconsistent findings. Some studies have suggested that patient-specific factors such as BMI, age, female gender, ASA score, nicotine consumption, and certain medical comorbidities correlate with perioperative complications and surgical revision, while others have failed to find such associations.^9–20 Despite these variable results, continued research into the risks factors for perioperative complications and outcomes after shoulder arthroplasty will improve preoperative patient counseling and shared decision-making between provider and patient.

While the coexistence of cervical disease and shoulder pathology is not uncommon,²² we were interested in determining whether a link exists between previous cervical spine surgery and outcomes in patients who undergo shoulder arthroplasty. Curiosity about this subject stemmed from recent arthroplasty literature demonstrating an analogous link between prior lumbar spine fusion and increased perioperative complication after THA. In a large retrospective cohort study utilizing a large Medicare database, Sing et al.²³ found higher rates of prosthetic dislocation, loosening, and revision within 2 years after THA in patients with prior lumbar spinal arthrodesis. Conducting a propensity score matched-pair analysis, Perfetti et al.²⁴ also concluded that patients with prior lumbar fusion and subsequent THA are at higher risk for dislocation and revision of their hip arthroplasty. While the exact pathophysiology of why lumbar spinal fusion places patients at higher risk for complication after THA is unknown, the anatomic connection between the hip and spine via the pelvis may provide an important clue. Lumbar fusion reduces spinal flexibility and places increased stress on adjacent structures.³⁰ Additional stress and rigidity can potentially affect spinopelvic dynamics and alter the mechanics of the hip joint, possibly predisposing THA patients to future complications. Unlike the lumbar spine and acetabulum, the cervical spine and glenoid do not share a direct anatomic connection. This could explain the negative findings of this study, indicating that a loss of neck motion does not seem to correlate with shoulder outcomes after arthroplasty.

This study has several limitations. This was a single-center study of a small cohort of patients and was likely underpowered to detect a statistically significant difference. Patient follow-up was also limited to 1-year, making it difficult to draw conclusions about the long-term effects of cervical arthrodesis and subsequent shoulder arthroplasty. Further, our study cohort was a heterogeneous population undergoing TSA or RTSA for varying indications, including revision for failed prior procedures on the shoulder. Consideration of multiple shoulder pathologies necessitating surgical intervention as well as the different methods of arthroplasty treatment may have limited this study’s ability to detect a significant difference in outcomes.

Conclusion

Prior cervical fusion does not appear to be a risk factor for increased perioperative complications or worse outcomes in patients undergoing shoulder arthroplasty.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Ma/Research: Zimmer, Dr. Feeley/Research: Zimmer. The remaining authors declare that there is no conflict of interest.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Effects of Prior Cervical Fusion on Patient Outcomes After Shoulder Arthroplasty

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods and Materials

Results

Discussion

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References