Cofield, J Shoulder Elbow Surg 2018 - What I've Learned About Open Shoulder Surgery - Article Summary

What I've Learned About Open Shoulder Surgery

Cofield·J Shoulder Elbow Surg·2018·1 citations·Review article

Robert Cofield distills five decades of open shoulder surgery experience at Mayo Clinic into technical and clinical lessons. Drawing on registry data, he quantifies outcomes for rotator cuff repair, glenohumeral instability, and shoulder arthroplasty that case-by-case impression alone could not reliably detect. This is a capstone reference piece, not a primary study — its value is in the crystallized decision thresholds and technique principles.

Key Findings

Revision rates were ~8% for both humeral head replacement and total shoulder arthroplasty, but the failure modes diverged completely by implant type.
- Hemiarthroplasty: progressive glenoid arthrosis pain
- TSA: component loosening and polyethylene wear/osteolysis
- Knowing this distinction is why you choose TSA over hemiarthroplasty in marginal cases — the hemi will eventually hurt from the glenoid side.
After an initial 2-year settling period, revision-requiring complications accrue at ~1% per year. In any given year of follow-up, only 1 in 100 asymptomatic patients will need revision. Supporting registry-style surveillance over routine annual clinic visits for those with no symptoms.
Periprosthetic shoulder infection occurred in >1% of primary cases, and the dominant organism has shifted from Staphylococcus to Cutibacterium acnes. Risk factors are male sex, younger age, higher BMI, and longer OR time. C. acnes grows slowly and requires extended culture incubation. Missing it is a real diagnostic trap.
Tuberosity healing failed in nearly half of nonunion cases treated with anatomic arthroplasty, and one-third of malunion osteotomies healed incompletely. Set realistic expectations with patients before post-traumatic reconstruction. The biology is fundamentally compromised.
Shoulder strength recovered to only two-thirds to three-quarters of normal at one year, even after successful arthroplasty. Passive motion achieved intraoperatively reliably converted to active motion within 6 months, but strength lagged substantially longer.
Metal-backed ingrowth glenoid components failed at a higher rate than cemented all-polyethylene components because polyethylene between two rigid metal surfaces wears at an accelerated rate. This is why the field returned to all-polyethylene cemented glenoids as the standard.
For open anterior instability repair, anterior capsular suturing was performed with the arm in neutral flexion-extension, 20° external rotation, and 20° abduction. This position balances restoration of stability with preservation of functional range of motion.

Board PearlAfter shoulder arthroplasty, revision-requiring complications accrue at 1% per year after year 2, and Cutibacterium acnes has replaced Staphylococcus as the dominant periprosthetic organism.

Supplemental

What I've Learned About Open Shoulder Surgery.