Reverse total shoulder arthroplasty in the younger patient (≤65 years): a systematic review

Low complication rate following reverse total shoulder arthroplasty at 90-days follow-up - A systematic review

IMPORTANCE

As reverse total shoulder arthroplasty (RTSA) has become an increasingly common procedure, rates of post-operative complications leading to potential hospital readmission are of greater importance. No previous systematic reviews have focused exclusively on post-operative complications and mortality rates at 90 days post RTSA.

OBJECTIVES

The purpose of this study was to review complication, readmission, and mortality rates within 90 days post RTSA.

EVIDENCE REVIEW

Two independent reviewers performed a literature search using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science databases. Only studies reporting on outcomes of RTSA at 90-days follow-up specifically were considered for inclusion.

FINDINGS

Our search included 79,037 shoulders (62.1 ​% female) from a total of 15 studies with an average age of 72.4 ​± ​5.8 years. The overall 90-day re-admission rates were reported in nine studies as 6.1 ​% (4205/69,127) following RTSA. Additionally, a total of five studies reported the overall 90-day mortality rate as 1.1 ​% (19/1733). The overall pooled rate of medical complications was 3.9 ​% (2998/77,826) as reported in 13 studies, at 90-days post-RTSA, with the occurrence of anaemia being the most commonly reported outcomes as 2.9 ​% (1013/34,385) in six studies. The overall rate of surgical complications was 1.1 ​% reported in 13 studies (1327/77,826), with the pooled rate of surgical revisions of 1.5 ​% (607/40,563) at 90-days follow-up. A total of 8, 5, and 3 studies reported rates of dislocation, requirement for closed reduction and glenoid loosening as 0.9 ​% (344/37,995), 0.6 ​% (7/1180), and 0.3 ​% (30/9115) respectively at 90-days following RTSA.

CONCLUSIONS AND RELEVANCE

This study established that the overall rates of mortality and medical and surgical complications are low in the short-term following RTSA, with only 6 ​% of patients requiring re-admission in the first 90 days.

LEVEL OF EVIDENCE

IV - Systematic Review of all levels of evidence.

Mid- to long-term outcomes of latissimus dorsi tendon transfer for massive irreparable posterosuperior rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

This study aims to analyze the mid-to long-term results of the latissimus dorsi tendon for the treatment of massive posterosuperior irreparable rotator cuff tears as reported in high-quality publications and to determine its efficacy and safety.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and EMBASE databases were searched until December 2022 to identify studies with a minimum 4 year follow-up. Clinical and radiographic outcomes, complications, and revision surgery data were collected. The publications included were analyzed quantitatively using the DerSimonian Laird random-effects model to estimate the change in outcomes from the preoperative to the postoperative condition. The proportion of complications and revisions were pooled using the Freeman-Tukey double arcsine transformation.

RESULTS

Of the 618 publications identified through database search, 11 articles were considered eligible. A total of 421 patients (432 shoulders) were included in this analysis. Their mean age was 59.5 ± 4 years. Of these, 277 patients had mid-term follow-up (4-9 years), and 144 had long-term follow-up (more than 9 years). Postoperative improvements were considered significant for the following outcome parameters: Constant-Murley Score (0-100 scale), with a mean difference (MD) = 28 points (95% confidence interval [CI] 21, 36; I2 = 89%; P < .001); visual analog scale, with a standardized MD = 2.5 (95% CI 1.7, 3.3; P < .001; I2 = 89%; P < .001); forward flexion, with a MD = 43° (95% CI 21°, 65°; I2 = 95% P < .001); abduction, with a MD = 38° (95% CI 20°, 56°; I2 = 85%; P < .01), and external rotation, with a MD = 8° (95% CI 1°, 16°; I2 = 87%; P = .005). The overall reported mean complication rate was 13% (95% CI 9%, 19%; I2 = 0%), while the reported mean revision rate was 6% (95% CI: 3%, 9%; I2 = 0%).

CONCLUSIONS

Our pooled estimated results seem to indicate that latissimus dorsi tendon transfer significantly improves patient-reported outcomes, pain relief, range of motion, and strength, with modest rates of complications and revision surgery at mid-to long-term follow-up. In well-selected patients, latissimus dorsi tendon transfer may provide favorable outcomes for irreparable posterosuperior cuff tears.

Trends in the treatment of proximal humerus fractures from 2010 to 2020

BACKGROUND

The incidence of proximal humerus fractures (PHF) is continuing to rise due to shifts towards a more aged population as well as advancements in surgical treatment options. The purpose of this study is to examine and compare trends in the treatment of PHFs (nonoperative vs. operative; different surgical treatments) across different age groups over the last decade (2010-2020).

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried using International Classification of Diseases and Current Procedural Terminology codes to identify all patients presenting with or undergoing surgery for PHF between 2010 and 2020. Treatment trends, demographics, and insurance information were analyzed during the study period. Comparisons were made between operative and nonoperative trends with respect to the number and type of surgeries performed among 3 age groups: ≤49 years, 50-64 years, and ≥65 years. The rate of postoperative complications and reoperations was evaluated and compared among different surgical treatments for patients with a minimum 1-year postoperative follow-up.

RESULTS

A total of 92,308 patients with a mean age of 67.8 ± 16.8 years were included. Over the last decade, there was no significant increase in the percentage of PHFs treated with surgery. A total of 15,523 PHFs (16.82%) were treated operatively, and these patients, compared with the nonoperative cohort, were younger (64.9 years vs. 68.4 years, P < .001), more likely to be White (80.2% vs. 74.7%, P < .001), and more likely to have private insurance (41.4% vs. 32.0%, P < .001). For patients ≤49 years old, trends in operative treatment have remained stable with internal fixation (IF) as the most used surgical modality. For patients 50-64 years old, we observed a gradual decline in the use of hemiarthroplasty (HA), with a corresponding increase in the use of reverse total shoulder arthroplasty (rTSA), but IF continued to be the most used operative modality. In patients over 65 years, a steep decline in the use of IF and HA was noted during the first half of the decade along with a significant exponential increase in the use of rTSA, which surpassed the use of IF in 2019. Despite the increase in the use of rTSA, no differences in rate of surgical complications were noted between rTSA and IF (χ2 = 0.245, P = .621) or reoperations (χ2 = 0.112, P = .730).

CONCLUSION

Nonsurgical treatment remains the mainstay treatment of PHFs. Although there is no increase in the prevalence of operative treatment in patients ≥50 years in the last decade, there is an exponential increase in the use of rTSA with a corresponding decrease in HA and IF, a trend more substantial in patients ≥65 years compared with patients between 50 and 64 years.

Improved functional, radiographic and patient-reported outcomes at midterm follow-up for shoulder arthroplasty patients 75 years and older

Background

Current discussion centers around the appropriateness of shoulder arthroplasty in elderly patients, and whether anatomic and reverse total shoulder arthroplasty yield acceptable results in this population. The purpose of this study was to examine midterm outcomes in patients 75 years and older who underwent either procedure.

Methods

A retrospective review was performed on patients who underwent anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) between 2000 and 2018. Inclusion criteria was patient age ≥75 years at time of surgery and ≥1 years postoperative follow-up. Primary outcomes were differences in Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, and range of motion. A secondary outcome was revision surgery.

Results

22 patients who underwent aTSA and 17 patients who underwent rTSA were included. Mean age at surgery was 79 and 80 in the aTSA and rTSA groups, respectively. Mean postoperative follow-up was 6.6 years across both cohorts. Anatomic TSA patients experienced improvements in VAS (7 preop vs. 1 postop; p < 0.001), ASES (16 vs. 75; p < 0.001), and SST (2 vs. 8; p < 0.001) scores. Reverse TSA patients also experienced improvements in VAS (7 vs. 1; p < 0.001), ASES (29 vs. 74; p < 0.001), and SST (1 vs. 7; p < 0.001) scores. Anatomic TSA patients experienced improved external rotation (17° vs. 53°; p < 0.001), forward elevation (108° vs. 155°; p < 0.001), and internal rotation (L5 vs. T10; p < 0.001). Reverse TSA patients experienced improved forward elevation (52° vs. 126°; p < 0.001). 21 aTSA patients (100%) and 16 rTSA patients (94%) experienced survival free from revision. 100% of aTSA and rTSA patients experienced survival free from loosening.

Conclusion

Both aTSA and rTSA can be performed in the elderly population with acceptable midterm outcomes, suggesting that implant survival and patient satisfaction have the potential to endure through the end of life.

Level of evidence

IV.

Outcomes of reverse shoulder arthroplasty in patients under 55 years old: Results from the New Zealand joint registry

Background

The appropriate age at which to perform reverse shoulder arthroplasty is controversial. The aim of this study was to compare the outcomes of reverse shoulder arthroplasty between younger and older patients.

Methods

Patients who underwent primary reverse shoulder arthroplasty between January 2000 and December 2019 were identified from New Zealand Joint Registry records. Patients were stratified into two cohorts according to age at the time of surgery: < 55 years and ≥ 55 years. These two groups were then compared with regard to baseline characteristics, indications for surgery, revision rates, and patient-reported outcomes using the Oxford Shoulder Score and American Shoulder and Elbow Score (ASES).

Results

A total of 5518 primary reverse shoulder arthroplasty cases were identified, with 75 patients < 55 years at the time of surgery (range: 34-54 years). The mean duration of follow-up was 2.36 years (range: 0.11-13.37 years) in the younger cohort and 3.10 years (range: 0.01-16.22 years) in the older patient cohort. Indications for surgery differed significantly between the two groups, with younger patients having higher rates of inflammatory arthritis (p < 0.001), posttraumatic arthritis (p < 0.001), and avascular necrosis (p = 0.049). The younger cohort had an inferior 6-month postoperative Oxford Shoulder Score compared to the older cohort (mean: 28.5 [younger cohort] vs. 35.7 [older cohort]; p < 0.001). There was no significant difference in revision rate between the younger and older patient cohorts during the study period (1.56 [<55 years] vs. 0.74 [≥55 years] revisions per 100 component-years; p = 0.332).

Conclusion

Our early results suggest that younger patients undergoing reverse shoulder arthroplasty demonstrate high implant retention rates, comparable to older patients. Longer-term patient-reported outcomes in younger patients are required to guide appropriate patient selection for reverse shoulder arthroplasty.

Level of evidence

Level III, retrospective case-control study.

The lifetime revision risk of primary anatomic and reverse total shoulder arthroplasty

BACKGROUND

Implant survival in total shoulder arthroplasty (TSA) is currently defined with reference to a set time period (eg, 5-year implant survival). This is a difficult concept for patients to understand, especially for younger patients who have more years of life remaining. Our study aims to calculate a patient's lifetime revision risk after primary anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty-a more meaningful projection of revision risk over a patient's remaining lifetime.

METHODS

The New Zealand Joint Registry (NZJR) and national death data was used to calculate the incidence of revision and mortality in all patients who underwent primary aTSA and rTSA in New Zealand between 1999 and 2021. Lifetime revision risk was calculated using previously described methods, and this risk was stratified by age (46-90 years, 5-year bins), sex, and procedure type (aTSA and rTSA).

RESULTS

In total, there were 4346 patients in the aTSA cohort and 7384 patients in the rTSA cohort. Lifetime revision risk was highest in the youngest age group (46-50 years) at 35.8% (95% CI 34.5%-37.0%) for aTSA and 30.9% (95% CI 29.9%-32.0%) for rTSA, with risk decreasing with increasing age. Across all age groups, the lifetime revision risk was higher for aTSA compared to rTSA. By sex, females reported higher lifetime revision risk for each age group in the aTSA cohort whereas males reported higher lifetime revision risk for each group in the rTSA cohort.

CONCLUSIONS

Our study demonstrates that younger patients have higher lifetime revision risk after total shoulder arthroplasty. Our results highlight the long-term revision risks associated with the trend of offering shoulder arthroplasty to younger patients. The data may be used among various health care stakeholders to inform the surgical decision-making process and plan for future health care resource use.

Reverse Shoulder Arthroplasty Patients Younger Than 60 Years Old Exhibit Lower Clinically Significant Single Assessment Numeric Evaluation (SANE) Scores Compared to Older Patients

INTRODUCTION

The incidence of reverse shoulder arthroplasty (RTSA) in the United States has increased. Patients under 60 years old with failed rotator cuff repairs or degenerative joint disease with glenoid deformity may be candidates for RTSA and contribute to this increase. The single assessment numeric evaluation (SANE) score is a reliable post-operative scoring technique when compared with other post-operative measures. This study aimed to compare the effect of age on the likelihood of reaching clinically significant SANE scores following RTSA.

METHODS

A multicenter retrospective review was performed with a consecutive series of RTSA from December 2015 to September 2021. Patients were stratified into groups based on their age at the time of operation: (1) less than 60 years old, (2) 60-69 years old, (3) 70-79 years old, and (3) greater than 80 years old. The proportions of patients in all cohorts reaching and surpassing clinically significant thresholds at each visit were determined. Likelihood ratios were determined for each age cohort to compare the likelihood of reaching clinically significant SANE scores.

RESULTS

A total of 292 of 885 (33%) patients had completed survey data over two years and were included in the study. The 70-79-year-old group was 3.152 (p=.035) times more likely to achieve minimal clinically important difference (MCID) and 2.125 (p=.048) times more likely to achieve patient-acceptable symptomatic state (PASS) compared with patients <60 years old. The cohort who was 80+ years old was also 4.867 (p=.045) times more likely to achieve MCID compared to the <60-year-old cohort. The <60 cohort had the lowest proportion of all patient cohorts achieving MCID.

CONCLUSION

A lower proportion of patients younger than 60 years old undergoing RTSA achieved clinically significant post-operative SANE scores. The 70-79-year-old age group was more likely to reach MCID and PASS, and the patients who were 80+ years old were more likely to reach MCID compared to patients younger than 60 years old.

Long-Term Results of Primary Reverse Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears Without Glenohumeral Arthritis with a Mean Follow up of 9.4 Years

Background

The aim of this single-center study was to analyze the long-term clinical results of reverse shoulder arthroplasty in patients with massive, irreparable rotator cuff tears without glenohumeral arthritis.

Methods

A retrospective cohort study of 105 patients (115 shoulders) was conducted. The mean age of the patient group was 76 years (range, 65 to 87 years). The mean clinical follow-up was 9.4 years (range, 5 to 17 years). Pain, range of motion, and complication rates were analyzed pre-operatively and at the last follow-up.

Results

The mean Constant-Murley score increased from 29 points (range, 21 to 34 points) preoperatively to 68.1 points (range, 57 to 81 points) postoperatively (p<0.05). Scapular notching was present in 50 shoulders (43.5%) and it was grade 1 or 2 in 47 of 115 cases (40.9%) and grade 3 or 4 in 3 of 115 cases (2.6%). Complications occurred in 19 patients (17%). Seven patients (6%) underwent revision surgery. The mean satisfaction rate was 94%.

Conclusions

Reverse shoulder arthroplasty is a viable treatment for massive, irreparable rotator cuff tears without glenohumeral arthritis with satisfactory clinical outcomes and low complication and reoperation rates with a mean follow up of 9.4 years after surgery.

Reverse Total Shoulder Arthroplasty for Younger Patients: A Comparable Analysis of Patients Older and Younger Than 65 Years

INTRODUCTION

Reverse total shoulder arthroplasty (rTSA) has become a popular option for the surgical management of rotator cuff arthropathy and complex fractures of the proximal humerus. However, there is a paucity of studies evaluating outcomes, especially between patients of different age groups. The purpose of this study was to compare functional outcomes and survivorship between patients older than 65 years (o65) and those 65 years and younger (y65).

METHODS

A retrospective review was conducted at a single academic medical center identifying a consecutive cohort of patients undergoing rTSA between 2018 and 2020. The minimum follow-up time was 2 years. Patients were stratified into two groups for comparative analyses (y65 and o65). Patient demographics, perioperative and postoperative data, and functional outcomes were collected. A Kaplan-Meier survival analysis was conducted to determine survivorship, defined as revision surgery or implant failure.

RESULTS

Forty-eight patients were included for final analysis. Nineteen patients comprised the y65 group while 29 patients comprised the o65 group. No difference was observed in Quick Disabilities of the Arm, Shoulder, and Hand scores at baseline nor at the latest follow-up between the two groups. Patients in the y65 group had significantly greater internal and external rotation (IR/ER) from 3 months to 2 years compared with patients in the o65 group (P ≤ 0.05). Finally, there were no differences in revision surgery rates between the y65 group and the o65 group (11% vs. 14%, P = 1.0). A KM survival analysis revealed no difference in implant failure, necessitating revision surgery between the two groups at the latest follow-up (P = 0.69).

DISCUSSION

Despite a notable difference in the number of baseline comorbidities, there were no notable differences in functional outcomes, survivorship, and revision surgery rates between each cohort. Although both groups had a similar function initially, by 3 months postoperatively, the y65 group had markedly greater range of motion in IR and ER. Longer term survivorship is needed; however, rTSA may offer a reliable option for shoulder reconstruction even in the y65 patient group.

Results after primary reverse shoulder arthroplasty with and without subscapularis repair: a prospective-randomized trial

INTRODUCTION

Indications for reverse shoulder arthroplasties (rTSA) have increased since their development by Paul Grammont in 1985. Prosthesis design was enhanced over time, but the management of the tendon of the M. subscapularis (SSC-tendon) in primary rTSA is still a controversial subject with regard to perform a refixation or not.

METHODS

50 patients were randomized in a refixation group (A) and a non-refixation-group (B) of the SSC-tendon in a double-blinded fashion. SSC-function was assessed at baseline before surgery, such as 3 and 12 months after surgery. Constant-Murley-Shoulder Score (CS), American Shoulder and Elbow Surgeons Score (ASES), strength, range of motion (ROM), and pain on numeric rating scale (NRS) were measured in all examinations. An ultrasound examination of the shoulder was performed for evaluation of subscapularis tendon integrity at 3 and 12 month follow-up visits. Pain was evaluated on NRS via phone 5 days after surgery. Surgery was performed by a single experienced senior surgeon in all patients.

RESULTS

Patients with a refixation of the SSC-tendon and primary rTSA had improved internal rotation [40° (20°-60°) vs. 32° (20°-45°); p = 0.03] at 12 months of follow-up. Additionally, the A-group had increased CS [74 (13-90) vs. 69.5 (40-79); p = 0.029] 1 year after surgery. Results were strengthened by subgroup analysis of successful refixation in ultrasound examination vs. no refixation. No differences were seen in ASES and NRS 1 year after rTSA.

CONCLUSION

SSC-tendon repair in rTSA improves CS and internal rotation 12 months after surgery.

Does reverse total shoulder arthroplasty with allograft-prosthesis composite (APC) have surgical benefits over hemiarthroplasty with APC in patients with tumors of the proximal humerus?

Background

The research on surgical outcomes of hemiarthroplasty and reverse total shoulder arthroplasty using allograft-prosthesis composites for the proximal humeral oncologic condition is still scarce. Therefore, this study aimed to compare surgical outcomes of shoulder joint reconstruction with hemiarthroplasty and reverse total shoulder arthroplasty using allograft-prosthesis composites for tumors of the proximal humerus.

Methods

Eleven patients underwent hemiarthroplasty or reverse total shoulder arthroplasty using allograft-prosthesis composites for tumors of the proximal humerus between July 2011 and April 2018 were reviewed. Radiographic analysis for bone union of allograft-host bone junction, implant loosening, stress shielding and shoulder dislocation or subluxation was performed. Functional outcomes were evaluated using visual analog scales for pain, range of motion, Simple Shoulder Test score and Musculoskeletal Tumor Society score. Furthermore, oncologic outcome and complications were also assessed, respectively.

Results

There were five patients with hemiarthroplasty (mean age, 23.2 years) and six patients with reverse total shoulder arthroplasty (mean age, 46.8 years, P = 0.05). Radiographically, there were no events associated with implant loosening, stress shielding and shoulder dislocation or subluxation in the two groups. There were no differences in functional outcomes between the two groups. There was no local recurrence in entire cohort. In the hemiarthroplasty group, one patient was required revision surgery to reverse total shoulder arthroplasty at postoperative 6 years due to rotator cuff dysfunction. In the reverse total shoulder arthroplasty group, one patient showed the fracture occurred at allograft-host bone junction at postoperative 6 months.

Conclusions

Surgical outcomes of hemiarthroplasty with allograft-prosthesis composites were not inferior to reverse total shoulder arthroplasty when applied in properly selected patients. The authors recommended that hemiarthroplasty with allograft-prosthesis composites could be used for young age patients without glenoid metastasis involvement, and reverse total shoulder arthroplasty with allograft-prosthesis composites could be used for patients with old age or metastatic bone tumors.

Midterm results of pyrocarbon interposition shoulder arthroplasty: good outcomes after posttraumatic osteonecrosis without malunion of the tuberosities

Background

In vitro data demonstrate the potential benefits of the pyrocarbon as a bearing material against cartilage or bone. And pyrocarbon-free interposition arthroplasty has been used with positive outcomes for over 10 years for hand and wrist joint replacements. This study reports the midterm results of a Pyrocarbon Interposition Shoulder Arthroplasty (PISA) in primary and secondary glenohumeral osteoarthritis and in avascular osteonecrosis.

Methods

This prospective noncontrolled, multicenter study included 67 consecutive patients who underwent PISA in France and Sweden.

Results

A cohort of 48 patients, aged 50 ± 12 years, was available for clinical assessment at a mean follow-up of 67.6 ± 9.3 months. A favorable change was reported with a mean absolute Constant score improvement of 32 ± 20 points. The highest Constant score improvement was observed in patients with avascular osteonecrosis (42 ± 18 points; P ≤ .0001). Between the earliest and the latest follow-up, radiographic analyses revealed only 2 major glenoid erosions and 4 tuberosity thinnings and thus that 86.4% of 44 shoulders remained stable with no or minor radiologic evolutions. The survival rate was 84 % at 65 months of follow-up considering all causes of revision.

Conclusion

The radiographic findings seem to confirm the interest of pyrocarbon in preserving bony surfaces. But the risk of tuberosity thinning suggests considering the use of PISA with caution in most degenerative glenohumeral joint pathologies, although the midterm outcomes highlight PISA as a suitable solution for patients presenting with posttraumatic osteonecrosis without malunion of the tuberosities and with an intact rotator cuff.

Patient-specific instrumentation improves the reproducibility of preoperative planning for the positioning of baseplate components with reverse total shoulder arthroplasty: a comparative clinical study in 39 patients

BACKGROUND

The application of patient-specific instrumentation (PSI) for reverse total shoulder replacement has been rapidly increasing, which could reduce errors in implant positioning. Although PSI theoretically holds promise, evidence of the accuracy and reliability of PSI in shoulder replacement surgery is limited.

METHODS

Thirty-nine shoulders that underwent reverse total shoulder arthroplasty were included in this study and categorized into two groups: the conventional (n = 20) and PSI (n = 19) groups. Screw (length and angle) and baseplate (version, inclination, translation, and rotation) positioning were calculated based on postoperative computed tomography images using a three-dimensional measurement tool. The difference between the values of the preoperative target and postoperative measurement was calculated to evaluate the reproducibility of preoperative planning. Screw involvement in the suprascapular and spinoglenoid notches was assessed. Thus, the correlation between the position of the baseplate and the screws was assessed.

RESULTS

The mean differences between the planned length and angle (anteroposterior and superoinferior angles) and postoperative measurement in the PSI group were significantly smaller than those in the conventional group. Similarly, the mean difference in baseplate rotation between the planned and postoperative measurements in the PSI group was significantly lower than that in the conventional group (4.5° vs 10.6°; P < .001). The spinoglenoid notch was involved in 10 cases in the conventional group and 2 cases in the PSI group, and this difference was significant (P = .014). Overall, the mean difference between the preoperative and postoperative version, inferior inclination, and rotation values for the baseplate position was significantly correlated with the values for screw position (length and angle).

CONCLUSIONS

PSI improves the reproducibility of preoperative planning for baseplate and screw positioning and reduces the risk of neurovascular injury in reverse total shoulder arthroplasty.

Revision Reverse Total Shoulder Arthroplasty in Patients 65 Years Old and Younger: Outcome Comparison to Older Patients

Background

Reverse total shoulder arthroplasty (RTSA) is a procedure growing in prevalence among younger populations. Consequently, its use in revision arthroplasty is growing in this demographic. However, studies examining the functional outcomes of revision RTSA in younger populations compared with older populations are lacking. The primary purpose of this study is to evaluate the functional outcomes of revision RTSA in patients 65 years old and younger compared with older patients who underwent revision RTSA. We hypothesized that younger patients would have similar outcomes to older patients and both groups would demonstrate improvement in outcomes.

Methods

A retrospective review was conducted on a prospectively collected research database at a single tertiary referral center of all patients who underwent RTSA between 2007 and 2018. Patients 65 years old or younger who underwent a revision RTSA and had minimum 2-year follow-up were evaluated. A control group of patients ≥70 years old who underwent revision RTSA were also evaluated. Demographics, surgical factors, active range of motion (ROM), and patient-reported outcomes (PROMs) were compared. The ROM parameters measured were forward elevation, abduction, external rotation, and level of internal rotation. The PROMs collected included American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, University of California–Los Angeles score, Constant score, normalized Constant, and Shoulder Pain and Disability Index 130. The differences in outcomes were compared against the minimal clinically important difference and substantial clinical benefit reported for primary reverse shoulder arthroplasty.

Results

A total of 81 patients undergoing revision RTSA were evaluated at a mean follow-up of 4.5 years with 42 patients in the study group and 39 patients in the control group. Both groups demonstrated similar demographics and rates of prior surgeries. Preoperative outcome scores were lower in the study group (≤65 years old) than those in the older control group with American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and Shoulder Pain and Disability Index 130 remaining worse postoperatively. Both groups experienced statistically significant improvements in ROM from before operation to after operation, with slightly higher improvements in overhead motion in the younger cohort. Both the study group and the control group demonstrated statistically significant improvements in all PROMs with improvement above the substantial clinical benefit for the Constant and Simple Shoulder Test scores. Despite lower functional outcomes reported in the study group postoperatively, the improvement from before operation to after operation in all PROMs was similar between groups.

Conclusion

Revision RTSA is a viable option for patients ≤65 years old with a poorly functioning shoulder arthroplasty. ROM and outcome improvements are similar compared with older patients undergoing revision RTSA, but the preoperative and postoperative functional outcomes are worse in the younger patients.

Clinically relevant results of reverse total shoulder arthroplasty for patients younger than 65 years compared to the older patients

Background

Reverse total shoulder arthroplasty was originally designed for older patients with rotator cuff arthropathy and produces good results. The main objective of this retrospective study was to compare the patients younger than 65 years vs. the older patients in terms of the complications of reverse total shoulder arthroplasty and the functional recovery.

Methods

From January 2014 to January 2020, 566 patients who underwent the reverse total shoulder arthroplasty were divided into two groups (group A, ≥ 65 years, n = 506; group B, < 65 years, n = 60). The patients reported the quality of life using the patient-reported Western Ontario Osteoarthritis of the Shoulder index. The Constant score was obtained preoperatively and 3 months postoperatively. The complications and reoperations were compared. Statistical significance was set at P < 0.05.

Results

Clinically relevant improvements were found in group A and B. There was a multivariate statistically-significant but not clinically relevant difference in the change over time between group A and B. The mean 12-month Western Ontario Osteoarthritis of the Shoulder indexes were 58 in group B and 71 in group A. The mean Constant scores were 44 in group B vs. 43 in group A. Compared to group A, group B had a non-significant odds ratio of 1.9, which did not reach the clinically relevant Western Ontario Osteoarthritis of the Shoulder index of group A.

Conclusion

In patients younger than 65 years of age, RTSA seems to be a safe procedure in short term follow-up. After 1 year, we found no increased risk of complications, revision, or inferior outcomes compared to patients older than 65 years of age. Consequently, after one-year, RTSA provided clinically relevant improvements in the patients’ quality of life and shoulder strength regardless of age.

Anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis is associated with excellent outcomes and low revision rates in the elderly

BACKGROUND

The relative indications of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) continue to evolve. Some surgeons favor RSA over TSA for elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff due to fear of a postoperative (secondary) rotator cuff tear in this age group. However, RSA is associated with unique complications and a worse functional arc of motion compared with TSA. Therefore, it is important to understand the clinical outcomes and rates of revision surgery and secondary rotator cuff tears in elderly patients undergoing TSA.

METHODS

Between January 1, 2010, and December 31, 2017, 377 consecutive TSAs were performed for primary GHOA in 340 patients 70 years of age or older. The mean age at surgery was 76.2 years (standard deviation [SD], 4.9). Clinical evaluation included pain, motion, and American Shoulder and Elbow Surgeons score. Radiographs were reviewed for preoperative morphology and postoperative complications. All complications and reoperations were recorded. The average clinical follow-up time was 3.3 years (SD, 2.0). Statistical analyses were performed, and Kaplan-Meier implant survival estimates were calculated. For all analyses, a P value <.05 was considered statistically significant.

RESULTS

The mean pain visual analog scale and American Shoulder and Elbow Surgeons score at the final follow-up were 1.6 (SD, 2.2) and 78.0 (SD, 17.8), respectively. Forward elevation and external rotation increased from 96° (SD, 30°) and 26° (SD, 20°) preoperatively to 160° (SD, 32°) and 64° (SD, 26°) postoperatively (P < .001 for each). The percentage of patients who had internal rotation to L5 or greater increased from 24.8% preoperatively to 71.8% postoperatively (P < .001). Revision surgery was performed in 3 shoulders (0.8%), and the 5-year implant survival estimate was 98.9% (95% confidence interval: 97.3%-100%). There were 3 medical (0.8%), 10 minor surgical (2.7%), and 5 major surgical (1.3%) complications. No shoulder had radiographic evidence of humeral component loosening, whereas 7 (2%) had evidence of some degree of glenoid component loosening. In total, there were 5 secondary rotator cuff tears (1.3%), of which 2 (0.5%) required revision surgery.

CONCLUSION

Elderly patients with primary GHOA and an intact rotator cuff have excellent clinical and radiographic outcomes after anatomic TSA, with high implant survival rates and a low incidence of secondary rotator cuff tears in the first 5 postoperative years. Age greater than 70 by itself should not be considered an indication for RSA over TSA.

Glenoid bony morphology of osteoarthritis prior to shoulder arthroplasty: what the surgeon wants to know and why

Shoulder arthroplasty is performed with increasing frequency, and osteoarthritis is the most common indication for this procedure. However, the glenoid side of the joint is widely recognized as a limiting factor in the long-term durability of shoulder replacement, and osteoarthritis leads to characteristic bony changes at the glenoid which can exacerbate this challenge by reducing the already limited glenoid bone stock, by altering biomechanics, and by interfering with operative exposure. This article reviews the Walch classification system for glenoid morphology. Several typical findings of osteoarthritis at the glenoid are discussed including central bone loss, posterior bone loss, retroversion, biconcavity, inclination, osteophyte formation, subchondral bone quality, and bone density. The three primary types of shoulder arthroplasty are reviewed, along with several techniques for addressing glenoid deformity, including eccentric reaming, bone grafting, and the use of augmented glenoid components. Ultimately, a primary objective at shoulder arthroplasty is to correct glenoid deformity while preserving bone stock, which depends critically on characterizing the glenoid at pre-operative imaging. Understanding the surgical techniques and the implications of glenoid morphology on surgical decision-making enables the radiologist to provide the morphologic information needed by the surgeon.