Is it worth the risk? Clinical and radiographic outcomes 24 months after reverse shoulder arthroplasty in an advanced geriatric population

Optimizing post-surgical outcomes: unveiling the importance of patient-reported outcomes with insights from the schulthess local shoulder arthroplasty registry

OBJECTIVE

The establishment of clinical registries is essential for the comprehensive evaluation of surgical outcomes. In 2006, the Schulthess Shoulder Arthroplasty Registry (SAR) was launched to systematically assess safety, implant longevity, functional outcomes, pain levels, quality of life, and patient satisfaction in individuals undergoing shoulder arthroplasty. This paper aims to outline the registry data and demonstrate how it is leveraged to improve clinical outcomes. Additionally, we provide guidance for organizations currently collecting or planning to collect similar data.

PARTICIPANTS

Our SAR systematically records adult patients' data undergoing either anatomic or reverse shoulder joint replacement at the Schulthess Clinic. Both primary and revision surgeries are comprehensively documented within the registry.

CURRENT OUTCOMES

From March 2006 to December 2023, the SAR included 98% of eligible operations. A total of 2301 patients were recruited, accounting for 3576 operations and 14,487 person-years of follow-up. At baseline, the mean age was 71 (range: 20-95), with 65% being female patients. The most prevalent indication was cuff tear arthropathy (46%), and the mean preoperative Constant Score was (31 ± 15). Notably, functional recovery peaked at 12 months postoperatively, displaying no clinically significant deterioration during the initial ten follow-up years in the overall cohort (including both primary arthroplasty and revisions). The registry has been instrumental in addressing various clinical and methodological inquiries, focusing particularly on comparing different implant configurations and surgical techniques to optimize functional recovery. Additionally, SAR data played a pivotal role in substantiating the clinical significance and reliability of radiological monitoring for cortical bone resorption, scapular notching, and glenoid component loosening.

Total Shoulder Arthroplasty in Octogenarians and Nonagenarians: A Database Study of 33,089 Patients

BACKGROUND

The utilization of total shoulder arthroplasty (TSA) in an aging population continues to rise, but the perioperative risk profile of TSA in the very elderly is not well-described. The objective of this study was to quantify the risk profile of 30-day perioperative adverse events after TSA in octogenarians and nonagenarians using a large national database over a recent 10-year period.

METHODS

The National Surgical Quality Improvement Program database was queried for TSA from 2011 to 2020. Patients were stratified into three age groups: (1) age < 80 years, (2) 80 years ≤ age < 90 years ("octogenarians" in this study), and (3) age ≥ 90 years ("nonagenarians" in this study). The primary outcome was 30-day complication, and secondary outcome variables included 30-day readmission, revision surgery, and mortality. Multivariable logistic regression analyses adjusted for relevant comorbidities were done.

RESULTS

The cohort included 33,089 patients who underwent TSA, including 28,543 patients younger than 80 years, 4,334 octogenarians, and 212 nonagenarians. Complication rates were 4% in patients younger than 80 years, 8% in octogenarians, and 16% in nonagenarians. Readmission rates were 3% in patients younger than 80 years, 4% in octogenarians, and 7% in nonagenarians. Mortality rates were 0.1% in patients younger than 80 years, 0.4% in octogenarians, and 2% in nonagenarians. Revision surgery was not markedly different among age groups. In the adjusted multivariable logistic regression analysis, compared with patients younger than 80 years, octogenarians had 1.9-times higher odds of complications and 1.5-times higher odds of readmission, and nonagenarians had 7.1-times higher odds of complications and 2.2-times higher odds of readmission.

DISCUSSION

Our findings are germane to preoperative counseling in very elderly patients considering TSA, to balance potential improvements in quality of remaining life years against the risk of adverse events.

LEVEL OF EVIDENCE

Level IV Prognostic.

Defining patient satisfaction after reverse total shoulder arthroplasty: a systematic review

BACKGROUND

The prevalence of reverse total shoulder arthroplasty (rTSA) has grown rapidly. As indications for the procedure expand, the proportion of patients who have satisfactory outcomes after rTSA has not been well defined. This systematic literature review explores overall patient satisfaction after rTSA and defines patient satisfaction based on indication for surgery.

METHODS

A literature search was performed for studies describing patient satisfaction after rTSA in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Papers were included if they investigated patient satisfaction after rTSA at a minimum of 2-year follow-up. Data were collected on patient demographics, including age, gender, and body mass index. Follow-up duration, indication for surgery, and patient reported outcome measures relating to patient satisfaction were also recorded.

RESULTS

There were a total of 5234 patients and 5288 shoulders from the 45 included studies. The overall study population was 61.2% female and the average age was 71.1 years (range 23-99). Satisfaction results were recorded at final follow-up, with average follow-up of 49.1 months (range 24-228). Overall patient satisfaction ranged from 77.7% to 87.8%, depending on patient satisfaction patient reported outcome measures. When stratified by diagnosis, patients with a diagnosis of glenohumeral osteoarthritis (GHOA) rated better satisfaction on all metrics when compared to patients with a diagnosis of cuff tear arthropathy or massive rotator cuff tear.

CONCLUSION

This systematic review demonstrated that patients who undergo rTSA for either GHOA, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. Focusing on patient satisfaction may provide the best overall assessment of health care quality in a very understandable and tangible form. Overall satisfaction rate is valuable information for patient education and can be utilized as part of effective surgical counseling.

Outcome of reverse shoulder arthroplasty secondary to rotator cuff arthropathy in a low-income population

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a valuable treatment for rotator cuff arthropathy (RCA) in developed regions. Socioeconomic issues impact access to specialized care and there is a lack of data on RSA outcomes in developing regions. We present our 24-month follow-up on RSA surgeries to treat RCA in our low-income population.

METHODS

Prospective evaluation of 26 patients subjected to RSA at Hospital Geral de Fortaleza-CE, Brazil, between January 2018 and December 2020. Literacy [>/≤ 8 school years(SY)] and income were documented. Outcomes considered pain (visual analogue scale; VAS) as well as SSV, SPADI, ASES, and UCLA scoring, and range of motion [forward flexion (FF); external rotation (ER)].

RESULTS

Patients were 68.5 ± 7.6 years-old with 16(61.5%) females; 65% had hypertension and 7 (26.9%) had diabetes. Over 90% declared < 900.00 US$ monthly family earnings and 10 (38.4%) patients declared ≤8 SY with > 80% exerting blue-collar jobs. Pain showed a significant reduction from baseline (8 ± 2) to 24 months (2.1 ± 2.3; p < 0.001). UCLA (10.3 ± 5.6 and 28.6 ± 7.2), ASES (16.7 ± 10.8 and 63.1 ± 28.4), SSV (326 ± 311 and 760 ± 234), and SPADI (98.3 ± 26.5) scores significantly improved from baseline to 24 months, achieving minimal clinically important difference. FF (89.2° ± 51.2° to 140.6 ± 38.3°) and ER (19.2° ± 22.5 to 33.4° ± 20.6°) significantly improved from baseline to 24 months (p = 0.004 and 0.027, respectively). There were 5 non-serious adverse events with one surgical revision. All patients returned to daily life activities.

CONCLUSION

This is the first outcome report 2 years following RSA in a low-income population. Data indicate this procedure is justifiable regardless of socioeconomic issues.

Reverse Shoulder Arthroplasty in Nonagenarians - NIS-based study of perioperative and postoperative complications

Purpose

Our aim is to investigate the length of stay (LOS), cost of care (COC) and postoperative complications associated with reverse shoulder arthroplasty (RSA) in nonagenarians (people aged 90-99 years old).

Methods

We used the National Inpatient Sample (NIS) database to identify 59,925 patients who underwent RSA between 2016 and 2019, including 555 nonagenarians. We investigated the incidences of various medical and orthopedic postoperative complications in nonagenarians compared to their younger counterparts, as well as compared nonagenarians undergoing elective and non-elective surgery.

Results

Nonagenarians were less likely admitted for elective surgery (69.9% in nonagenarians vs 92.8% in controls, p < 0.001) and were subject to longer LOS (3.5 days in nonagenarians vs 1.89 days in controls, p < 0.001) and greater COC ($91,794.69 US in nonagenarians vs $79,574.12 US in controls, p < 0.001). Nonagenarians had increased incidences of hospital mortality (0.72% in nonagenarians vs 0.06% in controls, p < 0.001), pneumonia (1.44% in nonagenarians vs 0.37% in controls, p < 0.001), blood loss anemia (22.34% in nonagenarians vs 10.12% in controls, p < 0.001), and ARF (6.85% in nonagenarians vs 2.18% in controls, p < 0.001). Nonagenarians undergoing elective RSA had fewer complications than those requiring non-elective RSA.

Conclusion

Nonagenarians undergoing RSA are subject to increased LOS, COC, and postoperative complications. Despite this, we feel that the associated complications can be deemed acceptable and that with adequate preparation, the benefits of a successful RSA may outweigh the associated complications in elderly patients. This is important to aid clinicians and patients in making informed decisions for patient care and resource allocation, as well as highlights room for improvement in costs and hospital stay, as well as sheds light on persistent health disparities in orthopedic surgery.

Level of evidence

IV.

Outcomes of anatomic and reverse total shoulder arthroplasty in patients over the age of 70: a systematic review

Background

Both anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) reliably improve pain and function for a variety of indications. However, there remain concerns about these procedures among elderly patients due to their general health, the potential for lesser functional gain, and the possible need for revision at an even older age. The purpose of this review is to compare the clinical outcomes, radiographic outcomes, and complications of ATSA and RTSA among patients older than 70 years.

Methods

A systematic review was performed using searches of PubMed, Embase, and Cochrane databases. The inclusion criteria were studies with patients older than 70 years who were treated with a primary ATSA or RTSA and clinical results reported at a minimum of 2 years. All indications for primary RTSA except for tumor were included. Outcomes of interest included patient-reported outcomes (PROs), range of motion, patient satisfaction, radiographic changes, complication and revision rates, and implant survival.

Results

A total of 24 studies met the inclusion criteria. At a mean follow-up of 3.4 years for ATSA and 3.1 years for RTSA, there were significant improvements in pain, range of motion, and PROs for both prostheses. Patients who underwent ATSA generally had better motion and functional outcomes compared to those who underwent RTSA, though these comparisons were made across different indications for arthroplasty. The satisfaction rate was 90.9% after ATSA and 90.8% after RTSA. Furthermore, 10.2% of ATSA patients and 9.9% of RTSA patients experienced a surgical complication, whereas 2.3% of ATSA and 2.2% of RTSA patients underwent a revision. Secondary rotator cuff tear was the most common complication after ATSA, occurring in 3.7% of patients, but only 1.1% of patients required revision surgery. Both ATSA and RTSA implant survivorship was reported to range from 93.1% to 98.9% at 5- and 8-year follow-up, respectively. Patient mortality was estimated to be 19.3% with a mean time to death of 6.1 years.

Conclusions

Elderly patients with primary osteoarthritis and an intact rotator cuff can have predictable pain relief, restoration of functional range of motion, and significant improvement in PROs after ATSA with low complication rates. Secondary rotator cuff failure and revision arthroplasty occur infrequently at early to mid-term follow-up. Although elderly patients who underwent ATSA generally had better functional outcomes compared to those who underwent RTSA for differing indications, patient satisfaction after both procedures were similar.