Introduction
The overall success of reverse shoulder arthroplasty (RSA) in rotator cuff deficient patients has led to the expanded use of the constrained prosthesis to include numerous conditions regardless of the condition of the rotator cuff. The use of anatomic total shoulder arthroplasty (TSA) in the patient with combined glenohumeral osteoarthritis (GHOA) with an intact, functioning rotator cuff (RTC) is universally accepted. Due to concerns of secondary rotator cuff tears in the elderly, trends in the use of RSA for these patients are increasing, even though RSA carries unique considerations in terms of complications and postoperative function.
Summary
The authors of this single institution retrospective cohort study aimed to determine clinical outcomes, complications, and rate of revisions in patients 70 years or older with primary GHOA undergoing TSA.
Materials and Methods
A total of 340 patients (377 shoulders) of mean age of 76.2 years underwent TSA for primary GHOA. All were performed by one of two fellowship trained shoulder and elbow surgeons. All subjects were evaluated for preoperative and postoperative forward elevation, external and internal rotation, as well as postoperative VAS and ASES. Preoperative radiographs evaluated glenoid morphology and degree of humeral head subluxation. Postoperative radiographs were evaluated for the presence of humeral head subluxation, as well as dislocation, fracture, or component loosening. Postoperative complications and reoperations were recorded.
Results
Mean follow up was 3.3 years. Fifty-three percent of the subjects were females. Walch types A2, B2, or B3 accounted for 77.8% of the preop glenoid morphology and 39.2% of the shoulders had some degree of preoperative posterior humeral head subluxation. No shoulders demonstrated preop superior humeral head migration.
| Clinical Evaluation | |||
| Preop | Postop | ||
| VAS | 1.6 | ||
| ASES | 78 | ||
| FE | 96° | 160° | P < .001 |
| ER | 26° | 64° | P < .001 |
| ≥ L5 IR | 24.8% | 71.8% | P < .001 |
| Radiographic Evaluation | |||
| Initial Postop | Final Postop | ||
| Anterior Subluxation | 2.6% | 8.9% | P < .001 |
| Posterior Subluxation | 1.2% | 2.7% | P = .157 |
| Superior Subluxation | 2.0% | 7.8% | P < .001 |
| Humeral loosening | 0% | ||
| Glenoid loosening | 2% | ||
There was a total of 18 complications. Five (1.3%) were major surgical complications (requiring a change in management), including 3 dislocations, 1 deep infection, and 1 periprosthetic humeral shaft fracture. There was a total of 5 (1.3%) secondary rotator cuff tears, including 2 subscapularis failures, and 3 diagnosed with advanced imaging due to worsening clinical function. There were 3 (0.8%) revisions surgeries performed for anterosuperior escape (2) and posterior instability (1). All were converted to RSA.
Discussion
Overall, this study demonstrated excellent clinical and radiographic outcomes, as well as favorable 5-year implant survivorship (98.9%). Secondary rotator cuff tears and revision surgery was low. Of note, this study demonstrated progressive anterior and superior humeral head subluxation rates over the course of the study with higher revision surgery rates among patients over the age of 80 years.
Reviewer Comments
Despite the rotator cuff dysfunction findings of this study, I believe there is sufficient clinical data with acceptable complication and revision rates, to support the use of TSA in patients over the age of 70 with GHOA with an intact RTC.