The authors of this single institution retrospective cohort study aimed to assess the mid-term outcomes following RTSA in patients sixty years or younger.
Introduction
Severe rotator cuff disease in the older low demand patient has reliably been managed by the reverse total shoulder arthroplasty (RTSA) prosthesis since its FDA clearance in 2003. Two decades of improvements in techniques and design has led to expanded indications with less strict patient selection criteria for the use of RTSA with favorable short-term and mid-term outcomes. However, outcomes, particularly among young patients who undergo RTSA, remain a concern. The literature is sparse regarding results of RTSA in younger patients. Short and mid-term results among this patient population are predictable, however, long-term outcomes carry a relatively high complication rate [1].
Summary
The authors of this single institution retrospective cohort study aimed to assess the mid-term outcomes following RTSA in patients sixty years or younger. The patients were categorized by their indications for surgery, their outcomes (clinic and radiographic) and complications.
Materials and Methods
A total of 89 patients (94 shoulders) under the age of 60 years old underwent RTSA (96% TM Reverse ZB) performed by one of four fellowship trained shoulder and elbow surgeons. All subjects completed ASES, VAS, WOOS and SF-12 questionnaires. Range of motion was assessed as well as postoperative complications. Postoperative radiographs examined the presence of component loosening, subsidence, and glenoid notching. Outcomes were analyzed for significant changes pre vs postoperative. Demographics, surgical/clinical characteristics vs complications, in addition postoperative changes and postoperative satisfaction were analyzed for associations.
Results
At the time of the surgery the average age of the subjects was 54.8 years. Mean follow up was 4.9 years. Fifty-eight of the subjects were females. The dominant shoulder was replaced 68% of the time. Fifteen patients were current smokers. Nine subjects classified their work as “heavy” or “very heavy,” the remainder were classified as “medium, light, or sedentary.” The majority (56%) of the subjects underwent RTSA for CTA; the remainder in descending frequency were: IRCT without arthropathy > inflammatory arthropathy > OA > revision SA > PH fracture sequalae > acute PH fracture. Fifty-eight of the stems were press-fit.
The overall complication rate was 12%. There were 7 (7%) reoperations (2 instability, 2 hematomas, 2 aseptic meteglene loosening, 1 broken cable removal). There were 4 (4%) (Levy type I) acromial stress fractures. Two subjects who had undergone structural bone graft to address glenoid bone deficiency experienced baseplate subsidence and subsequently underwent revision surgery. There were no cases of humeral stem subsidence or gross loosening. There was a 36% incidence of notching. Post-op ASES, WOOS and VAS scores were not significantly negatively impacted by minimal or high-grade scapular notching. Patient satisfaction was high at 95% and willingness to undergo the same procedure was 91%.
Clinical Outcomes
| Preop | Postop | ||
| ASES | 27.3 | 74.1 | P < .0001 |
| VAS | 7.1 | 1.4 | P < .0001 |
| WOOS | NR | 70.9 | |
| FE | 88° | 135° | P < .0001 |
| ER | 32° | 33° | P = .52 |
When considering preop age, gender, indication, and prior surgeries there was no significant correlation in change or improvement (pre/post) with ASES, pain, ROM, including the 4 patients with acromial stress fractures. However, positive correlations with worse overall postoperative WOOS scores and increasing number of prior operations, more physically demanding occupations and less pain improvement were demonstrated. Whereas, improved overall postop WOOS scores were correlated with OA as an indication.
Discussion
This study demonstrated that at mid-term RSA in patients 60 years old and younger can lead to predictable pain relief, improved shoulder function and high patient satisfaction. In addition, this study demonstrated lower rates of instability, reoperation and complications as compared to those in current literature.
Reviewer Comments
While joint related deterioration occurs with aging, as with all arthroplasties longer term raises the concerns of diminishing clinical outcomes. Constrained arthroplasty in the younger, active population, warrants important consideration in terms of complications, implant survivorship and quality of life. Patients involved in physically demanding jobs and those with multiple prior surgeries should be counseled on the risk of worse clinical outcomes.
References:
- Ek, E. T., Neukom, L., Catanzaro, S., & Gerber, C. (2013). Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. Journal of shoulder and elbow surgery, 22(9), 1199-1208.