Sunday, November 18, 2012

Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon's experience? JSES

Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon's experience? JSES

The authors compared their experience with 196 cases from 1995-2003 with that of 213 cases from 2003-2007. There was a high two year followup rate (213 of 240 cases in the most recent series). The two groups were similar in terms of age, gender, and shoulder dominance.  The number of deceased patients was greater in the first series and the number of interpretable radiographs was greater in the second. 

The more recent series had an increasing number of cases performed for cuff tear arthropathy (26 to 35%), a diminishing number for revisions of failed arthroplasty (23 to 9%) and an increasing percent for rheumatoid arthritis (0 to 6%). These experienced surgeons "prioritized the etiologies linked with the best outcomes and reduced the number of revision surgery cases, which are related to high complication rate".

Most of the other differences were not significant. It is of note, however that the patients in the more recent series experienced the following: notching (83% grade 0 and 1, 17% grade 2-4), dislocation (3%), infection (1%), glenoid loosening (1%), nerve palsy (4%), acromial fracture (1%), vein thrombosis (1%) and, reoperation and revision (5%). The authors suggest that the increase in nerve palsies may be related to the more inferior placement of the glenoid baseplate and an attempt to restore humeral length to avoid instability. 

It is terrific to have this perspective from Dr. Walch and his colleagues. We especially appreciated their pointing out that experience gave them the opportunity to refine not only their surgical technique but also their patient selection. As we like to say, we don't treat shoulders, we treat patients with shoulder problems - often the patient has more to do with the outcome than the shoulder. (Osler said "It is more important to know what kind of person has a disease than what kind of disease a person has"). 

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