Wednesday, April 10, 2013

Shoulder arthroplasty in younger patients

Shoulder arthroplasty in patients 59 years of age and younger

This is a retrospective cohort study of shoulder arthroplasties performed within the Permanente integrated healthcare system between 2005 and 2010. There were 2981 primary arthroplasties followed for a median time of 2.2 years,  90 (3.0%) of which required revisions. This represents an annualized revision rate of 1.4% per year.

After adjusting for procedure type and diagnosis, patients of 59 years and younger had a two times higher risk of revision than older patients. The adjustment for diagnosis is important in that Salzman and Saltzman pointed out that younger patients with shoulder arthritis tend to have different types of shoulder arthritis than older patients.

The authors conclude that patients 59 years and younger have an increased risk of revision at early follow-up.

It is of interest that the younger group had (a) a significantly higher percent of males (65%) than the older group (47%), (b) significantly fewer white patients (77% vs 84%), (c) significantly more hemiarthroplasties (41% vs 25%) and (d) significantly different diagnoses than the older group.

The most common reasons for revision were glenoid wear/arthritis (31%), infection (14%), instability (13%), cuff tear (10%), glenoid implant loosening (8%), cuff tear arthropathy (7%), and glenosphere failure (6%).

Univariate analysis revealed that age, hemiarthroplasty vs total shoulder, humeral head resurfacing vs total shoulder, reverse vs total shoulder, other diagnosis vs osteoarthritis increased the risk of revision. Multivariate analysis found that younger age, hemiarthroplasty, humeral head resurfacing, and reverse total shoulder were associated with increased risk of revision.

Comment: There are a lot of considerations in deciding the best treatment for an individual with shoulder arthritis and the outcomes of the procedures. These need to be considered in the application of the results of this study. While this study attempts to compare hemiarthroplasty, resurfacing, total and reverse shoulder arthroplasty, it seems likely that the surgeons considered many factors about the patient, the shoulder pathology, and their personal expertise in selecting among these options. Their observation that reverses had a higher revision rate than total shoulders, for example, cannot be taken to suggest that the operations were done on comparable patients.

The selection of treatment for a patient is based on the four "P"s: the shoulder Problem, the characteristics of the Patient with the problem, the Procedure to be performed and the Physician performing the procedure.

Finally, it is to be remembered that a ream and run is not a hemiarthroplasty. In the former the glenoid surface is managed by concentric reaming; in the latter it is not. In our experience, glenoid wear has not been an issue after the ream and run procedure.

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