Thursday, October 17, 2013

Reverse total shoulder in younger patients

Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years

There has been a progressive expansion of the use of reverse total shoulder beyond the classical indication of rotator cuff tear arthropathy or failed arthroplasty in the older population.

These authors present 36 shoulders in patients averaging 54 years of age at a mean follow-up of 2.8 years. 83% of these shoulders had had prior surgery (average 2.5 procedures per patient). The preoperative diagnoses were failed rotator cuff repair (12), fracture sequelae (11), failed arthroplasty (5), instability sequelae (4), cuff tear arthropathy (CTA) (4), and rheumatoid arthritis (2). 

At followup, the Simple Shoulder Test score had improved from 1.4 to 6.2 and the ASES score improved from 31.4 to 65.8. Active forward elevation improved from 56 to 121. In 9 patients (25.0%), they recorded an ASES score below 50, and these cases were considered failures.

Six (out of 36) patients had major complications.Three patients had revisions at 2 months, 6 months, and 2.8 years postoperatively. 

One with a complex post traumatic arthropathy had recurrent instability and finally  underwent revision to a large-head hemiarthroplasty.

One had recurrent instability and was revised to to a larger glenosphere for extra stability was necessary. This patient has subsequently remained stable with no pain and active elevation of greater than 130 .

One had a history of failed hemiarthroplasty for fracture fixation and had a traumatic dislocation at 2.8 years postoperatively that went untreated for 4 months. The shoulder was revised to a resection arthroplasty.

One patient had a traumatic dislocation requiring open reduction.

One patient had an intraoperative periprosthetic fracture.

One had a traumatic fracture of the acromion.

These results demonstrate that the diagnoses leading to reverse total shoulder arthroplasty are complex - often including failed prior surgery. While reverse total shoulder can be effective in improving comfort and function, the patient and the surgeon must be aware of a substantial serious complication rate. 

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