Tuesday, October 22, 2013

Reverse total shoulder in younger patients

Early Follow-up of Reverse Total Shoulder Arthroplasty in Patients Sixty Years of Age or Younger

Compare this article to that reviewed in the 10/17/13 post.

As the authors of this article point out there are concerns over the longevity of the reverse prosthesis. These concerns are not addressed by this review with a minimal followup of two years.

They present a retrospective multicenter review of 67 reverse total shoulders in patients with a mean age of 52.2 years. 29 had rotator cuff insufficiency, 11 had arthritis and cuff defeciency, 9 had failed primary shoulder arthroplasty, 6 had rheumatoid arthritis, 4 had posttraumatic arthritis, and 8 had other diagnoses. 45 had had at least one prior surgical intervention, and 31 had multiple prior surgical procedures.

While function was improved, patient satisfaction was lower than in older patients having this procedure. Function was best for the patients with the mildest preoperative pathology (cuff insufficiency) and worst for the most severe pathology (failed arthroplasty). 50% of patients in this study were either not satisfied, dissatisfied, or very dissatisfied with the final outcome.
29 had evidence of scapular notching with the Grammont-style reverse shoulder prosthesis used in this study. 2 patients had grade 3 notching at this short-term followup.

9 shoulders had 10 complications. 5 were dislocations; 2 required revision and 2  were treated with closed reduction. A 5th had a postoperative dislocation that required revision; subsequently, an infection developed requiring the performance of a resection arthroplasty. Two other patients also developed postoperative infection that required resection arthroplasty (one patient underwent a two-stage revision with reimplantation once the infection was eradicated, and the other had a resection arthroplasty as the final treatment). 

1 sustained a humeral stress fracture at the distal tip of the stem requiring revision to a long-stemmed component. 

1 patient had a postoperative radial and ulnar nerve palsy that was improving spontaneously but had not fully resolved at 30 months.

In the study reviewed in the 10/17/13 post, 25% of the cases were considered failures and 6 of 36 patients had major complications.

The combination of these two studies indicate that patients should be warned of a one in six or one in seven chance of a major complication, possibly including removal of the prosthesis. These results also suggest that shared surgeon-patient decision making should include consideration of non-operative management and less invasive surgical procedures. 

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