Friday, November 29, 2013

Reverse total shoulder - quality of life and functionality

Health-related quality of life and functionality after reverse shoulder arthroplasty.

80 patients operated by an individual surgeon were evaluated after an Delta III reverse total shoulder (Grammont design) for either primary osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy. At a mean 5-year follow-up, the cumulative survival rate was 97.3%. The Constant score was 93.2% of the sex- and age-matched normal values. The postoperative SF-36 scores showed no significant differences compared with age and sex matched controls. Younger patients and subjects with worse preoperative conditions achieved the greatest benefit after RSA. Scapular notching increased with the length of follow-up.

The complication rate was low ( 4 patients (5%)): dislocation (2), infection (1), and hematoma (1). 

One of the interesting aspects of this study is that it included patients with relatively benign diagnoses (43% had massive cuff tears, 41% had primary osteoarthritis, and 16% had cuff tear arthropathy.  Only 5% had had prior surgery. Patients were excluded if they had prior arthroplasty,  proximal humeral fractures and fracture sequelae, rheumatoid arthritis, tumors, evidence of an active infection, allergic reactions to metal implants, alcohol abuse, a predicted survival of less than 6 months, a patient’s unwillingness to cooperate, or legal incapacitation.

This is an idealized series of reverse total shoulders: single surgeon, single prosthesis design, basically healthy patients and benign shoulder diagnoses. Case series without these characteristics are unlikely to produce comparable results.

The authors justify the use of RSA (rather than an anatomic total shoulder) in their patients with glenohumeral OA because the average age of this patients was 73 years and they had concerns about subsequent cuff failure quoting a 16.8% incidence of cuff rupture after anatomic TSA. They note that cuff rupture has been associated with component loosening in anatomic arthroplasty. We must now decide on the indications for RSA and anatomic TSA in patients with 'ordinary' osteoarthritis. It was of great interest that one of our recent shoulder fellowship applicants related a residency experience consisting almost exclusively of RSAs for OA.

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