Wednesday, March 9, 2016

Reverse total shoulder in patients with morbid obesity

Outcomes of primary reverse shoulder arthroplasty in patients with morbid obesity.

These authors state that obesity is a risk factor for worse outcomes in anatomic shoulder arthroplasty. 

They sought to determine outcomes in patients with morbid obesity (BMI ≥40 kg/m2 ) having primary reverse shoulder arthroplasty (RSA) between January 1, 2005, and December 31, 2012. Of 60 of these patients, 41 had more than 2 years of clinical followup (57% female, mean BMI was 44 kg/m2,  mean age was 67.7 years). The outcome of 30% of the patients is not known. The average followup was 3.2 years.

Indications for RSA included glenohumeral arthritis with rotator cuff insufficiency in 30, proximal humerus fracture in 8, pseudoparalysis in 2, and chronic shoulder dislocation in 1. Implants used included the Encore Reverse Shoulder Prosthesis in 1 patient (DJO Surgical, Vista, CA, USA), the Delta III prosthesis in 5 and the Delta Xtend prosthesis in 12 (DePuy Orthopaedics, Warsaw, IN, USA), the Comprehensive prosthesis in 20 (Biomet, Warsaw, IN, USA), and the Aequalis Reversed Shoulder prosthesis in 3 (Tornier, Bloomington, MN, USA). 

Clinical outcomes were substantially improved. The only intraoperative complication was an inferior glenoid fracture that remained stable after glenosphere implantation. 
2 patients (5%) required revision surgery for infection (n = 1) and humeral loosening (n = 1). Survival was 98% at 2 years and 92% at 5 years. 
Additional postoperative complications included ulnar neuropathy (n = 1) and heterotopic ossification (n = 2).  1 (2%) had humeral lucency, and 2 (5%) had inferior scapular notching. 

Laborers had higher risk for revision surgery (P = .01), and females had worse functional outcomes and shoulder motion (P < .02).

Comment: This study shows that reverse shoulder arthroplasty can improve comfort and function at an average of 3.2 years for carefully selected obese patients with a variety of diagnoses when performed by expert surgeons. Knowing the high qualifications of the surgeons contributing cases to this study, we suggest that patient selection and surgical experience played major roles in arriving at the results presented. 

Obesity remains an important co-morbidity for all surgery and this fact needs to be included in the shared decision making discussions with patients considering anatomic and reverse total shoulder arthroplasty.


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