Sunday, January 22, 2017

Reverse total shoulder in young patients, why is it done and what are the results?

Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up

These authors reviewed sixty-seven patients (average age, 47.9 years; range, 21-54 years) having reverse total shoulders (RSA) at an average 62.3 months of follow-up (24-144 months). There were 35 patients (group 1) who had RSA for a failed arthroplasty and 32 patients (group 2) who had primary RSA.

Of note is that many of the patients in either group had had prior surgery.

While both groups showed significant improvements in ASES and SST scores, these improvements were modest. In group 1, ASES score improved from 24.4 to 40.8 (P = .003), and SST score improved from 1.3 to 3.2 (P = .043). In group 2, ASES score improved from 28.1 to 58.6 (P < .001), and SST score improved from 1.3 to 4.5 (P = .004). 

The total complication rate was 22.4%. 
The total reoperation rate was 13.4%.
The revision rate was 8.9%. 
Infection was the cause of all revisions. We are not informed of which types of bacteria caused the infection.

Group 1 had 2 patients with humeral lucency (1 treated conservatively), 2 with glenoid screw lucency (treated conservatively), 2 with periprosthetic fractures (1 treated conservatively), 1 with humeral dissociation, 1 with infection, and 1 with recurrent instability (treated conservatively).

Group 2 had 1 patient with scapular fracture (healed conservatively), 1 patient with symptomatic hardware after fixation for an os acromiale at the time of index surgery, and 4 patients with periprosthetic infections.

The total reoperation rate was 13.4% (11.4% in group 1 and 15.6% in group 2). The revision rate was 8.9% (5.7% in group 1 and 12.5% in group 2).

Group 1 had 1 reoperation for open reduction and internal fixation of a periprosthetic humerus fracture. One patient underwent a resection arthroplasty for a persistent periprosthetic infection. Two patients were revised in group 1 (1 for dissociation of humeral modular component and 1 for resorption of humeral allograft and humeral loosening).

Group 2 had 1 reoperation for removal of symptomatic hardware after open reduction and internal fixation of an os acromiale at the time of index surgery. Four patients required revision in group 2 (all were revised because of infection).

Comment: These results at the hands of high volume reverse arthroplasty surgeons can inform our decision making and discussions with young patients considering arthroplasty. While the authors present the results from two groups based on whether the patient had a prior arthroplasty, we can assume that essentially all of the patients had prior surgery. Mindful of the information in a prior post, "The risk of shoulder joint replacement infection is doubled by prior surgery on the shoulder", it is not surprising that infection was the most common reason for revision surgery. In patients having RSA after prior surgery, the surgeon may consider obtaining preemptive cultures at the time of the RSA and recognize that any deviation from the expected course may be due to the stealth presentation of an infection.