Tuesday, February 21, 2017

Shoulder arthritis in the younger patient - what to do about it?

Outcomes of total shoulder arthroplasty in patients younger than 65 years: a systematic review

These authors conducted a systematic review of six articles reporting retrospective analyses of total shoulder arthroplasty in patients under 65 years of age. The characteristics of the patients varied among the six studies. Of note is that the patients in each report include those under 40 years of age.

While the articles reported significant improvements in pain, range of motion, and patient reported outcomes were found across all studies that reported these measures, there was an average revision rate of 17.4% at an average of 9.4 years.   Glenoid loosening was the most common reason for revision (52%). 54% had glenoid lucency, and the rate appeared to increase with time.

The revision rate tended to be higher in studies with longer term followup.

Comment: The authors concluded that while TSA can lead to pain relief and improved function at midterm to longterm follow-up, the patient-reported outcomes in this population appear to be inferior to those of the overall TSA population. The rate of failure of the glenoid component continues to be a concern. The average revision rate of 17.4% at an average of 9.4 years would be a particular concern for the younger patients in the 'under 65 year old' age group. 

There are many differences between older and younger patients having shoulder arthroplasty: sex, patient expectations and desired activity levels, longevity, rates of prior surgery and, as emphasized previously (see this link and this link), the type of arthritis. 

Future analyses of shoulder arthroplasty need to include stratification by age, sex, and diagnosis. 

The bottom line is that younger patients considering total shoulder arthroplasty and their surgeons considering total shoulder arthroplasty need to be aware of the potential problems.

As Clint Eastwood says (see this link), we have to know our limitations.