Sunday, October 22, 2017

Reverse total shoulder - longer term outcomes

Reverse Total Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears Before the Age of 60 Years Long-Term Results

These authors present their outcomes and complications of RTSA for irreparable rotator cuff tears in patients younger than 60 years in twenty patients (23 shoulders) with a mean age of 57 years (range, 47 to 59 years)  at a mean of 11.7 years (range, 8 to 19 years) after reverse total shoulder arthroplasty. Fifteen shoulders (65%) had undergone previous non-arthroplasty surgery. 

Patients with active anterior elevation of <90 and preserved free passive anterior elevation were considered to have pseudoparalysis. The rotator cuff was considered to be irreparable if pseudoparalysis was chronic, if the acromiohumeral distance was <7 mm on an anteroposterior radiograph, and/or if fatty infiltration of the supraspinatus and infraspinatus muscles was greater than stage 2 according to the Goutallier classification.

Only patients with a minimum of 8 years of clinical and radiographic follow-up were included. At the time of final follow-up, the mean absolute and relative preoperative Constant score (CS) (and standard deviation) had improved from 24 ± 9 to 59 ± 19 points (p < 0.001) and from 29% ± 11% to 69% ± 21% (p < 0.001), respectively. The mean Subjective Shoulder Value (SSV) had increased from 20% ± 13% to 71% ± 27% (p < 0.001). There were also significant improvements in the mean active anterior elevation (from 64 to 117), active abduction (from 58 to 111), pain scores, and strength (all p £ 0.001). Clinical outcomes did not significantly deteriorate beyond 10 years and the functional results of patients with previous surgical procedures were not significantly inferior to the results of  those with primary RTSA. The grade of, and number of patients with, radiographically apparent notching increased over time; the mean relative CS was lower in patients in whom the notching was grade 2 or higher (57%) than it was in those with no or grade-1 notching (81%; p = 0.006). Nine (39%) had at least1 complication, with 2 failed RTSAs (9%). 

Dislocation occurred in 4 (17%) of the shoulders. One dislocation occurred within the first 6 weeks postoperatively. The other 3 dislocations were late complications, occurring after 50, 60, and 64months.

Infection at 1.5 years after surgery

 Dislocation of polyethylene liner noted at 5 years


Comment: This article provides important longer-term results of reverse total shoulder. It can be compared and contrasted to another recent post:

Long-Term Outcomes of Reverse Total Shoulder Arthroplasty

These authors provide a welcome longer-term (mean 150 months, minimum 120 months) follow-up of a previously reported series of 186 patients (191 shoulders) having a Grammont-style reverse total shoulder arthroplasty (RTSA) with a mean of 40 months follow-up.

Follow-up clinical evaluations were available for 84 patients (87 prostheses) and radiographic assessments were available for 64 patients (67 prostheses).

The mean absolute and relative Constant scores were 55 ± 16 points and 86 ± 26 points, respectively, with both having decreased significantly compared with the scores at the medium-term follow-up evaluation (p < 0.001 and p = 0.025, respectively).

The best results at both followup periods were in shoulders with rotator cuff arthropathy. In contrast, RTSA for a failed previous arthroplasty or posttraumatic arthritis was associated with limited functional outcomes.

Forty-nine shoulders (73%) exhibited scapular notching.

Forty-seven complications (29%) were recorded, with 10 cases (10%) occurring after 2 years. Sixteen (12%) of the original patients underwent revision surgery. 

The 10-year overall prosthetic survival rate using revision as the end point was 93%.

The authors concluded that despite a high arthroplasty survival rate and good long-term clinical results, RTSA outcomes showed deterioration when compared with medium-term results. They suggest that this deterioration may be related to patient aging, bone erosion and loss of deltoid function over time.

These reports demonstrate the importance of long term follow-up for all forms of shoulder arthroplasty.  It helps us answer the question patients often ask, "how long will it last?". This paper needs to be viewed in light of the fact that these surgeries were performed by high volume surgeons with extensive experience.

Are newer versions of the reverse total shoulder likely to yield better results? See this link.

The reader may also be interested in these posts:

Information about shoulder exercises can be found at this link.

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