Clinical and Radiographic Outcomes Following Reverse Total Shoulder Arthroplasty in Patients 60 Years of Age and Younger

These authors sought to compare the clinical and radiographic outcomes of 154 patients under the age of 60 to those of 1,763 patients aged 60-79 following primary reverse total shoulder (rTSA) after a mean 47 month (minimum 2-years) follow-up.

This is a prospective case-control study utilizing an international database of prospectively enrolled patients undergoing rTSA with the Equinoxe; Exactech, prosthesis with a neck shaft angle of 145 degrees, a medialized glenoid component and a lateralized humeral component.

The patient data were collected from 40 fellowship-trained shoulder surgeons in the United States and Europe.

The preoperative characteristics of patients in the two groups were not the same. Patients under 60 were more often male, had a higher BMI, higher rates of previous surgery, higher rates of post traumatic arthritis and inflammatory arthropathy, and lower rates of rotator cuff tear arthropathy.

Patients under 60 had statistically significant lower function and outcome metric scores, and higher pain scores at latest follow-up.

Patients under age 60 were three times more likely to require revision and had lower satisfaction scores.

Comment: This is an important paper for a number of reasons.

(1) The patients under 60 years of age having reverse total shoulders were different in substantial ways from those over 60 (sex, prior surgery, smoking, diagnoses to name a few). These differences can have a major effect on outcome.

(2) The revisions, poor clinical outcomes and adverse events were more prevalent among the younger patients than among the older patients. Therefore, it is important not to apply data from older patients to those younger than 60 years.

(3) Younger patients are likely to have different exceptions and to put their shoulders to different use for longer periods of time after rTSA than older patients.

(4) Younger patients are likely to live longer so that the 4 year mean followup in this study may not reflect the complications they are likely to experience in their lifetimes. A recent post (High Rate of Complications for rTSAs that have been in Place for a Decade - see this link) points out that complications and revisions continue to occur as long as the rTSA is in place; in that study, the cumulative rate revision at 10 years was essentially twice that at four years.

Another recent article again calls attention to the complication rate of rTSA in young individuals. Reverse Total Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears Before the Age of 60 Years Long-Term Results From May 1997 to May 2008, 29 shoulders in 26 consecutive patients (15 men and 11 women; mean age, 57 years [range, 47 to 59 years]) with a massive, irreparable rotator cuff tear and secondary pseudoparalysis of active anterior elevation were treated with RTSA. Twenty patients (23 shoulders) with a mean age of 57 years (range, 47 to 59 years) were evaluated at a mean of 11.7 years (range, 8 to 19 years) after RTSA.

Fifteen shoulders (65%) had undergone previous non-arthroplasty surgery. The mean absolute Constant score (CS) had improved from 24 to 59.The mean Subjective Shoulder Value (SSV) had increased from 20% to 71% ± 27%.. The mean active anterior elevation improved from 64 to 117 degrees. 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%).

Nine (39%) had at least 1 complication.

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