What is the average age for patients having shoulder joint replacement?

  ChatGPT is a interactive language model developed by OpenAI, that uses a deep learning framework to understand queries and to generate coherent, contextually relevant responses based on a set of books, websites, and texts selected by researchers at OpenAI. While search engines such as Google provide links to websites that may or may not be accurate or relevant, ChatGPT provides a readable synthesis of the information from its comprehensive sources,

We sought ChatGPT responses to questions frequently posed by patients with shoulder arthritis.  These responses cannot used as specific medical advice. Patients should consult medical professionals for the most current and accurate information on their shoulder condition.

We asked "What is the average age for a shoulder replacement?"

ChatGPT responded:

"The average age for shoulder replacement surgery can vary depending on several factors, including the underlying shoulder condition and individual patient characteristics. Generally, shoulder replacement surgery is more commonly performed on older individuals, but it can be necessary for younger patients as well.

The most common shoulder condition that leads to shoulder replacement surgery is osteoarthritis, which typically affects older adults. Therefore, the average age for shoulder replacement surgery is often higher than for other joint replacements such as hips or knees.

That being said, there is no strict age limit for shoulder replacement surgery. The decision to undergo surgery is based on factors such as the severity of the shoulder condition, the impact on daily activities and quality of life, and the individual's overall health and ability to tolerate surgery and rehabilitation.

While older individuals may undergo shoulder replacement surgery more frequently, younger patients may also require the procedure due to conditions like rheumatoid arthritis, post-traumatic arthritis, or severe shoulder injuries. Additionally, advancements in surgical techniques and implant design have made shoulder replacement surgery a viable option for a broader age range of patients.

It's important to consult with an orthopedic specialist or a shoulder surgeon who can evaluate your specific condition, consider your age and individual circumstances, and provide personalized recommendations regarding the potential need for shoulder replacement surgery."

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link)

Age, smoking and failure of total shoulder arthroplasty

Smoking has been portrayed as being glamorous or macho, leading young people to take it up. Its habit-forming tendency prompts older individuals to continue.

There are many adverse physiological changes that can result from smoking, changes that can contribute to complications after joint replacement.

The authors of The impact of tobacco use on clinical outcomes and long-term survivorship after anatomic total shoulder arthroplasty explored the effect of smoking status on the outcomes of anatomic shoulder arthroplasty. 

Patients were stratified into three cohorts based on their smoking status on the date of their operation: 1) non-smokers (n=78) 2) former smokers (n=49) 3) current smokers (n=16). Nonsmokers were defined as individuals who had never smoked tobacco. Former smokers were defined as individuals who quit smoking tobacco at least one year prior to their index procedure; these individuals had previously smoked at least 0.25 packs per day. Current smokers were defined as individuals who started smoking at least one year prior to surgery and continued to smoke within one year of their surgery (consumption of at least 0.25 packs per day for one year).

Interestingly and importantly at the time of surgery, smokers were younger (51.5 years) than both non-smokers (64.9 years) and former smokers (65.1 years; . 

Visual Analog Scale, American Shoulder and Elbow, and Simple Shoulder Test scores were lower for smokers comparatively; these differences did not reach significance with the numbers of patients in this study.

Revision rates were lower in the non-smoking cohort (7.7%) compared to both former (20.4%) and current smokers (37.5%). 

Survival curves showed that non-smoker implants lasted longer than those of current smokers.

Comment: While this study focuses on the relationship between smoking and surgical outcomes, it is also recognized that smoking increases the risk of medical problems, such as urinary tract infections, pulmonary complications, myocardial infarctions, and readmission. According to the World Health Organization, Smoking greatly increases risk of complications after surgery: Tobacco smokers are at significantly higher risk than non-smokers for post-surgical complications including impaired heart and lung functions, infections and delayed or impaired wound healing. Nicotine and carbon monoxide, both present in cigarettes, can decrease oxygen levels and greatly increase risk of heart-related complications after surgery. Smoking tobacco also damages the lungs making it difficult for the proper amount of air to flow through, increasing the risk of post-surgical complications to the lungs. Smoking distorts a patient’s immune system and can delay healing, increasing the risk of infection at the wound site. Smoking just one cigarette decreases the body’s ability to deliver necessary nutrients for healing after surgery. However, new evidence reveals that smokers who quit approximately 4 weeks or more before surgery have a lower risk of complication and better results 6 months afterwards. Patients who quit smoking tobacco are less likely to experience complications with anesthesia when compared to regular smokers. Every tobacco-free week after 4 weeks improves health outcomes by 19%, due to improved blood flow throughout the body to essential organs. This report provides evidence that there are advantages to postponing minor or non-emergency surgery to give patients the opportunity to quit smoking, resulting in a better health outcome.

Some important questions present themselves:
(1) In that current smokers were over a decade younger than former or non-smokers, to what degree is the poorer survivorship for smokers due to patient age or to smoking status (recalling that patients <60 years of age do less well after shoulder arthroplasty)?
(2) To what degree does smoking contribute to the earlier development of arthritis?
(3) Aside from its adverse effect on health, does smoking reveal a tendency to take risks that may jeopardize the longevity of the arthroplasty? See Smokers’ Decision Making: More than Mere Risk Taking: "The fact that smoking is bad for people’s health has become common knowledge, yet a substantial amount of people still smoke. Previous studies that sought to better understand this phenomenon have found that smoking is associated with the tendency to take risk in other areas of life as well. The current paper explores factors that may underlie this tendency. An experimental analysis shows that smokers are more easily tempted by immediate high rewards compared to nonsmokers. Thus the salience of risky alternatives that produce large rewards most of the time can direct smokers to make bad choices even in an abstract situation such as the Iowa Gambling Task (see this link). These findings suggest that the risk taking behavior associated with smoking is not related to the mere pursuit of rewards but rather reflects a tendency to yield to immediate temptation."

(4) To what degree does smoking cessation reduce the risk? See Smoking Cessation Initiatives in Total Joint Arthroplasty, An Evidence-Based Review. Points from this article follow:

Hospital costs for total joint arthroplasty (TJA) are about $5,000 higher for smokers compared with nonsmokers. Currently, smoking cessation programs are the only intervention demonstrated to reproducibly improve outcomes for smokers undergoing TJA. Several randomized controlled trials have shown that perioperative smoking cessation programs confer short-term quit rates between 40% and 89%.

Initiating a smoking cessation program 4 weeks preoperatively is likely adequate to provide clinically meaningful reductions in postoperative complications for smokers following TJA. The evidence is that 2 to 6 weeks of abstinence would be necessary to reduce the incidence of infection, 3 to 4 weeks to reduce wound-related complications, and 6 to 8 weeks to reduce pulmonary complications. Longer periods of smoking cessation decreased the rate of postoperative complications further, with each week of cessation increasing the magnitude of the effect.

How can a surgeon know if the patient has ceased smoking? Smoking status is typically measured by patient self-reporting, Cotinine testing, or CO breath testing. One study found that self-reporting was accurate 97% of the time while others found that 20% falsely reported abstinence. Cotinine is the major metabolite of nicotine and may be measured in the urine or saliva using immunoassay-based test strips. It has a half-life of 7 to 14 hours. CO breath tests measure the concentration of CO in expired air. Breath CO is a good indicator of recent smoking, but it has a half-life of only 2 to 3 hours and usually becomes undetectable around 24 hours after smoking cessation.

What are the other benefits of smoking cessation? Smoking adds approximately $100 billion in annual direct health-care costs annually. Thus smoking cessation programs can provide even further potential value if abstinence from smoking is maintained. Additionally, it has been observed that smoking cessation programs encourage other positive lifestyle changes such as improved exercise, eating, and drinking habits, which can further contribute to improved patient health and decreased costs.

A recent systematic review, Smoking cessation prior to total shoulder arthroplasty: A systematic review of outcomes and complications found 24 studies on this topic. The authors concluded that patients who quit smoking at least 1 month preoperatively had improved outcomes compared to current smokers. Current smokers had statistically significant higher pain scores or opioid use. Five studies found increased rates of revision surgery in smokers. Smokers were significantly more likely to have increased rates of surgical, wound, superficial, and deep surgical site complications.  The authors recommend a period of four weeks or more of preoperative smoking cessation.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Rotator cuff failure is part of getting older

Are degenerative rotator cuff disorders a cause of shoulder pain? Comparison of prevalence of degenerative rotator cuff disease to prevalence of nontraumatic shoulder pain through three systematic and critical reviews


These authors attempted to determine the prevalence estimates for rotator cuff partial or complete tears and to relate this prevalence to the prevalence of self-reported nontraumatic shoulder pain.

Their results remind us that the prevalence of rotators cuff lesions increases gradually after 50 years, whether on correlates clinical clinical findings with person age in the general population (see this link).

or whether one correlates cadaver findings with cadaver age

These data suggest that about 50% of 70 year old people have a partial or complete rotator cuff defect. Because degenerative cuff defects usually progress slowly with time the shoulder and the patient have time to successfully accommodate to the loss of cuff integrity(see this link).

This article prompted us to resurface some of the content of a previous post that emphasizes the clinical importance of recognizing the degenerative nature of cuff failue (see this link).

 Rotator cuff tear and rotator cuff wear.
 "The rotator cuff is the only tendon structure situated between two bones. Compressed between the acromion and the humerus by every motion of the shoulder, it succumbs to the ravages of attrition long before most other tendons. In youth, it is thick, strong, and elastic and can be disrupted only by great force; after middle age, it has worn thin and often becomes so weak and brittle that it ruptures with ease." McLaughlin 1962

Detachment of the rotator cuff tendons from the greater tuberosity is often described as a rotator cuff tear. The word 'tear' suggests an acute process, such as tear in otherwise great blue jeans that can be easily repaired.

On the other hand, most cuff defects arise in tendons of suboptimal quality without an acute traumatic episode and may be better referred to as cuff wear, similar to defects in worn jeans that defy repair.

We emphasize the distinction in an article on rotator cuff failure in the New England Journal as well as in the text, The Shoulder, where we quote McLauhglin's admonition regarding 'rotten cloth to sew' in an Instructional Course Lecture: "The wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis. [There was complete agreement of the Panel on this point.]" See these links to his work
Lesions of the musculotendinous cuff of the shoulder. The exposure and treatment of tears with retraction. 1944.

Lesions of the musculotendinous cuff of the shoulder. IV. Some observations based upon the results of surgical repair.

Rupture of the rotator cuff.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Shoulder arthroplasty in patients covered by workers' compensation

Anatomic total shoulder arthroplasty for patients receiving workers' compensation.

These authors compared 13 male patients, mean age 56 years covered by worker's compensation (WC) insurance having total shoulder arthroplasty (TSA) to 36 men and 27 women, mean age 63 years without worker's compensation insurance at a minimum of 2 years of follow-up.

The American Shoulder and Elbow Surgeons (ASES) scores at final follow-up were significantly lower in the WC cohort (73.6) compared with the control group (86.6).  Only 4 of the 13 WC patients returned to work.

Comment: While most surgeons recognize coverage by workman's compensation as a factor increasing the chance of a poor result, this study did not provide the reader with preoperative ASES scores, so the amount of improvement for the two groups cannot be compared. Furthermore this study  did not attempt to determine whether it was the insurance, the patient age, or the patient sex that exerted the predominant effect on the outcome.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Rotator cuff tears in young patients are different from those in elderly patients.

Rotator cuff tears in young patients: a different disease than rotator cuff tears in elderly patients.

These authors conducted a systematic search for clinical studies evaluating rotator cuff tears in patients younger than 40 years. 12 Level IV studies (336 patients) were included. The mean age of the patients was 28 years (range, 16-40 years), with a mean follow-up of 39 months. There were 2 distinct subgroups. The majority of studies (7 of 10) showed that patients typically had a full-thickness tear with an acute traumatic etiology. However, within the subgroup of elite throwers, 5 of 6 studies demonstrated a majority of tears that were partial thickness stemming from chronic overuse. Rotator cuff repair improved pain and strength in almost all studies reporting on these parameters. Eighty-seven percent of patients reported they were satisfied. However, all studies examining elite throwers showed significant difficulty in returning to play (25%-97%).

Comment: The results of this study can be anticipated from a few basic observations. 

*The incidence of cuff tears increases with age. 

*Young shoulders are used more vigorously than older shoulders. 

*These two observations indicated that the rotator cuff tendon attachments to bone are stronger in younger individuals. 

*Stronger attachments require more force (trauma) or extraordinary repetitive use to disrupt them.

Rather than being a 'different disease', it is more likely that there is a continuum from acute traumatic tears in the healthy cuffs of young shoulders to chronic degenerative tears in the age-weakened cuffs older shoulders. 

What we would have liked to learn from this study is the healing rate of repairs of cuff tears in younger individuals, but this information is not included. Our current 'wisdom' is that acute traumatic tears in otherwise healthy shoulders respond well to acute repairs. Hopefully we can garner evidence to support this wisdom.

Of course all older rotator cuffs are not weak. See here.

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Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Shoulder arthroplasty - what factors are associated with the outcome?

Factors Affecting Length of Stay, Readmission, and Revision After Shoulder Arthroplasty. A Population-Based Study

Increased length of hospital stay, hospital readmission, and revision surgery are adverse outcomes that increase the cost of elective orthopaedic procedures, such as shoulder arthroplasty. These authors suggest that awareness of the factors related to these adverse outcomes may help surgeons and medical centers design strategies for minimizing their occurrence and for managing their associated costs.

They analyzed data from the New York Statewide Planning and Research Cooperative System on 17,311 primary shoulder arthroplasties performed from 1998 to 2011 to identify factors associated with extended lengths of hospitalization after surgery, readmission within ninety days, and surgical revision.

They found that the factors associated with each of these three adverse outcomes were different.

Longer lengths of hospital stay were associated with female sex, advanced patient age, Medicaid insurance, comorbidities, fracture as the diagnosis for arthroplasty, higher hospital case volumes, and lower surgeon case volumes. 

Readmission was associated with advanced patient age and medical comorbidities. The most common diagnoses for readmission within ninety days were fluid and electrolyte imbalance (28%), acute pulmonary problems (21%), cardiac arrhythmia (20%), heart failure (15%), acute myocardial infarction (10%), and urinary tract infection (10%). 

Revision was associated with younger patient age and osteoarthritis or traumatic arthritis. The most common diagnoses at the time of revision surgery were unspecified mechanical complications of the implant (60%), shoulder pain (18%), dislocation of the prosthetic joint (12%), component loosening (10%), a broken prosthesis (8%), a cuff tear (7%), and infection (7%).

They concluded that a small number of easily identified characteristics (sex, age, race, insurance type, comorbidities, diagnosis, and provider case volumes) were significantly associated with longer lengths of stay, readmission, and revision surgery. Consideration of these factors and their effects may guide efforts to improve patient safety and to manage the costs associated with these adverse outcomes.

Comment:  The care of patients with risk factors for adverse outcomes may benefit from advanced planning for the prevention, management, and cost of these possible outcomes. Older individuals and those with comorbidities may merit extra attention to their fluid and electrolyte, cardiac, pulmonary, and urinary status prior to discharge. Young individuals with osteoarthritis and traumatic arthritis may need to be cautioned to be conservative in their use of the shoulder arthroplasty in light of their increased rate of revision surgery necessitated by mechanical failure.

On a socioeconomic note, the Affordable Care Act has provided a basic level of medical insurance for patients with a higher prevalence of risk factors for more costly care. As a result, health-care systems caring for a substantial number of these patients may have difficulty funding the care with the resources provided. The Hospital Readmissions Reduction Program creates a penalty risk for medical centers caring for large numbers of patients at increased risk for readmission . If the care of patients with risk factors for increased cost of care is not affordable within the fiscal limits of the reimbursement for the care, providers may be disinclined to care for them. Furthermore, it is evident that patients with increased risk for higher costs of treatment will create a challenge for providers pursuing the bundled payment approach to reimbursement.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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How does patient age affect the mortality risk of shoulder arthroplasty?

Patient age is a factor in early outcomes after shoulder arthroplasty.

These authors analyze the Nationwide Inpatient Sample for 58,790 patients undergoing total shoulder arthroplasty or hemiarthroplasty between 2000 and 2008 to determine whether patient age is independently associated with postoperative in-hospital complications or increased hospital charges after shoulder arthroplasty.

They found that patients aged 80 years or older had an increased in-hospital mortality rate (0.5%) compared with patients aged 50 to 79 years (0.1%) and patients aged younger than 50 years (0.1%). 

Factors associated with increased risk of death included female gender, total shoulder arthroplasty versus hemiarthroplasty, and Deyo score. Older patients had longer hospital stays, an increased incidence of postoperative anemia, and slightly higher charges after shoulder arthroplasty.  The authors did not find an increased incidence of other perioperative complications, including pulmonary

embolism and cardiac complications in older individuals.

Comment: In viewing this analysis, we need to recognize that surgeons may be progressively less likely to offer shoulder arthroplasty to progressively older patients. Thus, these data do not represent the mortality or the morbidity risk of all patients with arthritis or fracture that might be treated with arthroplasty, rather the data only represent the subset of patients for whom their surgeons advised that the risk-benefit ratio was favorable.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Many rotator cuff tears are a function of aging - how do you treat that?

A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age

These authors reviewed the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with advancing age.  Their search terms included cuff degeneration, tear, disruption, perforation, pathologic change, defect, lesion, or abnormality. They assessed the prevalence of cuff tear abilities in 4 groups: (1) asymptomatic patients, (2) general population (including cadavers), (3) symptomatic patients, and (4) patients after shoulder dislocation.Thirty studies including 6112 shoulders met their criteria.

The prevalence of abnormalities increased with age for each of the groups.

Comment:  A key comment in this article is that "Atraumatic rotator cuff defects are commonly referred to as tears, but if rotator cuff thinning is part of the normal aging process, the word tear which implies damage in need of repair may be inappropriate." We have previously posted on  cuff tear versus cuff wear.

The authors conclude that the prevalence of rotator cuff abnormalities in asymptomatic people is high enough for rotator cuff tendon failure to be considered a common aspect of normal human aging and not necessarily an indication for surgery. These results also point to the increasing frailty of the cuff with age, a characteristic that is not changed by rotator cuff repair surgery.

Against this background, it is important to consider the relative advantages and disadvantages of  non-opeartive, non-repair surgery and surgical repair attempt for each patient found to have a cuff tendon defect.

Our approach to the rotator cuff is summarized here. 

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Rotator cuff repair vs. non-repair of cuff tears in individuals over the age of 60 years.

Is rotator cuff repair appropriate in patients older than 60 years of age? Prospective, randomised trial in 103 patients with a mean four-year follow-up

These authors compared surgical rotator cuff repair to acromioplasty and biceps tenotomy in patients older than 60 years of age with a mean follow-up of 4 years.

Exclusion criteria included subscapularis tear, spontaneous long head biceps tear, and irreparable tear as determined arthroscopically.

Patients were randomly allocated to acromioplasty and tenotomy (AT group) or to acromioplasty, tenotomy, and tendon suture (CR group). In the repair group tendon suture was consistently achieved using metal anchors inserted into the tip of the greater tuberosity after abrasion of the footprint, in a single-row (n = 21) or double-row (n = 33). After surgery patients  wore a sling for 4 weeks with

passive self-rehabilitation on day 1.  After 4 weeks, physiotherapy sessions were prescribed if needed.

Of 130 initially included patients older than 60 years of age and having rotator cuff tears deemed amenable to surgical repair, 103 (79%) were evaluated after a mean of 4 years. 

The tear was distal in 41 patients, intermediate in 40, and retracted in 22. 

The complication rate was 4%. The mean Constant Score was 44 preoperatively; values after 4 years were 76 overall. The repair group had slightly greater Constant Scores (78) than the acromioplasty group (73). Less than 2/3 rds of the repairs (63%) were healed by sonography. 

The Constant Score was significantly better when tendon healing was achieved (82/73, P < 0.001). In the AT group, the acromio-humeral distance was significantly smaller (6.9 mm/7.8 mm, P = 0.03) and eccentric humeral head position was more common (44%/26%,P = 0.01).

Comment: It would have been interesting to know how many of the shoulders with cuff tears examined arthroscopically were deemed 'irreparable' and how this determination was made. Because the constant score includes a strength component, it is expected that shoulders with healed repairs would score better than those with unhealed or unrepaired tears. It is interesting to note, however, that the difference between repair and non-repair reported in this article did not reach the level of the minimal clinically important difference for rotator cuff tears (=10). Finally it is of note that acromioplasty sacrifices part of the coracoacromial arch and may not be benign for unrepaired cuffs. For that reason, we prefer the smooth and move procedure when cuff repair is not possible or desirable.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Risk factors for hospital readmission after shoulder arthroplasty - consequences

Hospital readmissions after primary shoulder arthroplasty.

These authors used State Inpatient Databases from 7 different states  to identify 26,218 patients who underwent hemiarthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty from 2005 through 2010.

These patients had an overall 90-day readmission rate of 7.3%. RTSA had the highest rate (11.2%), followed by hemiarthroplasty (8.2%) and TSA (6.0%; P < .001). Medical complications contributed to 82% of readmissions, and surgical complications contributed to 18%. Osteoarthritis was the most common medical diagnosis (11%), followed by deep venous thrombosis or pulmonary embolism (4.4%) and pneumonia (3.9%). Infection was the most common surgical cause of readmission (4.8%), followed by dislocation (4.6%). There was a stepwise increase in risk of readmission with increasing age as well as for patients with comorbidities. Patients with Medicaid insurance had more than a 50% greater risk of readmission than patients with Medicare. Procedures performed at medium-volume and high-volume hospitals showed lower risk of readmission than low-volume centers.

Comment: The importance of developing strategies for minimizing readmissions has recently be amplified by the Centers for Medicare and Medicaid Services' Readmission Reduction Program that requires CMS to reduce payments to hospitals with excess readmissions, a program that became effective for discharges beginning on October 1, 2012. It is of note that such a program can create an unintended consequence:  a disincentive to offer shoulder arthroplasty to older individuals on Medicaid insurance who have comorbidities. If such patients are to receive surgical care for shoulder arthritis, steps will be needed to modulate the risk to medical centers.

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Consultation for those who live a distance away from Seattle.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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To see other similar posts, click on the label of interest below.

Uncemented metal backed glenoids - high revision rate

Effect of glenoid cementation on total shoulder arthroplasty for degenerative arthritis of the shoulder: a review of the New Zealand National Joint Registry.

The first sentence of this article is worthy of our attention, "Despite the lack of literature showing improved results compared with cemented designs, uncemented glenoid components are still commonly used in total shoulder arthroplasty".

These authors used the New Zealand National Joint Registry data to compare the outcomes of uncemented and cemented glenoids in total shoulder arthroplasty for degenerative arthritis.

They retrieved data on 1596 patients, with a mean follow-up 3.5 years (range 2-10.7 years). 1065 had a cemented glenoid and 531 an uncemented component. The median follow-up time was 3.5 years (range, 2-10.7 years).There were no significant differences in any preoperative factors between the patients receiving cemented and uncemented glenoids. The revision rate for uncemented glenoids was 4.4 times higher than for cemented glenoids (1.92 vs 0.44 revisions per 100 component-years, P < .001).

Age <55 years was an independent risk factor for revision (P < .001). 

The uncemented prosthesis used in most of these cases has now been taken off the market. All of the cementless revisions were in shoulders receiving this component.

The most common reasons for revision are shown below.

These data are very interesting, in that (1) polyethylene failure and liner dissociation was the most common reason for revision in the uncemented metal backed glenoids, (2) rotator cuff failure was a common mode of failure, and (3) a high percentage of failures were related to posterior instability. It would be of great interest to know the glenoid pathology in these cases of posterior instability. 

The glenoid component remains the weakest link in total shoulder arthroplasty.

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To learn more about shoulder arthritis and what can be done about it, see the Shoulder Arthritis Book.

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Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, androtator cuff surgery as well as the 'ream and run essentials'

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Treatment of rotator cuff tears in patients over the age of 70 years

Rotator cuff tears after 70 years of age: A prospective, randomized, comparative study between decompression and arthroscopic repair in 154 patients.

The incidence of cuff tears in asymptomatic shoulders increases with age.

Thus discussion of management of cuff tears in older individuals is complicated by the observation that many are asymptomatic and probably chronic and atraumatic.

These authors report the results of a prospective, comparative, multicenter study of 154 patients 70 years of age or older in which treatment was randomize to arthroscopic repair or decompression. Of the included patients, 143 (70 repair and 73 decompression) were seen at one-year follow-up; these patients had an average age of 75 years. Inclusion criteria were:

patient 70 years of age or older (no upper limit);
complete supraspinatus tear that can be reduced without tendon release;
extension limited to the upper-third of the infraspinatus,
no significant subscapularis involvement;
fatty infiltration ≤ 3;
stage 1 or 2 retraction, according to the Patte classification;
flexible shoulder, with no subacromial or glenohumeralimpingement.

The exclusion criteria were :
massive tears requiring intra-operative arthrolysis;
non-reducible tear without excessive tension;
partial rotator cuff tear;
instability associated with the cuff tear.

This was not actually a randomized study; rather the authors used a comparative design because they felt that random allocation by drawing lots was "overly restrictive and hard for patients to accept". Instead they "indirectly randomized" consecutive cohorts to simplify the decision-making and explanations during patient care, and also to allow inclusion or every patient 70 years or older. The protocol attempted to recruit two consecutive 6-month cohorts. In half the centers, every patient of at least 70 years of age seen during the first 6 months was treated with surgical repair, while every patient seen in the next 6 months received palliative decompression. In the other half of the centers, the decompression cohort was recruited in the first 6 months and the repair cohort during the second 6 months. The patients in the two groups had similar ages, preoperative scores, severity of cuff tears and ease of tendon reduction. Nevertheless a more robust experimental design would be to randomize the treatment at surgery after the arthroscopic findings were documented; proper randomization avoids the risk of selection bias.

All patients had an acromioplasty; 92% had biceps tenotomy or tenodesis. The repair technique was single or double row according to surgeon preference. Apparently the decompression group received only an acromioplasty. Shoulders having only decompression were immobilized for 10 days and those having repair for six weeks.

Overall, patients were improved: Constant +33.81 (P<0.001), ASES +52.1 (P<0.001), SST +5.86 (P<0.001).
Patients having repair faired better than those having decompression: Constant (+35.85 vs. +31.8, P<0.05), ASES (+56.09 vs. +48.17, P=0.01), SST (+6.33 vs. +5.38, P=0.02). The difference observed between repair and decompression was greater in patients with more retracted tears and lesser in patients with more severe fatty infiltration.

No data on the integrity of the repairs is available. It has been reported that a high percentage of arthroscopic repairs may retear, even though the patients experienced excellent pain relief at one year.

So without the data on the integrity of the repairs, we do not know the relationship of the success of the repair in re-establishing the attachment of the tendon to bone to the success of improving the clinical outcome and do not understand the benefit of attempting a repair if it is not durable.

A final comment is that there is a risk in performing an acromioplasty in shoulders with a cuff defect: 'decompression' of a shoulder with a significant cuff defect may lead to anterosuperior escape and pseudo paralysis.

So, the bottom line is that careful thought needs to go into the decision of when to repair and when not to repair a cuff defect, especially atraumatic chronic tears in older individuals.

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Rotator cuff repair - age and tear retraction

Effect of age on functional and structural outcome after rotator cuff repair

Eighty-one men and 96 women with a mean age of 60.0 +/- 8.7 years had miniopen (47) or arthroscopic (130) single (59) or double row (118) rotator cuff repairs. The mean AP dimension of cuff tear at the footprint was 2.35 6 1.26 cm (range, 0.6-7.5 cm), and the mean retraction length was 2.32 6 1.12 cm (range, 0.5-5.0 cm). There were 7 small tears (<1 cm), 116 medium tears (1-3 cm), 39 large tears (3- 5 cm), and 15 massive tears (>5 cm).

An abduction brace was used for 4 weeks for small, 5 weeks for medium, and 6 to 7 weeks for large to
massive tears. Active-assisted ROM exercise was encouraged after the weaning off the brace. Muscle strengthening was started at 9 to 12 weeks postoperatively. All sports activities were permitted 6 months after the operation. Clinical and cuff integrity results by CT arthrogram were obtained at one year after surgery.

Patient age was higher in women (P .001); the nonsmoking group (P .001); the presence of biceps lesions (P <.001), higher fatty degeneration of the  cuff muscles (P <.001), larger size tear (P .001), more retraction of the tear (P <.001).

31% of the repairs were not intact at followup. Patients with retears had an average age of 63.7 +/- 7.5 while those with intact repairs had an average age of 58.4 +/- 8.7 years, (P <.001).

Univariate analysis were reported to be significant variables for the postoperative cuff integrity: symptom onset, level of sports activity, size and retraction of tear, status of the biceps, and the fatty degeneration of the supraspinatus, infraspinatus, and subscapularis, but the correlation coefficients, p values and confidence intervals are not provided. Retraction of the tear was an independent predictor of postoperative cuff integrity (p 0.011) as was fatty degeneration of the infraspinatus (p .04)

The Simple Shoulder Test scores for the entire group improved from 3 ± 3 to 8 ± 3. Age was not an independent variable of functional outcome.

This study demonstrates that age correlates with tear retraction and that tear retraction correlates with postoperative cuff integrity.

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