Shoulder arthroplasty in patients over 70 - risk of complications greater than 10%.

Arthroplasty in Patients 70 Years and Older With Glenohumeral Osteoarthritis and an Intact Rotator Cuff

These authors conducted a retrospective cohort study of 135 patients who underwent reverse total shoulder (RSA) or total shoulder arthroplasty (TSA) at a single tertiary orthopedic center between 2005 and 2015 and were 70 years of age or older at the time of surgery. All patients had preoperative advanced imaging confirming an intact rotator cuff but active forward elevation less than 90.

The decision to perform anatomic TSA versus RSA was left to the discretion of the treating surgeon based on a combination of clinical and radiographic findings. In general, RSA was chosen as the preferred treatment when there was clinical concern for the ability of the patient to regain functional range of motion based on their clinical presentation. 33 shoulders underwent RSA and 102 underwent TSA.

They found no significant difference in complication rate or revision surgery rate between patients undergoing TSA and RSA (complications 13.7% versus 12.1%; reoperations 6.9% vs 3.0%. There were no differences in patient-reported outcome measures between the two groups. 

One hundred percent of subjects following RSA and 98% of subjects following TSA rated their forward elevation as full or nearly full.

There were 4 complications (12.1%) in the RSA group and 14 complications (13.7%) in the TSA group. Complications in the RSA group included one infection, one fracture, one nerve palsy, and one vascular injury whereas complications in the TSA group included 11 rotator cuff tears, 2 fractures, and one recurrent dislocation.

Of the 102 TSAs , seven required repeat surgery at an average of 28 months after the initial surgery, for an overall revision surgery rate of 6.9%. Six of the seven revision surgeries were for conversion to RSA. The indications for revision to RSA were posterior rotator cuff tear (four subjects), greater tuberosity fracture with rotator cuff dysfunction (one subject), and persistent posterior instability (one subject). One of the seven revision surgeries was an irrigation and debridement of a hematoma performed 2 weeks postoperatively.

Of the 33 RSAs performed, one required repeat surgery at 21 months after the index procedure, for a reoperation rate of 3.0%. This procedure was an explant for infection. 

Comment: When considering the treatment options for patients over 70 with arthritis and the inability raise the arm above 90 degrees, these surgeons selected anatomic arthroplasty in over 75%.  It is not clear whether the inability to raise the arm was related to stiffness (limited passive motion) or to weakness (intact passive motion but limited active motion). 

While preoperative MRI and intra operative assessment indicated the cuff was intact, rotator cuff failure accounted for most of the complications (11 of 14) in the anatomic arthroplasty group. 

The complications after RSA were of different types and severity: nerve injury, infection and vascular injury. 

In our practice, we prefer anatomic arthroplasty for patients over 70 who have good strength on clinical examination. Reverse total shoulder is preferred for patients with pseudoparalysis or substantial cuff weakness on examination.

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