These authors investigated the outcome of primary reverse total shoulder arthroplasty (RTSA) in 171 shoulders for 159 patients older than 80 years of age (mean age 84±2)
The main indications for RTSA was cuff tear arthropathy (43%), isolated rotator cuff tear (22%) and fracture (21%).
136 (79%) had physical examination with a mean follow-up of 41 months. Relative Constant Score improved from 39% ± 19% to 77% ± 16% and Subjective Shoulder Value from 31% ± 18% to 74% ± 22%. The range of motion and force improved significantly as well.
Of the identified 171 shoulders (159 patients), 31 (18%) (30 patients) were not available for further clinical examination. 10 patients (6%) passed away before regular follow-up. 18 patients (11%) were unable to travel for further examination because of high age or poor health, three patients (1%) could not be contacted. This left a total of 140 cases. Four of these were excluded for further analysis because of glenoid component dislocation with massive bone loss. They were revised to hemiarthroplasty in three cases and persistent implantation of a spacer in one case.
The surgical site complication rate was 30% with a reoperation rate of 8% (13 patients) mainly due to fracture and glenoid loosening. These were periprosthetic fractures of the humeral stem in 6 cases (4%), fractures of the acromion in 5 cases (3%) and the scapular spine in 3 cases (2%). All fractures occurred postoperatively, 38% were related to a fall. 5 of the 6 stem fractures were treated operatively, all acromion and scapular spine fractures were treated conservatively. There were 9 cases (5%) of glenoid loosening potentially related to a fall. Four of them with complete displacement (2 following a definite fall) underwent revision surgery. Overall, there were 4 periprosthetic infections (2%), of which 2 needed multiple revisions surgeries. The other 2 were treated with antibiotics without revision surgery. In 2 cases a transient neurologic lesion of the radial nerve or the axillar nerve was recorded. There were 2 postoperative hematomas, one was treated surgically. Another patient underwent débridement for painful scarring.
Of 159 patients older than 80 years receiving an RTSA, a total of 26 patients (16%) in 30 cases (18%) died during the follow-up period. They passed away at a mean time of 53 ± 31 months all unrelated to the implant surgery.
During the hospitalization, no major medical complications occurred. There were three patients with treatment-requiring dyspnea. In two cases the dyspnea was explained by the regional anesthesia which involved the diaphragm. Pulmonary embolism was ruled out in these two cases but confirmed in the third. There were two cases of acute decompensation of chronic heart failure, which could be treated conservatively.
Comment: RTSA is a major surgical procedure, especially for octogenarians. At least 2/3rds of the cases were performed for elective indications (cuff tear arthropathy and rotator cuff tear). Over a third of the patients experienced serious complications, including glenoid component dislocation, glenoid loosening, fractures of the humeral stem, acromion and scapular spine, infections, neurolgic lesions, hematoma, dyspnea, and decompensation of chronic heart failure. Such complications are more threatening in older individuals.
The decision to perform an elective reverse total shoulder on a patient over 80 years of age must be made with caution and care. Non-operative management (see this link), non-prosthetic surgical approaches (see this link) and more conservative arthroplasty approaches to cuff tear arthropathy (see this link) and rotator cuff tear need to be considered in light of the risks highlighted in this study.
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