These authors point out that reverse shoulder arthroplasty (RSA) has gained popularity in elderly patients. They sought to compare the outcomes of RSA to those for anatomic total shoulder arthroplasty (TSA) in elderly patients at a minimum of 2 years after surgery.
They included patients between the age of 50 and 89 years who underwent primary TSA
for osteoarthritis with intact rotator cuff or primary RSA for cuff tear arthropathy. The minimum
and mean clinical follow-up was 2 and 3.1±1.3 years, respectively. All surgeries were performed by an individual highly experienced shoulder surgeon.
Four patient groups were formed for analysis:
[1] TSA aged 50-69 years (n=274),
[2] TSA aged 70-89 years (n=208),
[3]RSA aged 50-69 years (n=81), and
[4] RSA aged 70-89 years (n=104).
All groups showed significant improvements from preoperative to final follow-up for all outcome measures. Pain (VAS) decreased from 5.8 preoperatively to 1.1, with no significant differences between groups.
Final ASES scores and improvement from preoperative ASES score between the age groups were not significantly different .
There were no significant differences in outcomes between TSA in patients over 70 years of age versus patients less than 70 years, however older RSA patients reported better function during activities of daily living than their younger counterparts.
Overall, thirty-four patients were revised within 5 years of the primary arthroplasty. Patients undergoing TSA had a significantly lower revision rate with 19 of 482 (3.9%) of patients being revised as compared to 15 of 185 (8.1%) patients undergoing RSA.
In the TSA study groups, aseptic glenoid loosening was the most frequent indication for revision in the TSA group (6 patients; 1.2% of all TSA), followed by instability (5 patients; 1.0% of all TSA) and rotator cuff tears tied (5 patients; 1.0% of all TSA).
In the RSA group, instability accounted was the most common indication for revision (9 patients; 3.2% of all RSA), followed by infection (5 patients; 2% of all RSA) and periprosthetic fracture (1 patient; 0.5% of all RSA). All 5 patients in the RSA study groups initially revised due to infection underwent a second revision. The indications for the second revision were chronic infection in 3 patients, instability in 1 patient and 1 patient sustained a glenoid fracture.
Two patients who were initially revised for aseptic glenoid loosening with bone loss required second revisions for aseptic component loosening (1) and a periprosthetic fracture sustained from a fall (1).
Patients older than 70 years of age who underwent RSA were more nearly four times more likely to undergo revision at early to midterm follow-up compared to TSA in patients older than 70 years of age; however this comparison needs to be viewed in light of the different indications for each procedure.
Given satisfactory results following TSA in patients 70 years of age and older, these authors do not
routinely perform reverse total shoulder arthroplasty for primary osteoarthritis with an intact
rotator cuff in older patients.
Comment: This study demonstrates that results for anatomic TSA performed for arthritis are comparable to the results of RSA performed for cuff tear arthropathy. It does not compare TSA and RSA for patients with arthritis and intact rotator cuffs.
Interestingly, patient satisfaction was highest for patients over 70 having anatomic TSA.
The observation that older patients may do better with anatomic total shoulders is consistent with the results in a prior study (click on this link: Ream and run and total shoulder: patient and shoulder characteristics in five hundred forty-four concurrent cases).
Here is a figure from that paper showing (in orange) the results of TSA by patient age (the results in green are for patients selecting the ream and run procedure).
The bottom line is that a well done anatomic total shoulder arthroplasty is a highly effective and safe treatment for individuals with shoulder arthritis and an intact rotator cuff, especially in older individuals.
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