Anatomic Total Shoulder Arthroplasty for Primary Glenohumeral Osteoarthritis is
Associated with Excellent Outcomes and Low Revision Rates in the Elderly
These authors point out that the relative indications of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) continue to evolve. Some surgeons favor RSA over TSA for elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff due to fear of a postoperative (secondary) rotator cuff tear in this age group. However, RSA is associated with unique complications and a worse functional arc of motion compared to TSA.
They identified 377 consecutive TSAs performed for primary GHOA in 340 patients seventy years of age or older (mean 76.2 years (SD 4.9)). Augmented glenoid components were not used in this cohort even though 40% of the shoulders had "type B" glenoid pathology. The average clinical follow-up time was 3.3 years
Clinical scores and range or motion were significantly improved.
Revision surgery was performed in three shoulders (0.8%) and the five-year implant survival estimate was 98.9%. There were three medical (0.8%), ten minor surgical (2.7%), and five major surgical (1.3%) complications. There were three intraoperative fractures (0.8%), two of which involved the greater tuberosity and one that involved the anterior humeral cortex. All three fractures were nondisplaced and fixed at the time of the index procedure with non-absorbable suture. Postoperative management was not altered for these patients, and none of these three shoulders had radiographic evidence of component loosening or required a subsequent revision surgery. The major surgical complications included three dislocations, one deep infection that was treated with long term suppressive antibiotics, and one periprosthetic humeral shaft fracture due to a mechanical fall that was treated successfully in a fracture brace.
No shoulder had radiographic evidence of humeral component loosening while seven (2%) had evidence of some degree of glenoid component loosening.
The authors did find that there was a progression of anterior and superior humeral head subluxation rates between first postoperative radiographs and final radiographs. These radiographic findings may be indicative of anterosuperior rotator cuff thinning or dysfunction over time. However, no correlation could be identified between proximal or anterior humeral head migration and a decrease in VAS or ASES scores indicating that, even if radiographic anterior and superior subluxation is considered to be a surrogate of progressive rotator cuff wear, this radiographic finding in isolation may have limited clinical impact.
In total, there were five secondary rotator cuff tears (1.3%), of which two (0.5%) required revision surgery. The authors concluded that age greater than seventy by itself should not be considered an indication for RSA over TSA.
Comment: This article supports the view that older patients with osteoarthritis and an intact rotator cuff can achieve durable improvement in comfort and function with an anatomic total shoulder arthroplasty rather than a reverse total shoulder. These authors point out that the choice of RSA over TSA in patients with intact rotator cuffs is not without potential adverse consequences, however, as RSA is associated with certain unique complications not seen in TSA. These complications include acromial and scapular spine fractures, inferior glenoid notching, and subcoracoid impingement. Some authors have also found a higher rate of deep infection in patients undergoing RSA when compared TSA. In addition, restoration of motion seems to be superior with anatomic TSA, especially in terms of internal rotation.
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