Wednesday, March 31, 2021

Reverse total shoulder in patients over 80 years of age

 Primary reverse total shoulder arthroplasty in patients older than 80 years: clinical and radiologic outcome measures

These authors identified 171 shoulders in 159 patients treated by 11 different surgeons with RTSA at a mean age of 84 years with a  minimum follow-up of 1 year.

The main indication for RTSA was cuff tear arthropathy (43%), isolated rotator cuff tear (22%), and fracture (21%). 

For pain control, an interscalene catheter with ropivacaine was installed preoperatively and withdrawn

2 days postoperatively in most patients.

136 patients (79%) had clinical followup at 41 months. Relative Constant-Murley scores improved

from 39%  to 77%. The mean pain score was reduced from 6 points preoperatively to 14 Constant-Murley score points, where 15 points are defined as no pain and 0 points as the worst imaginable pain

The mean active anterior elevation improved from 64 to 109 degrees.

Overall, 76% of the patients rated their outcome as good or very good. 

The overall mortality was 16% with a mean time to death of 53 months. The earliest postsurgical

death occurred at 15 months postoperatively. The deaths were unrelated to the surgery.

During the hospitalization, 3 patients required treatment for dyspnea. In 2 cases, the dyspnea was explained by the regional anesthesia that involved the diaphragm. Pulmonary embolism was ruled out in these 2 cases but confirmed in the third. 

There were 2 cases of acute decompensation of chronic heart failure, which was treated conservatively.

A total of 30 (18%) local complications occurred, requiring reoperation in 13 cases (8%). 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, and 38% were related to a fall. 

Five 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 underwent revision surgery.

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 or axillar nerve was noted. 

There were 2 postoperative hematomas; 1 was treated surgically. Another patient underwent debridement for painful scarring.

Comment: This is an informative report of a substantial experience with RTSA in individuals over the age of 80. 

These authors used indwelling brachial plexus catheters X 2 days for pain management. Two patients experienced dyspnea from paresis of the diaphragm.

Falls were an issue in this patient population, resulting in humeral fractures, scapular fractures and glenoid component failure.

In our practice, we focus on the physiological age of the patient - some 85 year olds are better surgical candidates than some 60 year olds. Second, we strive to make sure all medical issues, such as cardiac disease, are under control before surgery. Third, we focus on social support, making sure the patient has a safe post-surgical environment. Fourth, we minimize the use of postoperative narcotics to reduce the risk of falls. Finally we consider more conservative procedures for rotator cuff tear arthropathy (see this link) and for painful irreparable rotator cuff tears (see this link).

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).