Shoulder Replacement in the Elderly with Anatomic versus Reverse Total Prosthesis? A Prospective 2-Year Follow-Up Study

These authors point out that in older patients with glenohumeral arthritis and an intact rotator cuff, there is uncertainty on whether an anatomic TSR (aTSR) or a reverse TSR (rTSR) is best for the patient.

They conducted a comparison study of same-aged patients aims to assess clinical and radiological outcomes of older patients (75 years or older) who received either an aTSR or an rTSR for either advanced primary glenohumeral osteoarthritis (OA) with or without an intact rotator cuff (RC), or an irreparable rotator cuff tear with minor osteoarthritis.

Decision on prosthesis type (aTSR or rTSR) depended on the rotator cuff’s status as assessed by clinical examination and imaging. If the patient had osteoarthritis but the cuff was intact and not degenerated, with no major muscle atrophy, the decision was made for an aTSR. If the patient had osteoarthritis and the RC was torn or degenerated, including severe fatty atrophy, the decision was made for an rTSR. If imaging demonstrated a massive irreparable RC tear with minor arthritis, an rTSR was indicated.

For the aTSR, a stemless Affinis® short humeral ceramic head component was used with a double-pegged, cemented, all-polyethylene glenoid component (below left). For rTSR, a Grammont-style humeral prosthesis was used—Aequalis Reversed II Shoulder System (below right).

They prospectively identified consecutive patients with a minimum age of 75 years who received an aTSR (n = 44) or rTSR (n = 51).

In addition to the differences in indications for the two procedures (see above), there were differences in age (77 aTSR vs 82 rTSR) and sex (%male 27% aTSR vs 10% rTSR). Preoperative active elevation was 84 degrees for aTSR and 72 degrees for rTSR.

They found postoperative improvement for ROM and all clinical assessment scores for both groups. Postoperative active elevation was 147 degrees for aTSR and 125 degrees for rTSR. Patient satisfaction was 98% for aTSR and 91% for rTSR.

There were significantly better patient reported outcome scores in the aTSR group compared with the rTSR patients. Both groups had only minor osteolysis on radiographs. No revisions were required in

either group.

The main complications were scapular stress fractures for the rTSR (n = 11) patients and acromioclavicular joint pain for both groups (aTSR = 2; rTSR = 6).

Comment: In contrast to yesterday's post, this is a prospective study with a low rate of patients lost to followup (albeit followup is easier to achieve at 2 years rather than 10).

Although the paper states, "both groups started from a similar basepoint for all indices", however, in fact the patient group differ with respect to diagnosis, demographics, and preoperative active range of motion - any or all of which can affect the postoperative assessment of comfort and function. This limits the ability to compare outcomes for aTSR and rTSR.

We agree with the authors that aTSR is an attractive option for most patients with osteoarthritis and an intact rotator cuff - irrespective of patient age - because of its dependable return of function and low rate of serious complications (our technique is shown in this link).

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