This study reported patient-reported outcomes, satisfaction, complications, revisions, and prosthesis survivorship of reverse shoulder arthroplasty (RSA) performed by a single, high volume shoulder arthroplasty surgeon at a minimum of 10 years using a Grammont design prosthesis.
The authors' prospectively collected shoulder arthroplasty registry included 471 patients who had RSA prior to December 31, 2010. The study sample included 94 patients (20%) with a minimum of 10 years’ follow-up: 63% female (60) and 37% male (34), with an average age of 66 years at the time of RSA. There were 70 (75%) primary RSAs and 23 (25%) revision RSAs.
For patients available at 10 years or more, the pain rating averaging 2 on a 0-10 scale and Single Assessment Numeric Evaluation (SANE) of 73. Overall, these patients were satisfied with the RSA procedure, with 52 (56%) very satisfied, 24 (26%) satisfied, 13 (14%) dissatisfied, and 4 (4%) very dissatisfied.
Kaplan-Meier prosthesis survival rate for all 471 RSA patients was 88% at 5 years and 81% at 10 years.
In the primary RSA group, 41 of 70 patients (58%) had postoperative complications; 4 patients had multiple complications. They were, in order of frequency, dislocation (11), PJI (11), periprosthetic fracture (7), acromial stress fracture/reaction (5), aseptic baseplate loosening (4), subjective
instability (defined as patients who felt that their shoulder was ‘‘clicking’’ or ‘‘near dislocating,’’ and whose symptoms improved after a polyethylene exchange) (2), traumatic glenoid loosening (1), early superficial wound infection (1), hematoma (1), symptomatic intra-articular loose body (1), and axillary nerve palsy (resolved at 6 months) (1). The percentage of patients who experienced complications that occurred during the 0-6-month, 6-month to 2-year, 2-5-year, 5-10-year, and post–10-year time points for primary RSA were 24%, 16%, 21%, 32%, and 8%, respectively.
In the revision RSA group, 19 of 23 (83%) patients had postoperative complications. These included PJI (6), dislocations (5), dislocations followed by diagnosis of PJI (3), periprosthetic humerus fracture (2), aseptic baseplate loosening (2), and aseptic humeral loosening (1). Twelve (53%) patients in the revision RSA group required revision.
The complications are presented by time of occurrence.
For the first 6 months (24%):
After 10 years (8%).
Comment: This is an important and insightful study providing long-term (10 year) followup on reverse total shoulders. 94 of 471 RSAs performed during the study period met inclusion criteria. Among these, the observed complication rate was 46% for the primary RSAs and 74% for the revision group. 51% of the patients required either a reoperation or component revision.
As could be expected, the percentage of patients available for long term study (20%) is only a fraction of the original cohort. We cannot know whether this selection bias would result in a relative over-representation of patients with complications because they may have returned for followup care at a higher rate than those without complications.
Nevertheless it is interesting is that dislocations, periprosthetic infections (PHI), baseplate loosening, acromial stress fractures, and humeral sided complications continued to occur throughout the entire period of the study - patients are apparently never "out of the woods" for this problems.
It is likely that the complication rate in this practice will have diminished with refinements in techniques, patient selection, implants and rehabilitation protocols. It will be of great interest to have an update from this highly experienced surgeon to confirm the this is the case.
In that many surgeons are now advocating "reverse for all" types of arthritis, including osteoarthritis with an intact cuff, the long term outcomes and complications of RSA need to be carefuelly measured against those of conventional approaches - such as anatomic total shoulder for osteoarthritis - with long term records of safety and efficacy. Surgeons also need to weigh off the prospects for successful revision for a failed RSA in comparison to those for a failed anatomic arthroplasty.
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