It is well recognized that patients under the age of 50 often have risk factors for inferior clinical outcomes from shoulder arthroplasty:
(1) more complex arthritis (avascular necrosis, capsulorrhaphy arthropathy, chondrolysis, rheumatoid arhritis, anchor arthropathy, post traumatic arthritis, failed non-arthroplasty surgery, post infectious arthritis, etc.),
(2) higher activity levels,
(3) higher expectations,
(4) increased longevity,
(5) increased risk of cutibacterium periprosthetic infection.
The arthroplasty options for managing arthritis in younger patients include: hemiarthroplasty, ream and run, total shoulder arthroplasty and reverse total shoulder arthroplasty. The choice among these options needs to be made by shared patient-surgeon decision making. Because of the many factors that weigh on this decision, it is unlikely that randomized controlled trials or propensity matching will yield patient-specific guidelines on "the best" approach for young patients with arthritis. Because the surgeon is the method, different surgeons will lean toward certain options based on their experience and training.
The authors of Anatomic Total Shoulder Arthroplasty Indications, Outcomes, and Survivorship in Patients Younger Than 50 Years of Age: A Systematic Review reviewed articles published in last 44 years and found 9 that met their inclusion criteria representing 184 shoulders in 173 patients with a mean age ranging from 33 to 44 years of age. As indicated above, a minority (38%) had primary osteoarthritis, while 35% had rheumatoid arthritis, 9% post-traumatic arthritis, 7% chondrolysis, 6% avascular necrosis, and 5% other. This spectrum is quite different from that of patients over the age of 50.
While patient reported outcomes were improved on average, the improvements were substantially less than those reported by older patients having primary osteoarthritis.
Implant survivorship ranged from 95 to 100% at 0 to 10yrs, 71% to 84% at 11 to 15yrs, and 61% to 84% at > 15yrs postoperatively. These data suggest that over one-third of patients having had an anatomic TSA at the age of 40 years of age had a revision for failure by the time they were over 55 years of age.
Revision rates and followup durations varied widely: 1/26 at 2.3yrs to 7/17 at 14.5yrs. The indications for revision are shown in this table below drawn from the data in the paper.
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Comment: As is the case in all reviews and longer term followup studies, it is likely that the implants and techniques used in these papers do not represent current practice. Longer term data on what is being done today will become available a decade from now, but at that time techniques and implants will be different than those used in current practice. As pointed out in Objective ignorance - a problem in predicting outcomes in climbing and in orthopaedic surgery we can't predict future outcomes from past data.
The one element that we do not expect to change is that, as pointed out by the authors of Comparison of patients undergoing primary shoulder arthroplasty before and after the age of fifty, younger patients have more complex pathological conditions, such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis. Only 21% of the younger patients had primary degenerative joint disease, whereas 66% of the older patients had that diagnosis.
With some of these diagnoses, such as rheumatoid and other inflammatory arthropathies, a glenoid component is commonly indicated. However when a glenoid component fails it typically leaves a large, difficult to manage defect in the glenoid bone.
- Therefore, for diagnoses such as capsulorrhapy arthropathy, secondary arthritis, AVN and primary osteoarthritis in patients with increased longevity and higher desired activity levels, there is a rise in interest in bone-preserving procedures that do not involve insertion of a glenoid component. Such procedures include a hemiarthroplasty alone or a ream and run (hemiarthroplasty with non-prosthetic glenoid arthroplasty).
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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).
