Patients having total shoulder arthroplasty are at increase risk for falling

Preoperative Screening in Patients having Elective Shoulder Surgery Reveals a High Rate of Fall Risk

These authors point out that patients having shoulder surgery are at increased risk for falls for a number of reasons, including advanced age, impaired upper extremity function, the use of shoulder abduction braces, and postoperative use of opioid medications. 

Their goal was to examine preoperative fall risk in patients undergoing elective shoulder surgery. They suggest that gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cut-off scores indicating increased fall risk.The TUG score (>14 seconds considered high fall risk) and 10 Meter Walk test (<0.7 m/s considered high risk for falls) were recorded for each patient. 

They quantified gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA).

Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed <0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group.  Twenty-nine percent of TSA patients and 12% of RCR patients were determined to be at high fall risk based on a TUG score >14 seconds. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk.

They conclude that  fall risk screening may be important for patients undergoing TSA and RCR surgeries and that higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.

Comment: This study uses preoperative measures of fall risk. The preoperative risk is often compounded after surgery by the after effects of anesthesia, pain medications, and shoulder immobilizers. Other important factors include eyesight, railings and lighting on stairs, shoe wear, cardiac conditions, seizures, lower extremity issues, anemia, alcohol, fluid and electrolyte disorders, hearing problems, frailty, dogs, and lack of social support.

In that the consequences of falls after surgery can be major (head injury, fractures, tendon disruption, dislocation), a good overall assessment before surgery is necessary as is a careful evaluation before the patient leaves the medical center. Taking a fall and balance history before surgery and checking to be sure the patient can get out of bed and walk securely before discharge are important and simple steps. 

A fall can ruin the results of a fine surgery. All efforts at prevention are worthwhile.

How you can support research in shoulder surgery Click on 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 total shoulder arthroplasty (see this link).

The ream and run technique is shown in 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).

More than one in ten patients fall after shoulder arthroplasty

High prevalence of outpatient falls following elective shoulder arthroplasty

These authors carried out a retrospective chart review of 198 of their patients undergoing anatomic or reverse total shoulder arthroplasty or hemiarthroplasties to determine the prevalence of inpatient and outpatient falls up to 90 days after discharge.

There were 23 falls in 22 patients within a 90-day postoperative period. The inpatient fall rate was 1.0% (2 of 198). The outpatient fall rate was 10.6% (21 of 198). Outpatient falls resulted in emergency department evaluation in 23.8% of cases (5 of 21), readmission in 19.0% (4 of 21), injury to an anatomic site other than the shoulder in 19.0% (4 of 21), and injury at the surgical site (eg, periprosthetic humeral fracture) in 4.8% (1 of 21). 

No significant risk factors were identified for inpatient falls. 

Independent risk factors for an outpatient fall were female sex, increased length of hospital stay, and history of a movement disorder (Parkinson's, stroke, paraplegia).

Almost a quarter (23.8%) of outpatient falls resulted in a new, serious injury.

Nearly half of outpatient falls occurred within 30 days of discharge, while 38% occurred in the last third of the 90-day postoperative period. More than half of outpatient falls occurred in the 6-week period in which patients are instructed to wear shoulder slings to allow the subscapularis tendon to heal. 

Comment: A fall can destroy the prospects of a good outcome following shoulder arthroplasty. We make it a practice to discuss and address fall risk prior to surgery, stressing the importance of proper eye-wear, avoiding loose carpets, stairways without railing or adequate lighting, icy surfaces and rushing around. If movement disorders, cardiac conditions, stroke, epilepsy or similar conditions are present, we insist that these be optimized prior to surgery. We minimize the use of narcotics and other medications that increase fall risk. In the office we observe the patient's ability to rise from a chair and walk as well as the need for canes, crutches, or walkers. 

Finally, we incorporate our fall risk assessment in our selection of the type of surgery, for example using a CTA arthroplasty rather than a reverse for patients with cuff tear arthropathy and a high risk of falls.

Many of our patients with classical cuff tear arthropathy want to lead active lives. They wish to avoid a reverse total shoulder because of concerns about activity limitations, dislocation, screw breakage or humeral shaft fracture should they fall. If these individuals have active elevation > 90 degrees and have no evidence of anterior superior instability, we discuss the option of a CTA prosthesis.


Here's the example of a lady in her mid sixties with a failed cuff repair. Two years after that surgery she presented to us with a weak and painful shoulder. She was taking prednisone, methotrexate and Humira for her rheumatoid arthritis. She had active elevation to 110 and passive elevation to 160 degrees. Her x-rays at this time are shown below.

She elected a CTA arthroplasty. At surgery she had an irreparable cuff defect involving her supraspinatus and infraspinatus.

She dropped by to see us nine years after surgery. Her films at that time are shown below.

Her shoulder was painless. Her active elevation is shown below.

As another example we recently we saw an active physician-rancher who had had bilateral CTA prostheses performed after failed cuff repairs. Because he recognized that his ranching was demanding on his shoulders and carried the risk of falls, he preferred the CTA over the reverse total shoulder.

Before his left shoulder surgery his films were as shown below and he reported the ability to perform only 5 of the 12 Simple Shoulder Test functions. He was able to elevate his arm to over 90 degrees and had no anterosuperior instability.

At the time of surgery he had no supraspinatus, no infraspinatus and a detached subscapularis.
We were able to reattach his subscapularis.

At four years after surgery, he could perform 8 of the 12 SST functions and had the radiographs shown below. Note the impaction grafted humeral stem and the articulation of the prosthesis with the undersurface of the coracoacromial arch.

 

Two years ago he presented with a similar situation in his right shoulder. His SST score was 3/12. He had active elevation of 100 degrees without anterosuperior escape. His preoperative x-rays shown below.

Two years after his right shoulder arthroplasty he could perform 8/12 SST functions and was back at work on his ranch. His 2 year films are shown below.

 

Here's a video of his function at his last clinic visit.

To see our technique for the CTA arthroplasty, click on this link.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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How you can support progress in shoulder surgery