Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up

doi:10.1016/j.jse.2016.09.051

Journal of Shoulder and Elbow Surgery

Volume 26, Issue 5, May 2017, Pages 792-797

https://doi.org/10.1016/j.jse.2016.09.051 Get rights and content

Background

This study reports the outcomes of reverse shoulder arthroplasty (RSA) in patients younger than 55 years with midterm to long-term follow-up.

Methods

Sixty-seven patients (average age, 47.9 years; range, 21-54 years) were identified who underwent RSA with an average 62.3 months of follow-up (24-144 months). There were 35 patients (group 1) who had a failed arthroplasty and 32 patients (group 2) who underwent primary RSA. Clinical outcomes included the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, and range of motion. Complications included radiographic failures (fracture, dislocation, notching, loosening), infections, and nerve palsies.

Results

Group 1 showed significant improvements in flexion and abduction but not in external or internal rotation. Group 2 showed significant improvements in flexion, abduction, and internal rotation but not in external rotation. Both groups showed significant improvements in ASES and SST scores. In group 1, ASES score improved from 24.4 to 40.8 (P = .003), and SST score improved from 1.3 to 3.2 (P = .043). In group 2, ASES score improved from 28.1 to 58.6 (P < .001), and SST score improved from 1.3 to 4.5 (P = .004). The total complication rate was 22.4%. The total reoperation rate was 13.4%, and the revision rate was 8.9%. The implant retention rate was 91% at last follow-up.

Conclusion

RSA in patients younger than 55 years provides significant clinical improvements with high implant retention at up to 12 years. Patients undergoing revision RSA begin with worse function than those undergoing primary RSA, but they can expect similar degrees of improvement. Complications were higher but reoperation rates were lower in the revision group. No mechanical failures occurred in the primary group, with infection the cause of all revisions.

Section snippets

Methods

A retrospective analysis of a prospectively collected database was performed on 1809 RSAs performed from 2001 to 2013. The analysis included patients younger than 55 years at 2 institutions.

Inclusion criteria for this study included (1) patients who underwent RSA before the age of 55 years and (2) minimum of 24-month follow-up. Exclusion criteria included (1) follow-up <24 months, (2) incomplete clinical or radiographic data, and (3) history of motor or sensory deficit of the involved

Results

Demographic data for groups 1 and 2 are listed in Table I. Clinical results are listed in Table II, Table III.

Discussion

The treatment of arthritic conditions and rotator cuff deficiency in young patients is a challenging task. Whereas total shoulder arthroplasty has been shown to have better long-term improvements in pain and function compared with hemiarthroplasty, the survivorship declines after 10 years, causing concern for the longevity of these implants.2, 27, 28

Many surgeons have had concerns with the use of RSA in patients younger than 70 years because of the lack of long-term studies on the survivorship

Conclusion

RSA in patients younger than 55 years provides significant improvements in clinical outcomes and ROM of forward elevation and abduction with a high rate of implant retention at up to 12 years of follow-up. Patients undergoing RSA as a revision for failed previous arthroplasty begin with worse function and do not obtain the same postoperative results as patients undergoing primary RSA, but they can expect similar degrees of improvement in ROM, patient satisfaction, and clinical outcome scores.

Disclaimer

DJO Surgical provided funding for this study to the Foundation for Orthopaedic Research and Education. DJO Surgical did not have input into the design, data collection, analysis, or manuscript preparation.

Mark A. Frankle receives royalties and consulting fees from DJO Surgical.

Randall J. Otto receives consulting fees from DJO Surgical and honoraria for educational services from Arthrex, Inc.

References (29)

R. Bartelt et al.
Shoulder arthroplasty in patients aged fifty-five or younger with osteoarthritis
J Shoulder Elbow Surg
(2011)
E.M. Black et al.
Reverse shoulder arthroplasty as salvage for failed prior arthroplasty in patients 65 years of age or younger
J Shoulder Elbow Surg
(2014)
W.Z. Burkhead et al.
Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder
J Shoulder Elbow Surg
(1995)
P.L. Burroughs et al.
Shoulder arthroplasty in the young patient
J Arthroplasty
(2003)
T.B. Edwards et al.
A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study
J Shoulder Elbow Surg
(2003)
E.T.H. Ek et al.
Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years
J Shoulder Elbow Surg
(2013)
S.J. Hattrup
Revision total shoulder arthroplasty for painful humeral head replacement with glenoid arthrosis
J Shoulder Elbow Surg
(2009)
O. Levy et al.
Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up
J Shoulder Elbow Surg
(2015)
C.S. Radnay et al.
Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review
J Shoulder Elbow Surg
(2007)
M.D. Saltzman et al.
Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less
J Shoulder Elbow Surg
(2011)

R.A. Sershon et al.

Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years

J Shoulder Elbow Surg

(2014)

J.W. Sperling et al.

Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty or younger

J Shoulder Elbow Surg

(2004)

E.J. Strauss et al.

The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis

J Shoulder Elbow Surg

(2014)

D.S. Bailie et al.

Cementless humeral resurfacing arthroplasty in active patients less than fifty five years of age

J Bone Joint Surg Am

(2008)

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There are limited data documenting the safety and clinical outcomes following outpatient total shoulder arthroplasty (TSA) and reverse TSA (RTSA) compared to inpatient shoulder arthroplasty. It was hypothesized that there would be no significant differences in complication and emergency room (ER) visit rate between outpatient TSA and RTSA.
A prospectively maintained institutional registry was retrospectively queried for all patients undergoing primary TSA or RTSA between September 2016 and April 2019 and confirmed as having undergone outpatient surgery, defined as surgery performed at an ambulatory surgery center. Ninety-day complications, readmissions, and ER visits were analyzed for outpatient TSA and RTSA. The 90-day complications included infection, thromboembolic disease (pulmonary embolism, deep venous thrombosis), neurovascular injury, revision surgery, and inflammatory processes.
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Overall, the rate of complications, ER visits, and readmission rates in outpatient TSA and RTSA was found to be relatively low given the sample size of this study and minor complications reported. In addition, there were no readmissions or reoperations in either TSA or RTSA patients. Elevated body mass index may significantly increase the risk of complications after both a TSA and RTSA. This study suggests that outpatient TSA and RTSA are safe in selected patients.
Incidence of primary anatomic and reverse total shoulder arthroplasty in patients less than 50 years of age and high early revision risk
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Compared with the overall incidence of shoulder arthroplasty (SA), the relative risk and burden of revision may vary among patients specifically 40-50 years of age and less than 40 years of age. Our aim was to investigate the incidence of primary anatomic total SA and reverse SA, rate of revision within 1 year, and determine the associated economic burden in patients younger than 50 years.
A total of 509 patients less than 50 years old who underwent SA were included, using a national private insurance database. Costs were based on the grossed covered payment. Multivariate analyses were performed to identify risk factors associated with revisions within 1 year of the index procedure.
SA incidence in patients less than 50 years old increased from 2.21 to 2.5 per 100,000 patients from 2017 to 2018. The overall revision rate was 3.9% with a mean time to revision of 96.3 days. Diabetes was a significant risk factor for revision (P = .043). Surgeries performed in patients less than 40 years old cost more than those performed in patients aged 40-50 years for both primary ($41,943 ± $23,842 vs. $39,477 ± $20,874) and revision cases ($40,370 ± $21,385 vs. $31,669 ± $10,430).
This study demonstrates that the incidence of SA in patients less than 50 years old is higher than previously reported in the literature and most commonly reported for primary osteoarthritis. Given the high incidence of SA and subsequent high early revision rate in this subset population, our data portend a large associated socioeconomic burden. Policymakers and surgeons should use these data for implementing training programs focused on joint sparing techniques.
Evaluation of muscle strength recovery following superior capsular reconstruction using a tensor fascia lata graft: a comparison with the unaffected side
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Superior capsular reconstruction (SCR) using a tensor fascia lata graft has been performed in patients with irreparable rotator cuff tears and shoulder pseudoparalysis (PPS), and good clinical results have been reported. This procedure can be indicated for younger patients who are highly active in sports and manual labor from the viewpoint of joint preservation. However, this procedure supplements the defect with a graft that has no muscle contractility; therefore, the extent to which shoulder muscle strength is recovered after SCR remains unclear. We hypothesized that the recovery of muscle strength after SCR would not be normalized and would be only approximately 50% of that of the healthy (unaffected) side. This study aimed to evaluate muscle strength after SCR in patients with PPS due to irreparable rotator cuff tears and the extent of recovery by comparing with that of the unaffected side.
In total, 20 patients who underwent SCR for PPS using a tensor fascia lata graft with a minimum 2-year follow-up were included. Shoulder muscle strength in abduction, internal rotation, and external rotation was evaluated using a handheld dynamometer. Muscle strength was compared to that on the unaffected side, and the affected/unaffected ratio was measured. Shoulder range of motionand acromiohumeral distance were also evaluated.
The postoperative range of motions and acromiohumeral distance (4.0 ± 1.4 mm vs. 8.4 ± 1.9 mm, P < .001) were significantly improved compared to those preoperatively. In external and internal rotation, the muscle strength of the affected side was recovered by approximately 80% compared to that of the unaffected side. However, in abduction, the muscle strength of the affected side (2.9 ± 1.5 kg) could not reach 50% (48.0 ± 15.9%, range: 25.0%-76.5%) of that of the unaffected side (5.9 ± 1.8 kg).
Abduction strength was not sufficiently restored after SCR when compared to that on the unaffected side.
Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review
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Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs.
A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies.
Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes.
Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.
How common is nerve injury after reverse shoulder arthroplasty? A systematic review
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Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature.
A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms “reverse shoulder,” “reverse total shoulder,” “inverted shoulder,” and “inverted total shoulder” with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected.
After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases.
Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.
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There were 94 shoulders in 89 patients enrolled. Mean age of the cohort was 54.8 (range 18-60 years). Surgical indications included rotator cuff tear arthropathy, irreparable rotator cuff tear without arthritis, glenohumeral arthritis with erosive glenoid deformity, inflammatory arthropathy, proximal humerus fracture nonunion/malunion and failed prior shoulder arthroplasty. Sixty-one shoulders (70%) had undergone at least one prior surgery. Of these, 6 shoulders (6% of total cohort) had a prior failed arthroplasty. Clinical outcomes (American Shoulder and Elbow Surgeons score, Western Ontario Osteoarthritis of the Shoulder index; visual analog scale pain), radiographic outcomes and complications were analyzed and assessed for correlation with patient demographic factors.
The mean follow-up for this cohort was 4.9 years (range 2-12 years). Subjects experienced improvements in ASES score and pain (P < .001) and active forward elevation (88° preop to 135° postop, P < .001). Prior operation correlated with worse postoperative ASES and WOOS scores. Higher demand occupation correlated with less improvement in pain scores. The overall complication rate was 12%. Seven shoulders (7%) underwent an additional procedure. There was a 2% incidence of dislocation and a 4% incidence of acromial stress fracture. There was a 36% incidence of notching.
With medium-term follow-up, RTSA is a reliable and predictable operation to manage various pathologic conditions in patients aged 60 years or less. Patients predictably experience significant improvements in pain and range of motion while assuming a modest complication risk. Long-term study is needed to understand potential for late complications or implant failure.

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: This study was determined to be exempt from review by the Western Institutional Review Board.

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Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Disclaimer

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