Is Anatomic Total Shoulder Arthroplasty an Appropriate Treatment for Older Patients with Glenohumeral OA?
Dr. Joaquin Sanchez-Sotelo answers ICJR’s questions about a study from Mayo Clinic evaluating outcomes in patients age 70 and older who underwent anatomic total shoulder arthroplasty to treat glenohumeral osteoarthritis.
ICJR: What question did you and your co-authors want to answer with this study?
Joaquin Sanchez-Sotelo, MD, PhD: In the field of shoulder arthroplasty, a common question is whether reverse shoulder arthroplasty (RSA) should be considered for the majority of patients requiring shoulder replacement after the age of 70. That question implies that anatomic shoulder arthroplasty (aTSA) is associated with poor outcomes and a high rate of complications in this age group and is, therefore, inappropriate for older patients. Yet RSA is associated with its own set of complications.
With that background, the primary purpose of our study was to determine the outcome of aTSA performed in older patients, specifically those age 70 and older, with primary glenohumeral osteoarthritis (OA) and an intact rotator cuff.
ICJR: What did you conclude about outcomes of aTSA in older adults with glenohumeral OA?
Dr. Sanchez-Sotelo: Between January 1, 2010, and December 31, 2017, Dr. John Sperling and I performed 337 aTSAs for primary glenohumeral OA at Mayo Clinic. We analyzed the outcomes of these procedures and found that our patients experienced substantial postoperative improvements in pain, motion, and function. More importantly, revision surgery was required for only 3 shoulders (0.8%), and the 5-year estimated survival free of reoperation was 99%.
With those results, we concluded that it’s hard to improve on the outcomes of aTSA in patients age 70 and older.
ICJR: How did you reach your conclusions? What was your study cohort and what did you find with your analysis?
Dr. Sanchez-Sotelo: This was a retrospective cohort study of all patients who had undergone primary aTSA for glenohumeral OA at age 70 or older. The mean age at the time of surgery was 76.2 years and 54% of patients were female. All shoulders were followed prospectively for an average of 3.3 years using our institutional Total Joint Registry Database. We did not lose any patients to follow-up. Information was retrieved from the registry and confirmed by review of the electronic medical record for each patient. We also reviewed radiographs obtained before and after surgery and at the most recent follow-up visit.
At most recent follow-up, the mean visual analogue scale score for pain was 1.6, the mean ASES score was 78, mean elevation was 160°, and mean external rotation was 64° at the most recent follow-up visit. More importantly, internal rotation higher than L5 was achieved by approximately 80% of patients. The very low rate of reoperation and encouraging survival free of reoperation were already highlighted. Complications were observed in only 19 patients: 4 medical complications, 10 minor surgical complications, and 5 major surgical complications.
ICJR: Why is this significant for clinical practice?
Dr. Sanchez-Sotelo: Based on the results of this study, we believe aTSA should be considered for the majority of patients age 70 and older with primary glenohumeral OA and an intact rotator cuff, provided the severity of preoperative glenohumeral subluxation and glenoid bone loss are not extreme. Age by itself cannot be considered an indication for RSA over aTSA. Reliable restoration of internal rotation in 80% of the shoulders and complete avoidance of fractures of the acromion or spine are additional comparative benefits of aTSA versus RSA. However, many older patients with a compromised rotator cuff or severe glenohumeral imbalance or bone loss would clearly benefit from RSA.
About the Expert
Joaquin Sanchez-Sotelo, MD, PhD, is a Consultant and Professor of Orthopedic Surgery and Chair of the Division of Shoulder and Elbow Surgery at Mayo Clinic, Rochester, Minnesota.
Jensen A, Tangtiphaiboontana J, Marigi E, Mallett KE, Sperling JW, Sanchez-Sotelo J. Anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis is associated with excellent outcomes and low revision rates in the elderly (Paper 761). Presented at the Presented at the 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons, August 31-September 3, San Diego, California.
Jensen A, Tangtiphaiboontana J, Marigi E, Mallett KE, Sperling JW, Sanchez-Sotelo J. Anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis is associated with excellent outcomes and low revision rates in the elderly. J Shoulder Elbow Surg. 2021 Jul;30(7S):S131-S139. doi: 10.1016/j.jse.2020.11.030. Epub 2021 Jan 20.