Is Total Shoulder Arthroplasty Appropriate for Patients Under Age 60?
Dr. Paul Cagle and Dr. Brad Parsons answer ICJR’s questions about their study evaluating long-term survivorship in patients with glenohumeral osteoarthritis who were younger than age 60 at the time of total shoulder arthroplasty.
ICJR: What question did you and your co-authors want to answer with this study?
Paul J. Cagle, MD: Young, active patients with glenohumeral osteoarthritis may be offered total shoulder arthroplasty (TSA) to relieve pain and restore function. Historically, however, TSA in this patient population has been under scrutiny due to reported high implant failure rates and challenging revision surgeries.
With this study, we wanted to understand the long-term viability of TSA in our younger patients, defined as those under age 60 when they underwent TSA. We hypothesized, based on our clinical experience, that TSA would offer them sustained pain relief and excellent range of motion at long-term follow-up, without significantly concerning revision rates.
ICJR: What did you conclude about outcomes of TSA in these younger patients?
Dr. Cagle: Total shoulder arthroplasty was found to be a safe option in our younger patients, with more than 80% survivorship at 20 years. We suspect that the few conversions to reverse TSA were due to age-related rotator cuff degeneration, not implant failure alone.
In addition, we saw significant and sustained improvements in range of motion and patient-reported outcomes. This suggests that the efficacy of TSA may be longer than 15 to 20 years, which will be better understood as these patients are tracked further.
ICJR: How did you reach your conclusions? What was your study cohort and what did you find with your analysis?
Dr. Cagle: We performed a retrospective, single-surgeon analysis of patients who were under age 60 at the time of TSA and who had a minimum of 10 years of follow-up. We included 29 patients with 34 operated shoulders. The mean age was 55 ± 5.5 years, with a mean follow-up of 16.1 ± 4.5 years.
We found that TSA significantly improved:
- Forward elevation: 119 ± 26º to 146 ± 21º; P<0.01
- External rotation: 21 ± 25º to 52 ± 15º; P<0.01
- Internal rotation: L5 to L1; P<0.01
In addition, TSA patients reported significantly increased ASES (32 ± 20 to 64 ± 27; P<0.01) and SST scores (3 ± 2 to 7 ± 4; P=0.0004), with a reduction in VAS pain scores (7 ± 3 to 3 ± 3; P=0.0001).
Radiographically, there was no significant difference between immediate postoperative and final follow-up radiographs in terms of mean lateral humeral offset (13 ± 6 mm vs 10 ± 12 mm; P=0.47) or acromiohumeral interval (20 ± 4.2 mm vs 16 ± 6 mm; P=0.06).
ICJR: Why is this significant for clinical practice?
Bradford O. Parsons, MD: The use of TSA in younger patients remains controversial. Although there is significant literature detailing improved shoulder function following TSA, there is limited literature showing excellent long-term survivorship in younger patients.
Our study contributes to the literature by demonstrating that TSA can be a viable option in younger patients with glenohumeral osteoarthritis, providing improved range of motion and function and reliable pain reduction. In addition, complication and revision rates in our study were comparable to those seen in older patients.
We believe that based on our findings, surgeons can feel comfortable offering TSA to their patients under age 60.
Brochin R, Zastrow R, Patel A, Parsons BO, Flatow EL, Cagle PJ. Long-term clinical and radiographic outcomes of total shoulder arthroplasty in patients under age 50 (Paper 411). Presented at the 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons, August 31-September 3, San Diego, California.
About the Experts
Paul J. Cagle, MD, is an Associate Professor and Associate Residency Program Director in the Leni & Peter May Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York.
Bradford O. Parsons, MD, is the Chief of Shoulder Service at the Mount Sinai Health System and a Professor of Orthopedic Surgery at the Icahn School of Medicine at Mount Sinai, New York, New York. He is also the Director of the Orthopedic Residency Program, Director of the Mount Sinai Shoulder Fellowship, and Vice-Chair of Education in the Leni and Peter W. May Department of Orthopedic Surgery.
Disclosures: Dr. Cagle has disclosed that he is a paid consultant for Arthrex, Inc., Johnson & Johnson Services, Inc., and Stryker Orthopaedics and that he has stock or stock options in Delphian Diagnostics. Dr. Parsons has disclosed that he receives royalties from and is a paid consultant for Arthrex, Inc.