Reverse Shoulder Arthroplasty in Patients Younger than 55 Years

ARTICLE IN PRESS J Shoulder Elbow Surg (2016) ■■, ■■–■■ www.elsevier.com/locate/ymse ORIGINAL ARTICLE Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up Randall J. Otto, MDa, Rachel E. Clark, BA, CCRCb, Mark A. Frankle, MDc,* a Shoulder and Elbow Service, Premier Care Orthopedics & Sports Medicine, St. Louis, MO, USA Clinical Research, Foundation for Orthopaedic Research and Education, Tampa, FL, USA c Shoulder and Elbow Service, Florida Orthopaedic Institute, Tampa, FL, USA b 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. Level of evidence: Level IV; Case Series; Treatment Study © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Reverse shoulder arthroplasty; young patients; long-term follow-up; revision arthroplasty; primary arthroplasty; complications This study was determined to be exempt from review by the Western Institutional Review Board. *Reprint requests: Mark A. Frankle, MD, Florida Orthopaedic Institute, 13020 N Telecom Pkwy, Tampa, FL 33637, USA. E-mail address: [email protected] (M.A. Frankle). The management of severe glenohumeral pathologic processes, such as arthritic conditions and rotator cuff deficiency, in the young adult has been a challenge in deciding the appropriate treatment. It has been shown that patients with glenohumeral arthritis younger than 50 years present with more 1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2016.09.051 ARTICLE IN PRESS 2 complex disease, and the outcomes of arthroplasty in this population of patients are less predictable than those of arthroplasty performed in older patients with osteoarthritis.1,2,5,17,18,22,23,25 Glenoid erosion can lead to failure of hemiarthroplasty and the need for conversion to total shoulder arthroplasty.7,11,12,22,27,28 Alternative techniques, such as glenoid biologic resurfacing and concentric reaming, have been suggested in combination with hemiarthroplasty to try to reduce the potential problems that may arise from the glenoid.4,9,14,19,21,24,29 Conversely, glenoid component loosening has been a concern with total shoulder arthroplasty in this population of patients.5,7,22,23,25 Previous studies on arthroplasty in young patients have reported significantly improved long-term pain relief and range of motion (ROM); however, the results, as assessed by the Neer rating system, were unsatisfactory in nearly half of the patients.27,28 Recent reports have suggested more favorable outcomes in short-term to midterm follow-up of total shoulder arthroplasty.1,2,7,22,23 In addition to arthritic processes, younger patients also present with rotator cuff deficiencies or failed arthroplasty operations that preclude the use of an anatomic shoulder arthroplasty. There are few reports specifically evaluating the outcomes of reverse shoulder arthroplasty (RSA) in younger patients.3,8,20,26 The purpose of this study was to report the clinical and radiographic outcomes of RSA in patients younger than 50 years and to discuss the complications, reoperation rates, and implant retention in midterm to long-term followup. Many of these young patients are still in the workforce and may have many working years remaining. Our goal was to evaluate the outcomes of RSA in these younger patients. Our hypothesis is that the results for primary and revision RSA in this population of patients will be similar to those reported in the literature. 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 24month 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 extremity, such as brachial plexopathy. The analysis revealed 67 patients younger than 55 years (average age, 47.9 years; range, 21-54 years) who underwent RSA with a minimum 2-year follow-up (average, 62.3 months; range, 24-144 months). These patients were separated into 2 groups. Group 1 included 35 patients with failed arthroplasty surgery converted to RSA (Fig. 1) Group 2 included 32 patients undergoing a primary RSA (Fig. 2). All patients underwent RSA by 2 fellowship-trained surgeons using the Reverse Shoulder Prosthesis (DJO Surgical, Austin, TX, USA). All primary surgeries were performed using a standard deltopectoral approach as previously described.10 Revision surgeries R.J. Otto et al. Figure 1 (A) A 53-year-old woman with a failed right total shoulder arthroplasty for a proximal humerus malunion and posttraumatic arthritis. (B) The same patient after revision to a reverse shoulder arthroplasty at last follow-up. Figure 2 (A) A 49-year-old man with right shoulder advanced glenohumeral arthritis and a rotator cuff tear. (B) The same patient with a right reverse shoulder arthroplasty at last follow-up. were performed through the previous incision if possible; otherwise, a new deltopectoral incision was made. Four revision cases with proximal humeral bone loss underwent proximal humeral bone grafting with a proximal humeral allograft, as previously described.6 Cases with glenoid bone loss requiring bone graft were reconstructed with autograft from the native humeral head in primary cases and femoral head allograft in revision cases by techniques previously described.13 There were 6 cases that required glenoid bone grafting. All cases had rotator cuff deficiencies preventing the use of an anatomic shoulder prosthesis. Clinical and radiographic data were obtained at intervals of 1 week, 6 weeks, 3 months, 6 months, 1 year, and yearly thereafter. Clinical outcome scores included the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Simple Shoulder Test (SST) score, and patient satisfaction scores. The patient’s ROM was assessed with clinical examination and video goniometer. Radiographic data consisted of a complete 4-view shoulder series consisting of anteroposterior, Grashey, scapular Y, and axillary lateral views. Radiographs were reviewed for notching, fracture, instability, polyethylene wear, and implant loosening. Complications were recorded, including radiographic failures, infections, and nerve palsies. Implant retention rates were performed ARTICLE IN PRESS RSA in patients younger than 55 years 3 for end points of reoperation for any reason and revision shoulder arthroplasty. The characteristics of the study population were described using measures of central tendency (mean) and variability (standard deviation and range). Significant differences between variables were evaluated using χ2 and analysis of variance. Nonparametric alternatives (Mann-Whitney U and Wilcoxon signed ranks tests) were used when assumptions for parametric methods are not met. All differences in comparisons were considered statistically significantly different at an α level of P < .05. Forward elevation* Abduction* External rotation* Internal rotation* ASES score SST score Results ASES, American Shoulder and Elbow Surgeons; SST, Simple Shoulder Test. * Range of motion is listed as the average. Table III Group 2 (primary) functional results Before surgery Final follow-up P value 64.8° 51.8° 11.3° Greater Trochanter 28.1 1.3 113.2° 107.8° 30° L3-L4 58.6 4.5 .001 <.001 .142 .019 <.001 .004 Demographic data for groups 1 and 2 are listed in Table I. Clinical results are listed in Tables II and III. P < .001), and internal rotation (greater trochanter to L3L4; P = .019) but not in external rotation (11.3° to 30°; P = .142). Range of motion Group 1 showed significant improvements in preoperative to postoperative forward elevation (49.5° to 85.7°; P = .001) and abduction (45.6° to 79°; P = .002) but no improvement in external rotation (13° to 15.7°; P = .712) or internal rotation (greater trochanter to L5-S1; P = .241). Group 2 showed significant improvements in forward elevation (64.8° to 113.2°; P = .001), abduction (51.8° to 107.8°; Table I Demographic data Number Male:female Age, years (range) Follow-up, months (range) Right:left Diagnosis Group 1 (revision) Group 2 (primary) 35 14:21 45.6 (21-54) 64.6 (25-143) 32 19:13 48.9 (22-54) 59.8 (24-141) 21:14 23 failed hemi 11 failed TSA 1 failed RSA 20:12 11 failed RC surgery 10 cuff tear arthropathy 5 fracture 4 osteoarthritis 2 rheumatoid arthritis Hemi, hemiarthroplasty; TSA, total shoulder arthroplasty; RSA, reverse shoulder arthroplasty; RC, rotator cuff. Table II Group 1 (revision) functional results Forward elevation* Abduction* External rotation* Internal rotation* ASES score SST score Before surgery Final follow-up P value 49.5° 45.6° 13° Greater trochanter 24.4 1.3 85.7° 79° 15.7° L5-S1 40.8 3.2 .001 .002 .712 .241 .003 .043 ASES, American Shoulder and Elbow Surgeons; SST, Simple Shoulder Test. * Range of motion is listed as the average. Clinical outcomes Both groups showed significant improvements in ASES and SST scores. Group 1 showed improvements in ASES score from 24.4 to 40.8 (P = .003) and in SST score from 1.3 to 3.2 (P = .043). Group 2 showed significant improvements in ASES score from 28.1 to 58.6 (P < .001) and in SST score from 1.3 to 4.5 (P = .004). There was no difference in satisfaction of patients between the groups (P = .321). With a satisfaction score on a scale of 1 to 10, group 1 had a score of 7.0 and group 2 had a score of 7.5. When asked if they would have surgery again, group 1 answered yes 97% and group 2 answered yes 96%. Both groups had similar degrees of improvements from their preoperative to postoperative function with regard to ROM, ASES score, and SST score (Δ ROM, P > .2; Δ ASES score, P = .08; Δ SST score, P = .364). There was no significant deterioration of results over time as the outcomes were recorded on a yearly basis. Complications The total complication rate was 22.4%. Group 1 had a complication rate of 25.7%, and group 2 had a complication rate of 18.7%. The total scapular notching rate was 4.5%. Group 1 had a notching rate of 2.8%, and group 2 had a notching rate of 6.2%. There were no documented nerve palsies in either group. Group 1 had 2 patients with humeral lucency (1 treated conservatively), 2 with glenoid screw lucency (treated conservatively), 2 with periprosthetic fractures (1 treated conservatively), 1 with humeral dissociation, 1 with infection, and 1 with recurrent instability (treated conservatively). Group 2 had 1 patient with scapular fracture (healed conservatively), 1 patient with symptomatic hardware after fixation for an os acromiale at the time of index surgery, and 4 patients with periprosthetic infections. ARTICLE IN PRESS 4 Reoperations and revisions The total reoperation rate was 13.4% (11.4% in group 1 and 15.6% in group 2). The revision rate was 8.9% (5.7% in group 1 and 12.5% in group 2). Group 1 had 1 reoperation for open reduction and internal fixation of a periprosthetic humerus fracture. One patient underwent a resection arthroplasty for a persistent periprosthetic infection. Two patients were revised in group 1 (1 for dissociation of humeral modular component and 1 for resorption of humeral allograft and humeral loosening). Group 2 had 1 reoperation for removal of symptomatic hardware after open reduction and internal fixation of an os acromiale at the time of index surgery. Four patients required revision in group 2 (all were revised because of infection). The implant was retained in 91% of patients at last followup. The implant retention rate for group 1 was 94.3%, and the implant retention rate for group 2 was 87.5%. 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 longterm 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 longterm studies on the survivorship of these implants. Few reports have looked at its use in the younger patient with shortterm to midterm outcomes.3,8,20,26 Sershon et al26 reported on 36 patients younger than 60 years (mean age, 54 years) with a follow-up of 24 to 48 months. They reported improvements in functional outcomes and ROM with a 75% success rate at 2.8 years based on an ASES score of 50 or above. Muh et al20 reported on 67 RSAs at a mean age of 52.2 years and a follow-up of 36.5 months. Patients had significant improvements in ROM, ASES score, and visual analog scale score, but there was a lower satisfaction rate compared with older patients in the literature. Ek et al8 reported a series of 46 RSAs in patients younger than 65 years (range, 46-64 years) with midterm to longterm follow-up of 60 to 171 months. Patients had significant improvement in clinical function but had a high complication rate of 37.5%. Twenty-five percent of patients underwent partial or total component exchange, conversion to hemiarthroplasty, or removal. Although patients had improvement in function that was maintained at up to 10 years, there was a high complication and reoperation rate, requiring appropriate patient counseling preoperatively. Black et al3 reported on 32 patients younger than 65 years (average age, 59.3 years) who underwent RSA as a salvage R.J. Otto et al. of failed prior arthroplasty with an average follow-up of 55.3 months. These patients were compared with a cohort of 33 patients undergoing primary RSA with an average age of 59.3 years and an average follow-up of 54.7 months. RSA was found to be effective in reducing pain and improving function, but complication rates were high (28% in the failed arthroplasty group and 18% in the primary group). Subjective outcome scores were worse for the failed arthroplasty group compared with the primary RSA group, but pain functional outcomes and complication rates were similar. This study did not evaluate ROM, reoperation rates, or implant survival. Whereas this study looked at young patients, the average age was almost 60 years, with the youngest patient 45 years old. Our study was similar in the setup of comparing failed arthroplasty patients with those who are undergoing primary RSA. However, we sought to evaluate a population of younger patients with these difficult problems. Many patients approaching 65 years old are close to retirement or are already retired; but there are patients with severe diseases who still have many years left in the workforce, leading us to evaluate those patients younger than 55 years who still have 10 years or more to work. It is important to know the outcomes of RSA in this young population. Previous studies either have very short follow-up or their definition of a young patient is <65 years old, many of whom are no longer working. It is also important to distinguish the patients who have had failed arthroplasty surgery from those who are undergoing a primary RSA. Failed arthroplasty patients typically begin with worse function preoperatively and will likely not achieve the same level of improvement as primary RSA patients. The results in this paper are similar to those previously reported for the use of RSA for failed hemiarthroplasty. Levy et al15 evaluated 29 patients at an average of 35 months who underwent RSA for failed hemiarthroplasty for proximal humerus fracture. The patients had improvements in ROM and functional outcomes, but the results were not as good as those of a primary RSA population. The forward elevation improved from 38° to 73°, abduction improved from 34° to 70°, and external rotation improved from 11° to 17°. The patient satisfaction was 79%. Similarly, Levy et al16 reported on 18 patients who underwent RSA for failed hemiarthroplasty in patients with glenohumeral arthritis and rotator cuff deficiency who were observed for 44 months. These patients also had worse function than reported for primary RSA patients. Forward elevation improved from 50° to 76° and abduction improved from 42° to 77°, with a satisfaction rating of 79%. Our results are similar to those reported in the literature for RSA in younger patients and similar to those of patients undergoing primary RSA vs. revision RSA for failed arthroplasty. However, there are limitations to this study. The indications for revision surgery were relatively heterogeneous and included failed RSA, total shoulder arthroplasty, and hemiarthroplasty for loosening, glenoid erosions, and infection. Therefore, the population was more heterogeneous, making it a little more difficult to compare groups. It was ARTICLE IN PRESS RSA in patients younger than 55 years important, however, to distinguish these failed arthroplasty patients from primary RSA patients, as the expected outcomes are different. In addition, the implant retention rate was higher in the revision group compared with the primary group. This is likely because the revision patients have already had multiple surgeries and often wished not to proceed with more surgeries if not necessary. For instance, there were 2 patients with lucencies around the implant and 1 patient with a recurrent dislocation who elected not to have additional surgery. Also, the follow-up period was relatively short in some patients with a minimum 24 months of follow-up. However, the average follow-up was >5 years and followed out to 12 years in some patients. This cohort of patients needs to continue to be observed to determine the true implant survivorship for a population of young patients. Despite these limitations, this is a relatively large cohort of young patients undergoing RSA and it is the first reported on patients younger than 55 years. This study shows that patients can achieve significant improvements in clinical function postoperatively for up to 12 years, but surgeons should manage these expectations appropriately and warn them of the potential complications and reoperations that may occur. 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. Complications are higher in the revision group, but the reoperation rates were lower compared with the primary group. There were no mechanical failures of the primary group, with infection being the cause of all revision surgeries. Young patients should be counseled appropriately about expectations if RSA is considered as a surgical treatment. Disclaimer DJO Surgical provided funding for this study to the Foundation for Orthopaedic Research and Education. 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