Department of Orthopaedic Surgery, University of California, Los Angeles, CA, USA.
Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA.
J Shoulder Elbow Surg. 2021 Jul;30(7S):S131-S139. doi: 10.1016/j.jse.2020.11.030. Epub 2021 Jan 20.
The relative indications of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) continue to evolve. Some surgeons favor RSA over TSA for elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff due to fear of a postoperative (secondary) rotator cuff tear in this age group. However, RSA is associated with unique complications and a worse functional arc of motion compared with TSA. Therefore, it is important to understand the clinical outcomes and rates of revision surgery and secondary rotator cuff tears in elderly patients undergoing TSA.
Between January 1, 2010, and December 31, 2017, 377 consecutive TSAs were performed for primary GHOA in 340 patients 70 years of age or older. The mean age at surgery was 76.2 years (standard deviation [SD], 4.9). Clinical evaluation included pain, motion, and American Shoulder and Elbow Surgeons score. Radiographs were reviewed for preoperative morphology and postoperative complications. All complications and reoperations were recorded. The average clinical follow-up time was 3.3 years (SD, 2.0). Statistical analyses were performed, and Kaplan-Meier implant survival estimates were calculated. For all analyses, a P value <.05 was considered statistically significant.
The mean pain visual analog scale and American Shoulder and Elbow Surgeons score at the final follow-up were 1.6 (SD, 2.2) and 78.0 (SD, 17.8), respectively. Forward elevation and external rotation increased from 96° (SD, 30°) and 26° (SD, 20°) preoperatively to 160° (SD, 32°) and 64° (SD, 26°) postoperatively (P < .001 for each). The percentage of patients who had internal rotation to L5 or greater increased from 24.8% preoperatively to 71.8% postoperatively (P < .001). Revision surgery was performed in 3 shoulders (0.8%), and the 5-year implant survival estimate was 98.9% (95% confidence interval: 97.3%-100%). There were 3 medical (0.8%), 10 minor surgical (2.7%), and 5 major surgical (1.3%) complications. No shoulder had radiographic evidence of humeral component loosening, whereas 7 (2%) had evidence of some degree of glenoid component loosening. In total, there were 5 secondary rotator cuff tears (1.3%), of which 2 (0.5%) required revision surgery.
Elderly patients with primary GHOA and an intact rotator cuff have excellent clinical and radiographic outcomes after anatomic TSA, with high implant survival rates and a low incidence of secondary rotator cuff tears in the first 5 postoperative years. Age greater than 70 by itself should not be considered an indication for RSA over TSA.
解剖全肩关节置换术（TSA）和反式肩关节置换术（RSA）的相对适应证仍在不断发展。由于担心老年患者（≥70 岁）在这一年龄组中术后（继发性）肩袖撕裂的风险，一些外科医生更倾向于 RSA 而不是 TSA 用于原发性全肩关节骨关节炎（GHOA）和完整肩袖的患者。然而，RSA 与 TSA 相比，具有独特的并发症和更差的功能活动度。因此，了解接受 TSA 的老年患者的临床结果、翻修手术和继发性肩袖撕裂的发生率非常重要。
2010 年 1 月 1 日至 2017 年 12 月 31 日，对 340 名≥70 岁的原发性 GHOA 患者进行了 377 例连续 TSA。手术时的平均年龄为 76.2 岁（标准差 [SD]，4.9）。临床评估包括疼痛、运动和美国肩肘外科医生评分。对术前形态和术后并发症进行 X 线检查。记录所有并发症和再次手术。平均临床随访时间为 3.3 年（SD，2.0）。进行了统计学分析，并计算了 Kaplan-Meier 植入物生存率估计值。所有分析中，P 值<.05 被认为具有统计学意义。
末次随访时，平均疼痛视觉模拟量表和美国肩肘外科医生评分分别为 1.6（SD，2.2）和 78.0（SD，17.8）。术前肩关节前屈和外展分别为 96°（SD，30°）和 26°（SD，20°），术后分别增加到 160°（SD，32°）和 64°（SD，26°）（P<.001）。术前内旋至 L5 或更高位的患者百分比为 24.8%，术后为 71.8%（P<.001）。3 例（0.8%）进行了翻修手术，5 年植入物生存率估计值为 98.9%（95%置信区间：97.3%-100%）。有 3 例（0.8%）为医疗并发症，10 例（2.7%）为轻微手术并发症，5 例（1.3%）为严重手术并发症。没有肩部出现肱骨组件松动的影像学证据，而 7 例（2%）出现了一定程度的肩胛盂组件松动。共有 5 例（1.3%）继发性肩袖撕裂，其中 2 例（0.5%）需要翻修手术。
对于原发性 GHOA 且肩袖完整的老年患者，行解剖性 TSA 后具有极好的临床和影像学结果，植入物生存率高，术后 5 年内继发性肩袖撕裂的发生率低。单纯年龄大于 70 岁不应作为 RSA 优于 TSA 的指征。
