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.