Shoulder & Elbow

Long-term results of reverse total shoulder arthroplasty

The position of the reverse shoulder arthroplasty as a successful, and in some cases essential, device in shoulder arthroplasty is now beyond doubt. Although there are still some concerns about longevity and the reporting of high complication rates with some implants and in some indications, the literature is reflective of an established and increasing use of reverse total shoulder arthroplasty in both elective and trauma practice.³ Despite the growing popularity of the implants, the precise indications and the long-term outcomes for these prostheses are yet to be fully defined. This large study from the team in Lyon (France) offers one of the few long-term studies evaluating reverse shoulder arthroplasty, and authors report the outcomes and survival at a minimum of ten years following surgery. This work was based on data from their original previously reported study of 186 patients with 191 Grammont-style prostheses implanted for a range of chronic pathologies.⁴ The authors were able to update this with their current study including 84 of these patients with 87 prostheses followed-up for a mean of 12.5 years. Within this cohort, radiographic assessment was available in 64 patients with 67 prostheses. The authors report a mean absolute Constant score of 55 and a mean relative Constant score of 86, which not unsurprisingly was significantly decreased when compared with the scores from the previous mid-term study. A total of 73% (49 shoulders) of cases demonstrated evidence of scapular notching and 29% (47) had complications, with dislocation and infection most commonly seen. There were 12% (16) of the original patients who had undergone revision surgery, with the overall ten-year survival at 93% when using revision as the endpoint. These results are consistent with shorter-term studies documenting a survival rate of 89% to 95%. This study adds important information regarding the long-term outcome of these implants, but without doubt more data are needed. As the technology matures, the long-term outcomes of these prostheses will become more and more important. We can’t help thinking that there may be more failures than the reported 12%, but given the difficulties of revising a reverse shoulder arthroplasty, many more may be poorly performing but still in situ due to the lack of a reasonable alternative.

Depression influences outcome following total shoulder replacement… but it is still worth doing?

Psychological factors such as depression, anxiety and inadequate coping mechanisms are known to influence both surgeon- and patient-reported outcomes for a variety of pathological conditions of the upper extremity.^5,6 Nonetheless, there is certainly more work to do in determining whether such patients still benefit from surgery and whether anything can be done to influence or optimise these psychological factors in order to improve outcome. In this retrospective case-control study, the team from the Hospital for Special Surgery, New York, New York (USA) examined the outcomes of 264 patients, all of whom underwent primary total shoulder arthroplasty (TSA) for osteoarthritis of the shoulder with a minimum of two years of follow-up. Outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) Score, and a subgroup of 88 patients with a pre-operative diagnosis of depression were compared with a control group of 176 patients. Cases were matched according to age and gender in a 2:1 ratio. As perhaps is to be expected, the only difference in baseline characteristics were the Short Form-12 (SF-12) Mental Component scores. There was a significant improvement seen in the ASES scores across the board, both for the patients with depression and the control group. However, the patients with depression reported final ASES scores that were significantly lower, and improved to a significantly lesser degree, than those of the comparative patients in the control group. This was echoed with significantly lower SF-12 Physical Component scores reported as well. The authors attempted to unpick the aetiology with multivariate analysis, and pre-operative depression was an independent predictor associated with a reduced improvement in the ASES score. The authors’ comment was that this is not a clinically relevant difference and should perhaps not discourage patients with a pre-operative depression diagnosis from undergoing TSA. However, there is clearly a take home message for surgeons that counselling patients prior to surgery as to what to expect may have a positive benefit. This message, although sometimes seemingly a standard conclusion of all outcome factor papers, is starting to accumulate evidence for its efficacy, and we would also draw the attention of 360 readers to the recent prospective randomised clinical trials already supporting the positive effects of pre-operative priming and patient-reported outcome scores.⁷