Abstract
Anatomic total shoulder arthroplasty is a widely used definitive surgical solution for end-stage glenohumeral joint osteoarthritis and is associated with good clinical outcomes. Anatomic total shoulder arthroplasty has a role for patients under 50 years of age who have exhausted nonoperative management and for patients over 80 years of age with an intact rotator cuff. Patients younger than 50 place greater demands on their replaced shoulders, raising concerns about implant survivorship and in particular the failure of the glenoid component. There are limited data on the long-term survivorship of anatomic total shoulder arthroplasty in patients under the age of 50 years in the literature. Modern bone-preserving designs utilizing newer materials may contribute to improved outcomes and survivorship. Achieving comparable functional outcomes in patients over 80 years of age remains a challenge with concerns related to rotator cuff failure. However, in appropriately selected patients over the age of 80 years, an anatomic total shoulder arthroplasty provides better pain relief and function than a reverse total shoulder arthroplasty.
Zusammenfassung
Die anatomische totale Schulterarthroplastik ist weitverbreitet im Einsatz, um eine definitive chirurgische Versorgung eines Glenohumeralgelenks mit Arthrose im Endstadium zu erzielen, und geht mit guten klinischen Ergebnissen einher. Bei Patienten unter 50 Jahren, bei denen alle nichtoperativen Behandlungsmöglichkeiten erschöpft sind, und bei Patienten über 80 Jahren mit einer intakten Rotatorenmanschette ist die anatomische totale Schulterarthroplastik von Bedeutung. Patienten unter 50 Jahren haben größere Ansprüche an ihre rekonstruierten Schultern, was zu Bedenken hinsichtlich des Überlebens von Implantaten und insbesondere des Versagens der glenoidalen Komponente führt. In der Literatur sind Daten zum Langzeitüberleben von anatomischen totalen Schulterarthroplastiken bei Patienten unter 50 Jahren nur begrenzt verfügbar. Moderne knochenerhaltende Designansätze mit Verwendung neuartiger Materialien könnten zu besseren Ergebnissen und besserem Implantatüberleben beitragen. Die Erzielung vergleichbarer funktioneller Ergebnisse bei Patienten über 80 Jahren bleibt weiterhin eine Herausforderung mit Bedenken in Bezug auf ein Versagen der Rotatorenmanschette. Jedoch geht bei entsprechend ausgewählten Patienten über 80 Jahren eine anatomische totale Schulterarthroplastik mit einer besseren Schmerzlinderung und Funktion einher als eine reverse totale Schulterarthroplastik.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Considerations for patients over 80 years of age
As life expectancy increases, a large number of older but active patients will suffer from shoulder arthritis with debilitating pain and functional loss that may threaten their independence. Ricchetti et al. demonstrated that total shoulder arthroplasty (TSA) can be performed on patients 80 years and older, and reported rates of perioperative complications and mortality comparable to those of younger patients [1]. However, there is a limited amount of literature on the outcome of anatomic total shoulder arthroplasty (aTSA) in older patients [2,3,4].
Indications for aTSA in older patients
Anatomic TSA is the definitive surgical solution for patients with primary glenohumeral joint osteoarthritis with an intact and functioning rotator cuff [4, 5]. Recently, there has been a shift, with some surgeons performing reverse TSA (rTSA) for all older patients despite the underlying pathology—even for patients who clearly meet the indications for aTSA [6, 7]. This is due to the fear of failure of the aTSA secondary to rotator cuff failure requiring revision to rTSA [8].
One of the major complications of aTSA failure is late rotator cuff failure [9]. Young et al. [10] reported a secondary rotator cuff dysfunction rate of 17% following aTSA and this was related to poorer clinical outcomes. As rotator cuff quality deteriorates with advancing age [11], there is additional concern about rotator cuff resilience and long-term outcomes of aTSA in patients over the age of 80 years. Foruria et al. [4] reported outcomes of aTSA in 50 shoulders of patients over the age of 80, with a mean follow-up of 5.5 years. Four shoulders had a preoperative full-thickness rotator cuff tear. The authors found a radiological upper migration of the humeral head in five shoulders and suggested that the high frequency may have been related to deficiency of the rotator cuff. However, excellent results can be expected when aTSA is performed on patients over the age of 80 with a preoperative intact rotator cuff [8].
Thus, increasing age should not be a contraindication in itself for the aTSA. A careful clinical examination of the range of motion (ROM) and a thorough rotator cuff examination are essential. Preoperative ROM has been shown to be a good predictor of postoperative outcomes after aTSA [12]. If there are any doubts about the clinical examination of the rotator cuff, preoperative magnetic resonance imaging (MRI) is recommended. An MRI examination will enable a detailed assessment of the rotator cuff including the presence of partial and/or full-thickness tears, muscle atrophy, or the presence of any fatty infiltration. It has been demonstrated that preoperative fatty infiltration of the infraspinatus muscle and superior inclination are negative prognostic factors for aTSA [10]. Chronic irreparable subscapularis deficiency is a contraindication as it tends to destabilize the joint secondary to an upward migration of the humeral head and eccentric contact pressure onto the glenoid [13]. Assessment of the critical shoulder angle (CSA) on plain radiographs is also useful. A CSA < 30° is strongly associated with glenohumeral joint arthritis [14]. A CSA > 35° is related to an increased supraspinatus loading to compensate for increased joint instability, and in the setting of aTSA it is related to an increased incidence of glenoid radiolucencies [15]. Furthermore, the acromiohumeral distance (AHD) should be maintained (7 mm), indicating that the glenohumeral joint is centered with an intact and functioning posterior–superior rotator cuff.
The surgical indications for rTSA have expanded to include primary glenohumeral joint osteoarthritis with the presence of a functioning rotator cuff. Some centers have reported that more than 50% of their primary shoulder arthroplasties are now performed using rTSA [16], and this percentage is even higher for older patients. However, the choice of an rTSA over aTSA is associated with some unique and challenging complications not seen after aTSA, such as acromial stress/scapular spine fractures [17], inferior glenoid notching [18, 19], and a higher rate of deep infection [20]. Additionally, function and ROM after rTSA are not comparable to aTSA, especially restoration of internal rotation.
Thus, despite the recent increase in the use of rTSA in older individuals with primary glenohumeral joint arthritis, aTSA provides better function and has a less challenging complication profile [21]. Moreover, patients undergoing aTSA have a faster recovery and achieve clinical improvement quicker than those undergoing rTSA [22]. Older patients with primary glenohumeral joint osteoarthritis with an intact rotator cuff, CSA < 30°, and a normal AHD meet the indications for an aTSA procedure with satisfactory and predictable clinical outcomes and longevity. When discussing shoulder arthroplasty as a definitive surgical solution in older patients with primary glenohumeral joint osteoarthritis with an intact rotator cuff, the treating surgeon should discuss both aTSA and rTSA. The patients should be informed of the risks, benefits, expectations, complications, and postoperative rehabilitation in detail, so that they can make a fully informed choice between aTSA and a rTSA—since the literature supports the use of aTSA for older adults [23].
Outcomes of TSA in older patients
Although the incidence of TSA in older patients has increased in recent decades [24], very few studies have reported outcomes of aTSA in patients over 80 years of age.
Foruria et al. [4] reported outcomes of aTSA for primary osteoarthritis in 50 shoulders of patients over the age of 80 to review its safety, efficacy, and complication rate. Although there was a requirement for more intense patient care in the perioperative period, the authors concluded that aTSA was effective in reducing pain and improving movement without increased risk of medical or surgical complications. Most of these patients had a pain-free and functional shoulder for the rest of their lives. Similar findings were reported by Ricchetti et al. [1] in a group of 40 patients over 80 years of age, with a comparable rate of perioperative complications to the younger patient group. The authors did, however, note that these older patients had an increased transfusion requirement and there were fewer cases of direct discharge to their homes. Mullett et al. [2] reported outcomes for 29 patients over the age of 80 with a Copeland surface replacement arthroplasty and a mean follow-up of 4.5 years in whom the Constant score improved from 15.1% to 77%. However, this was a heterogeneous group of patients, including individuals with documented rotator cuff tendon tears and the implantation of aTSA and hemiarthroplasty. Iriberri et al. [8] presented a more homogeneous group including only patients over 80 undergoing aTSA with an intact rotator cuff preoperatively. This was a relatively large series of 32 cases and they obtained good-to-excellent results comparable to patients around 70 years of age. Finally, Churchill et al. [3] published the outcomes for five cases of aTSA performed on patients over the age of 90 with intact rotator cuff and glenohumeral osteoarthritis. All patients had significant postoperative improvement in ROM, shoulder function (SST [Simple Shoulder Test] scores improved from a preoperative average of 2.0 to 7.4 at 2 years), and even general health status. In a 20-year follow-up of the Aequalis aTSA, Evans et al. noted that 72% of patients had died with the prosthesis in situ and acknowledged that older patients undergoing aTSA are unlikely to require revision of their prosthesis in their lifetime [25].
Reverse TSA is also a successful treatment option for patients older than 80 years. Triplet et al. [7] reported the outcomes of primary aTSA and rTSA in this group of patients. Although both treatment groups showed similar improvements in pain scores, functional outcome scores, and ROM at the 2‑year follow-up, those treated with aTSA showed significantly more postoperative motion, higher satisfaction, and fewer complication and transfusion rates. As life expectancy is increasing, active older patients expect better functional outcomes as well as good pain relief in order to return to their recreational activities after surgery [26]. A recent systematic review evaluated the rate of return to sport in older patients who underwent aTSA and rTSA [27]. The overall rate of return to sport was 82%. Not surprisingly, patients undergoing aTSA returned at a higher rate (90%) compared to those undergoing rTSA (77%).
Conclusion
Anatomic total shoulder arthroplasty (aTSA) has evolved over the last four decades to become a reliable procedure with satisfactory and predictable clinical outcomes and longevity. In appropriately selected older patients over the age of 80 years with primary glenohumeral arthritis and an intact rotator cuff, aTSA provides good pain relief and better function than the reverse TSA. Based on the current evidence, aTSA is an excellent option in managing patients with end-stage glenohumeral joint arthritis regardless of age.
References
Ricchetti ET et al (2011) Total shoulder arthroplasty in older patients: increased perioperative morbidity? Clin Orthop Relat Res 469(4):1042–1049
Mullett H et al (2007) Copeland surface replacement of the shoulder. Results of an hydroxyapatite-coated cementless implant in patients over 80 years of age. J Bone Joint Surg Br 89(11):1466–1469
Churchill RS (2008) Elective shoulder arthroplasty in patients older than ninety years of age. J Shoulder Elbow Surg 17(3):376–379
Foruria AM et al (2010) Total shoulder replacement for osteoarthritis in patients 80 years of age and older. J Bone Joint Surg Br 92(7):970–974
Norris TR (2002) Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg 11(2):130–135
Steen BM et al (2015) Outcome and value of reverse shoulder arthroplasty for treatment of glenohumeral osteoarthritis: a matched cohort. J Shoulder Elbow Surg 24(9):1433–1441
Triplet JJ et al (2015) Anatomic and reverse total shoulder arthroplasty in patients older than 80 years. Orthopedics 38(10):e904–e910
Iriberri I et al (2015) Anatomic shoulder replacement for primary osteoarthritis in patients over 80 years: outcome is as good as in younger patients. Acta Orthop 86(3):298–302
Chin PY et al (2006) Complications of total shoulder arthroplasty: Are they fewer or different? J Shoulder Elbow Surg 15(1):19–22
Young AA et al (2012) Secondary rotator cuff dysfunction following total shoulder arthroplasty for primary glenohumeral osteoarthritis: results of a multicenter study with more than five years of follow-up. J Bone Joint Surg Am 94(8):685–693
Tempelhof S, Rupp S, Seil R (1999) Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 8(4):296–299
Friedman RJ et al (2019) Preoperative parameters that predict postoperative patient-reported outcome measures and range of motion with anatomic and reverse total shoulder arthroplasty. JSES Open Access 3(4):266–272
Terrier A et al (2013) Importance of the subscapularis muscle after total shoulder arthroplasty. Clin Biomech 28(2):146–150
Moor BK et al (2013) Is there an association between the individual anatomy of the scapula and the development of rotator cuff tears or osteoarthritis of the glenohumeral joint? A radiological study of the critical shoulder angle. Bone Joint J 95(7):935–941
Watling JP et al (2018) Glenoid component loosening associated with increased critical shoulder angle at midterm follow-up. J Shoulder Elbow Surg 27(3):449–454
Chalmers PN et al (2018) Comparative utilization of reverse and anatomic total shoulder arthroplasty: a comprehensive analysis of a high-volume center. J Am Acad Orthop Surg 26(24):e504–e510
Otto RJ et al (2013) Scapular fractures after reverse shoulder arthroplasty: evaluation of risk factors and the reliability of a proposed classification. J Shoulder Elbow Surg 22(11):1514–1521
Ladermann A et al (2015) Scapular notching on kinematic simulated range of motion after reverse shoulder arthroplasty is not the result of impingement in adduction. Medicine (Baltimore) 94(38):e1615
Arenas-Miquelez A et al (2021) Impact of humeral and glenoid component variations on range of motion in reverse geometry total shoulder arthroplasty: a standardized computer model study. J Shoulder Elbow Surg 30(4):763–771
Moeini S et al (2019) Reverse shoulder arthroplasty has a higher risk of revision due to infection than anatomical shoulder arthroplasty: 17 730 primary shoulder arthroplasties from the Nordic Arthroplasty Register Association. Bone Joint J 101-B(6):702–707
Simon MJK, Coghlan JA, Bell SN (2022) Shoulder replacement in the elderly with anatomic versus reverse total prosthesis? A prospective 2‑year follow-up study. J Clin Med 11(3):540
Drager J et al (2021) Patients undergoing anatomic total shoulder arthroplasty achieve clinically significant outcomes faster than those undergoing reverse shoulder arthroplasty. J Shoulder Elbow Surg 30(11):2523–2532
Jensen AR et al (2021) Anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis is associated with excellent outcomes and low revision rates in the elderly. J Shoulder Elbow Surg 30(7s):S131–S139
Singh JA, Ramachandran R (2015) Age-related differences in the use of total shoulder arthroplasty over time: use and outcomes. Bone Joint J 97-B(10):1385–1389
Evans JP et al (2021) Survival of the Aequalis total shoulder replacement at a minimum 20-year follow-up: a clinical and radiographic study. J Shoulder Elbow Surg 30(10):2355–2360
Chalmers PN, Keener JD (2016) Expanding roles for reverse shoulder arthroplasty. Curr Rev Musculoskelet Med 9(1):40–48
Papalia R et al (2020) Return to sport after anatomic and reverse total shoulder arthroplasty in elderly patients: a systematic review and meta-analysis. J Clin Med 9(5):1576
Funding
Open Access funding enabled and organized by CAUL and its Member Institutions.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
S. Raniga has received research grants from Mathys and Medacta International and serves as a medical advisor to Mathys. D.J. Bokor has received research grants from Smith & Nephew and serves as a medical advisor to Smith and Nephew and Mathys. A. Arenas-Miquelez declares that he has no competing interests.
For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.
Additional information
Scan QR code & read article online
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Raniga, S., Arenas-Miquelez, A. & Bokor, D.J. Anatomic total shoulder arthroplasty in patients under 50 and over 80 years of age. Part 2. Obere Extremität 18, 37–40 (2023). https://doi.org/10.1007/s11678-022-00713-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11678-022-00713-9
Keywords
- Total shoulder replacement
- Long-term survivorship
- Shoulder prosthesis
- Glenoid component
- Glenohumeral joint