Abstract
Background
Surgeons may be hesitant to perform reverse total shoulder arthroplasty (rTSA) in elderly patients due to medical complexity, frailty, and possibility of higher rates of complications and mortality. Credence is given to this notion by reports from the hip and knee arthroplasty literature, which show higher rates of postoperative complications and mortality in elderly patients. As such, the purpose of the current study is to analyze outcomes and complications following rTSA in patients ≥90 years old.
Methods
All patients ≥90 years old who underwent primary rTSA from 2010 to 2024 were retrospectively identified. Patient demographics and perioperative data were recorded. Range of motion was assessed preoperatively and at 3, 6, and 12 months postoperatively. Postoperative and radiographic complications were identified. Paired student's t-tests were used to compare preoperative to postoperative outcomes.
Results
Thirteen patients (38.5% males) age 92.2 ± 1.7 years old were included. Average follow-up was 11.9 ± 11.0 months. Seven (53.9%) patients lived alone and 6 (46.1%) lived with family. Ten (76.9%) patients required no assistive device and 3 (23.1%) patients used a walker. Seven (53.8%) had cuff tear arthropathy and 6 (42.9%) had proximal humerus fractures. Seven (53.8%) patients had a heart condition and/or prior heart surgery. Eleven patients (84.6%) had an American Society of Anesthesiolgists score ≥3. Average operative time was 85.2 ± 20.3 minutes. Average estimated blood loss was 163.0 cc. Three (23.1%) patients achieved same day discharge. Average inpatient stay was 4.3 days. Six (46.1%) patients were discharged home, 6 (46.1%) to a subacute rehabilitation facility, and 1 (7.7%) to an acute rehabilitation facility. All patients ultimately returned to their preoperative living arrangements. From preoperatively to 1 year follow-up there were improvements in forward flexion from 35.4° to 144.3° (P < .05), external rotation at the side from 3.1° to 37.1° (P < .05), external rotation at 90° shoulder abduction from 10.0° to 85.0° (P < .05), and internal rotation from S1 to L2 (P < .05). Two (15.4%) inpatients experienced acute kidney injuries that resolved and 1 (7.7%) patient had an axillary motor nerve palsy during follow-up that resolved. No patients required a blood transfusion.
Conclusion
Performing rTSA is safe and effective in patients ≥90 years old. Various preoperative and intraoperative measures can be taken to decrease the risk of complications. Regardless of preoperative independence level, patients and family members should be prepared for the likelihood of rehabilitation and inpatient stay following surgery.
Keywords: rTSA, Elderly, Geriatric, Age, Arthroplasty, Disposition, Rehabilitation, Rehab
Since its pioneering by Dr Charles Neer in the 1970s and popularization by Dr Paul Grammont through the 1990s, reverse total shoulder arthroplasty (rTSA) has experienced a dramatic increase in clinical adoption.5,11,13 Initially, rTSA was primarily indicated for cuff tear arthropathy (CTA) or failed anatomic total shoulder arthroplasty (aTSA) with a deficient rotator cuff. However, advancements in both surgical technique and implant design have contributed to improvements in outcomes and a steady broadening of indications, which now include proximal humerus fractures (PHFs), massive irreparable rotator cuff tears without osteoarthritis, and glenohumeral osteoarthritis with significant multiplanar glenoid wear. Consequently, rTSA has become the most commonly performed shoulder arthroplasty procedure today.27
Despite the significant broadening of rTSA indications, surgeons may be hesitant to perform rTSA in elderly patients due to medical complexity, frailty, and the possibility of higher rates of complications and mortality. Credence is given to this notion by several reports from the hip and knee arthroplasty literature, which show higher rates of postoperative complications and mortality in elderly patients.6,14,15,18,22 Recent studies demonstrate favorable outcomes in patients ≥80 years old who underwent rTSA, although these data may not be generalizable to patients ≥90 years old.7,19 As such, the purpose of the current study is to analyze outcomes and complications following rTSA in patients ≥90 years old.
Materials and methods
All patients age ≥90 years old who underwent primary rTSA from 2010 to 2024 with the senior authors (C.M.J., M.L.K., and W.N.L.) were retrospectively identified. Patient demographics, including age, sex, hand dominance, and comorbidities, were recorded. Additionally, information about patients' living environments and ambulatory capabilities were recorded. Perioperative data, including preoperative medical clearance, anesthetic modality, implant type, intraoperative blood loss, and discharge disposition, were collected.
Range of motion (ROM) was assessed preoperatively and at 3, 6, and 12 months postoperatively. Assessment included forward flexion (FF), external rotation (ER) at the side, ER at 90° shoulder abduction, and internal rotation (IR). Postoperative complications associated with surgery were identified. Postoperative x-rays were evaluated for signs of prosthesis-related complications (eg, loosening, fracture, scapular notching, osteolysis).
Statistical analysis
Continuous variables were reported as means and ranges and categorical variables were reported as frequencies and percentages. Paired student's t-tests were used to compare preoperative to postoperative clinical outcomes. All statistical analyses were performed using STATA/MP Software 13.0 (StataCorp LLC, College Station, TX, USA). Statistical significance was set at P < .05.
Results
Thirteen patients were included (38.5% males) with an average age of 92.2 ± 1.7 year old. The average follow-up length was 11.9 ± 11.0 months (range: 0.6 to 37.2 months). Ten (76.9%) patients had greater than 6 months follow-up and 1 (7.7%) patient had less than 2 months follow-up. Seven (53.9%) patients lived alone and 6 (46.1%) lived with family. Ten (76.9%) patients required no assistive device and 3 (23.1%) patients used a walker (Table I). The indication for surgery was CTA for 7 (53.8%) patients and PHF for 6 (42.9%) patients (Table II). Seven (53.8%) patients had a heart condition and/or prior heart surgery (Table III). Eleven patients (84.6%) had an American Society of Anesthesiolgists (ASA) score ≥3 (Table IV).
Table I.
Patient demographics.
| Patient demographics | n (%) |
|---|---|
| Males | 5 (38.5) |
| Age (yrs) | 92.2 ± 1.7 (range: 90.0-95.0) |
| Follow-up (mo) | 10.8 ± 11.0 (range: 0.4-36.0) |
| Prior shoulder surgery | 2 (15.4) |
| Right side operated | 9 (69.2) |
| Dominant side operated | 9 (69.2) |
| Independence level | |
| Alone | 7 (53.9) |
| Lives with family | 6 (46.1) |
| Assistive device | |
| None | 10 (76.9) |
| Walker | 3 (23.1) |
| Cane | 0 (0) |
| Smoking | |
| Never | 7 (53.8) |
| Former | 6 (46.2) |
| Current | 0 (0) |
| Alive | 12 (92.3) |
Table II.
Diagnosis warranting reverse total shoulder arthroplasty.
| Diagnosis | n (%) |
|---|---|
| Proximal humerus fracture | 6 (42.9) |
| Parts | |
| 2 | 1 (16.7) |
| 3 | 3 (50.0) |
| 4 | 2 (33.3) |
| Cuff tear arthropathy | 7 (53.8) |
| Hamada | |
| 3 | 1 (14.3) |
| 4b | 5 (71.4) |
| 5 | 1 (14.3) |
Proximal humerus parts defined by Neer et al Cuff tear arthropathy classifications defined by Walch et al and Hamada et al.
Table III.
Patient comorbidities.
| Patient comorbidities | n (%) |
|---|---|
| Hypertension | 13 (100.0) |
| Heart disease | 7 (53.8%) |
| Coronary artery bypass graft + thoracic aortic repair | 2 |
| CHF | 1 |
| CHF + Atrial fibrillation | 1 |
| CHF + transcatheter aortic valve replacement | 1 |
| Coronary artery disease + stents | 1 |
| Mitral valve prolapse | 1 |
| Chronic kidney disease | 4 (30.8) |
| Diabetes mellitus | 2 (15.4) |
| Osteoporosis | 1 (7.7) |
CHF, congestive heart failure.
Table IV.
Proportion of patients within ASA score category.
| ASA score | n (%) |
|---|---|
| 1 | 0 (0) |
| 2 | 2 (15.4) |
| 3 | 10 (76.9) |
| 4 | 1 (7.7) |
ASA, American Society of Anesthesiolgists.
All patients received preoperative medical clearance by their primary care physician (if outpatient) or hospitalist team (if inpatient) and relevant specialists (e.g., cardiologist, nephrologist, pulmonologist). All patients received preoperative evaluation and clearance by anesthesiology. Additionally, all patients received an interscalene nerve block with sedation prior to surgery. All patients received 1 g intravenous tranexamic acid at the start of the procedure and during wound closure (2 g total). Postoperatively, all patients received deep vein thrombosis prophylaxis starting on postoperative day 1 based on recommendations by their medical clearance documentation. Patients were placed in a sling with an abduction pillow (“shaking hands” position) and were instructed to wear the sling only while sleeping and in public. Patients were non–weight-bearing on the operative extremity with an emphasis on moving the elbow, wrist, and fingers. The average operative time was 85.2 ± 20.3 minutes (Table V). Nine (69.2%) patients received the Zimmer trabecular metal (Zimmer Biomet, Warsaw, IN, USA), 2 (15.4%) received the Smith & Nephew Aetos (Smith & Nephew, Andover, MA, USA), 1 (7.7%) received the Smith & Nephew Titan (Smith & Nephew, Andover, MI, USA), and 1 (7.7%) received the Stryker Aequalis (Stryker, Kalamazoo, MI, USA). The average estimated blood loss was 163.0 cc.
Table V.
Hospital course following reverse total shoulder arthroplasty including disposition, complications, and inpatient stay.
| Hospital course | n (%) |
|---|---|
| Outpatient booking | 4 (30.8) |
| Outpatient final | 3 (23.1) |
| Operative time | 85.2 ± 20.3 min (range: 51-117) |
| Estimated blood loss | 163 ± 79.7 cc (range: 40-300) |
| Inpatient stay | 4.3 ± 4.4 d (range: 1-14) |
| Intraoperative complications | 0 (0) |
| Postoperative complications | 1 (7.7) |
| Axillary nerve palsy | 1 (100) |
| Inpatient complications | 2 (15.4) |
| Acute kidney injury | 2 (100) |
Four (30.8%) patients were booked for same-day surgery (SDD) but only 3 (23.1%) achieved SDD, all of whom had a primary diagnosis of CTA (Table VI). The average inpatient stay was 4.3 days. Six (46.1%) patients were discharged home, 6 (46.1%) patients were discharged to a subacute rehabilitation (SAR) facility, and one (7.7%) patient was discharged to an acute rehabilitation (AR) facility (Table VI). A significantly higher proportion of PHF patients were discharged to SAR/AR versus CTA (83.3% vs 28.3%, P < .05). All patients ultimately returned to their preoperative living arrangements.
Table VI.
Final disposition for patients following reverse total shoulder arthroplasty based on initial independence level.
| Final disposition | n (%) |
|---|---|
| Cuff tear arthropathy | 7 |
| Same-day discharge home | 3 (42.9) |
| Home after inpatient stay | 2 (28.5) |
| Subacute rehab | 1 (14.3) |
| Acute rehab | 1 (14.3) |
| Proximal humerus fracture | 6 |
| Same-day discharge | 0 |
| Home after inpatient stay | 1 (16.7) |
| Subacute rehab | 5 (83.3) |
| Acute rehab | 0 |
Preoperative FF was 35.4° ± 28.9, ER at the side was 3.1° ± 13.8, ER at 90° shoulder abduction was 10.0° ± 20.0, and IR was to S1. At 1 year postoperatively, patients experienced an average improvement of 108.9˚ FF, 34.1 ER with the arm at the side, 75.0° ER at 90° abduction, and IR from S1 to L2 (P < .05) (Table VII).
Table VII.
Preoperative vs postoperative range of motion following reverse total shoulder arthroplasty.
| Range of motion | Preoperative | 3 mo postoperative | 6 mo postoperative | 12 mo postoperative |
|---|---|---|---|---|
| FF | 35.4 ± 28.9, [0, 100] | 108.3 ± 26.9, [50, 140] | 118.3 ± 19.4, [90, 140] | 144.3 ± 11.3, [120, 150] |
| ER side | 3.1 ± 13.8, [−20, 20] | 27.5 ± 5.3, [20, 35] | 23.0 ± 14.9, [0, 40] | 37.1 ± 4.9, [30, 40] |
| ER 90° abduction | 10.0 ± 20.0, [0, 60] | not recorded | 65.0 ± 21.2, [50, 80] | 85.0 ± 5.8, [80, 90] |
| IR | S1, [L2, side] | L4, [L2, side] | L5, [L5] | L2, [T12, side] |
FF, forward flexion; ER, external rotation; IR, internal rotation.
Results presented as mean ± standard deviation, range [#, #].
Bolded values = significantly improved from preoperatively (P < .05).
Two (15.4%) inpatients experienced an acute kidney injury that subsequently resolved with fluid resuscitation. One (7.7%) patient presented with an axillary motor nerve palsy during follow-up that subsequently resolved. No patients required a blood transfusion. There were no other clinical complications. There were no radiographic complications, including presence of osteolysis, hardware loosening, scapular notching, or periprosthetic fracture.
Discussion
With the increasingly widespread use of rTSA, understanding its potential utility and limitations in the elderly population is important. Performing rTSA in patients ≥90 years old, who are often more frail and medically complex, may be approached with hesitancy due to concerns regarding suboptimal outcomes and increased complications. Despite these concerns, this study demonstrates that rTSA is a safe and effective procedure in patients ≥90 years old.
Patients in the current study demonstrated significant improvement in clinical outcomes following rTSA, which is consistent with the current literature.1,2,4,12,19,26 Preoperatively to 12 months postoperatively, FF improved from 35.4° to 144.3°, ER at the side improved from 3.1° to 37.1°, and ER at 90° abduction improved from 10.0° to 85.0°. A case series of 171 rTSA in patients ≥80 years old with 41 month follow-up demonstrated improvement in active range of motion (AROM) and patient-reported outcomes.19 Similarly, Almasri et al analyzed outcomes in 61 rTSA in patients ≥85 year old and found improvements in active FE, abduction, IR, and ER.2 These authors did not find a difference in final AROM or patient-reported outcomes between patients ≥85 to 89 years old and ≥90 years old. However, Almasri et al did not report associated comorbidities, inpatient/follow-up complications, or postsurgical disposition of patients ≥90 years old. IR did not significantly improve, which is a known limitation following rTSA.31
Disposition and immediate postoperative limitations are important to consider in elderly patients undergoing rTSA, regardless of preoperative independence level. All patients evaluated in the outpatient clinic met with physical therapy, orthotics, and social work to determine postoperative needs. All patients who were admitted preoperatively (i.e., through emergency department for PHF) had daily preoperative and postoperative sessions with physical therapy to assist with mobility and functionality, as well as social work evaluation for postoperative disposition. The current study demonstrates that rTSA patients for PHF are more likely to require inpatient hospitalization and disposition to SAR/AR compared to patients with CTA (83.3% vs 28.6%, P < .05). All 3 (23.1%) patients in this cohort who achieved SDD had a primary diagnosis of CTA. Although 53.9% of patients lived alone and were independent with activities of daily living, 10 (76.9%) required inpatient stay and 7 (70%) of inpatients were ultimately discharged to SAR/AR. Similarly, Almasri et al found 73.8% of rTSA patients ≥85 years old were discharged to a skilled nursing or rehabilitation facility, despite 86.9% living at home preoperatively.2 This may be attributed to the strict postoperative restrictions following rTSA raising concerns for safety and functionality, as well as pain secondary from PHF.29 This underscores the importance of setting preoperative expectations for patients and their family members. It is also important to ensure physical therapists can evaluate patients, if necessary, and social workers and case managers are available to coordinate safe disposition following surgery.
Elderly patients should be medically optimized and cleared prior to surgery, as greater incidence of medical comorbidities place them at risk of perioperative complications.4,17 In the current study, 2 patients (15.4%) experienced mild acute kidney injuries during the inpatient stay, both of which subsequently resolved with fluid resuscitation. The low complication rate in the current study may be partially attributed to all patients receiving preoperative medical clearance and optimization prior to surgery, as well as scalene nerve blocks and local anesthetics to help mitigate the risks associated with general anesthesia.3,21,30,32 The intraoperative and postoperative complication rates in this study are comparable to prior studies, despite most patients having an ASA score of ≥3 (84.6%). Almasri et al identified 25 complications in 20 patients ≥85 year old who underwent rTSA (32.8% of all patients), with the most common complication being acute blood loss anemia requiring transfusion (11.5% of all patients).2 Kriechling et al reported an inpatient complication rate of 3.1% and postoperative complication rate of 18.9% in elderly patients who underwent rTSA.19 However, this cohort had a smaller proportion of patients ASA ≥3 (49%) and the authors did not specify the timing of postoperative complications.19 Importantly, recent studies demonstrate comparable long-term complication rates between younger and elderly patients following rTSA.4,35
One patient (7.2%) presented to clinic with an axillary nerve motor palsy in the setting of rTSA for 3-part PHF, which subsequently resolved. Axillary nerve injury in rTSA can be a devastating complication, although the majority of neurapraxias resolve spontaneously.20,24 In this patient, the axillary nerve was identified and protected throughout the operation. To minimize the risk of iatrogenic injury, surgeons should identify the axillary nerve intraoperatively, be mindful about retractor placement, and avoid overtensioning in patients with CTA and significant proximal humeral migration. The axillary nerve and its circumflex branch can be identified by palpation, visualization in the subdeltoid space, or using the “tug test” described by Flatow and Bigliani.10 Placement of a small Darrach retractor between the medial calcar and capsule during humeral head exposure can avoid iatrogenic damage when performing the capsular release with a bovie. Alternatively, surgeons may utilize a Cobb elevator to carefully release the inferomedial capsule off the humeral neck. In nonagenarians with CTA, surgeons must weigh the benefit of rTSA distalization techniques (e.g., eccentrically placed glenosphere, 155° humeral neck cut, onlay tray/proud inlay tray) against overtensioning the nerve and risking acromial stress fracture in elderly patients.8,9,16,20,24,25,28,34
There are several limitations of this study. First, the average follow-up in this study was limited to 11.9 months, limiting long-term generalizability. However, 10 (76.9%) patients had greater than 6 months follow-up and only 1 (7.7%) patient had less than 2 months follow-up. Prior studies demonstrate progressive improvement in clinical and functional outcomes 1 year postoperatively following rTSA, with patients reaching 72% to 91% of maximal function by 6 months.1,4,19,23,26 Thus, these findings may be a proxy for long-term outcomes based on the average 11.9-month follow-up and 76.9% of patients with ≥6 months. However, the limited follow-up may limit the detection of postoperative complications. Second, the authors (C.M.J., M.L.K., W.N.L.) are all shoulder and elbow fellowship-trained surgeons who perform ≥200 shoulder arthroplasty procedures per year each, reflecting high-volume shoulder arthroplasty practices. Recent studies report lower complication and reoperation rates in surgeons performing greater than 11 to 15 arthroplasties per year, indicating that favorable outcomes in this cohort may be partially attributed to surgeon expertise and may not be generalizable to lower volume surgeons (i.e., ≤10 arthroplasties per year).33,36 Third, the cohort was limited to inclusion of 13 patients, which prevented any form of subgroup analysis amongst the included patients. This was not secondary to total volume of arthroplasty performed, but rather due to the surgeons in the current study only recently performing rTSA in patients ≥90 years old. Fourth, patients at the authors' institution are not routinely provided questionnaires (American Shoulder and Elbow Surgeons score, Disabilities of the Arm, Shoulder, and Hand score) preoperatively and postoperatively, so these outcome measures were not reported.
Conclusion
Performing rTSA is safe and effective in patients ≥90 years old with large improvements in ROM. All patients should receive preoperative medical clearance. The use of interscalene nerve blocks and local anesthetics can avoid the risks associated with general anesthesia. Regardless of preoperative independence level, patients and family members should be prepared for the likelihood of rehabilitation and inpatient stay following surgery.
Disclaimers:
Funding: No funding was disclosed by the authors.
Conflicts of interest: Michael L. Knudsen MD discloses receiving IP royalties and being a paid consultant at MR Surgical Solutions, LLC. Charles M. Jobin MD discloses Acumed, LLC: Paid consultant; American Board of Orthopaedic Surgery, Inc.: Board or committee member; American Shoulder and Elbow Surgeons: Board or committee member; Biomet: Paid consultant; Journal of the American Academy of Orthopaedic Surgeons: Editorial or governing board; Publishing royalties, financial or material support; Smith & Nephew: IP royalties; Paid consultant; Paid presenter or speaker; Springer Nature: Publishing royalties, financial or material support; Zimmer: Paid consultant; Paid presenter or speaker. William N. Levine MD discloses Zimmer Biomet Holdings, Inc: Royalties or licenses, consulting fees; American Shoulder and Elbow Surgeons: Past president; Journal of American Academy of Orthopaedic Surgeons: Editorial board; Journal of Shoulder and Elbow Surgery: Editorial board. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Footnotes
This study was approved by Columbia University Medical Center Institutional Reviw Board.
Investigation performed at Columbia University Irving Medical Center, New York, NY 10032, USA.
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