CORR Insights®: What Are the Complications, Survival, and Outcomes After Revision to Reverse Shoulder Arthroplasty in Patients Older Than 80 Years?

Where Are We Now?

The current study by Alentorn-Geli and colleagues highlights the importance of considering the risks and benefits of revision shoulder arthroplasty in elderly patients. This is the first study to analyze the risk of medical and surgical complications and outcomes after a reverse shoulder arthroplasty revision in an elderly population. Other studies have evaluated the risks associated with primary shoulder arthroplasty in an elderly patient population [1, 3, 4, 6, 8], and had demonstrated similar rates of perioperative medical complications and surgical. Whether in the revision setting or the primary setting, most studies conclude there is a higher risk of complications in the elderly population compared to younger cohorts.

Patients, providers, and payers all have an interest in care that is safe, effective, and of discernible value to patients. From an elderly patient’s perspective, a painful, dysfunctional shoulder may render the dominant arm dysfunctional to the point that they may lose the ability to live independently. A procedure that could provide relief and maintain independence for the remaining years of their life may be considered of value despite increased perioperative risks for reoperation in elderly patients with a relatively high 2-year mortality rate.

Where Do We Need To Go?

These findings raise a number of important questions. For example, at what point does the risk outweigh the benefit of pain relief and increased function that is experienced with primary and revision shoulder arthroplasty? How much should providers weigh the dangers of performing surgery that has a relatively high reoperation risk in elderly patients who may be especially vulnerable in the setting of multiple operations? Should payers continue to pay for an elective surgical procedure despite increased medical risk and potential?

To achieve evidence-based, cost-effective healthcare that provides the greatest value to patients we need to: (1) Expand our understanding of patient-specific perioperative risk factors in the elderly and (2) increase our understanding of the value of care provided as perceived by the patient. Although Alentorn-Geli and colleagues identified some likely etiologies of both medical and surgical complications after revision shoulder arthroplasty in their relatively small cohort, in the setting of generally rare complications, larger numbers of patients are needed to completely understand the relative risks of complications and their contributions to the likelihood of greater morbidity or death.

We also need to better understand what is of greatest value to older patients. How much do patients value the improvement in pain and function they expect to realize after surgery? Are they willing to endure the procedure-related recovery time and the potential risks associated with the surgery? Beyond understanding patient preferences and values, we will need to better recognize the actual costs of care including costs to patients and to the healthcare system. Many studies reporting on cost-effectiveness calculate “costs” in terms of reimbursements [2, 5, 9]; this approach has serious shortcomings. We need to be more precise in how we account for costs and include how we account for opportunity cost and risk unique to elderly patients such that we more accurately reflect cost-of-care activities.

How Do We Get There?

Gaining a more-accurate and precise understanding of perioperative risk is, appropriately, an increasingly common area of study in shoulder arthroplasty. Many existing studies have sought data from large national databases, which generate large numbers of subjects enrolled. However, these databases can be limited in their precision and granularity of data [7]. Thus, studies focusing on large databases may be limited in the specificity of their conclusions. Institutional databases, such as the one used in the present study, can typically provide more granular patient-level data and the data collected prospectively. Despite this, subject numbers from single institutional databases are typically too small to analyze rare outcomes. Data pooled from multiple institutions that gather commonly utilized outcome measures will provide a greater opportunity to broaden outcomes measures.

Large-scale efforts coordinated by multiple high-volume centers and pooled small-scale centers will need to be carried out to gather high-quality and prospectively collected data in large volumes such that reliable studies can analyze outcomes and associated risks. This will require a commitment from providers in all settings to participate in efforts in their own practice to collect meaningful outcome measures in their practice. Initiatives led by specialty societies may provide guidance and resources to coordinate these efforts. With a greater volume of high-quality outcomes data, opportunities to understand true costs of care will then allow us to more fully assess the overall value we can offer patients with shoulder conditions requiring arthroplasty among other musculoskeletal conditions.