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Discuss RSA surgery for severe rotator cuff deficiency with younger patients
Prior to surgery, review with patients that complications have been reported to be as high as 18% to 37%.
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Despite concerns about reverse shoulder arthroplasty in younger patients, the procedure has been shown to restore function and improve pain in advanced cases of severe rotator cuff deficiency with associated arthritis and/or bone loss, as well as complex fractures and fracture dislocations, according to a presenter at the American Orthopaedic Society for Sports Medicine Annual Meeting.
In the younger population, “Long- term results are mixed and there is a higher reoperation rate at 10 years,” Joseph A. Abboud, MD, said in a symposium that addressed reverse shoulder arthroplasty (RSA) outcomes in young patients with irreparable rotator cuff tears.
In an interview with Orthopedics Today, Abboud, who is in the shoulder and elbow division at Thomas Jefferson University and senior vice president of the Rothman Institute in Philadelphia, said, “I do not necessarily want to be somebody who is saying we should be considering it as the first-tier treatment, but in advanced cases where it is necessary it can work reasonably well. But, other options should be exhausted first.”
Risk of complications
In his presentation, Abboud noted studies of RSA have shown improvements in abduction and internal rotation, as well as Constant, American Shoulder and Elbow Surgeons and simple shoulder test scores. However, the complication profile is not insignificant with rates that range from 18% to 37%, he said.
“These patients are also usually patients who have been through a lot whether they have had trauma, whether they have had complex previous operative interventions,” Abboud told Orthopedics Today. “They are not necessarily purely healthy, unoperated-on shoulders ... It is more people who have had, potentially, several operations with scar tissue and are usually the patient you worry about more for developing a complication.”
Shoulder surgeons should be careful with patient selection when determining whether to perform RSA in a young patient and take steps to avert avoidable complications, such as notching, which may lead to early glenoid component loosening.
“Patients should be counseled that return to function is slightly more predictable than improvement in pain after RSA,” he said at the meeting.
Refined RSA techniques
Abboud noted in his presentation many of the long-term studies “are based on an early adoption period of this technology and more studies that are coming out are going to be based on more refined techniques.”
“I guarantee the complication rates will be significantly lower in these next-generation studies,” Abboud said. “Avoidable complication rates are becoming lower and will continue to do so as surgeons gain greater experience and companies refine the implants and their methods for implantation.”
In the interview, Abboud said orthopedic surgeons should make sure a younger patient has realistic expectations about RSA outcomes and is clear about the pros and cons of the surgery.
“If you spend the time to explain to them the complexities, the issues, it takes some time, but they will get it,” Abboud said.
Surgeons who are uncomfortable performing more complex RSA or who perform fewer than about 10 RSAs annually should probably refer a younger patient to a high-volume surgeon, he said. – by Casey Tingle
- References:
- Abboud JA. RSA: Here’s the data. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 20-23, 2017; Toronto.
- Ek ET, et al. J Shoulder Elbow Surg. 2013;doi:10.1016/j.jse.2012.11.016.
- Otto RJ, et al. J Shoulder Elbow Surg. 2017;doi:10.1016/j.jse.2016.09.051.
- For more information:
- Joseph A. Abboud, MD, can be reached at 925 Chestnut St., 5th Fl., Philadelphia, PA 19107; email: abboudj@gmail.com.
Disclosure: Abboud reports he is an implant designer for DJ Orthopaedics.