Both TSA, RTSA are viable options for low-demand patients aged 75 years or older

Jonathan C. Levy, MD

I read with great interest the recent article by Shah and colleagues comparing the outcomes of anatomic TSA and RSA among different age groups. Given the popularity of RSA at managing the cuff deficient and arthritic shoulder, I agree wholeheartedly with the authors that the “pendulum has swung toward reverse shoulder arthroplasty.” However, is this justified by evidence?

In this article, the authors focus on age differences and the impact on improvement of outcomes after shoulder arthroplasty. While overall results suggest that TSA patients demonstrated larger improvements in ASES scores, among patients 75 years and older, the achievements were more similar, with 90% of patients achieving minimal clinical important difference (MCID) after both TSA and RSA. However, the achievement of the greatest improvements (substantial clinical benefit) still favored the TSA group.   

While these findings might lead the reader to focus on RSA for all patients older than 75 years of age given seemingly equivalent outcomes, the study limitations discussed must first be critically considered. Complications following RSA can be devastating in the early postoperative period and were not examined in this study. Acromion fractures, nerve injuries and joint dislocations are more common after RSA and can result in high morbidity for patients older than 75 years old. Furthermore, the indications for TSA and RSA differed greatly in this series. Given that the outcomes and complications of RSA have been shown to differ significantly based upon indication, it is difficult to utilize the data presented in this study to support the use of RSA for the osteoarthritic shoulder that might otherwise do well with a TSA.

While I congratulate the authors for evaluating a large cohort of 831 shoulder arthroplasties and shedding light into the differences in outcome achievement based upon age, I would caution the reader to question the swing of the pendulum before “jumping on the ball.” Utilize patient-specific criteria to determine the type of shoulder arthroplasty when treating elderly patients with shoulder osteoarthritis, as activity demands, glenoid wear patterns, degree of passive motion and comorbidities, including osteoporosis, all help shape the optimal choice.