Wheelchair use associated with worse outcomes after total shoulder arthroplasty vs. no use
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Key takeaways:
- Wheelchair use was associated with increased complications and readmissions at 1 year after total shoulder arthroplasty.
- Readmission rates were 24.05% for wheelchair users and 9.55% for non-wheelchair users.
According to published results, wheelchair users had higher rates of complications and readmissions at 1 year after total shoulder arthroplasty compared with non-wheelchair users.
Researchers used the PearlDiver Mariner national administrative database to analyze surgical outcomes of 72,108 patients who underwent TSA for a rotator cuff tear between 2010 and 2020. They created two matched cohorts: a cohort of 869 patients who were wheelchair users and a cohort of 869 non-wheelchair users.
Overall, researchers found wheelchair users had increased rates of preoperative comorbidities and postoperative complications at 1 year after TSA compared with non-wheelchair users.
Among wheelchair users, common preoperative comorbidities included anemia, arrhythmia, osteoarthritis, hypertension, ischemic heart disease, pulmonary heart disease and chronic obstructive pulmonary disease. Postoperative complications included acute kidney injury, urinary tract infection, pneumonia, wound disruption and deep vein thrombosis.
According to the study, 1-year readmission rates were 24.05% for wheelchair users and 9.55% for non-wheelchair users. Researchers noted wheelchair users with OA, ischemic heart disease, pulmonary heart disease, chronic kidney disease and previous arrhythmia were most likely to be readmitted.
“For patients who depend on the use of a wheelchair for mobility, regular physical activity at the level recommended to reduce the risk of developing these comorbidities may be difficult, which could explain the higher prevalence of these comorbidities in the wheelchair population in our study,” the researchers wrote in the study.
Perspective
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The detailed article by Kevin Prabhu and colleagues definitively confirms the challenges with perioperative and postoperative complications in patients who are wheelchair dependent. Most are confined due to multiple medical comorbidities or neurologic compromise, and the significant increase in postoperative issues would be anticipated. While pre-surgical optimization is critical for all surgical patients, this study further demonstrates the expanded requirements in this patient population. Working collaboratively with medical specialists and rehabilitative teams would likely improve outcomes and reduce early complications.
Additionally, the long-term challenges of implant survivorship remain a concern. While reverse shoulder arthroplasty has become the implant of choice for the weight-bearing shoulder, intermediate follow-up studies have demonstrated decreased functional scores and increased complication rates. Symptomatology was significantly improved, however. Increased biomechanical stresses on the shoulder during propulsion with greater than 360% peak vertical force and 167% posterior force have unknown long-term consequences on implant survivorship. Modern implant designs allowing for avoidance of cement on the humeral side and maintaining non-weight-bearing status for 12 weeks, may enhance ingrowth and improve implant longevity.
Potentially, material advances such a vitamin E processing, highly cross-linked ultra-high-molecular-weight polyethylene and pyrolytic carbon may provide additional opportunities for improved implant durability in this growing patient population.
References:
Alentorn-Geli E, et al. PM R. 2018;doi:10.1016/j.pmrj.2017.10.010.
Collinger JL, et al. Arch Phys Med Rehabil. 2008;doi:10.1016/j.apmr.2007.09.052.
Kemp AC, et al. J Shoulder Elbow Surg. 2016;doi:10.1016/j.jse.2015.11.006.
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