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‘Reverse’ shoulder replacement offers lasting improvement in younger patients with irreparable rotator cuff tear

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A “reverse” shoulder replacement is a good treatment option for younger patients with severe damage to the rotator cuff muscles, as well as older patients, according to new research.

The study published in the Journal of Bone & Joint Surgery found that reverse total shoulder arthroplasty (RTSA) provides lasting improvement in shoulder function. And, despite a substantial risk of complications, most patients are satisfied with the outcomes of RTSA at follow-ups of a decade or longer.

Dr Christian Gerber of the University of Zurich and colleagues analysed the long-term outcomes of RTSA in 20 patients (23 shoulders) whose ages ranged from 47 to 59 years. All had “massive, irreparable” tears of the rotator cuff muscles, causing shoulder “pseudoparalysis”, with little to no ability to lift the arm.

A follow-up examination was conducted between eight and 19 years after surgery (average 11.7 years).

As journal publisher Wolters Kluwer explains, this group of patients typically gets limited benefit from shoulder replacement with conventional implants, which rely on the rotator cuff muscles to provide shoulder movement. In contrast, the RTSA technique — using an implant in which the natural locations of the shoulder “ball and socket” are reversed — uses other muscles to move the shoulder, providing an alternative when the rotator cuff is severely damaged or destroyed.

When it was first introduced, the procedure was performed mainly in elderly patients who placed low demands on the shoulder. As the technique and components have been refined in more recent years, RTSA has also been used in younger, more active patients. But there have been concerns about how well the results will hold up over time in this group of patients.

In the study, compared to their preoperative status, most patients had substantial long-term improvement after RTSA. The average Constant score — a standard assessment accounting for shoulder motion, strength, daily activities, and pain — at the time of final-follow-up improved from 24 to 59 (out of a possible 100).

Patients’ ratings of “subjective shoulder value” improved from 20% to 71% (compared to 100% for a normal shoulder). Shoulder movement and strength increased, while pain decreased. The improvement was similar for patients with and without prior shoulder surgery.

However, complications occurred in 39% of the shoulders. Further surgery was required in six shoulders, and in two cases the RTSA procedure was considered a failure.

When complications occurred, long-term shoulder functioning was not as good. But despite the high complication rate, 72% of patients rated their satisfaction level as excellent or good.

The researchers concluded that RTSA “provides substantial and lasting improvement” in shoulder function and pain, in a group of patients with limited treatment options.