Anatomic and reverse shoulder arthroplasty in patients 70 years of age and older: a comparison cohort at early to midterm follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has gained popularity in elderly patients because of its limited reliance on rotator cuff function and high survivorship rates. However, although there are theoretical advantages of RSA over anatomic total shoulder arthroplasty (TSA) in elderly patients, there is little data to guide surgeons on implant selection in this population. METHODS: Patients were identified from our prospectively collected shoulder arthroplasty registry. We included patients between the age of 50 and 89 years who underwent primary TSA for osteoarthritis with intact rotator cuff or primary RSA for cuff tear arthropathy. The minimum and mean clinical follow-up was 2 and 3.1±1.3 years, respectively. Four patient groups were formed for analysis: (1) TSA age 50-69 years (n=274), (2) TSA age 70-89 years (n=208), (3) RSA age 50-69 years (n=81), and (4) RSA age 70-89 years (n=104). We evaluated age group differences in pain, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, patient satisfaction, complications, and revisions. RESULTS: All groups showed significant improvements from preoperative to final follow-up for all outcome measures (P < .001). Visual analog scale for pain average score decreased from 5.8 preoperatively to 1.1, with no significant differences between groups (TSA P = .180; RSA P = .103). Final ASES scores and improvement from preoperative ASES score between the age groups were not significantly different (TSA P = .520; RSA P = .065). There were no significant differences in outcomes between TSA in patients older than 70 years vs. patients younger than 70 years (all P > .05); however, older RSA patients reported better function during activities of daily living (P = .020) than their younger counterparts. Patients undergoing TSA had a lower revision rate of 3.9% compared with 8.1% in the RSA group (P = .043). CONCLUSIONS: TSA and RSA are reliable procedures for patients older than 70 years, and have comparable results to their respective patient cohorts younger than 70 years. Although some surgeons anecdotally advocate for RSA in patients older than 70 years with primary osteoarthritis and an intact rotator cuff, we found no difference in outcomes for TSA based on our age cutoff. Given satisfactory results following TSA in patients 70 years of age and older, we do not routinely perform RSA for primary osteoarthritis with an intact rotator cuff solely based on age. Further studies and longer follow-up are needed to determine the optimal implant selection for elderly patients with primary osteoarthritis.

Pulmonary Embolism After Vaginal Delivery in a Fontan Patient.

The Fontan procedure was created to address the mixing of pulmonary and systemic venous return in patients with a single functional ventricle. The patient in this case with a Fontan repair experienced multiple pulmonary emboli 10 days post-partum. We outline management and recommendations when treating these patients. (Level of Difficulty: Beginner.).