Nicholas Kusnezov, MD, John C. Dunn, MD, Stephen A. Parada, MD, Kelly Kilcoyne, MD, and Brian R. Waterman, MD
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. The authors are employees of the US government. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the US Department of Defense or the US government.
The mean age of our study population (46 years) is one of the lowest in the literature. TSA in younger patients (age, <50-55 years) and older, active patients (>55 years) has received increased attention as a result of the expanding indications and growing popularity of TSA in these groups. Other studies have upheld the efficacy of TSA in achieving predictable pain relief and functional improvement in a diverse and predominantly elderly population.15,30-34 Alternative treatments, including humeral head resurfacing15,30,35 and soft-tissue interposition,15,36-40 have also shown inferior short- and long-term results in terms of longevity and degree of clinical or functional improvement.31-34,41 In addition, the ream-and-run technique has had promising early results by improving glenohumeral kinematics, pain relief, and shoulder function.13,42,43 However, although implantation of a glenoid component is avoided in young, active people because of reduced longevity and higher rates of component failure, the trade-offs are inadequately treated glenoid disease, suboptimal pain relief, and progression of glenoid arthritis eventually requiring revision. Furthermore, midterm and long-term survivorship of TSA in general is unknown, and there remain few good options for treating end-stage arthritis in young, active patients.
Our cohort had high rates of complications (46.2%) and revisions (23.1%). Two in 5 patients had postoperative complications, most commonly component failure resulting in reoperation. In the literature, complication rates among young patients who underwent TSA are much lower (4.8%-10.9%).16,23,24 Our cohort’s most common complication was component failure (23.1%), which was most often attributed to atraumatic, aseptic glenoid component loosening and required reoperation. Previously reported revision rates in a young population that underwent TSA (0%-11%)16,23,24 were also significantly lower than those in the present analysis (23.1%), underscoring the impact of operative indications, postoperative activity levels, and occupational demands on ultimate failure rates. Interestingly, all revisions in our study were for component failure, whereas previous reports have described a higher rate for infection.22 However, the same studies also found glenoid lucency rates as high as 76% at 10-year follow-up.16 Furthermore, in a review of 136 TSAs with unsatisfactory outcomes, glenoid loosening was the most common reason for presenting to clinic after surgery.44 Specifically, our population had a high rate of glenohumeral arthritis secondary to instability (50.0%) and posttraumatic osteoarthritis (26.9%). For many reasons, outcomes were worse in younger patients with a history of glenohumeral instability33 than in older patients without a high incidence of instability.45 This young cohort with higher demands may have had accelerated polyethylene wear patterns caused by repetitive overhead activity, which may have arisen because of a higher functional profile after surgery and greater patient expectations after arthroplasty. In addition, patients with a history of instability may have altered glenohumeral anatomy, especially with previous arthroscopic or open stabilization procedures. Anatomical changes include excessive posterior glenoid wear, internal rotation contracture, patulous capsular tissue, static or dynamic posterior humeral subluxation, and possible overconstraint after prior stabilization procedures. Almost half of our population had a previous surgery; our patients averaged 1.7 previous surgeries each.
Although estimates of component survivorship at a high-volume civilian tertiary-referral center were as high as 97% at 10 years and 84% at 20 years,7,16 10-year survivorship in patients with a history of instability was only 61%.3 TSA survivorship in our young, active cohort is already foreseeably dramatically reduced, given the 23.1% revision rate at 28.5-month follow-up. This consideration must be addressed during preoperative counseling with the young patient with glenohumeral arthritis and a history of shoulder instability.
