Despite the high rates of complications and revisions in our study, 92.3% of patients were satisfied with surgery, 88.0% experienced minimal persistence of pain (mean 3.8-point decrease on SRPS), and 100% maintained improved ROM at final follow-up. Satisfaction in the young population has varied significantly, from 52% to 95%, generally on the basis of physical activity.16,22-24 The reasonable rate of postoperative satisfaction in the present analysis is comparable to what has been reported in patients of a similar age (Table 6).7,16,22 However, despite high satisfaction and pain relief, patients were inconsistently able to return to the upper limits of physical activity required of active-duty military service. In addition, we cannot exclude secondary gain motivations for pursuing medical retirement, similar to that seen in patients receiving worker’s compensation.
Other authors have conversely found more favorable functional outcomes and survivorship rates.23,24 In a retrospective review of 46 TSAs in patients 55 years or younger, Bartelt and colleagues24 found sustained improvements in pain, ROM, and satisfaction at 7-year follow-up.24 Raiss and colleagues23 conducted a prospective study of TSA outcomes in 21 patients with a mean age of 55 years and a mean follow-up of 7 years and reported no revisions and only 1 minor complication, a transient brachial plexus palsy.23 The discrepancy between these studies may reflect different activity levels and underlying pathology between cohorts. The present population is unique in that it represents a particularly difficult confluence of factors for shoulder arthroplasty surgeons. The high activity, significant overhead and lifting occupational demands, and discordant patient expectations of this military cohort place a significant functional burden on the implants, the glenoid component in particular. Furthermore, this patient group has a higher incidence of more complex glenohumeral pathology resulting in instability, posttraumatic, or capsulorrhaphy arthropathy, and multiple prior arthroscopic and open stabilization procedures.
At final follow-up, only 33% of our patients were still on activity duty, 37.5% had completed or were completing medical separation from the military after surgery for persistent shoulder disability, and 37.5% were retired from the military. Five patients (20.8%) deployed after surgery. This young, active cohort of service members who had TSA for glenohumeral arthritis faced a unique set of tremendous physical demands. A retrospective case series investigated return to sport in 100 consecutive patients (mean age, 68.9 years) who were participating in recreational and competitive athletics and underwent unilateral TSA.21 The patients were engaged most commonly in swimming (20.4%), golf (16.3%), cycling (16.3%), and fitness training (16.3%). The authors found that, at a mean follow-up of 2.8 years, 49 patients (89%) were able to continue in sports, though 36.7% thought their sport activity was restricted after TSA. In another retrospective case series (61 TSAs), McCarty and colleagues19 found that 48 patients (71%) were improved in their sports participation, and 50% increased their frequency of participation after surgery.
There are no specific recommendations on returning to military service or high-level sport after surgery. Recommendations on returning to sport after TSA have been based largely on small case series involving specific sports46,47 and surveys of expert opinion.17,18 In a survey on postoperative physical activity in young patients after TSA conducted by Healy and colleagues,17 35 American Shoulder and Elbow Surgeons members recommended avoiding contact and impact sports while permitting return to nonimpact sports, such as swimming, which may still impart significant stress to the glenohumeral joint. In an international survey of 101 shoulder and elbow surgeons, Magnussen and colleagues18 also found that most recommended avoiding a return to impact sports that require intensive upper extremity demands and permitting full return to sports at preoperative levels. This likely is a result of the perception that most of these patients having TSA are older and have less rigorous involvement in sports at the outset and a lower propensity for adverse patient outcomes. However, these recommendations may place a younger, more high-demand patient at significantly greater risk. The active-duty cohort engages in daily physical training, including push-ups and frequent overhead lifting, which could account for the high failure rates and low incidence of postoperative deployment. Although TSA seems to demonstrate good initial results in terms of return to high-demand activities, the return-to-duty profile in our study highlights the potential pitfalls of TSA in active individuals attempting to return to high-demand preoperative function.