What are the indications for reverse shoulder surgery in an elderly patient with mild glenohumeral (shoulder) joint arthritis and multiple tendon tears?

Indications for Reverse Shoulder Arthroplasty in Elderly Patients with Mild Glenohumeral Arthritis and Multiple Tendon Tears

Reverse total shoulder arthroplasty (RSA) is indicated in elderly patients with multiple rotator cuff tears, even when glenohumeral arthritis is only mild, because traditional total shoulder arthroplasty is contraindicated in the presence of irreparable rotator cuff tears. 1, 2

Primary Indication: Irreparable Rotator Cuff Tears

• The American Academy of Orthopaedic Surgeons explicitly states that TSA should NOT be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear (Consensus recommendation). 1, 2

• RSA serves as the alternative surgical option specifically for cases with irreparable rotator cuff tears, regardless of the severity of arthritis. 2

• The presence of multiple tendon tears in your elderly patient likely represents an irreparable rotator cuff situation, making RSA the appropriate arthroplasty choice rather than traditional TSA. 1, 2

Why Mild Arthritis Doesn't Preclude RSA

• The degree of glenohumeral arthritis (mild in this case) is secondary to the rotator cuff status when determining arthroplasty type. 1, 2

• RSA was originally designed for older adults with rotator cuff deficiency and has proven effective in this population. 3

• The severity of symptoms, functional impairment, and patient age should guide the decision for surgical intervention, not just radiographic arthritis severity. 2

Clinical Decision Algorithm

Conservative management should be attempted first unless symptoms are debilitating:

• Physical therapy and activity modifications, though lacking high-quality evidence for glenohumeral OA specifically. 2

• Injectable corticosteroids (insufficient evidence but commonly used). 1, 2

• Viscosupplementation as a treatment option with weak supporting evidence. 1, 2

Proceed to RSA when:

• Conservative treatment fails to provide adequate pain relief or functional improvement. 2

• Multiple rotator cuff tears are confirmed to be irreparable on imaging (MRI or ultrasound). 4

• Patient has sufficient functional demands and medical fitness for surgery. 2

• Symptoms significantly impair quality of life despite conservative measures. 5

Critical Pitfalls to Avoid

• Do not perform traditional TSA in the presence of irreparable rotator cuff tears - this is a consensus contraindication that will lead to poor outcomes and likely revision surgery. 1, 2

• Ensure surgery is performed by a surgeon who performs at least 2 shoulder arthroplasties per year to reduce complication rates. 1

• Be aware that shoulder arthroplasty complications occur in up to 39.8% of cases, with revision rates up to 11%. 2

• For RSA specifically, common complications include scapular notching, dislocation, and periprosthetic fractures. 2

Age Considerations

• While the American Academy of Orthopaedic Surgeons expresses concern about arthroplasty in patients under 50 years due to prosthetic loosening and decreased survivorship, elderly patients are ideal candidates. 1, 3

• RSA was specifically designed for older adults with rotator cuff deficiency, making your elderly patient population appropriate. 3

Perioperative Management

• Use mechanical and/or chemical venous thromboembolism prophylaxis for all shoulder arthroplasty patients (American Academy of Orthopaedic Surgeons consensus recommendation). 2

• Pre-operative imaging is essential to evaluate glenoid morphology, bone loss, retroversion, and bone quality. 2