"Am I too old for a shoulder replacement?" The association between age and comorbidities on the outcomes following Reverse Shoulder Arthroplasty.

INTRODUCTION: Reverse shoulder arthroplasty (rTSA) is increasingly performed in elderly patients; however, the influence of advancing age and comorbidity on revision, medical complications, and mortality remains poorly defined. This study aims to use population reflective data in the National Joint Registry (NJR) to assess the outcomes of those ≥80 years old having an rTSA. METHODS: Elective rTSA procedures performed between 2012 and 2022 in patients aged ≥80 years were identified from the NJR and linked to Hospital Episode Statistics for England. The primary outcome was revision surgery. Secondary outcomes included 30-day medical complications, length of stay, and mortality. Associations with age, sex, and ASA grade were assessed using survival and regression analyses, with subgroup analyses in patients aged ≥85 and ≥90 years. RESULTS: A total of 6,988 patients aged ≥80 years were included. Revision rates were low (1.4% at 1 year,2.32% at 5 years and 3.35% at 9 years), with male sex associated with a higher risk of revision (HR 3.45, 95% CI 2.47-4.81). Increasing age was associated with a reduced likelihood of revision (HR 0.89 per year 95% CI 0.84-0.96, p=0.001), likely reflecting competing mortality and higher thresholds for reoperation. In contrast, medical complications occurred in 8.9% of patients aged ≥80 years, rising to 16.4% in those aged ≥90 years. Each additional year of age was associated with increased odds of a medical complication (OR 1.04, 95% CI 1.01-1.07), with substantially higher risk in patients with ASA III-IV. One-year mortality increased from 3.3% in patients aged ≥80 years to 8.2% in those aged ≥90 years. CONCLUSION: While revision following rTSA is uncommon in very elderly patients, medical complications and mortality increase substantially with advancing age and comorbidity. Chronological age alone should not preclude consideration of rTSA, but these risks should be central to pre-operative counselling and shared decision making.