Sunday, June 7, 2015

The reverse total shoulder - use in the Medicare population

Use of reverse total shoulder arthroplasty in the Medicare population.

These authors analyzed the 2011 Medicare Part A claims data for patients aged 65 years or older. During this period, 31,002 shoulder arthroplasty procedures were performed; 37% were reverse total shoulders (RSAs), 42% were anatomic total shoulders (TSAs), and 21% were hemiarthroplasties (SHAs). Osteoarthritis was the primary diagnosis code in 91% of TSAs, 37% of SHAs, and 45% of RSAs. A primary diagnosis of osteoarthritis with no secondary code for rotator cuff tear was found in 22% of patients undergoing RSA. The mean length of stay for RSA (2.6 days; SD, 2.1 days) was longer than that for TSA (2.1 days; SD, 1.5 days) and shorter than that for SHA (3.5 days; SD, 3.6 days) (P < .001). Lower-volume surgeons (<10 arthroplasties per year) performed most shoulder arthroplasties: 57% of RSAs, 65% of TSAs, and 97% of SHAs.

Comment: There is no denying the trend toward increasing numbers and percentages of reverse total shoulders over recent years. The reasons for this increase remain speculative, but one might consider the following rationales for this procedure:
(1) it has the appeal of seeming to be the 'cutting edge' technology
(2) it is an approach for reducing problems associated with delayed cuff failure,  secondary glenoid failure, and instability
(3) it is less technically demanding and more 'forgiving' than trying to balance mobility and stability with an anatomic prosthesis
(4) it may offer major advantages over internal fixation or anatomic arthroplasty in the management of proximal humeral fractures (a situation similar to the use of total elbows in severe supracondylar fractures).
(5) it may enable increased surgeon reimbursement if a 22 modifier is used
(6) it is now being used for non-arthritic, non- fracture conditions, such as the management of rotator cuff tears without arthritis

In our practice many patients present having been told by others that they need a reverse. However, currently reserve the use of the reverse for individuals with low activity expectations who also have either pseudo paralysis or instability that is not otherwise manageable. Our high success rate with anatomic arthroplasty has not tempted us to use the reverse at  nearly the rate reported in this paper.

In the attempt to sort out the place of the reverse in the practice of shoulder arthroplasty, one needs to understand that there are many different designs with different kinematics and different potential failure modes. Time and careful longitudinal followup will reveal the best circumstances for applying this technology.

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