Sunday, August 2, 2015

Reverse total shoulder - It is time to re-examine which patients are receiving it.

Reverse shoulder arthroplasty for massive rotator cuff tear: risk factors for poor functional improvement.

These authors reviewed their cases of primary RSA performed for massive rotator cuff tear without glenohumeral arthritis with minimum 2-year follow-up.

Poor outcomes were were defined as Simple Shoulder Test (SST) score improvement of ≤1, whereas controls improved SST score ≥2. Risk factors were chosen on the basis of previous association with poor outcomes after shoulder arthroplasty. Latissimus dorsi tendon transfer results were analyzed as a subgroup. Value was defined as improvement in American Shoulder and Elbow Surgeons (ASES) score per $10,000 hospital cost.

In a multivariate binomial logistic regression analysis, neurologic dysfunction (P = .006), age <60 years (P = .02), and high preoperative SST score (P = .03) were independently associated with poor functional improvement. Latissimus dorsi tendon transfer patients significantly improved in active external rotation (-0.3° to 38.7°; P < .01). The value of RSA (ΔASES/$10,000 cost) for cases was 0.8 compared with 17.5 for controls (P < .0001).

The authors emphasize the critical importance of patient selection.

Comment: We are in an era where surgeons are rapidly explaining the indications for RSA - a procedure originally developed for rotator cuff tear arthropathy (cuff deficiency + arthritis) with pseudo paralysis. Now surgeons are using RSA for cuff disease without arthritis and for osteoarthritis with biconcave glenoids. The average age of patients receiving this surgery is becoming younger and younger. And the severity of preoperative shoulder impairment is becoming less and less.

We were not sure from what populations the 'cases' and 'controls' were selected - for example were they from the same time period? Did the 'control' group include all the patients from this period? What percent of the RSAs done during this period were failures? Without this information can we be sure that this was an appropriate comparison. Nevertheless, we value this effort to define 'failure' as lack of clinical improvement (rather than complications or revisions) and to use data to rein in the exploding number of reverse total shoulders performed each year. 

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