Monday, May 14, 2018

Reverse total shoulder: trends and value

Current Trends in the Use of Shoulder Arthroplasty in the United States

These authors point out that reverse total shoulder arthroplasty (rTSA) has become increasingly popular since its introduction to the United States. The purpose of their study was to assess the current trends and use of rTSA, anatomic total shoulder arthroplasty (aTSA), and hemiarthroplasty (HA) from 2011 to 2014. 

Shoulder arthroplasty data from the National (Nationwide) Inpatient Sample database were analyzed for the years 2011 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. For each procedure, use and patient and hospital characteristics were identified. 

Shoulder arthroplasties increased by 24% between 2011 and 2014, to 79,105 procedures. The proportion of arthroplasties that were aTSA did not change substantially (44% for both years; P=.0585), while the proportion that were rTSA surpassed aTSA in 2014, increasing from 33% to 46% (P<.0001). Use of rTSA topped use of aTSA by 2013 for Medicare patients. 

The proportion that were HA procedures declined from 23% to 11% (P<.0001). The use of rTSA for fracture increased from 26% to 58% (P<.0001) of all arthroplasties for this indication, while the use of HA for fracture decreased from 69% to 40% (P<.0001). 

Orthopedists performed rTSA more often than aTSA for Medicare patients by 2013 and the general population by 2014. The use of rTSA for fracture has grown significantly, with rTSA being performed more frequently than HA for this indication. 

Comment: There is no question that reverse total shoulder provides an attractive option for selected patients, for example those with complex fractures of the proximal humerus as suggested by the figure below.

It is of interest to note that almost half of the reverse total shoulders are being done for  osteoarthritis, especially since it has not been documented that the clinical outcomes for reverse total shoulders for osteoarthritis are equal to or superior to those for an anatomic total shoulder for osteoarthritis.

The authors note the substantially high cost of the reverse total shoulder; thus we need to be sure that for each indication the increased cost is justified by increased benefit to the patient. Specifically, is there evidence that a rTSA for OA is of greater value to the patient than a aTSA for the same diagnosis?

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