Summary: Three takeaway points
(1) The commonly used and easy to measure "revision rate" is an inadequate endpoint for evaluating rTSA outcomes. The 8–20 percentage point gap that exists between the complication rate and the revision rate includes a substantial number of patients with failed but unrevised reverse shoulder arthroplasties. These patients are not considered in determining the failure rate when measured by the percentage having revision. Complication-free survival or patient-reported outcome measures should supplement or replace revision rate or "implant survival" as the primary outcome measure for rTSA.
(2) The most common complications of rTSA, acromial and scapular spine fractures, are unique and difficult to solve problems for patients having reverse arthroplasty. In contrast, the most common complications from aTSA - glenoid component loosening and rotator cuff tear - can be effectively managed by revision to a rTSA
(3) The salvage pathway for patients with rTSA failure is poor. Revision rTSA carries a 31% complication rate and 27% re-revision rate, with outcomes that are significantly worse than those for primary rTSA. This contrasts sharply with aTSA-to-rTSA conversion, the outcome of which approaches the outcomes for primary rTSA.
The details
Meta-analytic evidence reports that anatomic total shoulder (aTSA) has a higher rate of revision compared to reverse total shoulder (rTSA). This observation may have driven much of the shift toward rTSA for patients with cuff-intact arthritis. However, it may neglect the fact that surgeons and patients can decide against revision of a failed rTSA because of the low rate of success. Thus, the absence of a revision does not indicate a good outcome.
Consider the references below
Complications and further surgery after reverse total shoulder arthroplasty : report of 854 primary cases reported an overall complication rate of 18–22%, yet a revision rate of only ~10%. That 8–12 percentage point gap likely represents patients who are living with a failing implant — either because revision was technically not feasible, or because expected outcomes were too poor to justify reoperation
The Gap Between Revision-Free and Complication-Free Survival
Outcomes of Revision rTSA
Revision of reverse total shoulder arthroplasty: a scoping review of indications for revision, and revision outcomes, complications, and rerevisions and Revision of failed shoulder arthroplasty: epidemiology, etiology, and surgical options found the most common indications for revision to be instability/dislocation (28–30%), baseplate or glenoid complications (20–25%), and infection (15–23%). Notably low on the list is revision for the most common complication: acromial/spine fractures.
The Salvage Pathway Asymmetry: revision for aTSA Failure compared to revision for rTSA Failure
(2) The most common complications of rTSA, acromial and scapular spine fractures, are unique and difficult to solve problems for patients having reverse arthroplasty. In contrast, the most common complications from aTSA - glenoid component loosening and rotator cuff tear - can be effectively managed by revision to a rTSA
Complications and further surgery after reverse total shoulder arthroplasty : report of 854 primary cases reported an overall complication rate of 18–22%, yet a revision rate of only ~10%. That 8–12 percentage point gap likely represents patients who are living with a failing implant — either because revision was technically not feasible, or because expected outcomes were too poor to justify reoperation
Incidence, radiographic predictors, and clinical outcome of acromial stress reaction and acromial fractures in reverse total shoulder arthroplasty found 46 acromial stress fractures (5.4%) in 44 patients and 44 acromial stress reactions (5.2%) in 43 patients. The overall union rate was 55% but was significantly higher following operative treatment compared with nonoperative treatment. However, facture consolidation did not result in better clinical outcomes compared with nonunion; this may question the value of attempted fixation.
Comparison of complication types and rates associated with anatomic and reverse total shoulder arthroplasty found that the top 3 complications for rTSA were acromial/scapular fracture/pain ( complication rate 2.5%, revision rate 0.0%), instability (complication rate 1.4%, revision rate 1.0%), pain (1.2%, revision rate 0.2%). Compare the relationship of complications to revisions for rTSA to that for aTSA in the two charts below constructed from the data in this article. Note that a high percentage of the rTSA complications were not associated with surgical revision. Absence of revision ≠ absence of complication,
Comparison of complication types and rates associated with anatomic and reverse total shoulder arthroplasty found that the top 3 complications for rTSA were acromial/scapular fracture/pain ( complication rate 2.5%, revision rate 0.0%), instability (complication rate 1.4%, revision rate 1.0%), pain (1.2%, revision rate 0.2%). Compare the relationship of complications to revisions for rTSA to that for aTSA in the two charts below constructed from the data in this article. Note that a high percentage of the rTSA complications were not associated with surgical revision. Absence of revision ≠ absence of complication,
The Gap Between Revision-Free and Complication-Free Survival
Long-Term Outcomes of Reverse Total Shoulder Arthroplasty
A Follow-up of a Previous Study The 93% ten-year revision-free survival rate for rTSA did not capture the 29% of patients who experienced complications.
Long term clinical and radiological outcomes of primary reverse total shoulder arthroplasty at a minimum follow-up of 15 years: Norwegian registry data showed 10-year complication-free rates of only 76–80%, despite revision-free survival of 91–95%. That 15–20 percentage point gap represents patients living with failed implants who are invisible in the revision statistics. Again, this gap exists because many rTSA complications—particularly acromial fractures, low-grade infection, and baseplate loosening with severe bone loss—either cannot be addressed surgically or carry such poor expected revision outcomes that conservative management is chosen.
Revision rates alone remain an inadequate measure of rTSA performance; complication-free survival is the more appropriate endpoint.
A Follow-up of a Previous Study The 93% ten-year revision-free survival rate for rTSA did not capture the 29% of patients who experienced complications.
Long term clinical and radiological outcomes of primary reverse total shoulder arthroplasty at a minimum follow-up of 15 years: Norwegian registry data showed 10-year complication-free rates of only 76–80%, despite revision-free survival of 91–95%. That 15–20 percentage point gap represents patients living with failed implants who are invisible in the revision statistics. Again, this gap exists because many rTSA complications—particularly acromial fractures, low-grade infection, and baseplate loosening with severe bone loss—either cannot be addressed surgically or carry such poor expected revision outcomes that conservative management is chosen.
Revision rates alone remain an inadequate measure of rTSA performance; complication-free survival is the more appropriate endpoint.
Outcomes of Revision rTSA
Outcomes After Revision
Revision reverse total shoulder arthroplasty: clinical and radiographic outcomes compared to primary reverse total shoulder arthroplasty found a 31% complication rate and 27% re-revision rate of a failed rTSA: over five times these rates after primary rTSA. The most common complications after revision are recurrent instability (22%), fractures (18%), and baseplate issues (12%). Patients requiring revision rTSA experience markedly worse comfort and function in comparison to primary rTSA
The Salvage Pathway Asymmetry: revision for aTSA Failure compared to revision for rTSA Failure
Conversion of failed anatomic total shoulder arthroplasty to reverse shoulder arthroplasty yields similar pain and functional outcomes to primary reverse shoulder arthroplasty but has a higher baseplate failure rate: a matched cohort study. In contrast to the often grim outcomes for revision of a failed rTSA, revision of a failed aTSA to a rTSA yields outcomes approaching those of primary rTSA.
Summary: Three takeaway points (again)
(1) The commonly used and easy to measure "revision rate" is an inadequate endpoint for evaluating rTSA outcomes. The 8–20 percentage point gap that exists between the complication rate and the revision rate includes a substantial number of patients with failed but unrevised reverse shoulder arthroplasties. These patients are not considered in determining the failure rate when measured by the percentage having revision. Complication-free survival or patient-reported outcome measures should supplement or replace revision rate or "implant survival" as the primary outcome measure for rTSA.
(2) The most common complications of rTSA, acromial and scapular spine fractures, are unique and difficult to solve problems for patients having reverse arthroplasty. In contrast, the most common complications from aTSA - glenoid component loosening and rotator cuff tear - can be effectively managed by revision to a rTSA
(3) The salvage pathway for patients with rTSA failure is poor. Revision rTSA carries a 31% complication rate and 27% re-revision rate, with outcomes that are significantly worse than those for primary rTSA. This contrasts sharply with aTSA-to-rTSA conversion, the outcome of which approaches the outcomes for primary rTSA.
Swans reversing course
Trumpeter Swans
Union Bay Natural Area
Seattle
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