UW Shoulder and Elbow Academy: Why are surgeons performing reverse total shoulders rather than anatomic arthroplasties for cuff intact arthritis?

In the prior post we reviewed the evidence that - in contrast to reverse arthroplasty (RSA) - anatomic total shoulder arthroplasty (aTSA) is less expensive and provides patients with better comfort and function, fewer serious complications, and safer revision options for complications should they occur.

Paradoxically, however, the proportion of aTSAs being performed for cuff-intact arthritis is dropping precipitously.

We can speculate on possible reasons for this paradox.

(1) Surgeons may perceive that a lower revision rate for RSA is a positive factor for the patient, when in fact the lower RSA revision rate is due in large part to the fact that some of the most common and serious RSA complications are often not revisable (e.g. pain and poor function, displaced acromial/spine fractures).

(2) Surgeons may perceive that the RSA is easier to perform. This is, of course, due to the fact that few surgeons have training/experience in performing a basic aTSA, not that the operation is of itself more challenging.

(3) Industry influence and conflicts of interest preferentially motivate the more expensive/profitable RSA option.

(4) Recent "innovations" targeting the use of preoperative planning to achieve high levels of "accuracy and precision" - that may be clinically irrelevant - can make the aTSA unnecessarily complex, expensive and daunting.

The solution may lie in assuring that shoulder surgeons are well trained in both aTSA and RSA. This requires that organizations such as AAOS and ASES provide hands-on educational opportunities and that training programs assure that their fellows and residents have a meaningful experience in both. Interestingly in our most recent round of interviews for our fellowship, a number of applicants reported they had never seen, much less performed, an aTSA.

Below is the basic approach I use for anatomic arthroplasty presented at the amazing Nice Shoulder Course of Pascal Boileau. These steps may be helpful for surgeons wishing to build their aTSA skills.