Anatomic or reverse total shoulder for osteoarthritis? The 4Ps

Here's an often asked question: 

orfor?

Opinions range from "I use reverse for everything" to "My best anatomic is better than my best reverse. My worst anatomic is better than my worse reverse".

In comparing the outcomes of anatomic and reverse total shoulders, the outcome of each arthroplasty is influenced by the 4Ps: 

the problem - e.g. primary osteoarthritis, glenoid type, retroversion,
the patient - e.g. age, comorbidities, sex, social determinants of health, length of followup
the procedure - e.g. implant selection, surgical technique, 
the provider -  e.g. surgeon skill and experience.

With that in mind, let's look at some publications from 2023: 

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Patients 75 Years or Older with Primary Glenohumeral Arthritis and an Intact Rotator Cuff Show Similar Clinical Improvement after Reverse or Anatomic Total Shoulder Arthroplasty

Problem: Glenohumeral arthritis with intact cuff. B2 or B3 glenoids were present in 22% of ATSAs and 62% of RTSAs 

Patient: 75 years of age or older, followed for minimum of 2 yrs

Procedure: Not randomized or matched. Rationale for selecting ATSA or RTSA was based on "perceived risk of glenoid loosening". ATSA was Arthrex Univers Apex or Eclipse with corrective glenoid reaming. RTSA was Universe Revers.

Provider: Individual fellowship trained surgeon.

Summary

ATSA: n=67; Mean ASES score 84; complications 7% (cuff failure, painful stiffness); satisfaction 93%

RTSA: n= 37; Mean ASES score 90; complications 5% (acromial stress fracture, stiffness); satisfaction 92%

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Rotator Cuff Preserving Reverse Shoulder Arthroplasty Versus Eccentrically Reamed Anatomic Total Shoulder Arthroplasty for Glenohumeral Osteoarthritis and an Intact Rotator Cuff with B2 Glenoid Deformity

Problem:  Osteoarthritis with B2 glenoid and intact cuff, Type B2 glenoid

Patient: Age 65 years or older.

Procedure: Not randomized or matched. ATSA with eccentric reaming vs RTSA with cuff preservation. Rationale for selecting ATSA or RTSA not provided. Implant vendors not provided.

Provider: 3 fellowship trained surgeons

Summary

ATSA: n=18; mean retroversion 16 degrees; mean followup 4.7 years. Mean ASES score 87. No complications reported

RTSA: n=17; mean retroversion 19 degrees; mean followup 2.5 years. Mean ASES score 93. One case of scapular notching.

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Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy

Problem:  Osteoarthritis with intact rotator cuff

Patient: No age or glenoid pathology limitations, minimum 12 month followup.

Procedure: ASTA or RTSA with cuff preservation; Tornier Ascend Flex or Arthrex Universe Revers. Rationale for selecting ATSA or RTSA not provided.

Provider: Individual fellowship trained surgeon.

Summary

ATSA: n=93, 38% female; mean age 66 yrs; mean retroversion 15 degrees; mean followup 18 mo; Mean ASES score 84; 1 intraoperative fracture, 4 rotator cuff tears 

RTSA: n=24, 76% female, mean age 71 yrs, mean retroversion 18 degrees; mean followup 16 mo; Mean ASES score 75; 1 infection

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Anatomic vs. reverse shoulder arthroplasty for glenohumeral osteoarthritis with intact rotator cuff: a retrospective comparison of patient-reported outcomes using the systems outcomes database with up to 5-year follow-up

Problem:  Osteoarthritis with intact rotator cuff

Patient: from Arthrex Shoulder Oucomes System

Procedure: ATSA vs RTSA. Arthrex implants. Rationale for selecting ATSA or RTSA not provided.

Provider: 264 surgeons

Summary

ATSA: n=2693, mean age 65 years, 46% female. ASES scores 1 yr 86, 2 yr 87, 5 yr 87, complication rate not reported

RTSA: n=1758, mean age 71 years, 53% female. ASES scores 1 yr 81, 2 yr 81, 5 yr 82, complication rate not reported.

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Anatomic versus Reverse Total Shoulder Arthroplasty with glenoid retroversion of at least 15 degrees in rotator cuff intact patients: A comparison of short-term results.

Problem:  Osteoarthritis with intact cuff and at least 15 degrees of retroversion

Patient: Minimum 2 yr followup. Version not reported

Procedure: ATSA five different glenoid components (standard hybrid cage 33, augmented hybrid cage 55, standard all polyethylene peg 38,  augmented all polyethylene peg 54, keel 7). Rationale for selecting ATSA or RTSA not provided.

Provider: Multisugeon

Summary

ATSA: n=187; comorbidities 65%; mean age 66 years; mean followup 62 months; mean retroversion 21 degrees. Mean ASES score 84. Glenoid loosening 6%

RTSA: n=147; comborbidities 76%; mean age 71 years; mean followup 41 years; mean retroversion 24 degrees. ASES score 87. Glenoid loosening 1%, notching 7%.

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Clinical outcomes of anatomical versus reverse total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and limited forward elevation

Problem:  Osteoarthritis with intact rotator cuff with or without passive forward elevation ≤ 105° 

Patient: matched 1:1 by age, sex, and follow-up. Minimum 2 year followup.

Procedure: Many designs, 85% medialized glenoid lateralized humerus. The decision to undertake ATSA rather than RTSA was made by the surgeon based on patient-specific factors, such as the deformity of the glenoid and the functional demands of the patient

Provider: 4 fellowship trained surgeons

Summary

Matched groups

ATSA: Not Stiff n=85, mean age 66 yrs, 59% female ASES 72

ATSA: Stiff n=85, mean age 65, 59% female,  ASES 69

RTSA: Not Stiff n=74, mean age 71 yrs, 50% female, ASES 84

RTSA: Stiff n=74, mean age 72, 50% female ASES 83

Unmatched

ATSA: Stiff n=109.  Cuff tear 2%,  Glenoid loosening 3%, Infection 3%

ATSA: Not Stiff n=315  Cuff tear 2% Subscpularis failure 2% Glenoid loosening 4%, Fracture 1%

RTSA: Stiff n=99, Fracture 5%

RTSA: Not Stiff n=125, Glenoid loosening 4%, Fracture 3%

Comment: These six studies provide a bit more information bearing on the choice of ATSA or RTSA for arthritis with an intact cuff. They demonstrate the importance of the 4Ps: the problem, the patient, the procedure and the provider. They suggest the influence of patient sex, patient age, preoperative passive range of motion, glenoid type, glenoid version, and version correction on the choice and outcomes for ATSA and RTSA in the treatment of osteoarthritis with an intact cuff. 

It was interesting that most of these reports did not report on the rates of the most common complications following reverse total shoulder arthroplasty: instability, acromial/scapular fractures, periprosthetic humeral fractures, glenoid baseplate loosening, and infection as identified in My Reverse Has Failed: Top Five Complications and How to Manage Them. Of note, some of these are difficult/impossible to manage.

Other common limitations among these studies were (1) limited and unequal duration of followup and more importantly (2) lack of disclosure of the percentage of patients in each of the original cohorts that were lost to followup. As pointed out in  Loss to follow-up, "loss to follow-up is very important in determining a study's validity because patients lost to follow-up often have a different prognosis than those who complete the study." If a study includes only patients with, say, 2 year minimum followup, patients having a revision at 1.5 years may be systematically excluded. 

Let's see how much more we can learn from publications on the ATSA vs RTSA question in 2024.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Reverse total shoulders - which patients are satisfied?

Predictors of patient satisfaction after reverse shoulder arthroplasty

These authors sought to determine patient satisfaction and to identify predictors of satisfaction at two years after reverse shoulder arthroplasty (RSA) in 161 patients.

Improvements in ASES, Shoulder Activity Scale, VAS pain, and SF-12 physical component summary scores were associated with higher satisfaction.

On multivariate analysis, patients with higher preoperative ASES scores were less satisfied after surgery. In addition, patients with worse VAS fatigue and SF-12 mental and physical component summary scores preoperatively had lower satisfaction. 

Comment: This paper is instructive. First of all, it shows that patient factors (such as those measured by the SF-12 mental health and VAS fatigue scores) play heavily into the patients' satisfaction with this procedure (and probably with most other procedures as well).  Along with the problem, the procedure and the provider, the patient is one of the 4 Ps that determine the result of treatment.  

Secondly, while the means and medians are interesting, the variation is even more interesting as shown in the chart below. Patients with a preoperative ASES score of 100 have little room for improvement and are unlikely to be satisfied with surgery (see this link). Some patients experienced a drop of 64 points in their ASES score; these folks are likely to be unsatisfied.

Thus we come to the "tipping point"for  reverse total shoulders (see this link), i.e. when is it time to do this surgery. As shown in the link above, a recent study found that the tipping point for reverses was an ASES score of 38, a value approximately the same as the average preoperative ASES score of 35 in this paper.

The take away point is that surgeons should be cautious about offering elective surgery to patients with high levels of preoperative self-assessed comfort and function as well as those who have poor mental and physical health.

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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Rotator cuff repair- the surgeon is the method

Comparison of Surgeon Performance of Rotator Cuff Repair Risk Adjustment Toward a More Accurate Performance Measure

These authors suggest that movement toward a value-based health-care system necessitates the development of performance measures to compare physicians, hospitals, and health-care systems.

They note that patient-reported outcomes (PROs) are a potential metric. However, valid use of PROs hinges on the ability to risk-adjust for baseline patient differences across a surgeon’s panel of patients. 

They proposed an approach for baseline risk adjustment and evaluate the importance of risk adjustment when comparing surgeons’ performance of rotator cuff repair.

They identified patients (n = 995) treated with arthroscopic rotator cuff repair by 34 surgeons from 2010 to 2017 from a large sports medicine clinical data registry. A linear regression model was used to adjust for baseline PROs, patient demographics, and clinical characteristics to predict American Shoulder and Elbow Surgeons (ASES) change scores for each surgeon. 

They found that the differences between unadjusted and risk-adjusted performance scores varied widely across surgeons. Use of the risk-adjusted performance scores resulted in a dramatic change in the relative ranking of surgeons, compared with the ranking based on the observed ASES change scores, with 31 of the 34 surgeons’ rank changing following risk adjustment. 

In the risk-adjustment model, male sex, Workers’ Compensation status, higher scores on the Veterans RAND 12-item Health Survey (VR-12), lower baseline ASES scores, fair and poor tendon quality, and night pain all had a significant effect on the predicted ASES change scores (p < 0.05). Higher baseline VR-12 mental and physical component summary scores and male sex had a significant, positive effect on 6-month change scores,whereas higher baseline ASES scores, poor tendon quality, and Workers’ Compensation status had a significant, negative effect on 6-month change scores.

Their results showed wide variation of nearly 25 points in the risk-adjusted 6-month ASES performance difference from the highest to the lowest-performing surgeons.

91% of surgeons’ rank changed following risk adjustment. This suggests that performance measurement that does not account for baseline patient characteristics would likely result in incorrect conclusions about a surgeon’s relative performance based on PROs. 

Comment: The result of surgery depends on the 4Ps: the patient, the shoulder problem, the procedure, and the provider performing the procedure.  The patient (smoker, steroids, motivated?), shoulder problem (chronic, tendon quality, retraction), procedure (single row, double row, TOE, patch) and provider (age, training, volume, ability to pick "winners") effects may be difficult to separate one from the other.

These authors have tried to control a substantial number of the non-surgeon factors to focus on the "surgeon effect". We suspect that the "surgeon effect" exerts itself at every level, from the initial encounter, thorough patient selection, setting patient expectations, surgical technique, rehab, and post surgical support.

Here are some related posts:

The influence of patient- and surgeon-specific factors on operative duration and early postoperative outcomes in shoulder arthroplasty

These authors asserted that increased operative duration is associated with an increase risk of adverse outcomes and complications. They sought to determine if patient- and surgeon-specific factors correlated to operative duration in shoulder arthroplasty. They conducted a retrospective review of primary and revision total and reverse shoulder arthroplasties performed at a single institution from 2012 through 2015. Patients with postoperative readmission had a longer mean operative time (163 vs. 107.1 minutes).

They found that high surgeon volume (>30 shoulder arthroplasties/year) was associated with shorter operative duration (105.9 vs. 128.3 minutes; P < .001).

Progression through a fellowship academic year was found to be associated with decreased surgical times (100.7 vs. 116.5 minutes; P < .0001).

Reverse shoulder arthroplasty for sequelae of prior fracture, total shoulder arthroplasty for dysplastic glenoid morphology, revision surgery were also associated with increased operative times.

Comment: Increased annual surgical volume has the potential not only for shortening surgical time, but also for improving patient selection, preoperative preparation, surgical technique, postoperative rehabilitation, and justifying a consistent patient-care team around the high-volume practice - all of which can contribute to improved outcomes.

The challenges for the prospective shoulder arthroplasty patient include:
(1) 'exactly what is a 'high volume surgeon?'
(2) 'how do I find a high volume surgeon?'
(3) 'in a high volume practice, will I get personalized attention?'
(4) 'what is the trade-off between the convenience of a local lower volume surgeon and the experience of a more distant higher volume surgeon'?

Some of these questions can be informed by a recent publication:

Distribution of High-Volume Shoulder Arthroplasty Surgeons in the United States: Data from the 2014 Medicare Provider Utilization and Payment Data Release.

These authors point out that high-volume TSA surgeons are reported to have superior outcomes. They studied patient access to these surgeons using 2012 Medicare Provider Utilization and Payment Data Public Use File (MPUPD-PUF). This data base provided volume and reimbursement data for procedures performed by individual physicians participating in Medicare. They studied surgeon prevalence, surgeon distribution, and factors associated with higher or lower surgeon prevalence in metropolitan areas. Data were extracted for all physicians who performed a minimum of 11 TSA procedures for Medicare beneficiaries

The MPUPD-PUF included 774 surgeons across the United States who performed an annual minimum of 11 TSA procedures covered by Medicare, with a combined total of 19,505 TSA procedures. The median annual number of Medicare service claims for TSA was 19 (range, 11 to 163), and the mean was 25 (SE, 0.7).

Of these surgeons, 45% practiced within major metropolitan areas with a population of >1 million. Surgeons who had completed an ASES fellowship had a higher volume of procedural claims (median, 26; range, 11 to 120) compared with other surgeons (median, 17; range, 11 to 163; p < 0.001). 

The distribution among major metropolitan areas was highly unequal, and more surgeons were present in cities with an ASES fellowship program.

This study points to the challenges that patients in certain geographical areas have in accessing surgeons who perform at least 11 shoulder arthroplasties per year.

An interesting question arises from the use of an annual case volume of ≥11 as the definition of a 'high volume' surgeon. Historically, 'high volume' has been defined arbitrarily:

Surgeon Experience and Clinical and Economic Outcomes for Shoulder Arthroplasty categorized surgeons according to the total number of procedures performed within the total 6 year ( 1994 to 2000) study period  with one to five procedures considered low volume; six to thirty procedures, medium volume; and more than thirty procedures, high volume.

The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty defined a 'high volume' surgeon as one who performed 5 or more cases per year.

This study defines 'high volume' as ≥ 11 cases per year. The number is creeping up.

Last month this article was published:

Meaningful Thresholds for the Volume-Outcome Relationship in Total Knee Arthroplasty

These authors used a database of 289,976 patients undergoing primary total knee arthroplasty from an administrative database, they applied stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate sets of volume thresholds most predictive of adverse outcomes. The outcomes considered for surgeon volume included 90-day complication and 2-year revision.

They identified four volume categories: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. 

Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories without a 'bottom' in sight:

Revision rates followed a similar pattern.  This study supports the use of SSLR analysis of ROC curves for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons.

The question then arises, 'if a high volume knee arthroplasty surgeon is defined as one performing ≥65 cases per year, shouldn't the same threshold apply to shoulder arthroplasty surgeons?' Is there any reason to believe that the annual number of cases of shoulder arthroplasty necessary to achieve and maintain excellence should be lower than that for knee arthroplasty? Is a shoulder arthroplasty easier to learn and master than a total knee?

It is apparent that the higher the standard for 'high volume', the greater the challenge of finding a high volume surgeon.  

Never the less, there is no denying the benefits of volume. More practice

increases the chances of a good result

===
We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Shoulder joint replacement - is experience the great teacher?

The influence of patient- and surgeon-specific factors on operative duration and early postoperative outcomes in shoulder arthroplasty

These authors asserted that increased operative duration is associated with an increase risk of adverse outcomes and complications. They sought to determine if patient- and surgeon-specific factors correlated to operative duration in shoulder arthroplasty. They conducted a retrospective review of primary and revision total and reverse shoulder arthroplasties performed at a single institution from 2012 through 2015. Patients with postoperative readmission had a longer mean operative time (163 vs. 107.1 minutes).

They found that high surgeon volume (>30 shoulder arthroplasties/year) was associated with shorter operative duration (105.9 vs. 128.3 minutes; P < .001).

Progression through a fellowship academic year was found to be associated with decreased surgical times (100.7 vs. 116.5 minutes; P < .0001).

Reverse shoulder arthroplasty for sequelae of prior fracture, total shoulder arthroplasty for dysplastic glenoid morphology, revision surgery were also associated with increased operative times.

Comment: Increased annual surgical volume has the potential not only for shortening surgical time, but also for improving patient selection, preoperative preparation, surgical technique, postoperative rehabilitation, and justifying a consistent patient-care team around the high-volume practice - all of which can contribute to improved outcomes.

The challenges for the prospective shoulder arthroplasty patient include:
(1) 'exactly what is a 'high volume surgeon?'
(2) 'how do I find a high volume surgeon?'
(3) 'in a high volume practice, will I get personalized attention?'
(4) 'what is the trade-off between the convenience of a local lower volume surgeon and the experience of a more distant higher volume surgeon'?

Some of these questions can be informed by a recent publication:

Distribution of High-Volume Shoulder Arthroplasty Surgeons in the United States: Data from the 2014 Medicare Provider Utilization and Payment Data Release.

These authors point out that high-volume TSA surgeons are reported to have superior outcomes. They studied patient access to these surgeons using 2012 Medicare Provider Utilization and Payment Data Public Use File (MPUPD-PUF). This data base provided volume and reimbursement data for procedures performed by individual physicians participating in Medicare. They studied surgeon prevalence, surgeon distribution, and factors associated with higher or lower surgeon prevalence in metropolitan areas. Data were extracted for all physicians who performed a minimum of 11 TSA procedures for Medicare beneficiaries

The MPUPD-PUF included 774 surgeons across the United States who performed an annual minimum of 11 TSA procedures covered by Medicare, with a combined total of 19,505 TSA procedures. The median annual number of Medicare service claims for TSA was 19 (range, 11 to 163), and the mean was 25 (SE, 0.7).

Of these surgeons, 45% practiced within major metropolitan areas with a population of >1 million. Surgeons who had completed an ASES fellowship had a higher volume of procedural claims (median, 26; range, 11 to 120) compared with other surgeons (median, 17; range, 11 to 163; p < 0.001). 

The distribution among major metropolitan areas was highly unequal, and more surgeons were present in cities with an ASES fellowship program.

This study points to the challenges that patients in certain geographical areas have in accessing surgeons who perform at least 11 shoulder arthroplasties per year.

An interesting question arises from the use of an annual case volume of ≥11 as the definition of a 'high volume' surgeon. Historically, 'high volume' has been defined arbitrarily:

Surgeon Experience and Clinical and Economic Outcomes for Shoulder Arthroplasty categorized surgeons according to the total number of procedures performed within the total 6 year ( 1994 to 2000) study period  with one to five procedures considered low volume; six to thirty procedures, medium volume; and more than thirty procedures, high volume.

The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty defined a 'high volume' surgeon as one who performed 5 or more cases per year.

This study defines 'high volume' as ≥ 11 cases per year. The number is creeping up.

Last month this article was published:

Meaningful Thresholds for the Volume-Outcome Relationship in Total Knee Arthroplasty

These authors used a database of 289,976 patients undergoing primary total knee arthroplasty from an administrative database, they applied stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate sets of volume thresholds most predictive of adverse outcomes. The outcomes considered for surgeon volume included 90-day complication and 2-year revision.

They identified four volume categories: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. 

Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories without a 'bottom' in sight:

Revision rates followed a similar pattern.  This study supports the use of SSLR analysis of ROC curves for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons.

The question then arises, 'if a high volume knee arthroplasty surgeon is defined as one performing ≥65 cases per year, shouldn't the same threshold apply to shoulder arthroplasty surgeons?' Is there any reason to believe that the annual number of cases of shoulder arthroplasty necessary to achieve and maintain excellence should be lower than that for knee arthroplasty? Is a shoulder arthroplasty easier to learn and master than a total knee?

It is apparent that the higher the standard for 'high volume', the greater the challenge of finding a high volume surgeon.  

Never the less, there is no denying the benefits of volume. More practice

increases the chances of a good result

===

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Does the literature support surgery for shoulder arthritis?

Is there sufficient evidence to support intervention to manage shoulder arthritis?

The authors searched the literature published between 2002 and 2012 for Level 1 and 2  research studies concerning the management of shoulder arthritis to identify whether current management recommendations are adequate. As an indication of the lack of standardization in shoulder arthroplasty management, the authors point out that in the UK, the rates of TSA and hemiarthroplasty are approximately one-tenth and one-fifth the respective rates in the USA.

Sixteen studies met the inclusion criteria but they did not provide a clear indication of best intervention for shoulder arthritis.

The inclusion of a range of shoulder pathologies in some studies and the diversity in outcome measures used made it difficult for systematic reviews to effectively pool data. The outcome scales used in the studies varied widely, confounding comparisons between studies.

While better outcomes were reported with total shoulder replacement over hemiarthroplasty for shoulder osteoarthritis, the studies were often of limited quality. The type of glenoid component used in total shoulders employed had impact on revision rates, with 6.8% of TSAs with metal backed glenoids requiring revision compared to 1.7% of TSAs with polyethylene glenoids. For 'biological resurfacing' the overall complication rate was 13.3% and the re-operation rate was 26%, which was higher than the reported values for other treatment options.Sparse evidence was available for all other interventions, regardless of whether operative or non-operative.

The authors point to the need for standardization of outcome assessment following treatment of shoulder arthritis and find that more rigorous and robust primary studies are needed to guide clinical practice on the best interventions for arthritis of the shoulder.

Comment: The results of management for the patient with shoulder arthritis are influenced by the characteristics of the shoulder problem, the patient, the procedure and the physician performing the
procedure (the 4Ps). While the authors state that "determining the effectiveness of nonsurgical treatments, the optimal timing of surgical intervention and the effectiveness of surgical interventions would be best achieved by conducting large, multicentre randomized clinical trials," we suggest that such a process is unlikely to be put in place for many logistical, ethical and fiscal reasons. Instead we propose an approach that would increase the value of the commonly performed level III and Level IV studies: if each study provided in online appendix data for each case (including the characteristics of the shoulder problem, the patient, the procedure and the physician) as well as the outcome scale results before and after surgery, then the patients could be included as individuals in a combined analysis that would avoid the limitations of 'between study' comparisons.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Sex and the shoulder

Sex-specific Analysis of Data in High-impact Orthopaedic Journals: How Are We Doing?

These authors sought to determine the degree to which sex was considered in published orthopedic research and whether the trend showed an increase in the proportion of articles with sex-specific reporting over time, however sex-specific analysis was found in less than 1/3 of the studies.

They concluded, "Where evaluating conditions that affect males and females, studies should be designed with sufficient sample size to allow for subgroup analysis by sex to be performed, and they should include sex-specific differences among the a priori research questions."

Comment: We have consistently advocated for the inclusion of patient factors, including sex, in natural history and in therapeutic outcome studies. We have pushed the need for inclusion of the 4 P's in such studies: Patient, Problem, Physician, and Procedure (see here and here, for example).

Over the years, we have pointed out that when the severity of the condition and age are matched, the self-reported shoulder status reported by women using the Simple Shoulder Test is lower than that of males of comparable age as shown again here and here. We have also shown that the sex distribution can vary widely among different practices, so that consideration of sex in the comparison of results is critical. We have pointed out that women tend to have different arthritic pathoanatomy than males. The difference in range of motion between the shoulders of men and women is well recognized. We have shown that sex is a factor predictive of outcome, as shown here. Most recently, we have shown that sex is an important factor affecting the length of stay after shoulder arthroplasty.

Thus the importance of including patient sex as a factor in natural history and outcome studies is inescapable.  Women ≠ men. As the French would say, 'vive la difference!'

However, in our enthusiasm for considering sex, we must also consider the many other important patient factors that may have comparable importance: race, age, insurance, comorbidities, smoking status, and mental health. The need to include these key variables makes large sample size critical in clinical research.

P.s. The difference between sex and gender can be confusing. According to the World Health Organization,
Sex refers to the biological and physiological characteristics that define men and women.
Gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women.
In the current era where hormones and surgery can change the characteristics that traditionally define male and female, we will have to sort out whether we should be studying the effect of sex or gender or both.

===

Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Which reverse total shoulders are likely to get infected?

Risk factors for periprosthetic infection after reverse shoulder arthroplasty.

These authors reviewed 301 primary RSAs with a minimum of 1-year follow-up. Among these there were 15 periprosthetic infections. Patients having reverse shoulder for failed prior arthroplasty and patients younger than 65 years had an increased risk for development of an infection. Three patients cultured methicillin-sensitive Staphylococcus aureus, two cultured methicillin-resistant S. aureus, two cultured Probionibacterium, two coagulase negative staph and one  Enterobacter cloacae. Interestingly, five patients had no culture growth despite gross purulence noted at the time of surgery. 

Comment: A one year followup may not be long enough to capture the total number of infections after a reverse or, indeed, any type of shoulder arthroplasty as shown in this prior post. In fact 9 patients of the patients in this series developed an infection more than12 months after surgery. The number of specimens submitted for culture has been shown to be strongly related to the rate of positive cultures - this number is not specified in this report. Thus it is possible that the actual rate of infection was larger than what is presented here.

===

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

 

Perioperative complications after shoulder arthroplasty are related to patient comorbidities

Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent.

These authors studied the National Surgical Quality Improvement Program database for shoulder arthroplasty cases from the years 2005 through 2010. Major complications were defined as life-threatening or debilitating. All complications occurred within 30 days of the initial procedure.

They found  523 hemiarthroplasties and 1195 total shoulders.  The major complication rates were 5% for both types of arthroplasty. 

The factors associated with complications were emergency case, pulmonary comorbidity, anemia with a hematocrit level lower than 36%, and wound class of III or IV.

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Risk of readmission is associated with more comorbidity

Higher Charlson Comorbidity Index Scores are Associated With Readmission After Orthopaedic Surgery.

These authors sought to determine if Charlson Comorbidity Index (CCI) was correlated with the risk of  hospital readmission,  surgical site infection or other adverse events,  transfusion, or  mortality after orthopaedic surgery.

Of a total of 30,129 patients having orthopaedic surgeries performed between 2008 and 2011,

913 patients (3.0%) were readmitted within 30 days after discharge;

393 (1.4%) had adverse events occurred; 

417 (1.4%) had a surgical site infection develop; 

211 (0.7%) needed transfusions, and 

56 (0.2%) died within 30 days after surgery. 

Every point increase in CCI score added an additional 0.45% risk in readmission for patients undergoing arthroplasty. While it was  not associated with surgical site infection or other adverse surgical events, it was associated with the risk of transfusion and mortality. 

Comment: The patient's overall health is one of the major determinants of the outcome of surgery. As interest grows in bundled payment for elective surgery (that includes the risk of 90 day readmission), profiling of the risk of readmission will become increasingly important. We have posted previously on the importance of comorbidity

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Revision arthroplasties have a higher risk of failure.

Revision Total Knee Arthroplasty in the Young Patient: Is There Trouble on the Horizon?

These authors reviewed perioperative data for all total knee arthroplasty revisions performed from August 1999 to December 2009. They found a cohort of eighty-four patients who were fifty years of age or younger and a matched them to a cohort of eighty-four patients who were sixty to seventy years of age with similar dates of surgery, sex, and body mass indices (BMI).

The most common reason for the initial revision was aseptic loosening (27%; 95% confidence interval [CI] = 19% to 38%) in the younger cohort and infection (30%; 95% CI = 21% to 40%) in the older cohort. 

Of the twenty-five second revisions in younger patients, 32% (95% CI = 17% to 52%) were for infection, whereas 50% (95% CI = 32% to 68%) of the twenty-six second revisions in the older cohort were for infection. 

Infection and a BMI of >40 kg/m2 posed the greatest risk of failure of revision procedures, with risk ratios of 2.731 (p = 0.006) and 2.934 (p = 0.009), respectively.

This study showed a relatively poor six-year cumulative survivorship of revision total knee arthroplasties in the younger (71%) and older (66%) groups.

Comment: This series again emphasizes that arthritis in young individuals is a different matter than arthritis. It also emphasizes that revision arthroplasties have a greater risk of infection than primary arthroplasties and that revision of a previously infected arthroplasty has a higher risk of failure.

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