What's new? Anatomic total shoulder arthroplasty for cuff intact arthritis

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Anatomic total shoulder arthroplasty - aTSA (rather than reverse total shoulder - RSA) is for many surgeons the "go to" procedure for most patients with cuff-intact shoulder arthritis. While in the past there have been concerns about (1) glenoid component failure and (2) failure of the rotator cuff, modern glenoid implants and improved surgical techniques to assure excellent glenoid component seating along with proper preoperative evaluation of the rotator cuff have greatly reduced these risks. It is well documented that the range of motion is on average better for aTSA than RSA and that in contrast to RSA, aTSA essentially avoids the risks of two serious complications of RSA: dislocation and acromial/spine fractures. While some studies have shown lower revision rates for RSA than aTSA, these studies must be viewed from the perspective that in the uncommon occurrence of aTSA failure, a revision to an RSA is usually successful. However revision for an unstable RSA or an acromial/spine fracture may be avoided by the patient and surgeon because of concerns about complications and effectiveness.

Let's look at a few recent articles an aTSA from the past year. 

An informative study on aTSA in the management of two common forms of osteoarthritis can be found in Anatomic total shoulder arthroplasty for posteriorly eccentric and concentric osteoarthritis: a comparison at minimum 5-year follow-up. This article presents outcomes for aTSA performed using an all-polyethylene glenoid component inserted after conservative glenoid reaming with no attempt at changing glenoid version. Two hundred and ten patients were included of which 98 (47%) had posteriorly decentered humeral heads and 108 (51%) had centered humeral heads.  77 shoulders had Walch type A glenoids; 122 had Walch type B glenoids. At a mean 8-year follow-up, the final SST, change in SST and percentage of maximal improvement were not correlated with pre- or postoperative humeral head centering on the glenoid, Walch classification or glenoid version. Two patients (1%) underwent open re-operations during the study period. In patients with Walch B1 and B2 glenoids (n=110), there were no differences in outcome measures between patients with postoperative glenoid component retroversion of more or less than 15o. While 15 of 51 patients (29%) with 5-year radiographs had glenoid radioluciences, these radiographic findings were not associated with inferior clinical outcomes. On multivariable analysis glenoid component radiolucencies were most strongly associated with incomplete component seating.

Risk of complications: 

Patient, surgeon, indications and implant factors can influence the risk of complications after aTSA. 

A Preoperative Risk Assessment Tool for Predicting Adverse Outcomes among Total Shoulder Arthroplasty Patients studied  208,634 TSAs performed on Medicare-insured patients. More than one in ten (11.2%) had at least one adverse outcome (hospital readmission, postoperative complication, emergency room visit, or mortality during the 90 days post discharge). Patients with an adverse outcome were older, more likely to be female, have a diagnosis of fracture, issues related to social determinants of health, greater healthcare utilization, and comorbidities such as anemia. Notably, this study did not identify surgical technical factors related to adverse outcomes.

Risk factors for rotator cuff tears and aseptic glenoid loosening after anatomic total shoulder arthroplasty reviewed 2699  primary aTSAs (1823F/ 1,922M/27 unspecified; mean age: 65.6 years).  5 different glenoid design types were used (1779 nonaugmented hybrid cage glenoid components, 650 posterior augment cage, 731 nonaugmented peg, 212 posterior augment peg, 369 keel, and 31 unspecified). The indications for the different glenoid types was not specified. 3.2% aTSA shoulders had a cuff tear. The multivariate analysis identified that aTSA patients with cuff failure were more likely to have previous shoulder surgery and small size glenoids. 3.3% of aTSA shoulders had aseptic glenoid loosening; 15.5% loose glenoids also had a rotator cuff tear. 30 of the 123 glenoid failures were cage-glenoid dissociations. The multivariate analysis identified that aTSA patients with aseptic glenoid loosening were more likely to be younger (≤62 years) at the time of surgery, have small size glenoids and have a nonhybrid glenoids.

Glenoid Components: 

As the study above indicates, some glenoid implants use hybrid fixation - often with a metallic central post. 

Ten-Year Implant Survivorship and Performance of Anatomic Total Shoulder Arthroplasty Patients with the Zimmer Biomet Comprehensive® Shoulder System - a Short Stemmed Humeral Implant and Hybrid Glenoid concluded that patients having hybrid glenoid components had comparable long-term clinical results in comparison to the current longitudinal literature regarding survivorship of other implant systems. 

Some authors advocate metal-backed glenoid components; yet a number of studies, point to a higher revision rate for these implants. 

High revision rate of metal-backed glenoid component and impact on the overall revision rate of stemless total shoulder arthroplasty: a cohort study from the Danish Shoulder Arthroplasty Registry found that for the Eclipse stemless TSA system, the adjusted hazard ratio for revision of a metal-backed glenoid component was 8.75 in comparison to stemless Eclipse with an all-polyethylene glenoid component.

There is interest in the effect of the type of polyethylene used: cross linked, XLPE or non cross linked, non-XLPE. While many favor XLPE the article below emphasized the importance of controlling for other variables that can affect component longevity

Modelling XLPE vs non-XLPE glenoid revision rates for anatomic shoulder arthroplasty in osteoarthritis including differing polyethylene glenoid fixation designs. found that when restricted to procedures performed since 2017 there was no significant association between polyethylene type and revision rates after adjustment for patient age, sex, humeral head size, humeral fixation, stemmed or stemless and glenoid component type (metal backed, cemented polythylene, or all polyethylene with a modified central peg).

Keeled components are going out of favor, yet this 10 year followup of young patients is of interest. 

Anatomical Total Shoulder Arthroplasty with Keeled glenoids in Patients under 60 years at 10 years minimum: which risk factors of failure are still valid at long term follow-up? 87 shoulders in 82 patients 36 to 60 yo were included at a mean follow-up of 14 years. Revision-free survivorship was 81% at 10 years and 65% at 15 years. Among the 28 revised shoulders, 19 were for glenoid loosening. Heavy labor was a risk factor for glenoid component loosening. While Walch type did not influence revision rate, flat backed components and glenoids prepared with curettage (rather than reaming) were risk factors for glenoid. This reinforces the concept that glenoid component seating is an essential element for preventing loosening.

Some authors advocate for posteriorly augmented glenoid components in shoulders with posterior bone loss.

Total shoulder arthroplasty for glenohumeral arthritis associated with posterior glenoid bone loss: midterm results of an all-polyethylene, posteriorly augmented, stepped glenoid component. presents the use of a stepped glenoid component which requires the removal of some posterior glenoid bone as shown here.

Thirty-five shoulders with minimum 5-year follow-up underwent aTSA using a posteriorly augmented glenoid component for the treatment of glenohumeral osteoarthritis with posterior glenoid bone loss. Postoperative Grashey and axillary radiographs were reviewed to record the degree of radiolucency surrounding glenoid pegs on a scale of 0 (no radiolucency) to 5 (gross loosening), as described by Lazarus et al. The degree of central peg osseous integration was classified via x-ray on a scale of 1 to 3, as described by Wirth et al, with 3 representing complete integration and 1 indicating surrounding osteolysis. Survivorship free from revision was 92% at 8.8 years postoperatively.  Two patients experienced prosthetic instability requiring revision, leaving 33 shoulders with an average follow-up of 6.6 years. There was a progressive increase in Lazarus score and a decrease in Wirth score between 2- and 5-year follow-up. A significant correlation was identified between VAS pain scores and both Lazarus and Wirth scores, i.e. the severity of radiographic loosening correlated with subjective pain levels. The authors concluded that these outcomes were comparable ("noninferior") to those for patients undergoing TSA with a nonaugmented glenoid component for the treatment of posterior glenoid bone loss as reported in the literature.

Humeral Components:

What is the clinical importance of radiographic changes around the humeral component in anatomic shoulder arthroplasty?, investigated the frequency, patterns and clinical significance of radiographic findings around the humeral component of total shoulder arthroplasty (TSA n=91) and hemiarthroplasty (HA n=79) at minimum 4-year follow-up. The mean radiographic and clinical follow-up was 7.0 years. No patients were revised for loose humeral components during the study period. For both HA and TSA, the most common zones of cortical thinning or resorption involved the medial calcar, greater tuberosity and lateral humerus diaphysis. The mean metaphyseal filling ratio (MFR) was higher in patients with bone changes in ≥3 zones and resorption of the calcar. The frequency and degree of bone changes around the humeral component were higher in TSA patients with high-grade radiolucencies around the glenoid component. Patients with high-grade radiolucencies around the glenoid component had inferior SST scores in comparison to patients who did not have a high-grade radiolucencies around the glenoid component. This finding may represent the effects of other processes - such as osteolytic reaction to particulate debris - in addition to stress shielding.

There is increasing interest in stemless humeral components

Influence of humeral position of the Affinis short® stemless shoulder arthroplasty system on long-term survival and clinical outcome reviewed 80 patients treated with a stemless shoulder arthroplasty for OA of the shoulder at a mean follow-up of 92 months. Range of motion and outcome scores were improved. The center of rotation restoration was anatomical in 75 %  of all implants and in non-anatomical in 25 %. The humeral component position did not affect the functional outcome whereas the ten-year cumulative survival rate for the anatomic group was higher in comparison with the non-anatomical group (96.7 % vs. 75 %). 

Analysis of Factors Influencing Optimal humeral sided Reconstruction in Anatomic Total Shoulder Arthroplasty reviewed 298 patients who underwent anatomic total shoulder arthroplasty (aTSA) utilizing three stem types: 145 long stem,  102 short stem, and 51 stemless implants. The stemless implant was more replicable in recreating the anatomic shape with a mean COR shift of 3.0 mm and neck shaft angle of 137. Stemless arthroplasty was also quicker to master compared to standard or short stemmed implants but did have a greater initial operative time.

The Effect of Lateralization on Clinical Outcomes after Anatomic Total Shoulder Arthroplasty found that the shift in center of rotation from the  position determined by the "perfect circle" was the radiographic measure most closely associated with the ASES score, the WOOS score, and forward flexion. 

Stemmed VS stemless total shoulder arthroplasty: a systematic review was a review and metaanalysis of 14 articles (1496 patients). 792 had stemless humeral components and  704 had stemmed humeral implants. The Constant score,  elevation and abduction were similar in both groups, while external rotation was 4° higher in the stemless group. No differences were found in operating time and overall complications. However, deep infections were higher in the stemless group (2.2% vs. 0.8%) 

Preoperative Planning for the Humeral Component 

The Impact of Three-Dimensional Humeral Planning and Standard Transfer Instrumentation on Reconstruction of Native Humeral Anatomy for Anatomic Total Shoulder Arthroplasty To explore the utility of planning and transfer instrumentation in inserting a stemless component, three surgeons used 3D-printed humeri based on CTs of existing patients. Humeral neck cuts were performed on all specimens (phase 1) without any preoperative humeral planning; (phase 2) with 3D planning, and (phase 3) with a neck-shaft angle (NSA) guide and digital calipers used to measure humeral osteotomy thickness to aid in the desired humeral cut. For both 3D change in center of rotation (COR) and medial to lateral change in COR, use of preoperative planning alone and with standard transfer instrumentation resulted in a more anatomic restoration of ideal COR. The deviations from planned cut thickness decreased with each phase: phase 1: 2.6 ± 1.9 mm, phase 2: 2.0 ± 1.3 mm, phase 3: 1.4 ± 0.9 mm (P = .041 for phase 3 vs. phase 1). For neck shaft angle, in phase 1, 7 of 15 (47%) cases were in varus; in phase 2, 5 of 15 (33%) were in varus; and in phase 3, 1 of 15 (7%) cases was in varus.

Preoperative planning is always a good thing, however equivalent planning can be achieved quickly and more cheaply without 3D CT scans using a plain AP x-ray and PACS software

 

Biceps Tendon  

While some surgeons proclaim that they are "biceps killers", others retain the biceps because of its stabilizing function (unless it is frayed or unstable in its groove). The study Biceps Tenodesis in the Setting of Total Shoulder Arthroplasty: A Matched Cohort Analysis included 88 shoulders, half of which had and half of which did not have biceps temodesis. The authors found no significant differences between cohorts in postoperative forward elevation, external/internal rotation, VAS, ASES, or SST score.

Rotator Cuff

Preoperative Rotator Cuff Fatty Infiltration and Muscle Atrophy Do Not Negatively Influence Outcomes Following Anatomic Total Shoulder Arthroplasty sought to determine the effects of rotator cuff fatty infiltration (FI) and muscle atrophy (MA) on clinical outcomes following TSA. There were 163 shoulders from 154 patients with a mean age of 62.5 and a mean follow-up of 2.9 years that met inclusion criteria. Rotator cuff muscle area was not correlated with any preoperative or postoperative range of motion or patient reported outcome measures. No significant differences in preoperative ROM or PROMs were found between patients with minimal-to-mild and moderate-to-severe FI (P > .05).

Pain Management

Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner Patients were randomly assigned to receive intraoperative dexamethasone only (control group n=32) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group n=35). The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 postoperative days (POD). Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively.  At follow-up there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. 

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

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62 year old avid tennis player with right shoulder osteoarthritis - 13 year followup

 A 62 year old active tennis player presented with pain and stiffness of the right shoulder that kept him from enjoying his sport.

His x-ray at the time of presentation is shown below.

Wishting to avoid the risks and limitations of an anatomic or reverse total shoulder, he elected a ream and run procedure.  He has returned to tennis and at thirteen years after his procedure he continues to play competitively and reports the ability to perform 11 of the twelve functions of the Simple Shoulder Test.

His x-ray at 13 years after surgery shows complete remodeling of the glenoid joint surface and a well fixed humeral stem without evidence of stress shielding or adaptive changes.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Contact: shoulderarthritis@uw.edu

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). 

Osteoarthritis: Hemiarthroplasty vs Total Shoulder. A pitfall of propensity score matched analysis

Randomization enables unbiased estimation of treatment effects; randomization attempts to assure that treatment-groups are balanced with respect to the important covariates. Unfortunately for us shoulder surgeons, surgical treatments are rarely assigned randomly.

Propensity matching is an attempt to use observational data to compare two treatment groups by accounting for the covariates that are associated with the outcome. 

The possibility of bias arises because a difference in the outcome between treatment groups may be caused by factors that predict which treatment the patient receives rather than the effectiveness of each treatment. For example if an observational study matching patients for age and sex alone retrospectively compared the recurrence rates after Bankart repair and after the Latarjet procedure, it would be at risk for an incorrect conclusion because it did not match for the size of the glenoid defect which may have affected the choice of treatment.

With that background let's look at Shoulder Hemiarthroplasty Is Associated With Higher 30-Day Complication Rates Compared With Total Shoulder Arthroplasty for Glenohumeral Osteoarthritis: A Propensity Score Matched Analysis. So, everyone with OA should get a TSA rather than an HA, right? 

However, the title itself gives pause: why should a smaller operation (hemiarthroplasty) have a higher short term postoperative complication rate than a more involved procedure (total shoulder arthroplasty)? Sounds like a fundamental attribution error.

Let's take a deeper dive. The authors searched the American College of Surgeons National Surgical Quality Improvement Program database for records of patients who underwent either TSA or HA for glenohumeral osteoarthritis of the glenohumeral joint. 

Patients in each group underwent a 1:1 propensity match for age, sex, BMI, ASA classification, diabetes mellitus, hypertension requiring medication, congestive heart failure, chronic obstructive pulmonary disease, inpatient/outpatient status, smoking status, and bleeding disorders.  2188 received TSA and 2188 received HA. The question is, "among these supposedly similar patients, what determined whether they wound up getting HA or TSA? We'll get back to that question shortly.

The HA patients had a higher rate of any adverse event (7.18% vs 4.8%), death (0.69% vs 0.1%), sepsis (0.46% vs 0.1%), postoperative transfusion (4.62% vs 2.2%), postoperative intubation (0.5% vs 0.1%), and extended length of stay (23.77% vs 13.1%). 

Comment: While these differences are striking, it is apparent that putting in a plastic glenoid does not reduce the risk of death, sepsis, transfusion, intubation or extended length of stay.

As stated above, the possibility of bias arises because a difference in the outcome between treatment groups may be caused by factors that predict which treatment the patient receives rather than the effectiveness of each treatment. HA patients had a statistically significantly higher mortality probability (0.004±0.010 vs 0.002±0.003 and morbidity probability (0.027±0.015 vs 0.021±0.011) at baseline compared with the TSA cohort, even after propensity score matching.  Surgeons may prefer to perform HA for high-risk patients and those with more complex pathology. Less experienced surgeons may elect to perform HA because of its simplicity. Surgeons may be more likely to perform HA on patients that have worse social determinants of health (Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context), which are known to be associated with inferior outcomes.

Thus, while the authors state 

"HA was found to increase the odds of developing these complications when baseline demographics were controlled",

 perhaps a more accurate statement would be 

"Patients for whom the surgeons chose HA were found have increased odds of developing these complications when the selected baseline demographics were controlled."

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/RickMatsen or https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

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.

You can support cutting edge shoulder research and education that are leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/RickMatsen or https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Glenohumeral osteoarthritis: ream and run arthroplasty or anatomic total shoulder?

Anatomic total shoulder with a prosthetic glenoid component can reliably improve the comfort and function of patients with glenohumeral arthritis. However, some patients may wish to avoid the activity limitations and potential risks of glenoid loosening, polyethylene wear, and contribution of wear debris to glenoid bone loss, humeral osteolysis and loosening that can be associated with the prosthetic glenoid used in anatomic total shoulder arthroplasty (aTSA). 

In spite of what may be a more challenging rehabilitation and a greater risk of stiffness, these patients may consider the ream and run procedure (RnR), a glenohumeral arthroplasty that does not employ a prosthetic glenoid component (see this link). 

Thus, one can see from the outset that patients electing the RnR are different that those electing aTSA, even though their history, physical examination and x-ray findings may be similar. Important differences may lie in domains that are challenging to quantify:  resilience, optimism, goals, motivation, pain tolerance, and type of desired occupational and recreational activity. 

The characteristics and outcomes for patients having RnR are compared to those of a concurrent series of patients having aTSA by the same surgeon in Ream and run and total shoulder: patient and shoulder characteristics in five hundred forty-four concurrent cases. In that report, the outcomes of the RnR and aTSA were similar: the average two year SST score for the RnRs was 10.0  vs. 9.5 for the aTSAs. The percent of maximum possible improvement (%MPI) for the RnRs averaged 72%  vs. 73% for the aTSAs. While the outcomes were similar, the patients electing the RnR were different than those electing aTSA: patients selecting the RnR were more likely to be male (92.0% vs. 47.0%), younger (58 vs. 67 years), married (83.2% vs. 66.8%), from outside of the state (51.7% vs. 21.7%), commercially insured (59.1% vs. 25.2%), and to have type B2 glenoids (46.0% vs. 27.8%) as well as greater glenoid retroversion (19  vs. 15  degrees). Female patients having RnRs did less well than those having TSAs. However, this study did not attempt to capture other psychosocial characteristics that may be essential determinants of the arthroplasty choice and outcome mentioned above (resilience, optimism, goals, motivation, pain tolerance, and type of desired occupational and recreational activity). Furthermore the choice and outcome of aTSA and RnR depend heavily on the experience and enthusiasm that the surgeon has for the two procedures as described in The ream and run: not for every patient, every surgeon or every problem.

Based on the practice of an individual surgeon with extensive experience and expertise in both aTSA and RnR, the authors of Comparison of Humeral-Head Replacement with Glenoid-Reaming Arthroplasty (Ream and Run) Versus Anatomic Total Shoulder Arthroplasty A Matched-Cohort Study sought to compare the outcomes of RnR versus aTSA in younger patients with advanced glenohumeral osteoarthritis in a retrospective study of 110 patients who underwent aTSA and 57 patients who underwent RnR. Patients were <66 years of age and had a minimum of 2 years of follow-up. 

Propensity matching was performed using 21 preoperative variables, eliminating from analysis those patients that could not be matched. 39 patient pairs representing 35% (39/110) of the aTSAs and 68% (39/57) of the RnRs were matched. All patients were male, with a mean age of 58.6 years and a mean follow-up 4.4 years.

The 39 patients having aTSA improved from an average preoperative SST of 4.1 to 10.9 at followup and from an average preoperative ASES score of 33.3 to 89.9 at followup.

The 39 patients having RnR improved from an average preoperative SST of 4.7 to 10.3 at followup and from an average preoperative ASES score of 34.8 to 85.0 at followup.

At the time of final follow-up, using inverse probability-weighted data from all 167 patients, 22.9% were dissatisfied after aTSA, while 9.4% were dissatisfied after RnR. 

Three patients underwent revision arthroplasty after RnR because of pain without obvious signs of infection at a mean of 1.9 years. One of the 3 patients had repeat RnR, with an excellent final outcome. Cultures were positive for Cutibacterium, and the humerus was loose at revision. A second patient was revised to aTSA and had positive Cutibacterium cultures at revision. The third was revised to RSA; culture data were unavailable. No manipulations or capsular releases were performed after RnR.

Two patients underwent revision arthroplasty after aTSA for glenoid loosening, at 9.2 and 14 years after aTSA, and both were treated by conversion to a hemiarthroplasty. At revision, all cultures were positive for Cutibacterium for 1 patient, and negative for the other.

Comment: The authors of Comparison of Humeral-Head Replacement with Glenoid-Reaming Arthroplasty (Ream and Run) Versus Anatomic Total Shoulder Arthroplasty A Matched-Cohort Study are to be congratulated on their analysis of patients having aTSA and RnR leading to a better understanding of the management of the younger patient with glenohumeral arthritis. This paper is discussed in Can We Reliably Compare Outcomes of Ream-and-Run and Anatomic Total Shoulder Arthroplasty?

Taken together, this paper and the others identified above help illustrate the complexity of characterizing patients prior to these two types of anatomic shoulder arthroplasty (aTSA and RnR) as well as characterizing the outcomes of surgery.

It seems clear that 

(1) carefully selected patients with glenohumeral arthritis can do well after either ream and run or anatomic total shoulder arthroplasty when the procedures are performed by experienced surgeons

(2) the patients selecting these two procedures differ in many important ways (e.g. age, sex, psychosocial factors, glenoid morphology, resilience, motivation, pain tolerance, and activity expectations) some of which are difficult to quantify in a meaningful way; this creates substantial difficulties in comparing outcomes.

(3) while propensity matching is a useful method for analysis, it results in the exclusion of a substantial number of patients from analysis and, by intent, obscures the differences in the characteristics of patients having each of the two procedures.

(4) the practices of surgeons experienced in these two methods is biased by their analysis of past cases; their selections, techniques and outcomes may not be generalizable to surgeons with less experience in patient selection and the techniques of the two procedures

(5) shoulder arthroplasty failure is commonly associated with positive Cutibacterium cultures at the time of revision surgery

(6) followup of 10 years or longer is required to capture the rates of glenoid component failure in total shoulder arthroplasty whereas the failures of RnR appear to become evident substantially earlier.

(7) Usually, when a RnR is revised, the surgeon has substantial glenoid bone stock for revision to another RnR, an aTSA or a reverse shoulder arthroplasty (RSA). By contrast, the management of a failed glenoid component after aTSA can be challenging: revision to RSA for glenoid loosening after aTSA is associated with a high rate of baseplate failure

(8) Whether a patient is "satisfied" with the outcome of a shoulder arthroplasty depends on the patient's preoperative expectations and the degree to which these expectations are met after surgery.

(9) In answer to the question, "is RnR or aTSA better?", the best answer may be "it depends on the patient, the shoulder and the surgeon" (see The ream and run: not for every patient, every surgeon or every problem). The surgeon is the method.

(10) For each of these two types of anatomic shoulder arthroplasty, future clinical research should explore the relationship of postoperative patient comfort, function, satisfaction and activity levels to preoperative patient and shoulder characteristics, including such factors as resilience, optimism and expectations.

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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).