Incremental value in reverse total shoulder arthroplasty

Almost all shoulder surgeons would agree that reverse total shoulder is a high value treatment for patients with cuff tear arthropathy, value being defined as the clinical outcome for the patient divided by the total costs associated with the procedure. 

It is a natural tendency for us to try to make a good thing better. As nicely pointed out in a recent episode of HiddenBrain (see this link), doing better is usually equated with doing more. 

Importantly, there are two types of doing more.

One type is cost neutral. Examples are refinements in technique, such has modifying the approach to drilling and tapping (see this link) or the use of a humeral head autograft to improve the positioning and seating of the baseplate (see this link). If these innovations are associated with better clinical outcomes, value to the patient is increased.

The second type is cost additive. Examples are patient specific instrumentation, augmented reality, and augmented baseplates. A burden of proof lies on the advocates of such innovations to demonstrate that the increased cost is proportional to an increase the clinical outcomes realized by the patient. As a hypothetical example, let's say that the use of an augmented glenoid baseplate increases the total cost of a reverse total shoulder by 8% (+$4,000 / $50,000). Thus to be of increased value to the patient, augmented baseplates need to increase clinical outcomes by more than 8%. There are some recent data indicating the clinical value of augments in comparison to bone grafting (see this link). However there is also evidence that augmented components are associated with increased problems of baseplate seating in comparison to other techniques (see this link). Future clinical research will clarify the indications for augmented glenoid components, in other words, which patients are most likely to benefit from their use.

Another approach to improving the value of reverse total shoulder arthroplasty is reducing the price paid for the implant. Implant costs are the largest single element in the total cost of reverse shoulder arthroplasty, up to about 30% of the total. If the cost of an implant system is reduced by 10%, the value of the procedure is increased by the same amount.

Below are data from Orthopaedic Network News showing the average selling price for various reverse total shoulder arthroplasty systems. 

Of note is that the selling price for orthopaedic implants is established by confidential negotiations between the vendor and the hospital, negotiations that are not transparent to the public or the patient and often not transparent to the surgeon. Smaller hospitals with lower case volumes are likely to be disadvantaged in such negotiations.

Comment: In that reverse total shoulder arthroplasty is a common, increasingly frequently performed, costly and effective procedure, it is worthwhile considering means for optimizing its value to our patients.

Comments welcome at shoulderarthritis@uw.edu

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


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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). 

The value of anatomic and reverse total shoulder arthroplasty - changes with time and with how it's measured.

The value of shoulder arthroplasty is commonly defined as the benefit of the procedure to the patient divided by the costs associated with the procedure. "Benefit" is commonly measured as the preoperative to postoperative change in patient self-assessed comfort and function. "Costs" potentially include the expenses of the preoperative work-up, the implant, the hospital care, the postoperative care and the complications.

The authors of Longitudinal Analysis of Shoulder Arthroplasty Utilization, Clinical Outcomes, and Value: a Comparative Assessment of Changes in Improvement Over 15 Years with a Single Platform Shoulder Prosthesis conducted a longitudinal analysis of their extensive experience with anatomic (aTSA) and reverse total shoulder (rTSA) using a single shoulder arthroplasty prosthesis (Equinoxe; Exactech, Inc) with the goal of quantifying changes in clinical outcomes, cost, and value, associated with the introduction and adoption of new shoulder arthroplasty technologies.

They observed a dramatic increase in rTSA utilization over the 15-year study period.
In 2007 rTSA accounted for 19% of the prostheses compared to 57% aTSA.
In 2021 rTSA accounted for 76% of the prostheses compared to 14% aTSA

This article provides a wealth of data about these patients and their outcomes. The two tables below contain data extracted from the paper along with one type of calculation of value - the amount of improvement in SST score divided by $1,000 of implant cost.

For patients receiving anatomic total shoulders, the age at the time of surgery was less for more recent procedures while the % of male patients and the % of patients with primary osteoarthritis increased. The cost of the implants was stable as was the postoperative SST; however the preoperative SST scores indicated a higher degree of comfort and function in more recently operated patients. The result is that the benefit expressed as the SST improvement per $1,000 prosthesis cost was less for patients having more recent surgery.



For patients receiving reverse total shoulders, the age at the time of surgery was less for more recent procedures while the % of male patients and the % of patients with primary osteoarthritis increased. The cost of the implant was less for more recent procedures. While the postoperative SST scores were constant, the preoperative SST scores indicated a higher degree of comfort and function in more recently operated patients. As a result, the SST improvement per $1,000 remained essentially constant over time.



This paper uses a different outcome measure than that shown above: the percent of patients reaching the "ceiling" for various scores. As shown below, this approach shows improved outcomes in more recent surgeries for most of the scales. However, since this metric does not include the effect of higher preoperative scores in more recent surgeries (as shown in the tables above) it does not reflect the benefit of the procedure in terms of improvement in comfort and function.



The authors point out that implant pricing is negotiated by the vendor and the hospital. These negotiations are commonly associated with non-disclosure agreements. Since the implant cost is an important component of the denominator of the value equation, these negotiations may lead to different results for different hospitals and different implants.

CT-based preoperative planning was initiated in 2016 and was used in 93% of primary aTSA cases and 83% of primary rTSA cases by 2021. Use of CT-based preoperative planning was associated with a dramatic increase in the use of augmented glenoids, such that by 2018 augmented components were used in the majority of primary rTSAs and aTSAs.

Hybrid aTSA glenoids were introduced in 2011; by 2020 they were used in 100% of primary aTSAs in 2020. In this study overall 54% of the glenoids were hybrid and 46% were traditional cemented peg/keel glenoids.

Overall 76% of the antomic glenoids were nonaugmented and 24% were augmented. The rTSAs included 56% standard baseplates and 44% augmented baseplate.

The use of short humeral stems for rTSA and aTSA and the use of stemless humeral components in aTSA increased dramatically over the period of this study. Overall 8% of the aTSAs and 17% of the rTSAs used short humeral stems and 5% of the aTSAs used stemless humeral components.

The value of these technologies is not assessed in this study. The paper does not provide a comparison of the clinical outcomes achieved without and with CT-based preoperative planning, without and with augmented glenoid components, without and with hybrid aTSA glenoids, or without and with short stemmed or stemless humeral components.

It is apparent that many factors may go into the calculus of value, including patient age, sex, diagnosis, preoperative comfort and function, use or non use of technologies, implant design, and the negotiated implant cost. These authors appear to have the volume of carefully characterized patients that would enable an enlightening multivariate analysis of the factors affecting value for this prosthesis system.

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

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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).

What is the value of total shoulder arthroplasty - how can it be improved?

The value of a procedure to patients can be defined as quality of care divided by the costs associated with the procedure. Measures of quality include improvements in patient reported outcomes along with intra- and postoperative complications.

The authors of Measuring Patient Value after Total Shoulder Arthroplasty sought calculate the patient value delivered by total shoulder arthroplasty (TSA) for 116 consecutive TSAs.

Patient value was defined as quality of care divided by direct costs of surgery; the preoperative costs (i.e. imaging, planning) and postoperative costs (i.e. physical therapy) were not assessed.

Compared to a reference threshold of 1.0, ninety patients (78%) had a quality of care ≥1.0 and 61 patients (53%) had direct costs related to surgery ≤1.0. 

The average value delivered to patients was higher for non-smokers, for those receiving anatomic TSA (as opposed to reverse TSA),  those with higher pre-operative pain, and lower pre-operative function.

43% of the patients were in the highest value (green) rectangle below, while 13% were in the lowest value (red) rectangle.

19% of the patients had intraoperative or postoperative complications. 

 

Comment: The average value delivered to patients was higher for non-smokers, for those receiving anatomic TSA (as opposed to reverse TSA),  those with higher pre-operative pain, and lower pre-operative function. While not discussed in this publication, it seems likely that patients having complications would be likely to have both higher costs and poorer outcomes. If having a complication resulted in patients being in the red rectangle, avoiding complications might be a most effective means of optimizing value.

As suggested in Innovations in the Realm of Shoulder Arthroplasty the incremental preoperative, intraoperative and postoperative costs associated with preoperative planning, navigation, artificial intelligence, augmented reality, new prosthetic designs, custom augments, and three dimensional printing might be justified by actual improved outcomes in selected patients with certain complex pathologies......but perhaps not in shoulders with routine arthritic anatomy

Careful clinical research will be necessary to identify which patients are likely to achieve better outcomes with which of these technologies leading to the establishment of what the American Academy of Orthopaedic Surgeons refers to as clinical practice guidelines and appropriate use criteria.

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/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
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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).

Anatomic or reverse total shoulder for shoulder osteoarthritis with an intact rotator cuff?

Arthritis of the shoulder with an intact rotator cuff has been reliably managed with an anatomic total shoulder arthroplasty (TSA) for decades. However, the use of reverse total shoulder (RSA) to treat this diagnosis has recently increased dramatically to the point where fully one third of reverses are being performed for straightforward arthritis (see Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States). This shift may be a result of the "reverse for everything" approach espoused by some surgeons leading to the use of the reverse in almost two thirds of all shoulder arthroplasties. 

While there is a concern about rotator cuff failure and glenoid component loosening 10 - 15 years after anatomic arthroplasty, there is also a concern about dislocation and acromial/scapular spine fractures after reverse total shoulder arthroplasty. In that these complications may not lead to repeat surgery, revision and "survival" rates may not accurately reflect the complication rate. 

The value of an arthroplasty is defined as the benefit realized by the patient divided by the costs associated with the procedure. In that the cost of a reverse is substantially greater than that of an anatomic arthroplasty, the patient benefit must be substantially greater for RSA to achieve the same value as for TSA.

The authors of Outcomes After Anatomic and Reverse Shoulder Arthroplasty for the Treatment of Glenohumeral Osteoarthritis: A Propensity Score-Matched Analysis performed a retrospective matched-cohort study of patients with a minimum of 2 years of follow-up after a TSA and RSA for the treatment of primary osteoarthritis by a high volume shoulder arthroplasty surgeon. 

One hundred and thirty-four patients (67 patients per group) were included, each with an intact rotator cuff by MRI. The reasons for selecting RSA versus TSA are not described. Patients were propensity score-matched by age, sex, body mass index (BMI), preoperative American Shoulder and Elbow Surgeons (ASES) score, preoperative active forward elevation, and - importantly - for Walch glenoid morphology. 

Notably no augmented glenoid components were used.

The mean duration of follow-up (and standard deviation) was 32.8 ± 13.4 months for TSA and significantly shorter (27.2 ± 6.0 months) for RSA (p<0.001). 

No significant differences were found between the TSA and RSA groups in terms of the baseline or final VAS pain score (p = 0.99 and p = 0.99, respectively), ASES scores (p = 0.99 and p = 0.49, respectively), or SANE scores (p = 0.22 and p = 0.73, respectively). 

TSA was associated with significantly better postoperative active forward elevation (149° ± 13° versus 142° ± 15°; p = 0.003), external rotation (63° ± 14° versus 57° ± 18°; p = 0.02), and internal rotation (≥L3) (68.7% versus 37.3%; p < 0.001); however, there were only significant baseline-to-postoperative improvements in internal rotation (gain of ≥4 levels in 53.7% versus 31.3%; p = 0.009). 

Radiolucent lines were observed in association with 14.9% of TSAs, with no gross glenoid loosening. 

The complications in the TSA group were: 1 post operative cuff tear, 1 transient ulnar nerve palsy, and 1 postoperative hematoma.

The complications in the RSA group were: 1 transient radial nerve palsy, 1 intraoperative glenoid fracture, and 1 acromial stress fracture. 

Comment: We concur with the the authors that "when performed for the treatment of osteoarthritis, TSA and RSA resulted in similar short-term patient-reported outcomes, with better postoperative range of motion after TSA. Longer follow-up is needed to determine the ultimate value of RSA in the setting of osteoarthritis".

An important commentary on this article can be found at "Different Surgeries, Same Result?"

"When weighing the risk of revision of TSA due to rotator cuff failure and aseptic glenoid loosening against slightly greater improvements in range of motion, it is tempting to move our indications toward RSA in older and lower-demand patients. However, using survivorship free from revision as the primary factor in deciding to perform RSA may be short-sighted. The complications and failures of TSA and RSA are as different and unique as the implants themselves.When considering revision rates, care should be taken to acknowledge that revision may not be an option in what is otherwise considered to be a failed implant or poor patient outcome after RSA. Specifically, acromial insufficiency fracture and persistent pain are 2 of the 3 most frequently encountered complications associated with RSA. These complications not only lead to compromised patient outcomes but also do not have reliable solutions. In contrast, TSA failure can be corrected with revision to RSA in most circumstances. "

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/shoulderarth

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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).

For shoulder arthroplasty, local infiltration analgesia was of greater value to the patient than interscalene block

 Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty A Prospective Randomized Clinical Trial

These authors point out that while interscalene blocks can provide effective analgesia following shoulder arthroplasty, they risk serious complications in 5% to 16% of cases, including infection, pneumothorax, hematoma, peripheral nerve injuries, Horner syndrome, phrenic nerve palsy, respiratory distress and “rebound” pain as the block wears off. They also alter sensory and motor function of the upper extremity, removing protective sensation and precluding accurate neurologic examination in the immediate postoperative period. Finally, they are more expensive than local infiltration analgesia (LIA). See Interscalene blocks for shoulder surgery - more costly and more risky. and Interscalene block complications

The purpose of their study was to compare pain and opioid consumption between LIA and an interscalene block following shoulder arthroplasty in a prospective randomized clinical trial of patients undergoing primary shoulder arthroplasty.

Both groups had general anesthetics. The block group (n=37) received a preoperative interscalene block using liposomal bupivacaine, and the injection group (n=37) received an intraoperative LIA injection of ropivacaine, epinephrine, ketorolac, and normal saline solution. 

The mean hospital charge for the interscalene block procedure was $1,718, which was over ten times greater than that for LIA injection ($157). The difference in anesthesia professional fees and total procedure time were not presented. The mean hospital length of stay was significantly longer for the patients receiving blocks. 

There was no significant difference in opioid consumption between the groups at any time points postoperatively. 

In noninferiority testing for the mean pain scores during the first 24 hours, the injection group was found to be noninferior to the block group. 

One patient in the block group developed transient phrenic nerve palsy with hypoxemia.  One patient in the injection group developed dislocation after reverse arthroplasty related to noncompliance. 

In this study local infiltration analgesia was of substantially greater value than interscalene block because both methods provided similar analgesia while interscalene block was over ten times more costly and risked serious complications.

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/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).

What is the value of SCR, LTTT, and RSA in the treatment of patients with irreparable rotator cuff tears?

 Cost comparison and complication profiles of superior capsular reconstruction, lower trapezius transfer, and reverse shoulder arthroplasty for irreparable rotator cuff tears

Irreparable rotator cuff tears (IRCTs) are common; many patients with IRCT's can manage their symptoms effectively or respond to conservative approaches, such as a simple exercise program (see this link) or a minor surgery, such as the smooth and move procedure (see this link). 

More involved surgeries, such as superior capsular reconstruction (SCR), lower trapezius tendon transfers (LTTT) and reverse total shoulder arthroplasty (RSA) pose challenges both clinically and financially. These authors performed an analysis of their costs, complications, and readmission rates of these three surgical treatments for IRCTs: 20 SCRs, 47 LTTTs, and 88 RSAs as performed by experienced surgeons at a major medical center.

The cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation. The data are shown below.

In this study, implants represented the highest proportion of the index costs for all 3 procedures with 27.2% in LTTT, 29.1% in RSA, and 31.8% in SCR.

Surgeon charges accounted for 6.2% of the total for SCR, 7.3% for LTTT, and 11.0% for RSA.

Comment: Patients with irreparable rotator cuff tears and others may be bewildered by the completely different options for treating IRCTs: "we could insert a preparation of cadaver skin, we could transfer a tendon, we could replace the joint with a prosthesis that reverses the normal shoulder anatomy or we could not do any of these procedures." How to choose? The cost-effectiveness or value of a surgical procedure is measured as the improvement in comfort and function realized by the patient divided by the cost of the procedure. While these relative cost data from the Mayo Clinic are of interest, it would have been most informative to have seen data on the relative effectiveness of the different procedures in improving the comfort and function of the patients in each group. The combination of cost and effectiveness data would enable determination of the value of these procedures for patients with irreparable cuff tears. See: 30% unsatisfactory results for patients with massive rotator cuff tears having reverse total shoulder arthroplasty

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/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).

Total shoulder arthroplasty: how should we measure the value of care: improvement in comfort and function or HCAHPS score?

Hospital satisfaction does not predict functional outcome one year after total shoulder arthroplasty

These authors point out that currently 2% of Medicare reimbursements is linked to value measures including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) hospital satisfaction survey. In this study they sought to determine whether HCAHPS survey results correlated with patient self-assessed measures of comfort and function in 84 patients undergoing elective total shoulder arthroplasty. 

Patients were contacted by a third-party survey company between 48 hours and 6 weeks after hospital discharge to complete the HCAHPS survey by telephone. All patients enrolled in this study were attempted to be contacted one time by the survey company to complete the HCAHPS survey.  

Patients completed the ASES and WOOS questionnaires by mail or online at the 3-month and 1-year post-operative time points. They were also asked to complete a self-reported satisfaction questionnaire about how effective surgery was in improving pain and function (0–10 ordinal scale). Patients who failed to complete the enrollment packet, HCAHPS survey, or the 1-year ASES follow-up survey were excluded from the analysis. 

Approximately 200 patients were approached for study enrollment of which 163 consented to participation. Of these 84 patients  completed the necessary forms for inclusion in the study. 

As can be seen below, the HCAHPS score is based on questions related to the process of care rather than the functional outcome.

The average ASES scores improved by 45 points from 36 before surgery to 82 at one year. The HCAHPS scores ranged from 57 to 100 

As can be seen from the above chart, the HCAHPS scores were not correlated with ASES (r=0.09, P=0.44) at one year after surgery. HCAHPS was also not correlated with the absolute improvement in ASES (r=−0.02, P=0.85)  from pre- to one year post-operatively.

The single question “How effective was the surgery in restoring a normal level of function?” at three months after surgery showed high correlation with improvements in ASES score (r=0.38, P=0.001) at the one-year post-operative time point. Similarly, the question “How helpful was the surgery in relieving pain?” at three month post-operatively was associated with improvements in ASES (r=0.43, P<0.001) scores at one year after surgery. Neither the function question (r=0.21, P=0.07) nor the pain question (r=−0.06, P=0.62) at three months was correlated with HCAHPS scores.

Comment: This is an interesting study indicating that the 2 day to 6 week post op HCAHPS score did not correlate with improvement in comfort and function at 1 year. The HCAHPS is based on patient-nursing interactions, patient-doctor interactions, hospital environment, and pain management, As might be suspected, recollection of these characteristics would be fresh in the patient's mind soon after discharge ("the bathroom was clean/dirty", "the nurses brought my pain meds promptly/late"). On the other hand, at a year after surgery the patient's mind is more likely to be focused on improvement in and current function of the shoulder. Thus it is not a surprise that the two metrics which measure different things at different times would be discordant. It would be of interest to obtain an HCAHPS score at one year to compare with (1) the ASES score at one year and (2) the HCAHPS immediately after surgery. It seems likely that the recollection of a dirty bathroom would subside in the presence of a comfortable functional shoulder.

The authors point out that under CMS procedures, reimbursement to hospitals is directly affected by survey results which in turn may directly or at least indirectly affect providers in some health care models. 

As far as we know, there are no direct Medicare incentives for improving shoulder comfort and function, yet that is presumably the reason patients have shoulder arthroplasty to begin with (not to have a pleasant hospital stay). 

The author of What Switching to Value-Based Care from Fee-for-Service Reimbursement Means for Healthcare Providers states, "The transition to value-based care revolves around a recalibration of how healthcare is measured and how payments are reimbursed. The traditional model, known as fee-for-service, simply assigns reimbursements based on what services a healthcare organization provides. But in value-based care, reimbursement is contingent upon the quality of the care provided and it comes tethered to patient outcomes." The authors of Hospital satisfaction does not predict functional outcome one year after total shoulder arthroplasty point out that current measures of the quality of patient care (vis HCAHPS) are NOT, in fact, "tethered to patient outcomes". 

At present, the incentives for surgeons to safely improve the comfort and function of patients with shoulder arthritis via shoulder arthroplasty are patient gratitude ("you gave me back a shoulder that works and is comfortable") and surgeon satisfaction ("I did good"). For now, that's plenty. Meanwhile, we will continue to urge our medical centers to support our efforts to provide a good patient experience. 

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Do short stemmed or stemless reverse humeral components add value for the patient?

Stemless Reverse Total Shoulder Arthroplasty: A Systematic Review

Stemless humeral components in reverse total shoulder arthroplasty are only approved for clinical trials with an Investigational Device Exception (IDE) in the United States. These authors conducted a systematic review of 10 studies that utilized either a TESS or Verso implant. 

There were 430 total patients and 437 total procedures; 266 in the TESS group underwent a total of 272  procedures and 164 patients in the Verso group underwent a total of 165 procedures. 

Mean age at time of surgery was 73.8 years (range, 38 to 93 years. The mean follow-up per study ranged from 6.4 to 101.6 months. 

There was a 0.2% humeral component loosening rate and a 11.2% complication rate.

The review did not establish an advantage to patients for these implants in comparison to the standard stemmed implants. 

Comment: The Verso implant is actually a short stemmed humeral component. Intraoperative "cracks" and fractures were not uncommon in the review of this implant. As shown below this metaphyseal fit reverse humeral implant has the same risk of stress shielding as has been noted for anatomic short stems.

The review of the TESS implant revealed issues of migration of the humeral cup and intraoperative metaphyseal fracture. This implant requires removal of substantial proximal humeral bone and would seem to risk fracture of the tuberosity.

It is unclear what percent of patients needing a reverse total shoulder are not candidates for short stemmed or stemless humeral implants because of proximal humeral deformity, humeral deficiency or osteopenia. Of note, most of the failures of stemless and short stemmed humeral components were revised to standard stemmed implants.

These implants should be compared to the flexibility of a standard stemmed implant inserted with impaction grafting as shown below and in this video (see link).

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).