Anatomic or reverse total shoulder for primary glenohumeral osteoarthritis? What do 10 recent articles say?

There is a growing trend to treat primary glenohumeral osteoarthritis in older individuals with reverse total shoulder arthroplasty (RSA). However, as pointed out by the authors of Limited Preoperative Forward Flexion does not Impact Outcomes Between Anatomic or Reverse Shoulder Arthroplasty for Primary Glenohumeral Arthritis (Sears 2024), "RSA has been shown to generally result in diminished range of motion, particularly internal rotation, compared to anatomic TSA. Additionally, RSA has several unique complications not seen in TSA patients including dislocation, component dissociation, scapular spine fractures and scapular notching."

These authors compared the minimum two year outcomes between TSA and RSA in matched patients under the age of 80 years with primary glenohumeral arthritis and limited preoperative active forward flexion (≤90 degrees). The average preoperative active forward flexion was 68±20 for the TSA and 64±19 for the RSA  groups. The post operative ranges of active flexion were 141±22 and 139±21.

They also examined a subset of matched patients having TSA and RSA with severely limited preoperative forward flexion (≤70 degrees). They found no significant differences in postoperative forward flexion, external rotation, strength, ASES score, VAS, Constant score, SANE score or revision rates between the the TSA and RSA groups. The limited active forward flexion TSA group achieved significantly improved internal rotation compared to the RSA group. 

This article prompted a review of some of the other articles published in 2023 and 2024 that compared TSA and RSA. Eight of these articles addressed particular subsets of patients with glenohumeral arthritis/intact cuff: limited active flexion, limited external rotation range, weak external rotation, and age. The chart below allows the reader to compare the pre and final post operative range of active forward flexion for the shoulders in these eight articles. 

Here is a brief review of the articles.

Comparison between Anatomic Total Shoulder Arthroplasty and Reverse Shoulder Arthroplasty for Older Adults with Osteoarthritis without Rotator Cuff Tears (Kim 2024) compared the clinical outcomes of anatomic TSA and reverse shoulder arthroplasty (RSA) in patients aged over 70 years with primary glenohumeral osteoarthritis without rotator cuff tears. Of the 67 patients included in this study, TSA was performed in 41 patients, and RSA was performed in 26 patients. The two groups had no clinical differences in the patients’ preoperative demographic and radiographic data. At final follow-up, both groups showed improved pain, ROM, and functional outcomes. The TSA group demonstrated significantly better postoperative ASES and Constant-Murley scores than the RSA group. The TSA group showed significantly better postoperative active forward flexion, external rotation and internal rotations than the RSA group. 

In 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 (Nazzal 2023) TSA was compared to RSA in shoulders with preservation of the rotator cuff. While the TSA patients had more external and internal rotation, there were no significant differences in outcome scores or complication rates.

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 (Ardebol 2023) studied patients 75 years of age or older who underwent TSA (n=67) or RSA (n=37) for primary GHOA with an intact rotator cuff with a minimum 2-year follow-up.  The TSA cohort showed significantly greater improvement in external rotation; however both TSA and RSA provided similar clinical outcomes otherwise. 

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative rotational stiffness and an intact rotator cuff: a case control study (Hao 2023) compared stiff patients(ER ≤ 0 degrees) having RSAs to matched stiff patients having TSAs.  Postoperative outcome scores were similar across all matched cohort comparisons. Preoperative limitations in passive ER did not appear to be a limitation to utilizing TSA.

Clinical outcomes of anatomical versus reverse total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and limited forward elevation (Trammel 2023) compared the minimum 2 year outcomes in matched patients with glenohumeral osteoarthritis, an intact rotator cuff, and limited forward elevation (FE ≤ 105°) having TSA (n=344) or RSA (n=163). The outcome scores were significantly better in stiff RSAs compared with stiff TSAs. The complication rate did not significantly differ between stiff TSAs and stiff RSAs, but there was a significantly higher rate of revision surgery in stiff TSAs.

After accounting for confounders, the authors of Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients (Orvets 2023) observed no significant difference in all-cause revision risk for RSA vs. TSA . The most common reason for revision following RTSA was glenoid component loosening. Over half of revisions following TSA were for rotator cuff tear. No difference based on procedure type was observed in the likelihood of 90-day ED visits or 90-day readmissions.

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative external rotation weakness and an intact rotator cuff: a case-control study (Hones 2024) analyzed the two year minimum outcomes for 333 TSAs and 155 RSAs performed for primary cuff-intact osteoarthritis and having ER weakness (strength <3.3 kilograms (7.2 pounds)). When comparing weak TSA vs.weak RSA, no differences were found in postoperative outcome measures, rate of complications or rate of revision surgery. 

Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty (Karimi 2024) sought to determine whether there was a difference in functional outcomes and postoperative range of motion between TSA and RSA in patients with preoperative restricted motion (≤90 degrees of active elevation). There was no difference in outcome scores between RSA (57 patients) and TSA (59 patients). Postoperative active ROM was similar between RSA and TSA cohorts in forward flexion and external rotation. However, internal rotation was less in the RSA group. There was no statistically significant difference in complication rates between cohorts. 

Reverse total shoulder replacement versus anatomical total shoulder replacement for osteoarthritis: population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England (Valsamis 2024) sought to compare the risk-benefit and costs associated with reverse total shoulder replacement (RSA) and anatomical total shoulder replacement (TSR) in patients having elective primary shoulder replacement for osteoarthritis. RSA had a reduced hazard ratio of revision in the first three years with no clinically important difference in revision-free restricted mean survival time, and a reduced relative risk of reoperations at 12 months. Serious adverse events and prolonged hospital stay risks, change in Oxford Shoulder Score, and modelled mean lifetime costs were similar. Outcomes remained consistent after weighting.  Despite a significant difference in the risk profiles of revision surgery over time, no statistically significant and clinically important differences between RSA and TSA were found in terms of long term revision surgery, serious adverse events, reoperations, prolonged hospital stay, or lifetime healthcare costs.

Comment: These articles show similar outcomes for anatomic and reverse total shoulder arthroplasty in treating patients with primary osteoarthritis with an intact rotator cuff, even for older patients, stiff shoulders and weak shoulders. 

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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).

Rotator Cuff 6 - Clinical examination for a rotator cuff tear

Today, we'll consider how the physical examination of a shoulder can help discern if a rotator cuff problem may be present


Inspection can reveal atrophy, as well as incisions and scars indicating previous surgery and penetration. The physical examination may reveal subacromial roughness from hypertrophic bursa or from the superior edges of torn tendon rubbing against the coracoacromial arch that can be felt by a hand placed over the acromion as the shoulder is rotated.

Palpation can reveal gaps in the cuff tendon as shown in the figures below.

The range of motion examination can reveal restrictions due to contracture surrounding the area of injury or scarring in the humeroscapular motion interface. Limited range of motion is particularly common in the presence of partial thickness tears of the rotator cuff. The most common partial thickness tear is that of the supraspinatus tendon. In this situation it is characteristic to have loss of the motions that places this tendon under tension – internal rotation with the arm at the side

 internal rotation of the arm in 90 degrees of abduction

 and cross body movement

While, in the past, pain on these maneuvers has been attributed to ‘impingement,’ it is now recognized as being due to the pull on the partially torn tendon attachment which is analogous to the pain experienced on stretching the origin of the extensor carpal radialis brevis in tennis elbow.



Cuff strength is conveniently examined using manual tests of isometric torque. Isometric testing removes potential interference from pain on motion, from crepitance, or from stiffness. These tests examine the integrity of the supraspinatus

 the infraspinatus

and the subscapularis

Pain or weakness on these maneuvers constitutes an abnormal tendon sign for the specified tendon-muscle unit. These tests are relatively specific to each muscle, but are not specific to the cause of weakness; for example, a suprascapular nerve lesion or a cuff tear may each produce abnormal supraspinatus and infraspinatus tendon signs. 

Using these simple tests, the examiner can assess crepitance, loss of range of motion and pain or weakness on examination of specific tendons.

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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).

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).

Revision surgery for failed total shoulder replacement arthroplasty for weakness - our approach, Part 5

If weakness is an issue after shoulder arthroplasty, it may be due to (1) insufficient time and effort at rehabilitation (recognizing that shoulder joint replacement is performed on shoulders that have been 'out of action' for a long period of time with some disuse atrophy of the muscles), (2) technical problems with the arthroplaty, (3) nerve injuries, (4) rotator cuff defects, or (5) subscapularis tendon detachment.

In a technically well done joint replacement and in the absence of some intercurrent injury, persistence of the rehabilitation program will usually lead to progressively more strength and function. If this fails, the shoulder should be scrutinized for evidence of other causes of weakness as listed above.

Failure of the subscapularis reattachment may result from excessive early loading of the repair or from poor quality of the tendon. 

This situation is suggested by weakness of internal rotation and be an increased range of external rotation.

 If there has been an acute injury causing the disruption, a re-repair may be indicated. Otherwise a reconstruction with a tendon graft may be helpful in restoring some of the function of the subscapularis.

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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.

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Revision surgery for failed total shoulder replacement arthroplasty - our approach, Part 4

Before embarking on a surgical revision of a shoulder arthroplasty, it is important to determine the nature of the patient’s problems.  The following is a list of the common causes of shoulder arthroplasty failure:

(1)            Infection

(2)            Reaction to polyethylene or polymethylmethacrylate

(3)            Fracture

(4)            Stiffness

(a)            Poor rehabilitation

(b)            Unwanted bone

(c)            Tuberosity malunion

(d)            Overstuffing of the joint

(5)            Instability

(a)            Anterior

(i)            Subscapularis deficiency

(ii)            Glenoid component anteversion

(iii)            Tuberosity nonunion

(iv)            Supraspinatus/infraspinatus defect

(v)            Humeral component anteversion or anterior head offset

(vi)            Insufficient anterior glenoid bone

(b)            Posterior

(i)            Glenoid component retroversion

(ii)            Posterior cuff defect

(iii)            Excessive humeral component retroversion or posterior head offset

(iv)          Insufficient posterior glenoid bone

(c)            Superior

(i)            Loss of rotator cuff

(ii)            Loss of coracoacromial arch

(6)            Weakness

(a)            Reduced muscle strength

(b)            Subscapularis deficiency

(c)            Supraspinatus/infraspinatus deficiency

(d)            Tuberosity nonunion or malunion

(e)            Deltoid detachment

(f)            Nerve injury

(7)            Humeral component

(a)            Malpositioned

(b)                       Loose

(8)            Glenoid

(a)            Bone eroded (hemiarthroplasty)

(b)            Component malpositioned

(c)            Component loose

The history and previous records are reviewed to learn the status of the patient and shoulder prior to the index arthroplasty.  What were the details of the reconstruction including the manufacturer, model and size of the prostheses?  How was the rehabilitation conducted?  Is there evidence of infection or allergic reaction?  Has there been an intercurrent injury?  What is the patient’s status with respect to nutrition, pain medications, smoking, alcohol, and other concurrent health conditions?

The workup includes a detailed examination of the motion, stability, strength and smoothness of the shoulder.

EMG’s and nerve conduction studies, CT scans, and expert sonography may be useful in evaluating the nerve function, bone, and rotator cuff, respectively.

Laboratory studies include a CBC, sedimentation rate, and serum albumin.

Radiographs include an anteroposterior view in the plane of the scapula, an axillary view, and a full humeral view, all of high quality. Here is an AP view and an axillary view showing a glenoid component that has completely loosened from the bone and is floating free within the joint (two white dots near the letter "G").

 In cases of instability, examination under fluoroscopy may be useful.  The radiographic evaluation must confirm the type and size of components, their position, and the nature of their fixation to bone.  The preoperative plan must include a definitive plan for removal of the glenoid and humeral components should this prove necessary, as well as a plan for reconstruction of the humerus and the glenoid after prosthesis removal.  If removal of a cemented humeral component may be necessary, it is essential to have a full set of cement removal tools, a high speed saw capable of cutting a prosthetic stem, fluoroscopy, and long stem prostheses of all possible sizes.  The possible need for bone and tendon graft is also anticipated. 

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Revision surgery for failed total shoulder replacement arthroplasty - our approach, Part 2

SURGICAL CONSIDERATIONS

General Principles of Revision Surgery

Before the anesthetic, the patient’s consent is checked to make sure it is complete.  The instrument and implant inventory are verified for possible variations on the preoperative plan, including the need to modify a prosthesis or to possibly use a special implant (e.g., a long stemmed humeral implant in case of shaft fracture).

The patient is anesthetized, positioned, prepped and draped in a manner that anticipates all possible variations on the surgical plan.  The entire forequarter is prepped so that incisions can be made anteriorly, posteriorly or distally as needed.  The arm is draped so that it can be moved freely.  Ipsilateral iliac crest and hamstring autograft donor sites are prepped if their possible need is anticipated.

Preoperative antibiotics are not administered.  Prophylactic antibiotics are administered only after specimens are collected for culture and sensitivity testing.

The incision is made in a manner that provides optimal access to the mechanical problem and, if possible, incorporates or respects previous skin incisions.  The possible need for extending the incision is anticipated. As shown below, the coracoid is an important landmark when the normal anatomy of the deltopectoral interval is scarred from previous surgery through the anterior approach.

The surgical approach is conducted carefully to protect and preserve the deltoid, the rotator cuff, and the neurovascular structures about the shoulder – each of which may have been altered by previous surgery. The coracoid process serves as a lighthouse for proper orientation in a scarred shoulder. It divides the lateral (safe side) from the medical side (suicide), where the brachial plexus and vascular structures are located.

The humeroscapular motion interface is entered and all adhesions lysed. The axillary nerve is identified and protected.

Specimens are collected for aerobic, anaerobic, and fungal culture, sensitivity, and gram stains.  Frozen and permanent sections are obtained of any tissue suspicious for inflammation, infection, or neoplasm.  Prophylactic antibiotics are given intravenously at this point.

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Use the "Search the Blog" 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.

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

Revision surgery for failed total shoulder replacement arthroplasty - our approach, Part 1

Principles of Revision Surgery

CONCEPTS

Considering Revision Surgery

Revision shoulder surgery calls on judgment, experience, and technical skills that are an order of magnitude greater than for primary shoulder surgery.  There are ten questions that we ask before taking on a revision case:

(1)         Do we have sufficient past records on this case?

(2)        Is the problem a mechanical one that is clearly identified (as opposed to a problem that is manifest as pain or frustration without a clear mechanical cause)?

(3)        Is there a nonoperative approach to the problem?

(4)        Is the mechanical problem treatable?

(5)        Is the patient of sufficient mental and physical health and strength to undergo a revision surgery – are the patient’s metabolism and the skin over the shoulder ready for another surgery, has the patient ceased smoking, are alcohol consumption and pain medication use under control?

(6)        Are the patient’s expectations reasonable?

(7)        Does the patient fully understand the risks and possible outcomes of surgery, including the anticipated incision and the possibility that infection may be encountered?

(8)        Do we need a consultation to help define the cause and treatment of the problem?

(9)        Are we the best surgeons to carry out the revision surgery?

(10)    Do we have the right tools and team to carry out the surgical revision?

To answer these questions, we seek the following information prior to considering a surgical revision:

(1)         An understanding of the patient’s status prior to the index procedure.

(2)        Previous operative notes, including information on the type, manufacturer, and size of implants.

(3)        An assessment of the legal and insurance aspects of the case.

(4)        Knowledge of the medical status of the patient including:

a.            Health conditions that may affect the patient’s surgery

b.            Current medications including pain medications and dosages

c.             The amount of nicotine and alcohol currently being consumed

d.            The psychological status of the patient

e.             The vocational status of the patient

f.              The social situation and support systems for the patient

g.            Current laboratory values including a CBC, sedimentation rate, and serum albumin.

(5)        High quality anteroposterior and axillary radiographs as well as an anteroposterior radiograph of the entire humerus.

(6)        Completed Simple Shoulder Test and Short Form-36 Questionnaires.

(7)        A physical examination of the neck and shoulder, including the location of skin incisions and the health of the skin in the areas of possible incision.

(8)        An EMG if there is concern about radiculopathy or neuropathy.

(9)        Consent for bone autograft, tendon autograft, or allograft as necessary.

(10)    Medicine, anesthesiology, and pain service consults as necessary.

(11)     Urine analysis to screen for drug, alcohol and nicotine, if indicated.

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Revision surgery for failed total shoulder replacement arthroplasty

When a shoulder replacement fails to result in satisfactory restoration of comfort and function, the surgeon and the patient are challenged to determine the most likely causes and how the failure can be best managed. It is always important to keep in mind the wide range of potential causes of joint replacement failure. These have been well characterized by our shoulder fellows Hasan and Franta

While pain is often a presenting complaint, we try to determine as well if the shoulder is stiff, unstable, weak or crepitant, in that each of these mechanical characteristics provides clues to what may be going on with the joint.  For example a shoulder arthroplasty may be stiff because of adhesions (scar), blocking osteophytes (bone spurs), or overstuffing (too large prosthetic components). Weakness may result from rotator cuff failure, subscapularis detachment, nerve injury, deltoid detachment, or disuse atrophy of the muscles. Instability may result from suboptimal positioning of the components, component loosening or soft tissue imbalance. Crepitation, clicking, or clunking may result from component loosening, soft tissue ingrowth, loose bodies within the joint or joint surface irregularities.

As pointed out by Hasan and Franta infection is an ever present concern in painful shoulder arthroplasties. Trying to better understand the causes, prevention, diagnosis and treatment of shoulder joint replacement infections has become a major interest of mine. Stay tuned on this blog for some of our late-breaking discoveries. For now, suffice it to say that shoulder infections most often present themselves only by shoulder pain - the 'traditional' evidences of infection, such as fever, chills, redness, swelling, elevated while blood cell count, elevated sedimentation rate, and elevated C reactive protein are usually absent.

So a thorough evaluation of the patient and the shoulder are essential before considering the best treatment. A careful history is needed to determine the original diagnosis, the initial result of the joint replacement, the onset of discomfort or loss of function, any injuries, dental or other procedures that may have introduced infection, and any intercurrent diseases.  The physical exam must seek evidence of stiffness, weakness, instability or crepitance. Finally, high quality x-rays are needed to look for the position and relationship of the prosthetic components as well as evidence of loosening or wear of these components.

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Use the "Search the Blog" 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.

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

Rotator cuff disorders - how do they figure in?

The photograph above shows a surgical view looking down on the top of a shoulder with a rotator cuff tear. The muscle of the rotator cuff is at the upper left.  The edge of the rotator cuff tendon should be attached to the area to the side of the humeral head near the metal retractor at lower left. When this tendon is not attached, the muscle cannot deliver its force to the arm, resulting in weakness.

The rotator cuff is a common source of shoulder problems.  Use this link <rotator cuff > to take you to some useful information about the evaluation and management of rotator cuff problems.
These disorders may require surgical treatment if the symptoms are substantial and if gentle exercises are not of benefit. We had the opportunity to write a comprehensive article for the New England Journal of Medicine on this topic. You can see it here.

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Use the "Search the Blog" 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.

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