These authors conducted a single-center retrospective review of 1,600 primary anatomic total shoulders (TSAs) and 1,192 reverse total shoulders (RTSAs).
During the decade between 2005 and 2015, RTSA increased from 27% to 52% of the shoulder arthroplasties. The number of RTSAs performed for osteoarthritis and irreparable rotator cuff tears increased, and the proportion of RTSAs performed for rotator cuff tear arthropathy decreased.
Comment: Let's first consider the relative economics (reference Orthopaedic Network News)
From these data we see that the average selling price of a reverse is 60% of the medicare payment to the hospital, whereas the average selling price of an anatomic total shoulder is 41%. Surgeons should review with their hospitals the effect of implant choice on the ability to cover the costs of patient care.
Let's next consider the effect of the aTSA vs RTSA decision on the patient, take for example a 72 year old active man with capsulorrhaphy arthropathy and these x-rays (no CT scan needed!).
He recently wrote: "Greetings from Alaska! It's coming up on the end of two years since my shoulder surgery. I just wanted to express to you my deepest thanks for a job well done. My only regret is that I did not find you sooner! Unfortunately with my experience and disappointment with the original surgery 20 plus years ago, it put me off and influenced my decision to wait so long! I had almost giving up on any normal active life that I had been so used to before that surgery (an instability repair)!
Since my surgery , I have traveled and I still fly my airplane! I have killed a moose to help put meat in our extended families' freezers and I have fly fished and fished salmon and halibut to my heart's content without any discomfort whatsoever. In general, I seem to have no problems with any other recreational activity or physical activity!
Thank you for going with the traditional total replacement surgery and not going with a reverse replacement as had been suggested by three other surgeons! I am forever grateful for how it all turned out - you have given me my life back! "
The point is that three prior surgeon had tried to convince him to have a reverse, but he was unwilling to accept the limitations.
Thirdly, as the authors of this paper point out, " few long-term outcomes studies are available, and they suggest that functional survival after RTSA at 10 years may only be 58% to 76%" While they report a trend to performing RTSA in younger patients, younger patients are reported to have higher revision rates and higher rates of unsatisfactory results.
Finally and most importantly, the trend toward increasing volumes of RTSAs does not indicate that this is best treatment for conditions such as osteoarthritis (see case example above). It would seem that these authors are in a great position to compare cost and outcome data for anatomic TSA and RTSA stratified by diagnosis, age and sex, but these data are not presented. We hope that this information will be forthcoming.
In our practice we use RTSA only when it is clearly the best option: pseudoparalysis, anterosuperior escape, and complex proximal humeral fractures. For many other diagnosis, there are safer and less costly approaches that enable higher levels of activity.
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Thirdly, as the authors of this paper point out, " few long-term outcomes studies are available, and they suggest that functional survival after RTSA at 10 years may only be 58% to 76%" While they report a trend to performing RTSA in younger patients, younger patients are reported to have higher revision rates and higher rates of unsatisfactory results.
Finally and most importantly, the trend toward increasing volumes of RTSAs does not indicate that this is best treatment for conditions such as osteoarthritis (see case example above). It would seem that these authors are in a great position to compare cost and outcome data for anatomic TSA and RTSA stratified by diagnosis, age and sex, but these data are not presented. We hope that this information will be forthcoming.
In our practice we use RTSA only when it is clearly the best option: pseudoparalysis, anterosuperior escape, and complex proximal humeral fractures. For many other diagnosis, there are safer and less costly approaches that enable higher levels of activity.
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We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
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