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. "

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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).