"The most functional patients after an anatomic total shoulder are more functional
than the most functional patients after a reverse total shoulder.
The least functional patients after an anatomic total shoulder are more functional
than the least functional patients after a reverse total shoulder. "
The clinically relevant outcome measure for shoulder arthroplasty is the patients' ability to regain the shoulder functions of importance to them (see Shoulder joint replacement arthroplasty - what outcomes do patients care about?). Large population-based registries are often used to assess patient outcomes, but these commonly rely on revision rates (did the patient have another surgery on the shoulder) and "survivorship" (was the original implant changed at the time of revision?).
Revision rates and survivorship are commonly used to compare anatomic and reverse total shoulder outcomes, although rarely are the patients having the two procedures matched for age, sex, diagnosis, health, and pathoanatomy (cuff status, version, decentering).
An important consideration when evaluating revision rates/survivorship is the ability of a revision operation to safely address the mode of failure, i.e. how much function and function is the patient likely to regain after the revision and what are the risks of complications?
Most of the important causes of failed anatomic total shoulder - such as rotator cuff failure and glenoid component loosening - can be safely and effectively revised either to a revision anatomic or to a reverse total shoulder. By contrast, some of the most important causes of failed reverse total shoulder - such as acromial/spine fractures, instability, baseplate failure, humeral bone loss, and neurologic injury - can be difficult to revise safely and effectively.
The decision to revise a failed shoulder arthroplasty is based on (1) the surgeon's identification of a problem that can be safely and effectively addressed by revision and (2) the patient's willingness to undergo a revision procedure.
Thus, the revision rate is not an indication of the clinical failure rate for patients having a shoulder arthroplasty.
These points are recognized by the authors of the article below: "Reverse total shoulder replacement had the lowest revision rate at mid-term follow-up. Given the limitations of using revision as a primary endpoint foroutcome, the results of this study should be considered with caution in clinical practice. RTSA has fewer revision options compared with the other classes of shoulder arthroplasty, which may confound the results. If RTSA is considered by surgeons in the primary setting to treat young patients with osteoarthritis, consideration should be given at surgery to mitigate the higher risk of early dislocation in the first 2 years postoperatively."
Survivorship of shoulder arthroplasty in young patients with osteoarthritis: an analysis of the Australian Orthopaedic Association National Joint Replacement Registry assessed the survivorship and reasons for revision of shoulder arthroplasties in patients aged <55 years with a primary diagnosis of osteoarthritis using data on 1564 patients from a large national arthroplasty registry. The cumulative percent revision for anatomic total shoulders (ATSA) was 6.4% at two years and 10.1% at five years. The cumulative percent revision for reverse total shoulders (RTSA) was 3.1% at two years and 5.5% at five years.
Of note, the durations of followup were substantially shorter for the RTSA patients (mean 3.5 yrs, median 2.6 yrs) than for the ATSA patients (mean 6.2 yrs, median 5.8). So 5 year followup was only available on about half of the patients.
The diagnoses thought by surgeons to be amenable to revision are shown below.
Lifetime revision risk was highest in the youngest age group (46-50 years) at 35.8% for aTSA and 30.9% for RTSA.
Females reported higher lifetime revision risk for each age group in the ATSA cohort whereas males reported higher lifetime revision risk for each group in the RTSA cohort.
Younger patients (51-55 years) were at an 11-fold increased risk of lifetime revision for rTSA and 8-fold increased risk of lifetime revision ATSA compared to older patients (81-85 years).
The diagnoses thought by surgeons to be amenable to revision are shown below.
The authors of Incidence of primary anatomic and reverse total shoulder arthroplasty in patients less than 50 years of age and high early revision risk sought to investigate the incidence of primary anatomic total shoulder and reverse total shoulder, rate of revision within 1 year, and the associated economic burden in 509 patients younger than 50 years identified in a national private insurance database.
The one year revision rate was 3.1% for anatomic and 6.8% for reverse total shoulders,
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 sought to determine whether there was a difference in outcomes in patients aged 70 years who received RTSA (n=685) vs. ATSA (n=3106) for glenohumeral osteoarthritis with an intact cuff using data from a US integrated health care system’s shoulder arthroplasty registry. The mean age was 75.8 years; 43.4% of patients were men.
After accounting for confounders, they observed no significant difference in all-cause
revision risk for RTSA vs. ATSA.
The most common reason for revision following aTSA was for rotator cuff tear (54.0%); the next most common reasons were dislocation (26.4%) and glenoid component loosening (14.9%).
The most common reason for revision following RTSA was glenoid component loosening (40.0%, followed by dislocation (20.0%) and periprosthetic fracture (20.0%).
Again, it is apparent that revision of an ATSA for cuff tear, dislocation or glenoid component loosening is likely to be more straightforward than revision of RTSA for baseplate failure, dislocation or periprosthetic fracture. Furthermore this study did not capture the rates of other major RTSA complications that may not be suitable for revision, such as acromial/scapular spine fracture, humeral bone deficiency, and neurologic injury.
Anatomic versus reverse total shoulder arthroplasty: usage trends and perioperative outcomes evaluated patient revision rates and medical complications for ATSA (n = 57,680) and RTSA (n = 90,551) from the PearlDiver database after 1:1 patient matching based on age, sex, and Elixhauser-Comorbidity Index.
Patients undergoing RTSA were older, more likely to be female, and had higher ECI.
After matching for these criteria, 33,582 were available from each of the ATSA and RTSA cohorts. Of these matched patients, no difference was observed on multivariable analysis with regard to overall revision rates between the two groups.
Matched patients undergoing RTSA were at significantly greater risk for transfusion, wound dehiscence, any adverse event, sepsis, acute kidney infection, pneumonia, urinary tract infection, and severe adverse events.
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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).
