Monday, December 25, 2023

Anatomic or reverse total shoulder for osteoarthritis? The 4Ps

Here's an often asked question: 

orfor?

Opinions range from "I use reverse for everything" to "My best anatomic is better than my best reverse. My worst anatomic is better than my worse reverse".

In comparing the outcomes of anatomic and reverse total shoulders, the outcome of each arthroplasty is influenced by the 4Ps: 

the problem - e.g. primary osteoarthritis, glenoid type, retroversion,
the patient - e.g. age, comorbidities, sex, social determinants of health, length of followup
the procedure - e.g. implant selection, surgical technique, 
the provider -  e.g. surgeon skill and experience.

With that in mind, let's look at some publications from 2023: 

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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


Problem: Glenohumeral arthritis with intact cuff. B2 or B3 glenoids were present in 22% of ATSAs and 62% of RTSAs 
Patient: 75 years of age or older, followed for minimum of 2 yrs
Procedure: Not randomized or matched. Rationale for selecting ATSA or RTSA was based on "perceived risk of glenoid loosening". ATSA was Arthrex Univers Apex or Eclipse with corrective glenoid reaming. RTSA was Universe Revers.
Provider: Individual fellowship trained surgeon.

Summary
ATSA: n=67; Mean ASES score 84; complications 7% (cuff failure, painful stiffness); satisfaction 93%
RTSA: n= 37; Mean ASES score 90; complications 5% (acromial stress fracture, stiffness); satisfaction 92%

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Rotator Cuff Preserving Reverse Shoulder Arthroplasty Versus Eccentrically Reamed Anatomic Total Shoulder Arthroplasty for Glenohumeral Osteoarthritis and an Intact Rotator Cuff with B2 Glenoid Deformity

Problem:  Osteoarthritis with B2 glenoid and intact cuff, Type B2 glenoid
Patient: Age 65 years or older.
Procedure: Not randomized or matched. ATSA with eccentric reaming vs RTSA with cuff preservation. Rationale for selecting ATSA or RTSA not provided. Implant vendors not provided.
Provider: 3 fellowship trained surgeons

Summary
ATSA: n=18; mean retroversion 16 degrees; mean followup 4.7 years. Mean ASES score 87. No complications reported
RTSA: n=17; mean retroversion 19 degrees; mean followup 2.5 years. Mean ASES score 93. One case of scapular notching.

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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

Problem:  Osteoarthritis with intact rotator cuff
Patient: No age or glenoid pathology limitations, minimum 12 month followup.
Procedure: ASTA or RTSA with cuff preservation; Tornier Ascend Flex or Arthrex Universe Revers. Rationale for selecting ATSA or RTSA not provided.
Provider: Individual fellowship trained surgeon.

Summary
ATSA: n=93, 38% female; mean age 66 yrs; mean retroversion 15 degrees; mean followup 18 mo; Mean ASES score 84; 1 intraoperative fracture, 4 rotator cuff tears 
RTSA: n=24, 76% female, mean age 71 yrs, mean retroversion 18 degrees; mean followup 16 mo; Mean ASES score 75; 1 infection

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Problem:  Osteoarthritis with intact rotator cuff
Patient: from Arthrex Shoulder Oucomes System
Procedure: ATSA vs RTSA. Arthrex implants. Rationale for selecting ATSA or RTSA not provided.
Provider: 264 surgeons

Summary
ATSA: n=2693, mean age 65 years, 46% female. ASES scores 1 yr 86, 2 yr 87, 5 yr 87, complication rate not reported
RTSA: n=1758, mean age 71 years, 53% female. ASES scores 1 yr 81, 2 yr 81, 5 yr 82, complication rate not reported.

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Problem:  Osteoarthritis with intact cuff and at least 15 degrees of retroversion
Patient: Minimum 2 yr followup. Version not reported
Procedure: ATSA five different glenoid components (standard hybrid cage 33, augmented hybrid cage 55, standard all polyethylene peg 38,  augmented all polyethylene peg 54, keel 7). Rationale for selecting ATSA or RTSA not provided.
Provider: Multisugeon

Summary
ATSA: n=187; comorbidities 65%; mean age 66 years; mean followup 62 months; mean retroversion 21 degrees. Mean ASES score 84. Glenoid loosening 6%

RTSA: n=147; comborbidities 76%; mean age 71 years; mean followup 41 years; mean retroversion 24 degrees. ASES score 87. Glenoid loosening 1%, notching 7%.

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Clinical outcomes of anatomical versus reverse total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and limited forward elevation

Problem:  Osteoarthritis with intact rotator cuff with or without passive forward elevation ≤ 105° 
Patient: matched 1:1 by age, sex, and follow-up. Minimum 2 year followup.
Procedure: Many designs, 85% medialized glenoid lateralized humerus. The decision to undertake ATSA rather than RTSA was made by the surgeon based on patient-specific factors, such as the deformity of the glenoid and the functional demands of the patient
Provider: 4 fellowship trained surgeons

Summary
Matched groups
ATSA: Not Stiff n=85, mean age 66 yrs, 59% female ASES 72
ATSA: Stiff n=85, mean age 65, 59% female,  ASES 69
RTSA: Not Stiff n=74, mean age 71 yrs, 50% female, ASES 84
RTSA: Stiff n=74, mean age 72, 50% female ASES 83

Unmatched
ATSA: Stiff n=109.  Cuff tear 2%,  Glenoid loosening 3%, Infection 3%
ATSA: Not Stiff n=315  Cuff tear 2% Subscpularis failure 2% Glenoid loosening 4%, Fracture 1%
RTSA: Stiff n=99, Fracture 5%
RTSA: Not Stiff n=125, Glenoid loosening 4%, Fracture 3%

Comment: These six studies provide a bit more information bearing on the choice of ATSA or RTSA for arthritis with an intact cuff. They demonstrate the importance of the 4Ps: the problem, the patient, the procedure and the provider. They suggest the influence of patient sex, patient age, preoperative passive range of motion, glenoid type, glenoid version, and version correction on the choice and outcomes for ATSA and RTSA in the treatment of osteoarthritis with an intact cuff. 

It was interesting that most of these reports did not report on the rates of the most common complications following reverse total shoulder arthroplasty: instability, acromial/scapular fractures, periprosthetic humeral fractures, glenoid baseplate loosening, and infection as identified in My Reverse Has Failed: Top Five Complications and How to Manage Them. Of note, some of these are difficult/impossible to manage.



Other common limitations among these studies were (1) limited and unequal duration of followup and more importantly (2) lack of disclosure of the percentage of patients in each of the original cohorts that were lost to followup. As pointed out in  Loss to follow-up, "loss to follow-up is very important in determining a study's validity because patients lost to follow-up often have a different prognosis than those who complete the study." If a study includes only patients with, say, 2 year minimum followup, patients having a revision at 1.5 years may be systematically excluded. 

Let's see how much more we can learn from publications on the ATSA vs RTSA question in 2024.

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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).



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