The 2024 Austrialian Orthopaedic Association National Joint Replacement Registry reports, "The cumulative percent revision of primary total conventional shoulder replacements for osteoarthritis is 12.7% at 10 years" Instability/dislocation was the most common reason for revision (24%) followed by rotator cuff insufficiency (23%) and loosening (17%).
We obviously have room to improve our care of these patients.
We must ask, "what might have been done differently to minimize this high revision risk for patients having elective shoulder arthroplasty for arthritis?"
These data are important because they are derived from all the shoulder arthroplasties performed for the national population, not from case series from individual surgeons or institutions. As a result they reflect the outcomes for all patients having arthroplasty by all surgeons in Australia. They provide a unique opportunity for Shoulder Arthroplasty Research (SAFR) causal modeling.
The registry provides data on non-modifiable patient and shoulder factors (age, sex, ASA score, BMI, preperative shoulder pathoanatomy) and on surgeon-controlled variables (choice of implant, technique of component fixation, use of glenoid augments, size of implants, and technologies such as computer navigation and image derived instrumentation (IDI).
Here are some take-home points based on the remarkable AOA registry.
Non-modifiable risk factors
Younger age was significantly associated with a higher revision rate (older patients have a hazard ratio (HR) for revision of 0.47). Patients under 55 years of age had the highest revision rate.
Female sex was significantly associated with a higher revision rate (female patients have a 1.27 hazard ratio for revision)
Neither higher ASA score or higher BMI had a statistically significant relationship with revision rate (HRs 1.3 and 0.92, respectively).
Preoperative Walch pathoanatomy did not have significant relationship with revision rate. Importantly, and contrary to the belief of many surgeons, type B2 glenoids were not associated with an increased revision rate (in fact B2 glenoids had the lowest revision rate).
Surgeons can use these data in discussing the revision risk with patients considering elective shoulder arthroplasty for osteoarthritis.
Surgeon controlled, modifiable risk factors Cementless fixation was associated with a significantly higher revision rate than cemented or hybrid fixation (HR 3).
Modular metal backed components have a significantly higher revision rate than all-polyethylene components (HR 3).
Modular metal backed and non-modular metal-backed have significantly higher revision rates that glenoid components with a modified central peg (HR 4 and 2, respectively).
Arthroplasties with augmented glenoid components had a significantly higher risk of revision (HR 1.95).
The use of augments did not lower the rates of different types of failure for anatomic total shoulder performed for osteoarthritis.
The use of augmented glenoid components was associated with a significantly higher risk of revision for type A glenoids and did not lower the risk of revision for type B glenoids.
Arthroplasties in which short humeral stems were used had a lower long term risk of revision.
Arthroplasties in which smaller humeral heads were used were associated with higher rates of revision.
The use of technology assistance (computer navigation, image derived instrumentation (IDI)) was not associated with a decrease in the risk of revision.
Comment: The surgeon is the method; the surgeon must ask "what can I do to reduce the risk of revision for my patient?"
(1) The surgeon manages patient selection for surgery and the preoperative discussion with the patient, including the non-modifiable risk factors that increase the risk of revision (young age, female sex, preoperative rotator cuff status) as well as those that appear not to (ASA score, BMI, Walch classification).
(2) The surgeon selects and carries out the procedure in light of the factors that may increase revision risk (metal backed, cementless, and augmented glenoid components) and those that may decrease that risk (larger humeral head and short humeral stems).
(3) Apparently surgeons cannot depend on technology assistance (computer navigation, image derived instrumentation) to reduce the rate of total shoulder revision.
It's about making good choices
Lewis' Woodpecker
Tualatin, OR
2023
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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).
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/
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).
