Reverse total shoulder or anatomic total shoulder for osteoarthritis for patients 70 years old and above?

           

As pointed out in yesterday's post (see this link), failure of the rotator cuff can be a problem after anatomic total shoulder arthroplasty (TSA). However, this did not lead to an increased revision rate in comparison to reverse total shoulders (RSA) for patients with arthritis and an intact cuff. Since the risk of cuff failure increases with age, some surgeons may be inclined to use RSA for older patients.

The authors of Similar rates of revision surgery following primary anatomic compared to reverse shoulder arthroplasty in patients ≥70 years old with glenohumeral osteoarthritis: A cohort study of 3,791 patients, sought to determine whether RSA was associated with lower rates of revision surgery in comparison to TSA for patients with arthritis and an intact cuff aged 70 and above. The mean age was 75.8 years; 43.4% were male.

TSA was more commonly performed for these patients: 685 RSA and 3,106 TSA. Completeness of follow-up was excellent: 97.1% for the overall cohort (97.7% for RSA and 97.0% for TSA).

The cumulative revision probability at 5-years follow-up was 2.4% and 3.4% for RTSA and TSA. After accounting for confounders, no significant differences in revision risk or 90-day emergency room visit or readmission rates were observed when comparing RSA to TSA.

The most common reasons for revision following RSA were glenoid component loosening, followed by dislocation and periprosthetic fracture.

Over half of those who had a revision following TSA did so for rotator cuff tear, followed by dislocation and glenoid component loosening. The relatively high dislocation rate after TSA has not been commonly observed in other series.

This study did not evaluate radiographic findings, patient reported outcome measures, or complications not requiring revision surgery, such as scapular spine fractures and closed reductions in the RSA group and subscapularis failure in the TSA group.

The authors point out that within their healthcare system, there is a higher implant cost for RSA compared to TSA and that "As value-based care continues to be a focus in healthcare, future analysis should explore the long-term cost effectiveness of either procedure".

Comment: While data from this study suggest that the cumulative revision probability for RSA levels off two years after surgery,



this may be related to the observation that the percent of patients available for longer term followup was lower RSA than for TSA.






This is important in that the authors of Total shoulder replacement stems in osteoarthritisdshort, long, or reverse? An analysis of the impact of crosslinked polyethylene found that the revision rates, especially for RSA, continue to rise with increasing time after arthroplasty as seen below





The authors of Similar rates of revision surgery following primary anatomic compared to reverse shoulder arthroplasty in patients ≥70 years old with glenohumeral osteoarthritis: A cohort study of 3,791 patients have an impressive population-based registry with >90% followup. It will be of great interest to see future publications regarding implant survivorship for TSA and RSA in patients 70 years old and above.

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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).

Is workers' compensation a comorbidity - if so what do we do about it?

Inferior outcomes and higher complication rates after shoulder arthroplasty in workers’compensation patients

These authors compared the complication rates and clinical outcomes after shoulder arthroplasty in workers' compensation (WC) patients and control non-WC patients.
They queried their institutional shoulder arthroplasty database for patients with minimum 2-year follow-up who underwent total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. 45 WC patients were age and sex matched with 45 non-WC patients and retrospectively evaluated for complication rates, patient-reported outcomes, and range of motion.

The WC group had twice as high rate of prior surgery (82% vs 38%).

The WC group had an eight times higher reoperation rate (16% vs 2%) 

The WC group had three times the rate of persistent pain at final follow-up (33% vs 11%). 

The WC group had half the improvement for the SST (from 3.2 to 5.8) in comparison to the non WC group  (4.3 to 9.7).

On multivariate regression controlling for other variables including number of prior surgical procedures, WC status remained associated with lower improvements in the Simple Shoulder Test  scores, as well as a higher reoperation rate and a higher rate of persistent pain.

Comment: This article demonstrates that patients with workers' compensation insurance are at greater risk for adverse outcomes after shoulder arthroplasty.

From these data it appears that the value of shoulder arthroplasty (improvement measured against cost, reoperations and complications) is less for patients on WC insurance. It appears that WC gets less return on its investment in shoulder arthroplasty than other forms of insurance. This study did not assess the success rate of returning patients to work for patients on WC and those not on WC; if shoulder arthroplasty were successful in getting a substantial number of patients back to work, this fact might tip the value equation.

A number of questions arise:

(1) Should these results influence the decision of WC to fund shoulder arthroplasty? 

(2) Should these results influence the surgeon's decision to perform shoulder arthroplasty on WC funded patients? 

(3) When a patient has chronic osteoarthritis with work-related aggravation, to what degree should WC insurance be fiscally responsible for the total cost of shoulder arthroplasty? 

(4) Does WC insurance coverage of time off work disincent patients from "getting better"?

We do not know for sure how to answer these questions, but we must think about them in each case.

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