Clinical Review

Reverse Total Shoulder Arthroplasty: Indications and Techniques Across the World

Publish date: September 26, 2018

References

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4. Clark JC, Ritchie J, Song FS, et al. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg. 2012;21(1):36-41. doi:10.1016/j.jse.2011.04.009.

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10. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(1):91-97. doi:10.1016/j.jse.2014.08.026.

11. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994.

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27. Steen BM, Cabezas AF, Santoni BG, et al. Outcome and value of reverse shoulder arthroplasty for treatment of glenohumeral osteoarthritis: a matched cohort. J Shoulder Elbow Surg. 2015;24(9):1433-1441. doi:10.1016/j.jse.2015.01.005.

Rotator cuff tear arthropathy was the most common indication for RTSA overall in 5459 patients, followed by pseudoparalysis in 1352 patients (Tables 2 and 3). While studies in North America reported rotator cuff tear arthropathy as the indication for RTSA in 4418 (75.8%) patients, and pseudoparalysis as the next most common indication in 535 (9.2%) patients, studies from Europe reported rotator cuff tear arthropathy as the indication in 895 (33.5%) patients, and pseudoparalysis as the indication in 795 (29.7%) patients. Studies from Asia also had a relatively even split between rotator cuff tear arthropathy and pseudoparalysis (45.3% vs 37.8%), whereas those from Australia were mostly rotator cuff tear arthropathy (77.7%).

Table 2. Number (Percent) of Studies With Each Indication by Continent

	North America	Europe	Asia	Australia	Total	P-value
Rotator cuff arthropathy	29 (56%)	19 (44%)	3 (75%)	3 (75%)	54 (52%)	0.390
Osteoarthritis	4 (8%)	10 (23%)	1 (25%)	1 (25%)	16 (16%)	0.072
Rheumatoid arthritis	9 (17%)	10 (23%)	0 (0%)	2 (50%)	21 (20%)	0.278
Post-traumatic arthritis	3 (6%)	5 (12%)	0 (0%)	1 (25%)	9 (9%)	0.358
Instability	6 (12%)	3 (7%)	0 (0%)	1 (25%)	10 (10%)	0.450
Revision of previous RTSA for instability	5 (10%)	1 (2%)	0 (0%)	1 (25%)	7 (7%)	0.192
Infection	4 (8%)	1 (2%)	1 (25%)	0 (0%)	6 (6%)	0.207
Unclassified acute proximal humerus fracture	9 (17%)	5 (12%)	1 (25%)	1 (25%)	16 (16%)	0.443
Acute 2-part proximal humerus fracture	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	N/A
Acute 3-part proximal humerus fracture	2 (4%)	0 (0%)	0 (0%)	0 (0%)	2 (2%)	0.574
Acute 4-part proximal humerus fracture	5 (10%)	0 (0%)	0 (0%)	0 (0%)	5 (5%)	0.183
Acute 3- or 4-part proximal humerus fracture	6 (12%)	2 (5%)	0 (0%)	0 (0%)	8 (8%)	0.635
Revised from previous nonop proximal humerus fracture	7 (13%)	3 (7%)	0 (0%)	0 (0%)	10 (10%)	0.787
Revised from ORIF	1 (2%)	1 (2%)	0 (0%)	0 (0%)	2 (2%)	1.000
Revised from CRPP	0 (0%)	1 (2%)	0 (0%)	0 (0%)	1 (1%)	0.495
Revised from hemi	8 (15%)	4 (9%)	0 (0%)	1 (25%)	13 (13%)	0.528
Revised from TSA	15 (29%)	11 (26%)	0 (0%)	2 (50%)	28 (27%)	0.492
Osteonecrosis	4 (8%)	2 (5%)	1 (25%)	0 (0%)	7 (7%)	0.401
Pseudoparalysis irreparable tear without arthritis	20 (38%)	18 (42%)	2 (50%)	1 (25%)	41 (40%)	0.919
Bone tumors	0 (0%)	4 (9.3%)	0 (0%)	0 (0%)	4 (4%)	0.120
Locked shoulder dislocation	0 (0%)	0 (0%)	1 (25%)	0 (0%)	1 (1%)	0.078

Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.

Table 3. Number of Patients With Each Indication as Reported by Individual Studies by Continent

	North America	Europe	Asia	Australia	Total
Rotator cuff arthropathy	4418	895	24	122	5459
Osteoarthritis	90	251	1	14	356
Rheumatoid arthritis	59	87	0	2	148
Post-traumatic arthritis	62	136	0	1	199
Instability	23	15	0	1	39
Revision of previous RTSA for instability	29	2	0	1	32
Infection	28	11	2	0	41
Unclassified acute proximal humerus fracture	42	30	4	8	84
Acute 3-part proximal humerus fracture	60	0	0	0	6
Acute 4-part proximal humerus fracture	42	0	0	0	42
Acute 3- or 4-part proximal humerus fracture	92	46	0	0	138
Revised from previous nonop proximal humerus fracture	43	53	0	0	96
Revised from ORIF	3	9	0	0	12
Revised from CRPP	0	3	0	0	3
Revised from hemi	105	51	0	1	157
Revised from TSA	192	246	0	5	443
Osteonecrosis	9	6	1	0	16
Pseudoparalysis irreparable tear without arthritis	535	795	20	2	1352
Bone tumors	0	38	0	0	38
Locked shoulder dislocation	0	0	1	0	1

Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.

The ASES, SST-12, and VAS scores were the most frequently reported outcome scores in studies from North America, whereas the Absolute Constant score was the most common score reported in studies from Europe (Table 4). Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° +/- 11.3°) (P = .004) compared with studies from Europe (Table 5).

Table 4. Outcomes by Continent

Metric (number of studies)	North America	Europe	Asia	Australia	P-value
DASH	1	2	0	0
Preoperative	54.0	62.0 ± 8.5	-	-	0.582
Postoperative	24.0	32.0 ± 2.8	-	-	0.260
Change	-30.0	-30.0 ± 11.3	-	-	1.000
SPADI	2	0	0	0
Preoperative	80.0 ± 4.2	-	-	-	N/A
Postoperative	34.8 ± 1.1	-	-	-	N/A
Change	-45.3 ± 3.2	-	-	-	N/A
Absolute constant	2	27	0	1
Preopeartive	33.0 ± 0.0	28.2 ± 7.1	-	20.0	0.329
Postoperative	54.5 ± 7.8	62.9 ± 9.0	-	65.0	0.432
Change	+21.5 ± 7.8	+34.7 ± 8.0	-	+45.0	0.044
ASES	13	0	2	0
Preoperative	33.2 ± 5.4	-	32.5 ± 3.5	-	0.867
Postoperative	73.9 ± 6.8	-	75.7 ± 10.8	-	0.752
Change	+40.7 ± 6.5	-	+43.2 ± 14.4	-	0.670
UCLA	3	2	1	0
Preoperative	10.1 ± 3.4	11.2 ± 5.7	12.0	-	0.925
Postoperative	24.5 ± 3.1	24.3 ± 3.7	24.0	-	0.991
Change	+14.4 ± 1.6	+13.1 ± 2.0	+12.0	-	0.524
KSS	0	0	2	0
Preopeartive	-	-	38.2 ± 1.1	-	N/A
Postoperative	-	-	72.3 ± 6.0	-	N/A
Change	-	-	+34.1 ± 7.1	-	N/A
SST-12	12	1	0	0
Preoperative	1.9 ± 0.8	1.2	-	-	N/A
Postoperative	7.1 ± 1.5	5.6	-	-	N/A
Change	+5.3 ± 1.2	+4.4	-	-	N/A
SF-12	1	0	0	0
Preoperative	34.5	-	-	-	N/A
Postoperative	38.5	-	-	-	N/A
Change	+4.0	-	-	-	N/A
SSV	0	5	0	0
Preopeartive	-	22.0 ± 7.4	-	-	N/A
Postoperative	-	63.4 ± 7.9	-	-	N/A
Change	-	+41.4 ± 2.1	-	-	N/A
EQ-5D	0	2	0	0
Preoperative	-	0.5 ± 0.2	-	-	N/A
Postoperative	-	0.8 ± 0.1	-	-	N/A
Change	-	+0.3 ± 0.1	-	-	N/A
OOS	1	0	0	0
Preoperative	24.7	-	-	-	N/A
Postoperative	14.9	-	-	-	N/A
Change	-9.9	-	-	-	N/A
Rowe	0	1	0	0
Preoperative	-	50.2	-	-	N/A
Postoperative	-	82.1	-	-	N/A
Change	-	31.9	-	-	N/A
Oxford	0	2	0	0
Preoperative	-	119.9 ± 138.8	-	-	N/A
Postoperative	-	39.9 ± 3.3	-	-	N/A
Change	-	-80.6 ± 142.2	-	-	N/A
Penn	1	0	0	0
Preoperative	24.9	-	-	-	N/A
Postoperative	66.4	-	-	-	N/A
Change	+41.5	-	-	-	N/A
VAS	10	1	1	1
Preoperative	6.6 ± 0.8	7.0	8.4	7.0	N/A
Postoperative	2.0 ± 0.7	1.0	0.8	0.8	N/A
Change	-4.6 ± 0.8	-6.0	-7.6	-6.2	N/A
SF-36 physical	2	0	0	0
Preoperative	32.7 ± 1.2	-	-	-	N/A
Postoperative	39.6 ± 4.0	-	-	-	N/A
Change	+7.0 ± 2.8	-	-	-	N/A
SF-36 mental	2	0	0	0
Preoperative	43.6 ± 2.8	-	-	-	N/A
Postoperative	48.1 ± 1.0	-	-	-	N/A
Change	+4.5 ± 1.8	-	-	-	N/A

Abbreviations: ASES, American Shoulder and Elbow Surgeon score; DASH, Disability of the Arm, Shoulder, and Hand; EQ-5D, EuroQol-5 Dimension; KSS, Korean Shoulder Scoring system; N/A, not available; OOS, Orthopaedic Outcome Score; SF, short form; SPADI, Shoulder Pain and Disability Index; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; UCLA, University of California, Los Angeles; VAS, visual analog scale.

Table 5. Shoulder Range of Motion, by Continent

Metric (number of studies)	North America	Europe	Asia	Australia	P-value
Flexion	18	22	1	1
Preoperative	57.6 ± 17.9	65.5 ± 17.2	91.0	30.0	0.060
Postoperative	126.6 ± 14.4	121.8 ± 19.0	133.0	150.0	0.360
Change	+69.0 ± 24.5	+56.3 ± 11.3	+42.0	120.0	0.004
Abduction	11	12	1	0
Preoperative	53.7 ± 25.0	52.0 ± 19.0	88.0	-	0.311
Postoperative	109.3 ± 15.1	105.4 ± 19.8	131.0	-	0.386
Change	55.5 ± 25.5	53.3 ± 8.3	43.0	-	0.804
External rotation	17	19	0	0
Preoperative	19.4 ± 9.9	11.2 ± 6.1	-	-	0.005
Postoperative	34.1 ± 13.3	19.3 ± 8.9	-	-	<0.001
Change	+14.7 ± 13.2	+8.1 ± 8.5	-	-	0.079

Continue to: DISCUSSION...

References

2. Gupta AK, Harris JD, Erickson BJ, et al. Surgical management of complex proximal humerus fractures-a systematic review of 92 studies including 4,500 patients. J Orthop Trauma. 2014;29(1):54-59.

11. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994.

18. Peppers TA, Jobe CM, Dai QG, Williams PA, Libanati C. Fixation of humeral prostheses and axial micromotion. J Shoulder Elbow Surg. 1998;7(4):414-418. doi:10.1016/S1058-2746(98)90034-9.

25. Renfree KJ, Hattrup SJ, Chang YH. Cost utility analysis of reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22(12):1656-1661. doi:10.1016/j.jse.2013.08.002.

Arthroscopically-Guided, Cannulated, Headless Compression Screw Fixation of the Symptomatic Os Acromiale

Reverse Total Shoulder Arthroplasty: Indications and Techniques Across the World

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