Longitudinal analysis of shoulder arthroplasty utilization, clinical outcomes, and value: a comparative assessment of changes in improvement over 15 years with a single platform shoulder prosthesis.

BACKGROUND: The goal of this longitudinal analysis of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) utilization from 2007 to 2021 is to quantify changes in clinical outcomes, cost, and value, resulting from the introduction and adoption of new shoulder arthroplasty (SA) technologies. METHODS: We analyzed an international database of a single SA prosthesis (Equinoxe; Exactech, Inc.; Gainesville, FL, USA) for all clinical sites that have continuously enrolled cases from 2007 to 2021 to compare changes in primary aTSA and primary rTSA utilization and outcomes across 3, 5-year cohorts based upon the date of implantation. A value analysis was conducted across the 5-year implantation cohorts, with value measured by the ratio of each postoperative outcome measure at 24-36 months and 36-60 months after surgery, and the average implant selling price each year for the U.S. sites in constant 2007 U.S. dollars. These measures of value were compared between cohorts to quantify the impact of new technology introduced over the study period. RESULTS: A dramatic increase in rTSA utilization was observed across the 6 sites over the 15-year study period, along with a rapid adoption of new aTSA and rTSA technologies. The average patient receiving primary aTSA and primary rTSA changed over the 15-year study period, with significant shifts in diagnosis, comorbidities, and preoperative functional status. A comparison of postoperative results demonstrated that both aTSA and rTSA clinical and radiographic outcomes showed improvement relative to 2007-2011. Over this 15-year study period, the average aTSA implant selling price has been relatively stable while the average rTSA implant selling price has significantly declined. As a result, the value associated with the Equinoxe rTSA significantly increased for nearly every outcome measure at 24-36 months and 36-60 months after surgery, while value associated with the Equinoxe aTSA stayed relatively constant from 2007 to 2021. CONCLUSION: Our 6042-patient longitudinal analysis quantified numerous changes in utilization, outcomes, and value across 6 clinical sites over the 15-year study period. Rapid adoption of new aTSA and rTSA technologies was observed and clinical and radiographic outcomes improved relative to 2007-2011. These clinical improvements, in combination with steady aTSA and declining rTSA implant prices, have driven rTSA value to continuously increase while aTSA value has been maintained at a high-level over the 15-year study period with this particular SA system, even when considering the cost and adoption of new technologies.

Effect of Tuberosity Healing on Clinical Outcomes in Elderly Patients Treated With a Reverse Shoulder Arthroplasty for 3- and 4-Part Proximal Humerus Fractures.

OBJECTIVES: To evaluate tuberosity union rate and clinical outcome after 3- and 4-part proximal humerus fractures in the elderly. DESIGN: Retrospective, multicenter database cohort study. SETTING: Level I and Level II trauma centers. PATIENTS: Fifty-five patients older than 65 years had insertion of reverse shoulder arthroplasty (RTSA) for OTA/AO 11-B and 11-C proximal humerus fractures. INTERVENTION: Treatment with RTSA using a dedicated low profile onlay fracture stem using variable tuberosity fixation. MAIN OUTCOME MEASURES: Constant score, the American Shoulder and Elbow Surgeons score, Shoulder Pain and Disability Index score, University of California at Los Angeles score, Simple Shoulder Test score, visual analog pain score, shoulder function score, active range of motion, external rotation (ER)-specific tasks and position, rate of greater tuberosity healing, effect of tuberosity healing on overall clinical metrics, incidence of humeral lucency, and scapular notching. RESULTS: Eighty-three percent of the greater tuberosities that were repaired united. Greater tuberosity union resulted in greater active ER (P = 0.0415). There was a statistically significant difference in the ability to do ER-type activities between the 2 cohorts reflected in the ability to position one's hand behind their head with the elbow forward (P = 0.002) and comb their hair (P < 0.001). CONCLUSION: The use of a low profile onlay fracture stem in RTSA for acute 3- and 4-part proximal humerus fractures in the elderly can result in a high tuberosity union rate. Greater tuberosity healing significantly influences ER and ER-type activities that are not apparent by analysis of the overall metrics studied. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Rate of Improvement in Clinical Outcomes with Anatomic and Reverse Total Shoulder Arthroplasty.

INTRODUCTION: The rate of clinical improvement has never been studied after anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty. This study quantifies the rate of improvement after aTSA and rTSA using five different scoring metrics for 1,641 patients. METHODS: We evaluated 1,641 (69 ± 9.3 years old) patients treated by 14 orthopaedic surgeons using either aTSA or rTSA with a single platform shoulder system. Seven hundred twenty-nine patients received aTSA, and 912 patients received rTSA. Each patient was scored preoperatively and at various follow-up intervals (2 weeks, 6 weeks, 3 months, 6 months, annually, etc.) with a maximum follow-up time of 139 months using the SST, UCLA, ASES, Constant, and SPADI metrics. In addition, range of motion was measured. The rate of improvement was analyzed using a 40-point moving filter treadline over the entire range of follow-up. RESULTS: All metrics improved in a majority of patients with less than 5% worsening after 6 months. While gains in motion were present in the majority of patients after aTSA, a higher incidence of patients failed to experience improvement in range of motion after rTSA. Clinical worsening was seen in up to 10% and 20% of the visits for active flexion and abduction and external rotation, respectively. The majority of clinical improvement after aTSA and rTSA was noted in the first 6 months with full improvement noted by 12 to 24 months. During the first 12 months, the rate of improvement associated with rTSA patients was generally 30% larger than that of aTSA patients. DISCUSSION: The results of this large-scale database analysis demonstrate the reliability of improvements in outcomes and motion achieved with both aTSA and rTSA for various indications. For both aTSA and rTSA, less than 5% of patients reported worsening in each of the five clinical metrics after 6 months postoperative follow-up time. This study is significant because it quantifies how patient outcomes improve with time following treatment with both aTSA and rTSA. These results can be used to establish realistic patient expectations regarding the typical follow-up time required for pain to be reduced and function restored following surgical treatment with a total shoulder prosthesis.

A Comparison and Correlation of Clinical Outcome Metrics in Anatomic and Reverse Total Shoulder Arthroplasty.

INTRODUCTION: Indications for anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty are well defined and dependent on the function of the rotator cuff; however, indications for rTSA have gradually extended to complex fractures, revisions, and primary arthritis in very elderly patients. The risk of secondary rupture of a weakened or degenerative rotator cuff is difficult to assess and can lead the orthopaedic surgeon to hesitate between aTSA or rTSA. It, therefore, seems appropriate to compare these two types of prostheses in terms of pain, functional, clinical outcome metric scores, and complications, despite suspected differences between populations and the respective diseases. METHODOLOGY: 1,145 patients (69.2 ± 8.9 years) were treated by 12 orthopaedic surgeons in France and in the USA, using either aTSA or rTSA with one platform shoulder system. Five hundred twenty-eight patients received aTSA (66.2 ± 9.0 years; 283 female, 245 male) for treatment of degenerative arthritis, and 617 patients received rTSA (71.8 ± 8.0 years; 392 female, 225 male) for treatment of cuff tear arthroplasty, rotator cuff tear, and osteoarthritis. Each patient was scored preoperatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics; active range of motion was also measured. The average follow-up for all patients was 39.7 ± 18.7 months (aTSA: 42.7 ± 21.9 months; rTSA: 37.1 ± 15.1 months). Improvements in outcome using each metric score were normalized on a 100 point scale, correlated, and compared. A Student's two-tailed, unpaired t-test was used to identify differences in preoperative, postoperative, and pre-to-postoperative improvements, where p < 0.05 denoted a significant difference. RESULTS: Preoperatively, rTSA patients had significantly lower mean outcome scores and significantly lower mean active range of motion as compared to aTSA patients. Post-operatively, rTSA and aTSA patients showed no significant difference in active forward flexion or in mean outcome scores as measured by four of the five metrics. rTSA patients had significantly lower active abduction, internal rotation, and active and passive external rotation than aTSA patients. However, they had significantly better strength (9.7 vs. 7.3 lbs, p < 0.0001). Preoperative to postoperative mean improvements were compared between both cohorts. rTSA patients were associated with significantly larger improvements in outcomes and also had significantly better improvements in active forward flexion and strength. Conversely, aTSA patients had significantly better improvement in active and passive external rotation and active internal rotation. Analysis of complications demonstrated a very similar rate between cohorts, with aTSA patients associated with a slightly lower rate (6.6 vs. 7.3%). CONCLUSION: This retrospective analysis of prospectively acquired data from 1,145 patients who received either a primary aTSA or rTSA prosthesis demonstrates that each device provides significant improvements with very similar mean results. In fact, the mean clinical outcomes associated with the reverse shoulder prostheses approach that of the "gold standard" anatomic device for their respective indications. Furthermore, the complication rates in this series are very similar and also favorable relative to the clinical literature. Findings, such as these, may at some point extend the indications of the reverse prosthesis to patients for whom an anatomical prosthesis could lead to a premature deterioration of the result.

Scapular notching in reverse shoulder arthroplasty: validation of a computer impingement model.

PURPOSE: The purpose of this study is to validate a reverse shoulder computer impingement model and quantify the impact of implant position on scapular impingement by comparing it to that of a radiographic analysis of 256 patients who received the same prosthesis and were followed postoperatively for an average of 22.2 months. METHODS: A geometric computer analysis quantified anterior and posterior scapular impingement as the humerus was internally and externally rotated at varying levels of abduction and adduction relative to a fixed scapula at defined glenoid implant positions. These impingement results were compared to radiographic study of 256 patients who were analyzed for notching, glenoid baseplate position, and glenosphere overhang. RESULTS: The computer model predicted no impingement at 0° humeral abduction in the scapular plane for the 38 mm, 42 mm, and 46 mm devices when the glenoid baseplate cage peg is positioned 18.6 mm, 20.4 mm, and 22.7 mm from the inferior glenoid rim (of the reamed glenoid) or when glenosphere overhang of 4.6 mm, 4.7 mm, and 4.5 mm was obtained with each size glenosphere, respectively. When compared to the radiographic analysis, the computer model correctly predicted impingement based upon glenoid base- plate position in 18 of 26 patients with scapular notching and based upon glenosphere overhang in 15 of 26 patients with scapular notching. CONCLUSIONS: Reverse shoulder implant positioning plays an important role in scapular notching. The results of this study demonstrate that the computer impingement model can effectively predict impingement based upon implant positioning in a majority of patients who developed scapular notching clinically. This computer analysis provides guidance to surgeons on implant positions that reduce scapular notching, a well-documented complication of reverse shoulder arthroplasty.

Comparison of outcomes using anatomic and reverse total shoulder arthroplasty.

UNLABELLED: Worldwide, the usage of both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthro- plasty (rTSA) has increased significantly due, in part, to the predictability of acceptable outcomes achieved with each prosthesis type. This study quantifies outcomes using five different metrics and compares results using one platform total shoulder arthroplasty system that utilizes the same humeral component and instrumentation to perform both aTSA or rTSA. METHODS: 200 patients were treated by two orthopaedic surgeons using either aTSA or rTSA. 73 patients received aTSA for treatment of osteoarthritis (OA), and 127 patients received rTSA for treatment of rotator cuff tear arthro- plasty (CTA). Each was scored preoperatively, and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics, motion was also quantified. The average follow-up for all patients was 31.4 ± 9.7 months. RESULTS: All patients demonstrated significant improvements in pain and function following treatment of OA with aTSA and treatment of CTA with rTSA. No instances of instability or glenoid loosening were reported in either cohort; one instance of infection occurred in the rTSA cohort. aTSA was associated with significantly higher pre- and postoperative outcome scores and significantly larger pre- and postoperative range of motion than rTSA. However, rTSA was demonstrated to be significantly more effective at improving outcome scores, active forward flexion, and strength than was aTSA. DISCUSSION AND CONCLUSIONS: Significant improvements in outcome scores were observed for both aTSA and rTSA using one platform shoulder system at a mean follow-up of 31.4 months. Significant differences were observed between prosthesis type and between scoring metrics, particularly between the Constant and ASES scoring metrics. Additional and longer term follow-up is required to confirm these observed differences.