Shoulder replacement surgery, highlighting the intricate mechanics of reverse total shoulder replacement, focusing on the shoulder's anatomy and the medical equipment used in surgery. The scene emphasizes a calm, clinical environment with a doctor overseeing the patient’s progress.
Reverse total shoulder replacement (RTSR) has emerged as a viable option for patients aged 60 and older with osteoarthritis and intact rotator cuff tendons. The increasing global use of RTSR raises important questions about its long-term effectiveness compared to traditional anatomical total shoulder replacement (TSR). This study sheds light on the relative outcomes of these two approaches, providing key insights for patients and healthcare providers.
Comparative Effectiveness of RTSR and TSR
Shoulder replacement surgeries are a cornerstone treatment for end-stage shoulder arthritis, and RTSR has gained popularity despite limited high-quality evidence. “We were aware that more evidence was needed to clarify whether RTSR could offer better outcomes than TSR in certain patient populations,” said one of the researchers. Using data from the National Joint Registry and Hospital Episode Statistics for England, the study sought to answer these critical questions.
The study focused on adults aged 60 years or older who underwent RTSR or TSR for osteoarthritis between 2012 and 2020. With a matched population of over 7,000 procedures and a follow-up period extending up to 8.75 years, the research team assessed key outcomes, including revision surgery rates, reoperations, and healthcare costs.
Risk of Revision Surgery and Reoperations
One of the most critical outcomes of shoulder replacement surgeries is the risk of revision surgery. “We found that RTSR had a reduced risk of revision surgery within the first three years post-operation compared to TSR,” the researchers reported. Specifically, the hazard ratio for revision surgery was significantly lower for RTSR in the short term, with an odds ratio of 0.33 during the first three years.
However, long-term results showed no clinically significant difference between the two types of shoulder replacements. “Over the entire follow-up period, the risk profiles between RTSR and TSR converged,” noted the team. They emphasized that although RTSR showed early benefits, patients receiving either procedure had similar revision-free survival rates in the long term.
In terms of reoperations within 12 months of surgery, RTSR again demonstrated advantages. The relative risk of reoperations was nearly halved compared to TSR. Despite this, the absolute risk reduction was modest, indicating that the benefits, while statistically significant, may not be of high clinical relevance for all patients.
Costs and Healthcare Implications
One major concern in elective surgeries like shoulder replacements is the associated healthcare costs. Both RTSR and TSR were found to have similar lifetime costs to the healthcare system, with no significant differences in modeled mean lifetime costs between the two procedures. “This finding provides reassurance that cost should not be a deciding factor when choosing between RTSR and TSR,” the researchers concluded.
The use of national datasets allowed the team to simulate long-term costs and outcomes, giving them a comprehensive view of the economic implications of each procedure. “Our analysis highlights that both procedures are cost-effective and viable options for patients needing shoulder replacement,” the team emphasized.
Insights for Clinical Practice
The study offers important implications for clinical practice, particularly when considering patient preferences and surgeon expertise. RTSR may be an attractive option for patients seeking to minimize the risk of early reoperation or revision surgery, especially within the first three years. However, the long-term outcomes of both procedures appear to be similar, allowing surgeons and patients to base their decisions on factors other than just revision risk.
“There’s no clear winner when it comes to choosing between RTSR and TSR for patients with osteoarthritis,” the lead author commented. “Both approaches are effective, and the choice should ultimately be guided by individual patient needs and surgeon recommendations.”
This study provides the necessary reassurance for patients considering RTSR as an alternative to TSR. Given the lack of long-term differences in outcomes, both options are viable for those over 60 with osteoarthritis and intact rotator cuffs.
Citation:
Valsamis EM, Prats-Uribe A, Koblbauer I, et al. Reverse total shoulder replacement versus anatomical total shoulder replacement for osteoarthritis: population-based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England. BMJ. 2024;385. doi:10.1136/bmj-2023-077939.
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