“Reversomania” – Are We Operating Too Soon?

Kaveh R. Sajadi, MD

Read complete study: A 10-year experience with reverse shoulder arthroplasty: are we operating earlier?

When Dr. Paul Grammont introduced the reverse total shoulder arthroplasty (rTSA) in the late 1980s/early 1990s, it was a revolutionary treatment for a previously unsolved clinical condition, rotator cuff tear arthropathy. The original design had an unfortunately high complication rate which limited its use. Modern designs have significantly improved the complication rate as well as the success of the operation, and indications for rTSA have significantly increased. This increasing utilization has led some to coin the phrase “reversomania”, suggesting it is being done too often or perhaps too soon.

Clearly, complication rates for rTSA have decreased,1 and the rate of rTSAs performed have significantly increased with more rTSAs now being performed than anatomic shoulder arthroplasty (aTSA).2 The authors of the study, “A 10-year experience with reverse shoulder arthroplasty: are we operating earlier?”, sought to determine if, due to increased comfort and success with rTSA, surgeons are performing rTSA earlier in the disease process. In other words, has the “tipping point”, the point at which the patient’s symptoms are severe enough that the patient and surgeon elect to undergo rTSA changed, or has the threshold for performing surgery moved?

The authors performed a retrospective review of a prospectively collected, multi-surgeon, multi-institutional database. They included all patients over a 10-year period undergoing rTSA with a preoperative diagnosis of osteoarthritis with rotator cuff deficiency, irreparable rotator cuff tear, and rotator cuff tear arthropathy. All patients had preoperative range of motion evaluations and completed patient-reported outcome measures (PROM) including ASES and SST, as well as Constant scores. A total of 3,536 patients were included, with mean age (72 years), sex distribution, height, weight, and BMI stable over the 10-year period examined. Preoperative PROM scores and range of motion were similar regardless of diagnosis, so the data set was combined for all three diagnoses included.

The results of the study seem to show small, non-significant differences year-to-year in ASES scores. There were also significant year-to-year differences with SST and Constant, but only when comparing 2018 with 2013. Forward elevation and abduction showed significant year-to-year differences with higher tipping points in 2018. Using linear regression analysis, however, the year-to-year differences in PROMs were very unlikely to be real, but significant trends were noted in overhead range of motion over time. This suggests that surgeons are not operating on patients sooner in the process, but they are more comfortable performing the surgery on patients with better range of motion preoperatively.

One limitation of the study is that it utilized a single database of experienced shoulder surgeons utilizing a single implant system. This database, however, involves numerous surgeons from multiple institutions with varying surgical indications. This makes the results of the study more generalizable.

In summary, surgeons do appear to be performing rTSA on patients with better ROM, likely due to their successful experience with functional results of rTSA, particularly with the medialized glenoid/lateralized humerus onlay design used in this study. The decision to proceed (made by patients and surgeons), however, is occurring at basically the same score on outcome measures, or the same perceived level of disability. The “tipping point” remained stable over the study period.

This study suggests that, although overall rates of rTSA shave increased, patients and surgeons still elect to proceed with rTSA at a similar threshold or perceived level of disability. This counters the concept of “reversomania” that too many rTSAs are performed, or performed too early, in the disease process. Surgeons, at least in this database, continue to maintain appropriate indications and do not appear to be performing it on patients with less disability.

References:

  1. Kang JR, et al. Primary reverse shoulder arthroplasty using contemporary implants is associated with very low reoperation rates. J Shoulder Elbow Surg. 2019 Jun;28(6S):S175-S180. doi: 10.1016/j.jse.2019.01.026. Epub 2019 Apr 20.
  2. Chalmers PN, et al. Comparative Utilization of Reverse and Anatomic Total Shoulder Arthroplasty: A Comprehensive Analysis of a High-volume Center. J Am Acad Orthop Surg. 2018 Dec 15;26(24):e504-e510. doi: 10.5435/JAAOS-D-17-00075.
  3. Reams RC, et al. A 10-year experience with reverse shoulder arthroplasty: are we operating earlier? J Shoulder Elbow Surg. 2020 Jul;29(7S):S126-S133. doi: 10.1016/j.jse.2020.04.040.

Kaveh Sajadi, MD, practices orthopaedics with Kentucky Bone and Joint Surgeons and is an instructor in the University of Kentucky’s residency program. He completed his residency at the Campbell Clinic and his fellowship at the NYU Langone Hospital for Joint Diseases. Dr. Sajadi is a frequent instructor at Exactech domestic and international shoulder courses.

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