Convertible implants: Simplifying the revision from anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty

Modern shoulder arthroplasty techniques include hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse shoulder arthroplasty (RSA). Out of all arthroplasty procedures, total shoulder arthroplasty produces more satisfactory outcomes for osteoarthritis and inflammatory arthropathy (Sanchez-Sotelo, 2011 [1]). As shoulder arthroplasty procedures continue to increase in popularity, so do revision surgeries (revision TSAs and revision RSAs). Implants used in shoulder arthroplasty procedures have been transformed substantially from generation to generation, going from 1st to 4th generation implants. We propose 5th generation convertible implants that enable a more patient-specific, anatomic reconstruction with the potential to solve major issues that exist with implants from previous years.     

Arthroplasty costs excluding implants: anatomic total shoulder versus reverse shoulder arthroplasty

BackgroundThe incidence of reverse total shoulder arthroplasty (rTSA) has been rising exponentially in recent years. Compared to anatomic total shoulder arthroplasty (aTSA), rTSA incurs higher total hospital costs, largely due to implant prices. However, rTSA typically requires less operating room (OR) time and is a cementless procedure, potentially representing important cost savings. Our aim is (1) to evaluate the difference in total hospital costs for rTSA and aTSA excluding implant costs and (2) to identify cost factors between the two procedures. Our hypothesis is that rTSAs and aTSAs will have similar costs excluding implants due to offsetting personnel and supply costs.MethodsTime-driven activity-based costing was utilized to determine the costs of rTSAs and aTSAs at our single-specialty hospital from January 2018 to 2020. Implant costs were subtracted from total hospital costs to determine costs excluding implants. Other demographic and cost parameters were also compared.ResultsNine hundred twenty-one primary shoulder procedures were analyzed (577 rTSAs and 344 aTSAs). Patients undergoing rTSA were significantly older, had a larger American Society of Anesthesiologists classification, had a longer length of stay, and were more likely to have Medicare as the primary insurance. Additionally, patients undergoing rTSA had significantly less OR time and fewer home discharges (P < .05). However, excluding implants, supply costs and overall hospital costs were 0.86× and 1.01× the cost of aTSA, respectively (P < .001 and P = .560), indicating that there was no significant difference between rTSA and aTSA overall hospital costs when omitting implant costs. Implants accounted for 97% of the difference in overall hospital costs between rTSA and aTSA.ConclusionExcluding implants, rTSA and aTSA have similar hospital costs. The savings with rTSA attributed to decreased OR time and supplies (excluding implants) are offset by personnel costs and length of stay from the postanesthesia care unit through discharge. Decreasing rTSA implant prices to the level of aTSA would equate the costs for these two procedures. As the incidence of rTSA rises, strategies to decrease implant costs are important for decreasing overall health expenditures.     

Can the reverse total shoulder arthroplasty provide as good of an outcome as an anatomic shoulder arthroplasty

BackgroundReverse total shoulder arthroplasty (RTSA) is an excellent treatment option for a variety of shoulder pathologies. Anatomic total shoulder arthroplasty (TSA) remains an excellent treatment for patients with glenohumeral arthritis and a functioning rotator cuff. RTSA has become a much more common procedure than TSA in recent times. It is currently unclear if patients who have a good outcome following TSA outperform patients who have a good outcome following RTSA. The purpose of this study was to compare the 2-year outcomes of patients with good outcomes, defined as having forward flexion of >130° and American Shoulder and Elbow Surgeons score of >70, following TSA and RTSA.MethodsAll patients who underwent TSA or RTSA between 2015 and 2019 with minimum 2-year follow-up were eligible for inclusion. Patients were included if their postoperative forward flexion was >130° and American Shoulder and Elbow Surgeons score was >70. Patients were excluded if they were a revision surgery, were treated with an arthroplasty for fracture, or had a latissimus transfer. Demographic variables were analyzed between groups. Range of motion (ROM), strength, and patient-reported outcome (PRO) scores were compared between groups.ResultsOverall, 318 TSAs were included; 155 (49%) met the criteria for a “good” outcome. Among RTSAs, 428 were included; 154 (36%) met the criteria for a “good” outcome. When comparing PROs between groups, RTSA patients had worse preoperative and postoperative PRO scores (all P < .05). When comparing preoperative physical examination findings, RTSA patients had worse ROM and strength (all P < .05) and worse Constant Power scores and Constant scores (P < .001 in both cases). Postoperatively, RTSA patients had worse ROM and strength (all P < .05) and worse Constant scores (P = .028). The magnitude of change (delta) from preoperative to postoperative function was often greater following RTSA than TSA. There were no significant differences in whether expectations were met or exceeded between RTSA and TSA patients in regards to pain control (99% vs. 98%; P = .177), motion and strength (93% vs. 96%; P = .559), ability to return to activities of daily living (98% vs. 99%; P = .333), or return to sporting activities (95% vs. 91%; P = .268).ConclusionPatients do well following both TSA and RTSA. In patients who have a good outcome following either TSA or RTSA, those patients who underwent TSA have superior outcomes to patients following RTSA. However, the change in outcome scores from pre- to post-surgery is often more significant with RTSA, as they often start out with worse motion and clinical scores.